Oakview Nursing and Rehabilitation

Inspectors wrote3. Review of the MDS assessment for Resident #18, dated 4/8/25 revealed the resident scored 12 out of 15 on a BIMS exam, which indicated moderate impaired cognition. Per the assessment, the resident received antidepressant medication. Review of Resident #18's Care Plan revealed an undated Focus area to address Resident receives psychotropic antidepressant medication related to depression. Undated Interventions included, in part: Review continued need for medication with prescriber, attempt dose reduction as warranted. Review of Resident 18's Clinical Physician Orders for Sertraline (antidepressant) revealed the resident had been on Sertraline 50 milligrams (mg) since 2/24/2024. Review of the the Pharmacy Review Note, dated 9/29/24, revealed the following documentation: MRR - GDR. The clinical record lacked documentation of any other GDR in the last 12 months (6/1/24 to 6/18/25). [...]

Inspectors wroteBased on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to treat 1 of 6 residents (Resident #30) with dignity and respect when staff took more than an hour to assist with a transfer request made by a resident who required substantial assistance. The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident and staff interview, the facility failed to offer the pneumococcal vaccine to 3 of 5 residents (Residents #23, #36, and #40) reviewed for immunizations. The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, the facility failed to provide monitoring, assessment and intervention services causing a pressure ulcer present on admission to worsen, and the development of new pressure ulcers. Resident #9 admitted on [DATE] with a Stage 2 pressure ulcer present on the right heel. The pressure ulcer deteriorated to a Stage 3 by 7/5/24. The clinical record revealed the resident experienced pain and a referral to the wound clinic. During the first wound clinic appointment on 6/11/24, the right heal pressure ulcer was not assessed or treated. The facility did not follow up with the clinic. On 6/25/24, the wound clinic assessed the right heel as a Stage 3 pressure ulcer with necrotic (dark, dead tissue) tissue and identified a new unstageable pressure area on the left heel, and Stage 3 Pressure ulcers on bilateral buttocks. [...]

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to ensure the Care Plan revisions to indicate; a resident use of prophylactic antibiotics, resident wandering, and the presence of pressure ulcers for 3 of 13 residents reviewed for Care Plans (Resident #29, Resident #45, and Resident #9). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to ensure use of antiplatelet medication and seizures were included on the resident's comprehensive plan of care for two of thirteen residents reviewed for care plans (Resident #16, Resident #20). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews the facility failed to administer medications as directed for one of one residents (Resident #254) reviewed. The facility reported a census of 49 residents. Findings Include: The admission Minimum Data Set (MDS) assessment, dated 6/27/2024, list of diagnoses included: hypokalemia (low potassium), paroxysmal atria fibrillation (irregular heartbeat), hypotension, and adult failure to thrive. The MDS listed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating a moderate cognitive impairment. A review of the clinical record revealed Resident #254 admitted to the facility on [DATE] at 3:00 PM. The Physician Order dated 6/21/2024 documented, Metoprolol Tartrate Oral Tablet 50 mg related to Essential (Primary) Hypertension. Give 2 tablet by mouth two times a day. [...]

Inspectors wroteBased on observation, staff interview, and clinical record review the facility failed to ensure an antibiotic was initiated timely for treatment of a urinary tract infection (UTI) and failed to ensure clear process for frequency of urinary catheter change for one of one resident reviewed for catheters (Resident #45). The facility reported a census of 49 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to ensure medications including a diuretic, antibiotic, and blood pressure medication were available from the pharmacy to administer to a resident for one of three resident reviewed for medication availability (Resident #45). The facility reported a census of 49 residents.

Inspectors wroteBased on observation, record review, interviews, and the facility policy, the facility failed to document food temperatures and dishwasher temperatures on multiple occasions between October 2023 and January 2024. Failure to check food and dishwasher temperatures can lead to food borne illness and serving food that are not palpability to the residents if the food and dishwasher did not meet or exceed the required temperatures to prevent illness or infection. The facility reported a census of 50 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently assess, monitor, and document change in condition for a resident's urinary catheter site for one of three residents reviewed for catheters (Resident #1). The facility reported a census of 50 residents.

Inspectors wroteBased on record view, interviews, and facility policy review, the facility failed to implement its water management program to ensure measures were in place to prevent potential growth of Legionella (a pathogenic gram-negative bacteria). This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on interviews and record review, it was determined the facility failed to provide advance beneficiary notices timely for 2 (Resident #26 and Resident #44) of 3 sampled residents reviewed for beneficiary notices.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to ensure staff immediately reported an allegation of abuse when Resident #11 reported they had gotten into an argument with an unnamed facility staff member. This deficient practice affected 1 (Resident #11) of 1 sampled resident reviewed for abuse/neglect.

Inspectors wroteBased on interviews, record review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure that a significant change assessment was completed after a resident who was placed on hospice services for 1 (Resident #33) of 1 sampled resident reviewed for hospice services.

Inspectors wroteBased on interviews and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed for 2 (Resident #33 and Resident #47) of 24 sampled residents for whom MDS assessments were reviewed. Specifically, Resident #33's 03/30/2023 annual MDS assessment did not reflect the resident was receiving hospice services, and Resident #47's 04/27/2023 quarterly MDS assessment indicated the resident had a stage two pressure ulcer, when the resident had no current skin breakdown.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to obtain informed consent prior to implementing side rails/bed rails for 1 (Resident #8) of 3 sampled residents reviewed for side rail use.