Every finding on record at Oakview Health and Rehabilitation

Based on observations, staff interviews, and review of the facility policies titled, MDS Compliance, and Center for Medicare Services Resident Assessment Instrument Manual, the facility failed to complete a significant change Minimum Data Set (MDS) assessment following a decline in status for one of 29 sampled residents (R) (R9). The deficient practice placed R9 at risk of unassessed and unplanned care needs.Findings include: Review of the policy titled, MDS Compliance reviewed 12/27/2025, section titled, Guideline, documented, .Centers will complete a Significant Change in Status MDS Assessment when a major decline or improvement in a resident's status is identified by the Interdisciplinary Team. 'Significant Change' is a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacts more than one areas of the resident's health status, and requires interdisciplinary review and/or revision of the care plan.Significant Change in Status MDS Assessment will be completed within 14 days after a determination has been made that a significant change in the resident's status from baseline occurred. The center will document in the medical record when the determination is made that the resident meets the criteria for a Significant Change in Status Assessment.Review of the Resident Assessment Instrument (RAI) Manual Version 3.0 manual documented on page 45 under Significant Change documented, A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. Documented on page 48 under Some Guidelines to Assist in Deciding if Change is Significant or Not documented, Decline in two or more of the following: Resident's decision-making ability has changed; Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-2 to 9(C)), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior); Changes in frequency or severity of behavioral symptoms of dementia that indicate progression of the disease process since the last assessment; Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and does not reflect normal fluctuations in that individual's functioning; Resident's incontinence pattern changes or there was placement of an indwelling catheter; Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days).Review of the electronic medical record (EMR) revealed resident R9 was admitted to the facility on [DATE], and pertinent diagnoses included, but were not limited to, Type 2 diabetes mellitus without complications, carpal tunnel syndrome, bilateral upper limbs, chronic pain syndrome, bipolar disorder, unspecified, and chronic diastolic (congestive) heart failure.Review of R9 admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R9 had little to no cognitive impairment. Section GG, functional status, documented R9 benefits from use of walker and wheelchair without functional limitations in upper extremities. Required set-up assistance with eating and oral hygiene; Required set-up/clean-up assistance with toileting hygiene and personal hygiene. R9 required supervision/touching assistance with transfers and walking 50 feet with assistance of one person. Review of R9 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R9 had little to no cognitive impairment. Section GG, functional status, documented R9 benefits from use of a walker and wheelchair with functional limitations in upper extremities. Required supervision or touching assistance with eating and oral hygiene; Required partial/moderate assistance with toileting hygiene and personal hygiene. R9 required Substantial/maximal assistance dressing, transfers, and walking 50 feet, which indicated R9 declined in more than two ADLs.Review of R9 care plan updated 06/03/2026 indicated a problem of Focus: Self-care deficit and need for assistance with ADLs. Review of the EMR nurse notes dated 03/19/2026 documented, R9 with c/o {complaints of} of pain in her upper arms as well as difficulty using her hands. She is receiving therapy services at this time. Therapy voices resident having difficulty grasping utincels (sic) and c/o neuropathy.Review of the EMR Patient's at Risk (PAR) review dated 04/23/2026 documented, Resident voicing decline in ADL's, she is noted to need more assistance with ADLs. She is encouraged to use her call light and call for assistance when getting up.Observation made on 06/16/2026 at 1:01 PM revealed R9 sat in the main dining room at a table with other residents being assisted with eating. R9's hands were in her lap and staff were feeding her.Interview on 06/18/2026 at 1:43 PM with Certified Nursing Assistant (CNA) CNA AA revealed when R9 first arrived she was very independent and needed minimal help to no help at all [with activities of daily living]. CNA AA confirmed R9 was able to go to the bathroom by herself and change her clothes by herself. CNA AA stated she noticed a decline with R9, but heard she declined after R9 left with a friend [in February] and declined since her return. CNA AA revealed she currently assisted R9 with eating, wiping after using the