The Oaks at Longview

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 4 residents (Resident #1) reviewed for therapeutic diets. The facility failed to ensure Resident #1 received a diabetic diet (CCHO). This failure could place residents at risk for altered nutritional status and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident self-determination through support of resident choice for 4 of 19 residents reviewed for resident rights. (Resident #16, Resident #33, Resident #40, and Resident #64). The facility failed to ensure Resident #16, Resident #33, Resident #40, and Resident #64 were allowed to smoke two cigarettes during the facility smoking times. This failure could place dependent residents at risk for feelings of depression or lack self-determination and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to promptly resolve grievances for 6 of 6 Anonymous residents reviewed for grievances during a confidential meeting. The facility failed to ensure 6 of 6 Anonymous residents' grievances related to wet napkins on room trays were promptly resolved. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect or hopelessness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, homelike environment maintaining a comfortable noise level for 1 of 18 residents (Resident #39) reviewed for dining services. The facility failed to ensure the noise level in the dining room was kept at a comfortable level for Resident #39 on 08/25/25 during the lunch meal. This failure could place residents at risk for a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 19 residents (Resident #3 and Resident #12) reviewed for MDS assessment accuracy. The facility did not ensure Resident #3's and Resident #12's MDS assessments accurately identified a medication as an anti-platelet instead of an anticoagulant. These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 2 of 2 (Resident #1 and Resident #2) residents reviewed for gastrostomy tube. 1. The facility failed to ensure Resident #1 received potassium chloride (supplement), acidophilus (probiotic), Bactrim DS (antibiotic), and valproic acid (anticonvulsant) within the scheduled time frame on 08/26/25. 2. The facility failed to ensure Resident #2 received apixaban (anticoagulant), ferrous sulfate (iron supplement), furosemide (diuretic), and valproic acid (anticonvulsant) within the scheduled time from on 08/26/25. These failures could place residents at risk for medication errors and adverse effects from medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 4 of 7 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for quality of care. The facility failed to ensure Resident #1's had a skin assessment performed weekly on 8/9/24 and 8/16/24 per facility policy. The facility failed to ensure Resident #2, Resident #3, and Resident #4 had skin assessment performed weekly on 8/16/24 per facility policy. These failures could result in skin issues on residents being missed, skin issues deteriorating without being monitored, and decreased quality of life. Findings Included: 1. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 5 of 21 residents reviewed for the right to be informed. (Resident's #21, #31, #33, #35, and #69) 1. The facility failed to ensure Resident #21 had a signed psychotropic consent form for Duloxetine (antidepressant medication) or Haloperidol (antipsychotic medication). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 4 of 6 staff (CNA F, CNA H, CNA G, the DOR) reviewed for abuse policy. 1. The facility failed to ensure CNA F, CNA G, and DOR had criminal history background checks in their personnel file. 2. The facility failed to ensure CNA H had EMR in the personnel file. These failures could place residents at risk for unsafe environment and abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 10 resident reviewed for assessments. (Resident #31, Resident #33, and Resident #54) The facility failed to ensure Resident #31's diagnoses of anxiety (persistent and excessive worry that interferes with daily activities) and depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest) was coded on her MDS. The facility failed to ensure Resident #33's diagnoses of bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depression was coded on her MDS. The facility failed to ensure Resident #54's diagnosis depression was coded on her MDS. These failures could place residents at risk of not having individual needs met.

Inspectors wroteased on interview and record review the facility failed to complete a performance review of each Certified Nurse Assistant (CNA) at least once every 12 months, for 5 of 5 (CNA J, CNA F, CNA H, CNA K, and CNA G) reviewed for annual competency evaluations. The facility failed to complete annual CNA competency evaluations for CNA J, CNA F, CNA H, CNA K and CNA G based on the personnel file review results. This failure could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 4 (Resident # 33, Resident #35, Resident #54, Resident #69) of 5 residents whose medications were reviewed in that: 1. The facility failed to ensure Resident #33 had side effect monitoring (are defined as unintended responses to approved pharmaceuticals (is any kind of drug used for medicinal purposes) given in appropriate dosages) for her prescribed Seroquel ((is an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia (is a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration)), Buspirone (antianxiety; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 19 of 74 residents (Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60, Resident# 107, Resident #51, Resident #72, Resident #108, Resident #44, Resident# 109, and Resident #110) reviewed for immunizations. The facility failed to offer and administer the influenza and pneumococcal vaccination to Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60. [...]

