Oakview Terrace

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 18, 2024

  Based on South Dakota Department of Health (SD DOH) event report review, medical record review, physical therapy evaluation review, care plan review, interview, and policy review, the provider failed to ensure one of one certified nursing assistant (CNA) (I) had followed one of one sampled resident's (7) care plan for using two staff persons to transfer resident 7 using a [NAME] Plus stand lift, resulting in a fall and a fractured hip. Findings include: 1. Review of the SD DOH event report received on 12/28/23 from the provider revealed at 12/19/23 at 7:30 p.m.: *Resident 7 was being transferred with the use of a [NAME] Plus stand lift from a wheelchair to his bed by CNA I when He slipped out of the lift. -CNA I had been supporting his upper body as he fell to the floor. […]

• Actual harm, isolatedF686Feb 15, 2023

  Based on observation, interview, record review, and policy review, the provider failed to ensure: *Ongoing and timely skin assessments were conducted and documented by licensed nurses prior to the development of pressure ulcers for three of three sampled residents (9, 28, and 33) who had been identified as at risk for pressure ulcers. *Complete and accurate ongoing documentation of identified pressure ulcers for three of three sampled residents (9, 28, and 33) who developed pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF732Jun 26, 2025

  Based on observation, record review, and interview, the provider failed to post the required daily nursing staffing information that included the facility name, total number of staff hours. and the actual hours worked by nursing staff for 33 or 33 random days reviewed in March, April, and June of 2025. 1. Observation on 6/24/25 at 9:39 a.m. of the posted nurse staffing information revealed: *It was posted on a board near the nurses' station. *It did not contain the name of the facility as required. *There were six categories of staff listed on the sheet: RN (registered nurse), LPN (licensed practical nurse), CNA (certified nursing assistant), Medication aide, Restorative aide, and shift totals. *Within each of those categories the number of staff scheduled for the day was listed by shift. […]

• No harm, potential for more than minimal, patternF689Aug 20, 2026

  Based on observation, interview, record review, and policy review, the provider failed to ensure a safe environment and supervision for one of one sampled resident (15), identified at risk for falling and with a fall prevention intervention that directed staff to not leave him in his wheelchair alone in his room, who fell from his wheelchair and sustained bruising and a laceration (a deep cut) above his left eyebrow when he was left in his room and his wheelchair alone by nursing staff. Findings include: 1. Observation and interview on 8/18/26 at 9:55 a.m. with resident 15 in his room revealed he was sitting in a recliner with his wheelchair folded up and tucked behind the bedroom door. […]

• No harm, potential for more than minimal, patternF655Jun 26, 2025

  Based on record review, interview, and policy review, the provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to the resident or their representative for seven of seven recently admitted sampled residents (11, 14, 17, 37, 38, 40 and 195) within 48 hours of their admission to the facility. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her baseline care plan revealed her preferred wake time had been left blank. *There was no documentation that indicated the resident's baseline care plan was developed and reviewed with her, her representative, or that they had been provided or offered a copy of her baseline care plan within 48 hours of her admission. 2. […]