bathroom and pulling up her pants. She assisted R9 to make phone calls as well. CNA AA stated when R9 asked for assistance she assisted and encouraged her to do it herself, but her mood changed to sadness if R9 was unable to complete the task. Staff ended up assisting R9. CNA AA confirmed she reported the decline.Interview on 06/18/2026 at 2:13 PM with Assistant Director of Nursing (ADON) ADON BB revealed R9 was admitted to the facility completing care independently. ADON BB revealed R9 was continent of bowel and bladder with or without a walker, she currently needed extensive assistance with care. She could not get in the car yesterday to go on leave; she was scared she was going to fall so she decided not to go. She needed assistance with ambulation and transfers and there was a decline. ADON BB revealed R9 got upset and voiced that she had declined. She reported the decline to the nurse practitioner. R9's status was discussed in the PAR meeting and is consistently reviewed according to ADON BB. She further revealed PAR meetings are weekly and attended by the Administrator, Director of Nursing (DON), ADON's, Wound Care, MDS Nurse, and Social Services.Joint interview on 06/18/2026 at 2:33 PM with MDS CC and MDS DD revealed they were aware R9 had declined according to the ADL charting, the PAR meetings and speaking to R9. Both MDS CC and MDS DD revealed R9 had communicated she had a decline where her arms were involved. MDS CC revealed she focused on what was causing the decline verses if R9 would get better, when asked about a significant change assessment being completed. MDS CC revealed in PAR they spoke about it and revealed her understanding of a significant decline is a decline in two or more areas that are not self-limiting.Joint interview on 06/18/2026 at 2:51 PM with the DON and Administrator revealed any changes that are noted on a resident, they talked about those things and discuss it in morning meeting. The Administrator further revealed the Nurse Practitioner (NP) had entered several notes on R9 so looked at her often. When it came to completing the MDS assessments accurately the expectation was that they were completed accurately as they know how. If not completed accurately we are not providing the best care for the residents and we can't be [providing the best care] if we do not have that information correctly.

Based on staff interviews and record review, the facility failed to provide documentation of a written agreement or contract with the company providing hemodialysis services for one of four residents (R) (R84) receiving dialysis services. The deficient practice had the potential to result in R84 not to obtain services that meet professional standards and experience diminished quality of life. Findings include: Review of the electronic medical record (EMR) revealed R84 was admitted to the facility with diagnosis including but not limited to end stage renal disease (ESRD). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognition) documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition, Section O (Special Treatments, Procedures, and Programs) revealed R84 received dialysis while a resident in the facility. Review of care plan dated 7/12/2024 revealed Focus: ESRD-Receives dialysis Monday, Wednesday, and Friday. Resident has been on dialysis for years. Resident receives dialysis at 'name of dialysis clinic' per her request, Goal: Patient will not experience complications secondary to dialysis through the review period, Intervention: After dialysis treatment, observe resident for adverse reactions to treatment, communicate patient's status with dialysis center. Review of the Physician's Orders dated 2/18/2024 revealed orders that included: R84 to receive dialysis on Mondays, Wednesdays, and Fridays. Review of facility documents revealed no documentation of a written agreement or contract with the dialysis center, which provides hemodialysis services to R84. Interview on 9/12/2024 at 5:32 pm with the Restorative Nurse (RN) GG who has management responsibilities, revealed R84 had been receiving dialysis services at 'name of dialysis center'. She further revealed that an email was sent to the 'name of dialysis center' office for a copy of the contract to be sent to the facility. Interview on 9/12/2024 at 5:33 pm with the Administrator revealed she confirmed R84 had been receiving dialysis services at 'name of dialysis center' and an email was sent to their office for a copy of the contract to be sent to the facility. She further confirmed that Area Operations Director AOD FF will send a copy of the contract as soon as possible. Phone interview on 9/12/2024 at 5:34 pm with AOD FF, he stated the facility made the request today, 9/12/2024, for a contract with 'name of dialysis center' to be sent to the facility. He further stated that the information from the facility was submitted to the name of dialysis center' legal department and the legal department will make a decision on the effective start of the contract date.

