Oakview Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Oakview Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jul 17, 2024

  Based 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. […]

• Actual harm, isolatedF684Aug 12, 2021

  Based on clinical record review, policy review, hospital record review, and staff interview, the facility failed to document wound care treatment, assess wounds, and report signs of infection timely for a surgical wound in 1 of 5 sampled (Resident #5) with wounds. This resulted in Resident #5 being hospitalized for surgical debridement of the wound. The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #5 admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880May 5, 2023

  Based 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. Findings included: Review of the facility's Water Management Program, dated January 2023, revealed a policy titled, Legionella Prevention Water Management Plan, revised January 2023. This policy indicated, Purpose: To set forth basic responsibilities and outline actions to be taken to protect patient health, safety, and well-being from potential Legionella exposure. […]

• No harm, potential for more than minimal, patternF756Jun 23, 2025

  3. 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. […]

• No harm, potential for more than minimal, patternF657Jul 17, 2024

  Based 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. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #45, dated 6/13/24, revealed the resident scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment the resident had an indwelling catheter and took an antibiotic. […]