Oakview Nursing & Rehab

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 17, 2025

  Based on interview and record review, the facility failed to provide an environment free of accident hazards for 1 (R16) of 4 residents reviewed for accidents in the sample of 42. This failure resulted in R16 acquiring a laceration to her left lower leg resulting in 12 sutures being placed. This past noncompliance occurred between 11/27/24 and 11/28/24. The findings include: R16's Admission Record documented an admitted [DATE], and diagnoses including neurocognitive disorder with lewy bodies, weakness, and unspecified diastolic (congestive) heart failure. R16's Minimum Data Set (MDS), dated [DATE], documented under section GG- Mobility that R16 is dependent, which means helper does more than half the effort. […]

• Actual harm, isolatedF689Nov 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were free from falls with serious injury, transferred safely with a mechanical lift using two staff members, and fall interventions were implemented to prevent falls for 4 of 4 residents (R3, R4, R8, and R9) reviewed for falls in a sample of 42. This failure resulted in R9 falling backwards out of the transport van approximately three feet onto the ground, which resulted in a fracture of her back in two places. Findings Include: 1. R9's Admission Record, with a print date of 11/20/24, documents R9 was admitted to the facility on [DATE], with diagnoses that include diabetes, fibromylagia, hypertension, and difficulty in walking. […]

• Actual harm, isolatedF686Feb 14, 2022

  Based on observation, interview, and record review, the facility failed to effectively monitor and apply interventions to prevent new pressure wounds from forming for 2 of 5 residents (R4 and R44) reviewed for residents at risk for skin breakdown in the sample of 45. This failure resulted in R44 acquiring an unstageable pressure ulcer to the right heel causing pain and discomfort. Findings include: 1. R44's EHR (Electronic Health Record) showed R44 was admitted to this facility on 2/17/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R44's most recent MDS (Minimum Data Set) assessment, completed on 2/10/2022, documents R44 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R44 is cognitively intact. […]

• No harm, potential for more than minimal, widespreadF814Jun 3, 2026

  Based on interview and record review, the facility failed to ensure garbage was removed in a timely manner. This deficient sanitation practice has the potential to affect all 60 residents who reside in the facility.Findings include:On 6/3/26 at 10:04 AM, V6 (Registered Nurse/ RN) said the facility's garbage disposal company did not come to empty the dumpsters for a week and the 2 dumpsters in the parking lot were overflowing with garbage. V6 said during this time, there was an abundance of garbage being left in the facility's soiled utility rooms.On 6/3/26 at 11:47 AM, V5 (Housekeeper) said the weekend prior to Memorial Day, 5/25/26, and a few days after Memorial Day, the facility's dumpsters were overflowing with garbage. […]

• No harm, potential for more than minimal, widespreadF729Apr 28, 2025

  Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant was certified by verifying continuous employment on the Health Care Worker Registry. This has the potential to affect all 80 residents currently residing at the facility. Findings Include: The facility undated Resident Matrix provided to this surveyor on [DATE] documents 80 residents reside at the facility. The untitled and undated staff roster given to this surveyor on [DATE] documents V11 (Certified Nursing Assistant/CNA) was hired by the facility on [DATE]. V11's Health Care Worker Registry Check, dated [DATE], documents under Work Eligibility: Eligible. The registry documents the following statement. […]