Oakview Skilled Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure policies and procedures (P&P) were implemented for two of three sampled Residents (Resident 1 and Resident 3) when nursing staff failed to verify residents' wishes regarding Cardiopulmonary Resuscitation (CPR - is an emergency lifesaving procedure performed when the heart stops beating) upon admission. This failure had the potential to result in the facility staff providing or delaying medical treatment and services against the will of the residents.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 05/2024, the P&P indicated, Policy: . [facility name] shall promote the exercise of rights for all residents, including those who face, barriers, such as communication problems, hearing problems, and cognition limits, in the exercise of these rights .13. Right to formulate an advanced directive. F. a) If the physician agrees to admit the resident, the physician will be referred to the appropriate nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure infection control practices were implemented when: 1. Rehabilitation staff entered a Contact Isolation (infection control measures used to prevent spread of infections through direct (touching resident) or indirect (residents environment)) room without personal protective equipment (PPE - protective clothing such as gowns, gloves, face shields or other equipment) for one of three sampled Residents (Resident 2). 2. Proper identifier for enhanced barrier precautions (EBP - an infection control intervention used to reduce transmission of MDROs (multidrug-resistant organisms that includes use of PPE during high-contact resident care) was not placed on Residents door alerting staff to use PPE, for one of three sampled residents (Resident 3). These deficient practices had the potential to cause cross contamination and the spreading of MDRO's among residents. 1. During a review of the facility's policy and procedure P&P titled, Enhanced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure an opioid medication (pain medication that has a high risk of addiction) that was administered was documented on the appropriate record. This failure resulted in an inaccurate narcotic count and had the potential to result in diversion of a controlled medication. Findings: During a medication observation on 1/29/25 at 6 a.m. of Medication Cart 1, a narcotic blister pack (card with vacuum sealed medications) of Tramadol (opioid/pain medication that has a high risk for addiction and dependence [Schedule IV under the Controlled Substance Act]) 50 mg. was observed to contain 29 tablets. During a concurrent interview and record review on 1/29/25 at 6:05 a.m. with Licensed Nurse (LN 1), the Controlled Substances Declining Inventory Record or Narcotic Count Sheet/Log (Narcotic Log), dated 1/25/25 was reviewed. The Narcotic Log indicated, there were 30 tablets of Tramadol 50 in Medication Cart 1. Observation of Medication Cart 1 indicated, there were 29 tablets of Tramadol. LN 1 stated punched out the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to follow it's policy and procedure to consistently monitor temperature controls from the time food leaves the kitchen to transport and distribution to residents. This failure occurred in 1 of 21 opportunities for monitoring. This failure risks residents receiving their food outside of appropriate temperature range. Findings: During a review of facility policy and procedure titled, Service Temperature of Food, dated 10/17/22, indicated in part .Record reading on Food Temperature Chart form 401, at beginning of tray line and at end of tray line . During a concurrent interview and record review on 12/01/22, starting at 2 p.m., with lead cook (LC), while reviewing the Temperature Log for breakfast, lunch and dinner for the week of 11/05/23 through 11/11/2023, log temperature recordings were missing for the dinner meal on 11/07/23. LC acknowledged missing temperature recordings, while also acknowledged that the responsibility for filling out log is the LC. LC confirmed she was the LC on 11/07/23, and stated, I think it slipped my…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had an accurate assessment recorded on their Minimum Data Set Assessment ((MDS) a tool for implementing standardized assessment and for planning care). For Resident 1, this failure had the potential to result in a plan of care (a communication tool for healthcare providers to ensure quality care is being provided) that did not match their actual needs. Findings: During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated, Resident 1 ' s functional status (ability to physically perform tasks) related to bathing was Total dependence [unable to participate in any of the bathing activity] . One-person physical assist [assisted by one staff person]. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated, Resident 1 ' s functional status related to bathing was Supervision – oversight help only . Two+ person physical assist [assisted by two or more staff persons]. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to accurately document the health condition related to medical condition for two of five sampled residents (Resident 9 and Resident 196), using the Minimum Data Set ((MDS - a tool used to assess and plan care of residents in a nursing facility) when: 1. For Resident 9 - had a missing diagnosis for anxiety. 2. For Resident 196 - had a missing diagnosis for depression. This facility failure resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS). Findings: During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI), dated 10/2019, the P&P indicated, Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. 1. During a review of Resident 9's Face Sheet (FS), dated 4/23, the FS indicated, Resident 9 had a diagnosis of Unspecified Anxiety Disorder. During a review of the Physician's Order (PO),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain equipment in a safe and sanitary manner for one of 12 sampled residents (Resident 12). This facility failure had the potential for Resident 12 to develop an infection from a surface that could not be adequately sanitized. Findings: During an observation and concurrent interview with the Director of Staff Development (DSD), on 10/22/19, at 3:54 p.m., a two inch tear was noted in the vinyl on the left arm rest of a reclining geriatric chair (large, padded, comfortable chair with casters designed to allow patients to sit comfortably while being fully supported) occupied by Resident 12. The DSD acknowledged that the chair cannot be adequately sanitized, and should not be in use. The facility policy and procedure titled, Community - Care Equipment, dated 9/21/17, indicated in part, It is the policy of [facility name] to maintain resident care equipment in a sanitary manner, both in appearance and also in terms of reduction of infectious potential.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 37) had a splint applied to the left hand as ordered by the medical doctor (MD). This facility failure had the potential for Resident 37 to suffer complications, such as worsened contracture (a permanent shortening of muscle, tendon, or scar tissue) producing deformity or distortion. Findings: According to [NAME] and Perry's, 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice, Nurses are obligated to follow physician order unless they believe they orders are in error or would harm clients. During an observation on 10/21/19, at 4:14 p.m., Resident 37's left hand was noted to be clenched into a fist, and no splint was in place. Resident 37's Responsible Party (RP) manually opened Resident 37's fingers and stated Resident 37's splint is supposed to be on. During a review of the clinical record for Resident 37, the Order Listing Report,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications and medical supplies were properly labeled and stored when: 1. Two vials of expired heparin (a blood thinning medication) were found in a facility emergency medication kit (E-Kit) (a kit that stores a variety of medications intended for emergency resident use). 2. Expired supplies were found in the intravenous (IV) supply cart. These failures had the potential for residents to receive medications which may be ineffective or altered, and for residents to to have potential complications from use. Findings: 1. During an observation and concurrent interview with a licensed nurse (LN1), on [DATE], at 10:20 a.m., two expired vials of heparin were found in a facility E-Kit with a labeled expiration date of [DATE]. LN1 confirmed the two vials of heparin were expired and acknowledged she would contact pharmacy to get them replaced. 2. During an observation on [DATE], at 10:40 a.m., in the IV supply cart the following items were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.