Based on observations, resident and staff interviews, and review of the facility's policy titled, Use of Oxygen (O2) Therapy, the facility failed to obtain physician orders for O2 and failed to maintain appropriate O2 levels for one of 16 residents (R) (R62) on O2 therapy. The deficient practice had the potential to place R62 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of the facility's policy titled Use of Oxygen Therapy revealed under the section titled INTENT: To ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. Under the section titled Guideline, it revealed, Physician's order for oxygen should be obtained and include: Oxygen with liter flow as ordered, indicated if use should be continuous or PRN (as needed), method of oxygen delivery via nasal cannula, mask, etc. A review of the electronic health record (EHR) for R62 revealed diagnoses including, but not limited to chronic diastolic (congestive) heart failure (CHF), chronic obstructive pulmonary disease (COPD), unspecified, and non-ST elevation (NSTEMI) myocardial infarction. A review of R62's quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. Further review of R62's MDS revealed section O (Treatments) documented O2 treatment. A review of R62's care plan dated 7/25/2024 revealed a focus area of respiratory difficulties/risk for further decline related to diagnosis of COPD and oxygen in place for CGH (Comparative Genomic Hybridization) and COPD, does remove oxygen at times as evidence by Trelegy Ellipta (breathing medication), oxygen via nasal cannula 2 liter per minute (LPM) nasally every eight (8) hours, breathe sounds diminished and oxygen use. Further review of care plan revealed interventions of administer medication/treatments as ordered, monitoring vital signs, notifying physicians of changes, and oxygen as ordered. R62 also had focus area for cardiovascular disease as evidence by history of cardiac related to dyslipidemia and atherosclerosis. Further review of care plan revealed the goal to be that patient will experience no complications related to cardiac symptoms through review period. During an observation on 9/10/2024 at 1:01 pm, R62 was observed in her room with O2 on. Upon further observation, R62's O2 level was set at 3.5 LPM. Upon asking, R62 stated her O2 level was supposed to be set at 2 LPM. During record review on 9/10/2024 it was revealed that there were no physician orders for O2 for R62. During an interview on 9/11/2024 at 10:25 am with Registered Nurse (RN) AA confirmed all residents on O2 must have physician orders since it is considered a medication. RN AA stated it was the responsibility of the nurse in charge to verify all physician orders were obtained. RN AA stated a potential negative outcome of a resident not having physician order for O2 was that the resident's O2 levels could decrease, and residents could be in distress and possibly end up in the hospital. During an interview on 9/11/2042 at 10:29 am with the Director of Nursing (DON) confirmed that physician orders were required for residents who are on O2. The DON stated her expectations were that all residents were required to have physicians' orders when they were receiving O2. She stated it was the nurse in charge's responsibility to make sure all residents who had O2 had physician orders. The DON confirmed that she oversaw nurses in charge and was not aware there was a physician's order missing for O2. The DON stated a negative outcome for not obtaining physician orders for O2 was that it could affect resident care because the facility could not verify if the resident needed O2 or not. The DON further stated a resident could have too much O2 and could cause respiratory issues. Review of the EHR revealed a physician order for Oxygen: Nasal Cannula 2 liter per minute nasally every eight (8) hours. Diagnosis (DX) Chronic diastolic (congestive) heart failure. The order has an order/start date for 9/11/2024. The order was electronically signed by the facility's RN on 9/11/2024. The order was electronically signed by the physician on 9/12/2024. During an observation and interview of R62 on 9/12/2024 at 9:06 am revealed her O2 level set at 1.5 LPM. R62 was receiving .5 LPM less O2 than the prescribed physician orders. R62 once again confirmed that her O2 level was supposed to be set at 2 LPM. During an interview on 9/12/2024 at 9:11 am with Licensed Nurse Practitioner (LPN) DD confirmed R62 was to always be receiving 2 LPM of O2. LPN DD stated it was her or the nurse who was administering medications responsibility to check every eight hours if R62 was receiving prescribed O2 levels. During an interview on 9/12/2024 at 10:28 am with RN CC confirmed R62 did not have physician orders for O2 as of 9/10/2024. RN CC further revealed O2 orders for R62 were ordered on 9/11/2024. RN CC stated nurses in charge and the Unit Manager oversaw submitting orders and RN CC stated R62 most likely came into the facility with O2 and her orders where not transferred over. During an interview on 9/12/2024 at 9:49 am with the Administrator confirmed that R62 O2 levels were supposed to be set at 2 LPM. The Administrator revealed it was her expectations that residents who were on O2 were receiving the correct amount of O2 per physician orders. The Administrator further revealed a negative outcome for residents not receiving proper O2 levels was that residents may experience shortness of breath and may get confused if they don't receive enough or if they receive too much.