Inspectors wroteased on interview and record review, the facility failed to maintain ensure the required in-service trainings were sufficient for the continuing competencies of nurse aides but must be no less than 12 hours per year for 5 of 5 staff, (CNA F, CNA G, CNA H, CNA J, and CNA K) records reviewed for staff training. The facility failed to provide CNA F, CNA G, CNA H, CNA J, and CNA K 12 hours of training per year. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteased on interview and record review the facility failed to provide respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life for 1 of 18 residents reviewed for resident rights. (Resident #178) The facility failed to treat Resident #178 with respect and dignity when staff told her to urinate in her brief. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, for 1 of 5 residents (Resident #31) reviewed for a homelike environment. The facility failed to ensure Resident #31's wheelchair was clean. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source were reported immediately, but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 18 residents (Resident #35) reviewed for abuse and neglect. The facility failed to report Resident #35's injury of unknown origin to her face, within 24 hours to the state agency. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 6 residents reviewed for new admissions. (Resident #69) The facility failed to complete a baseline care plan for Resident #69 within 48 hours of admission. The facility failed to provide Resident #69's RP, a copy of the summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 2 of 18 residents (Resident #17 and Resident #68) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan for Resident #17's positioning rail. 2. The facility failed to ensure Resident #68 was care planned as smoker. 3. The facility failed to perform quarterly smoking assessments for Resident #68. 4. The facility failed to perform Resident #68's quarterly elopement risk assessments. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents who were reviewed for quality of care. (Resident #279) 1. The facility failed to ensure Resident #279 had orders for the size and amount of fluid in the bulb of her indwelling urinary catheter (tube inserted into the bladder to drain urine). 2. The facility failed to ensure Resident# 279 had orders catheter care with an indwelling urinary catheter. The failures could place residents at risk for indwelling urinary catheter pain, urinary tract infections, and not receiving needed care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care. (Resident #35) The facility failed to ensure Resident #35's nasal cannula (is a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) was stored in a bag when not in use. The facility failed to ensure Resident #35's nebulizer mask (provide vaporized medicine into the airway) was stored in a bag after use. These failures could place residents at risk of respiratory infections. 1. [...]

Inspectors wroteBased on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 7 (Dietary Aide A) reviewed for qualified dietary staff. The facility failed to ensure the DA A met the requirements for food handling by obtaining a food handler's certificate. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 1 of 4 resident (Resident#31) reviewed safe, functional equipment. The facility failed to ensure Resident #31's wheelchair brake handle was not loose. This failure could place resident at risk for usage of unsafe equipment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 3 of 5 residents (Resident #13, #18, #215) reviewed for urinary catheters. 1. Resident #13 had an indwelling urinary catheter since admission on [DATE] without a physician's order with an acceptable diagnosis for use. 2. The facility failed to ensure Resident #215 had a physician's order for her indwelling urinary catheter with appropriate diagnosis for use. 3. The facility failed to ensure Resident #215's and Resident #18's foley catheters were properly secured to prevent pulling or trauma. These deficient practices could affect residents who had urinary catheters at risk of not receiving care needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wrote2. During an observation on 06/12/23 at 11:32 a.m., RN A left the medication cart #2 unlocked when entering a resident's room. Staff and other residents observed in hallway. RN A came back to the medication cart, left medication cart unlock again leaving access to unauthorized personal to enter the cart. During an interview on 06/12/23 at 11:44 a.m., RN A said she forgot to lock the medication cart before walking into the resident's room. RN A said she was aware she was supposed to lock the medication cart anytime she stepped away. RN A said failure to lock the medication cart could leave access for anyone to get into the cart and take medication. During an observation and interview on 06/13/23 at 8:53 a.m., RN B observed to walk down hallway leaving the treatment cart unlocked. Observed staff, residents and visitors walking the by the nurse's station unlocked treatment cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerated foods were properly labeled and dated. 2. The facility failed to ensure expired foods were not in the refrigerator. 3. The facility failed to ensure food was thawed properly. These failures could place residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, The facility failed to comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives) for 1 of 3 (Resident #41) residents reviewed for advance directive The facility failed to ensure Resident #41 ' s code status was communicated and correctly indicated in his physical chart. This failure could result in residents receiving unwanted treatment or not receiving desired treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #13) of 6 residents reviewed for privacy and confidentiality. The facility failed to ensure RN A protected Resident#13's Medication Administration Record (MAR). This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained free of accident hazards by not adequately monitoring the proper storage of oxygen cylinders for 1 of 1 resident (Resident #16) reviewed for accident hazards. The facility failed to ensure Resident #16's oxygen cylinder was properly stored. This deficient practice could place residents at risk of injury.

Inspectors wrote2. Record review of Resident #46's face sheet, dated 06/13/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (impaired ability to remember, think, or make decisions), and stroke( occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). Record review of Resident #46's quarterly MDS assessment, dated 03/31/23, indicated Resident #46 was sometimes understood and sometimes understood others. Resident #46's BIMs score was 04s, which indicated she was severely cognitively impaired. [...]

Inspectors wrote2. Record review of Resident #41's face sheet, dated 06/14/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included heart attack (when your heart muscle begins to die because it isn't getting enough blood flow), high blood pressure, dementia (impaired ability to remember, think, or make decisions), respiratory failure (when the respiratory system cannot adequately provide oxygen to the body),and anxiety (feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat). Record review of Resident #41's admission MDS assessment, dated 05/21/23, indicated Resident #41 was understood and understood others. Resident #41's BIMs score was 12, which indicated he was moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #13) reviewed for infection control. The facility failed to ensure RN A performed hand hygiene while preforming glucometer checks (a small, portable device that lets you check your blood sugars) and administering insulin for Resident #13. This deficient practice could place residents at risk for infection due to improper care practices.