Oakview Nursing & Rehablitation - Marion

Inspectors wroteBased on observation, clinical record review, facility documentation, interviews, and policy review the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. A Certified Nurse's Aide (CNA) and a nurse became aware of allegations of abuse and did not report to facility management or the designated state agency. When the facility became aware of an allegation of abuse, they didn't report it to the state agency in a timely manner for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 39 residents.

Inspectors wroteBased on record review, interviews, and the Medicare Claims Processing Manual the facility failed to provide residents ending skilled care with current Advanced Beneficiary Notice (ABN) and Notice of Medicare Non Coverage (NOMNC) documents for 3 of 3 residents reviewed (Residents #22, #41, #42). The facility reported a census of 36.

Inspectors wroteBased on observation, clinical record review, staff and resident interviews the facility failed to prevent one resident from wandering into another resident room and putting their hand on a resident for 1 out of 6 residents reviewed (Resident #1). The facility reported a census of 29 residents.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to hold hot foods at an adequate minimum temperature for 1 of 1 meal service observed. The facility reported a census of 39 residents.

Inspectors wroteBased on observation, policy review, and staff interviews, the facility failed to store and prepare food under sanitary conditions for 3 of 3 kitchen areas reviewed. The facility reported a census of 39 residents.

Inspectors wroteBased on review of Quality Assurance and Performance Improvement(QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance(QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 39 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure dignity was provided to residents with catheters by not placing the catheter bags in dignity bags for 2 of 4 residents reviewed for catheters (Residents #8 and #143). The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to ensure residents remained free of physical abuse when a staff member hit a resident on the shoulder for 1 of 1 residents reviewed for abuse(Resident #23). The facility reported a census of 39 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to ensure sanitary conditions of a food service area, failed to monitor and record resident refrigerator temperatures according to facility schedule, failed to ensure all staff entering kitchenettes wore a hair covering during food service, and failed to cover all food and drinks transported through the hallway to resident rooms to prevent contamination. The facility further failed to serve one resident, on a pureed texture diet, all menu items when side dish and dessert were omitted for 1 of 1 meal services observed. The facility reported a census of 39 residents. Findings Include: On 2/12/24 at 10:40 AM, observation of the C-Wing kitchenette refrigerator, which contained resident food and drinks, noted with splatters of liquid and crumbs collected on shelves. [...]

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to cover clean linen carts in compliance with infection control protocol while transported through 2 of 2 hallways. The facility reported a census of 39 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews and facility policy review the facility failed to serve 2 out of 16 resident in the dining room (DR) in a dignified manner when meals served on trays (Residents # 12 and 17). The facility reported a census of 39 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #12 dated 12/21/23, included diagnoses of Alzheimer's Disease, and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severely impaired cognition. The MDS identified Resident #12 required partial or moderate assistance for eating. The Care Plan for Resident 12 dated 7/7/23, directed to provide adaptive equipment per the dietary list. The Dietary Seating Chart dated 2/6/24, failed to include a tray for Resident #12 while eating. 2. [...]

Inspectors wroteBased on clinical record review, staff interview, and Facility Assessment Tool review, the facility failed to include anti-depressant and diuretic medications in Care Plan for one of five residents (Resident #2) reviewed for unnecessary medications. The facility reported a census of 39 residents. Findings Include: The Medication Administration Record (MAR), dated February 2024, revealed current orders for Furosemide (diuretic) 40 milligrams (mg) one tablet daily for Chronic Diastolic Heart Failure, initiated on 11/28/23, and Trazodone (antidepressant) 50 mg one tablet at bedtime for generalized anxiety disorder, initiated on 11/27/23. The Care Plan, revised on 2/12/24, lacked a focus areas to inform care needs and the side effects related to anti-depressant and diuretic medications. [...]

Inspectors wroteBased on clinical record review, observations, resident interview, and Call Light Log review, the facility failed to answer resident call lights in a timely manner resulting in long wait times for 2 of 39 residents reviewed for call light response time (Residents #1 and #3). The facility reported a census of 39 residents. Findings Include: 1. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (intact cognition). Resident required substantial/maximal staff assistance for transfers and dependence on staff for toileting hygiene. Resident #3 diagnoses included: End Stage Renal Disease, Neurogenic bladder, arthritis, seizure disorder, anxiety disorder, and depression. The Care Plan, revised on 01/03/24, revealed focused areas related to risk of falling and deterioration in ability to perform activities of daily living. [...]