Based on observations, resident and staff interviews, and review of the facility's policy titled, Snuff and Chewing Tobacco Use, the facility failed to maintain snuff in a secure location for one of 51 sampled residents (R) (R40). The deficient practice had the potential to put the residents at risk for avoidable accidents, injuries, and a diminished quality of life Findings include: A review of the policy titled Snuff and Chewing Tobacco Use with a review date of 12/29/2023 revealed under section titled Intent, Our center realizes the threat that snuff and chewing tobacco use present to the safety and health of the patient. Snuff and tobacco use are prohibited in a tobacco free center. It is not the intention of the center to deprive patients the pleasures of using snuff and chewing tobacco, but to ensure their safety and the safety of other patients. Under section titled Guideline, it revealed, Storage of Tobacco products: Non-smoking tobacco products should be kept at the nurse's station and given to the patient upon request. Non-smoking tobacco products do not have to be limited to smoke breaks unless proper usage and sanitation is not maintained. Further record review of the facilities policy titled, Snuff and Chewing Tobacco Use did not reveal that tobacco products had to be stored in a lock box. A review of electronic health record (EHR) for R40 revealed diagnoses including, but limited to Parkinson's disease without dyskinesia, with fluctuations, and dementia in other diseases classified elsewhere, unspecified severity, with agitation. A review of R40's quarterly Minimum Data Set (MDS) dated [DATE] section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. A review of the care plan for R40 dated 7/1/2024 revealed a focus area of cognitive impairment related to Parkinson's disease as evidence by poor decision making/needs cue. Further review of care plan revealed a focus area of tobacco use related to resident using snuff as evidence by resident using snuff daily. Care plan revealed the goal is that patient will abide by tobacco guidelines when using snuff though review period and interventions are to observe for changes in patients' capabilities and needs. During on observation on 9/11/2024 at 8:58 am in R40's bedroom revealed a can of 'name of snuff' snuff by his bed side table. During an interview and observation on 9/11/2024 at 10:47 am in R40's bedroom, R40 was observed in his wheelchair with no visible snuff in mouth and stated that he liked to use snuff. During this time, observation revealed a can of 'name of snuff' by his bed side table, with the lid on and no spit cup around. Further observation at 10:51 am revealed R40 spitting in cup then putting more snuff in his mouth. During an interview on 9/11/2024 at 9:06 am with Certified Nursing Assistant (CNA) BB revealed that if residents had tobacco products, she would inform the nurse to see if the resident was allowed to have the tobacco product. CNA BB stated usually when residents have snuff, they are given a bit of snuff at a time throughout the day. CNA BB stated she was not aware of all the residents who use tobacco products. During an interview on 9/11/2024 at 10:20 am with Registered Nurse (RN) AA revealed that residents who use tobacco products are care planned and some of them keep the tobacco products in their room. She stated a negative outcome of residents who have tobacco products readily accessible to them would be in infection risk, residents could eat the tobacco product and be poisoned and could even cause death. RN AA further revealed she did know if residents must be assessed to be able to have tobacco products by their bedside. During an interview on 9/11/2024 at 10:36 am with the Director of Nursing (DON) revealed that residents do not keep tobacco products like snuff in their rooms. The DON stated that snuff was normally locked away. The DON further revealed possible negative outcomes caused by having snuff not locked away could be that residents could aspirate and if they have visitors, the visitors could get into the snuff. An interview on 9/12/2024 at 9:38 am with RN CC revealed all residents who use tobacco products were educated on tobacco risks and they were provided with lock boxes. RN CC stated per facility policy, all residents who have tobacco products have lock boxes, but sometimes they lose the keys. An interview on 9/12/2024 at 9:44 am with the Administrator revealed her expectations were that all tobacco products are to be in a lock box or always kept at the nurse's medication cart. The Administrator further revealed that a possible negative outcome was that residents with cognitive issues might eat the tobacco product or make them sick.

