Oakview Skilled Nursing

Inspectors wroteBased on interview and record reviews, the facility failed to ensure written bed-hold notice was provided to the resident representative at the time of transfer to the hospital for 1 of 12 sampled residents (Resident 51). This failure had the potential to prevent the resident representative from understanding the duration of the bed hold policy and the resident's rights to return to the facility. During a review of Resident 51's admission Record (AR), dated 7/16/26, the AR indicated, Resident 51 was admitted in the facility on 5/2/26. During a review of Resident 51's Progress Note (PN), dated 5/26/26, the note indicated, Resident 51 was transferred to hospital for further evaluations. During a review of Resident 51's admission Note (AN), dated 5/27/26, the note indicated staff spoke with Resident 51's wife regarding holding the resident's bed. The wife declined to hold the bed. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure specific diagnoses were included in the MDS (Minimum Data Set - a health status screening and assessment tool used for all residents of long term care nursing facilities) assessment for 1 of 12 sampled residents (Resident 22). This oversight resulted in an inaccurate representation of Resident 22's health condition and could potentially introduce risks to the resident's health and safety. During a review of Resident 22's hospital records, prior to admission to this facility, the Emergency Provider Report (emergency room physician documentation that details a patient's urgent medical visit. assessment findings. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan addressing anticoagulant medication use and the associated risk for bleeding for one of 12 sampled residents (Resident 17). This failure had the potential for staff to be unaware of the interventions necessary to monitor for and reduce the risk of bleeding complications. During a review of the facility's policy and procedure (P&P) titled, Nursing Services - Care Plan, dated 10/24/25, the P&P indicated, The facility shall implement each patient's care plan according to patient needs, physician orders, resident preferences, and facility protocols as indicated. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan on self-administration of medications was updated accordingly based on staff evaluation and resident preferences for 1 of 12 sampled residents (Resident 47). This failure had the potential to negatively affect Resident 47's responsiveness to care and treatment. During a review of Resident 47's admission Record (AR), dated 7/16/26, the AR indicated in part that Resident 47 is a [AGE] year-old female who was initially admitted to the facility on [DATE], with admitting diagnoses including chronic diastolic congestive heart failure (a condition where the heart becomes stiff and can not relax properly between beats), gastroesophageal reflux disease (GERD - a chronic digestive condition where stomach acid repeatedly flows back into the esophagus), and dependence on supplemental oxygen. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure policies and procedures (P&P) were implemented for two of three sampled Residents (Resident 1 and Resident 3) when nursing staff failed to verify residents' wishes regarding Cardiopulmonary Resuscitation (CPR - is an emergency lifesaving procedure performed when the heart stops beating) upon admission. This failure had the potential to result in the facility staff providing or delaying medical treatment and services against the will of the residents. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 05/2024, the P&P indicated, Policy: . [facility name] shall promote the exercise of rights for all residents, including those who face, barriers, such as communication problems, hearing problems, and cognition limits, in the exercise of these rights .13. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure infection control practices were implemented when: 1. Rehabilitation staff entered a Contact Isolation (infection control measures used to prevent spread of infections through direct (touching resident) or indirect (residents environment)) room without personal protective equipment (PPE - protective clothing such as gowns, gloves, face shields or other equipment) for one of three sampled Residents (Resident 2). 2. Proper identifier for enhanced barrier precautions (EBP - an infection control intervention used to reduce transmission of MDROs (multidrug-resistant organisms that includes use of PPE during high-contact resident care) was not placed on Residents door alerting staff to use PPE, for one of three sampled residents (Resident 3). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an opioid medication (pain medication that has a high risk of addiction) that was administered was documented on the appropriate record. This failure resulted in an inaccurate narcotic count and had the potential to result in diversion of a controlled medication.

Inspectors wroteBased on record review and interview, the facility failed to follow it's policy and procedure to consistently monitor temperature controls from the time food leaves the kitchen to transport and distribution to residents. This failure occurred in 1 of 21 opportunities for monitoring. This failure risks residents receiving their food outside of appropriate temperature range.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had an accurate assessment recorded on their Minimum Data Set Assessment ((MDS) a tool for implementing standardized assessment and for planning care). For Resident 1, this failure had the potential to result in a plan of care (a communication tool for healthcare providers to ensure quality care is being provided) that did not match their actual needs.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the health condition related to medical condition for two of five sampled residents (Resident 9 and Resident 196), using the Minimum Data Set ((MDS - a tool used to assess and plan care of residents in a nursing facility) when: 1. For Resident 9 - had a missing diagnosis for anxiety. 2. For Resident 196 - had a missing diagnosis for depression. This facility failure resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS).