Oakview Nursing Home

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 5, 2026

  Based on record review, staff interviews, facility investigation, and policy review, the facility failed to follow the transfer technique to safely transfer a resident for 1 of 3 residents reviewed (Resident #1). On 12/10/25, Resident #1 complained of severe pain with the inability to move her ankle free in all movements. Resident #1 reported that she got her legs tangled when she got transferred. In reviewing Resident #1's clinical record her Kardex (a pocket Care Plan) instructed the staff to transfer her with the assistance of 2 staff and a full-body mechanical lift. The staff interviews determined the staff transferred Resident #1 at times without the full-body mechanical lift. The physician documented Resident #1 received her ankle fracture during a transfer. […]

• No harm, potential for more than minimal, patternF887Jul 15, 2026

  Based on record review, policy review and staff interviews, the facility failed to offer the COVID-19 (Coronavirus disease) vaccine for 5 of 5 residents reviewed (Residents #3, #21, #29, #39, and #45). The facility reported a census of 43 residents. Findings include:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS indicated Resident #3 didn't receive an updated COVID-19 vaccine and lacked up-to-date status. Resident #3's Electronic Health Record (EHR) lacked documentation of vaccine receipt or a vaccine offer. On 7/15/26 at 9:55 AM, the Director of Nursing (DON) reported the facility should offer the vaccine at least annually. […]

• No harm, potential for more than minimal, isolatedF638Jul 15, 2026

  Based on record review, staff interviews and the Resident Assessment Instrument (RAI) manual the facility failed to complete the quarterly Minimum Data Set (MDS) assessment in the required timeframe for 1 of 1 residents reviewed (Resident #34). The facility reported a census of 43 residents. Findings include:Resident #34's Minimum Data Set (MDS) assessment report in the Electronic Health Record (EHR) documented completion of the last MDS assessment on 3/4/26. The MDS report showed the facility didn't complete the current quarterly MDS assessment. On 7/13/26 at 10:20 AM, the MDS Coordinator reported the tracking system in the EHR didn't exist, causing the facility to miss the quarterly MDS. […]

• No harm, potential for more than minimal, isolatedF692Jul 15, 2026

  Based on clinical record review, policy review and staff interview, the facility failed to identify a weight loss resulting in a failure to offer nutritional interventions, notify the Physician, Dietitian, or their family related to weight loss and poor intakes at meals for 1 of 1 resident reviewed (Resident #11). The facility reported a census of 43 residents. Findings include:Resident #11's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS revealed Resident #11 ate independently. The MDS included diagnoses of Heart Failure (weakened heart), renal failure (kidney failure), and fatigue (extreme tiredness). […]

• No harm, potential for more than minimal, isolatedF880Jul 15, 2026

  Based on observations, staff interviews and policy review, the facility failed to prevent cross-contamination during peri cares for 1 of 1 residents reviewed (Resident #2). The facility reported a census of 43 residents.Findings include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #2's impairment to both sides of the upper and lower extremities and total dependence on staff for toileting hygiene and dressing. The MDS included diagnoses of dementia (chronic memory loss) and stroke (blood clot or bleed in the brain). […]