Based on interview, record review, and facility policy review, the facility failed to ensure residents, residents' representatives, and residents' families were notified by 5:00 PM the following day, if/after a resident of the facility tested positive for COVID-19. On 9/18/20 the facility was notified Resident (R) #1 tested positive for COVID-19; however, the facility did not notify residents, residents' representatives, and residents' families of the new positive case until 9/22/20, four days after the facility received the positive result. The facility's failure had the potential to affect all residents, residents' representatives, and residents' families of the facility. The facility census was 111. Findings include: Review of the facility's undated policy titled, Practice Guidelines for Associate and Patient Testing for COVID-19, revealed .Family Notification of Results. Centers should inform patients, their representatives, and families of those residing in centers by 5 p.m. the next calendar day following the occurrences either a singe confirmed infection of COVID-19, or three or more patients or associates with new-onset of respiratory symptoms occurring within 72 hours of each other . Review of Resident (R) #1's undated Face Sheet, provided by the facility, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#1's COVID-19 test results, dated 9/18/20, located in the resident's EMR under the medication administrator record (MAR) revealed the resident tested positive for COVID-19. Review of R#1's Nurses Note, dated 9/18/20, located in the resident's EMR under the nurses note tab, revealed Resident did test positive this AM for COVID, placed on contact and droplet precaution and COVID protocol initiated . Interview on 9/22/20 at 4:27 PM with the Director of Nursing (DON) revealed in the past, the facility had updated residents and their representatives after residents and/or staff of the facility had tested positive for COVID-19; however, the facility did not notify all residents and their families by 5:00 PM the following day after R#1 tested positive on 9/18/20. The DON stated the facility did completed the notifications until today (9/22/20). When asked who was responsible for making theses notifications, the DON stated it was the nursing management's responsibility and this was an oversite by the facility. Interview on 9/22/20 at 4:44 PM with the Administrator revealed, the facility prioritized residents' care over notifying the residents and their families after a staff or resident tested positive for COVID 19

Based on observation, staff, resident and family interview, and review of facility policy titled Personal Care, Care of Fingernails / Toenails the facility failed to provide nail care according to facility policy for one resident, (R) (#126) from a sample of 28 residents. Findings include: Review of facility policy titled Personal Care, Care of Fingernails / Toenails, date October 2016, revealed the following: It is the intent of this center to provide appropriate nail care to all patients. On 4/26/17 at 10:33 a.m. R#126 was observed to have untrimmed, jagged fingernails with brown substance under each nail. Observation on 4/26/17 at 1:10 p.m. revealed R#126 had untrimmed jagged fingernails with a brown substance under each nail. Interview 4/26/17 at 2:25 p.m. with the Director of Nurses (DON) revealed each Certified Nursing Assistant (CNA) is educated to provide nail care with each residents shower, twice a week. The CNA's are informed of this expectation during orientation and again annually with skills re-education. Observation 4/27/17 at 11:25 a.m. revealed R#126 had untrimmed, jagged fingernails with brown substance under each nail. Interview 4/27/17 at 11:35 a.m. with R#126 revealed he had not had his nails cleaned or trimmed in the shower two days earlier. R#126 indicated he had very poor vision and was unable to see that his nails were not clean but his wife had told him during her visit yesterday that his fingernails were dirty. Interview 4/27/17 at 12:52 p.m. by telephone with the family member of R#126 revealed she noticed the resident had jagged and dirty nails yesterday and was concerned because her husband had always been very particular about his grooming and never would have eaten a meal with dirty nails when he was able to take care of himself. Observation 4/27/17 at 1:20 p.m. revealed the family of R#126 was in his room cleaning and clipping his nails. Interview 4/28/17 at 10:36 a.m. with CNA AA revealed she had been made aware during orientation, of the expectation to clean and trim each residents nails when showering them twice a week. CNA AA was unable to remember if she had provided nail care when showering R#126 three days ago.

Based on observation, clinical record review, staff and resident interview, the facility failed to provide nail care according to the plan of care for one resident (R) (R#126) from a sample of 28 residents. Findings include: Record review for R#126 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which indicated in Section B - Hearing Speech and Vision, a moderate visual impairment. Section C - Cognitive Patterns indicated the resident did not have cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 15. Section G - Functional Status indicated R#126 was able to eat with supervision and required extensive assistance with personal hygiene. Review of the care plan for R#126, dated 3/31/17, revealed he receives extensive assistance with Activities of Daily Living (ADL) related to poor vision. Able to recognize objects, but not fine print. Interventions included: Assist with ADL. Observations on 4/26/17 at 10:33 a.m., 4/26/17 at 1:10 p.m. and 4/27/17 at 11:25 a.m. revealed R#126 had untrimmed, jagged fingernails with brown substance under each nail. Interview on 4/26/17 at 2:25 p.m. with the Director of Nurses (DON) revealed she expects resident's fingernails to be cleaned on each shower day, twice a week. The DON confirmed during orientation the Certified Nursing Assistants (CNA's) are taught during orientation to clean residents fingernails every shower day. Interview 4/27/17 at 11:35 a.m. with R#126 revealed his fingernails had not been trimmed or cleaned when he had a shower Tuesday. R#126 indicated he was unable to see his fingernails due to poor vision, and would not have known they were dirty, but his wife had expressed concern regarding the condition of his fingernails when she visited yesterday. Interview 4/28/17 at 10:36 p.m. with Certified Nursing Assistant (CNA) AA revealed she does not usually give residents showers but on Tuesday 4/25/17 she had worked as a shower aide. She had given R#126 his shower between noon and 1:00 p.m. but could not remember if she had cleaned and trimmed his fingernails. CNA AA acknowledged she had received education during orientation to always perform nail care when giving residents showers. Cross Refer to F 312