Oakview Nursing & Rehablitation - Marion

Based on observation, clinical record review, facility documentation, interviews, and policy review the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. A Certified Nurse's Aide (CNA) and a nurse became aware of allegations of abuse and did not report to facility management or the designated state agency. When the facility became aware of an allegation of abuse, they didn't report it to the state agency in a timely manner for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 39 residents.Findings include:The Minimum Data Set (MDS) for Resident #2 dated 11/20/25 identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. The MDS included diagnoses of multiple sclerosis ( MS, an autoimmune disease that affects the nerves that effects coordination, memory, and emotions), dysarthria (speech disorder caused by muscle weakness), and anarthria (motor speech disorders affecting muscle control), and chronic pain. On…

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 record review, interviews, and the Medicare Claims Processing Manual the facility failed to provide residents ending skilled care with current Advanced Beneficiary Notice (ABN) and Notice of Medicare Non Coverage (NOMNC) documents for 3 of 3 residents reviewed (Residents #22, #41, #42). The facility reported a census of 36.Findings include: 1) The Minimum Data Set (MDS) dated [DATE] for Resident #22 documented an admission date of 4/17/25 and a Medicare end date of 5/5/25. A document titled Notice of Medicare Non-Coverage (NOMNC) for the resident was signed by their representative on 5/2/25. The document footnote was Form CMS 10123-NOMNC (approved 12/31/2011). A document titled Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) for the resident was signed by their representative on 5/2/25. The document footnote was Form CMS-10055 (2018). 2) The Minimum Data Set (MDS) dated [DATE] for Resident #41 documented an admission date of 5/5/25 and a discharge date of 6/3/25. A document…

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, clinical record review, staff and resident interviews the facility failed to prevent one resident from wandering into another resident room and putting their hand on a resident for 1 out of 6 residents reviewed (Resident #1). The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses of non-Alzheimer's dementia, and stroke. The Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive impairments). The MDS revealed Resident #1 showed verbal and physical behavior towards others on 1-3 days of the look back period. The MDS reflected Resident#1 wandered 2-6 days in the look back period. The Care Plan dated 3/11/25, identified Resident #1 had impaired cognition related/to dementia. Cue, reorient and supervise as needed. The Care Plan dated 3/14/25, identified Resident #1's physical and verbal behavioral symptoms toward others (e.g. hitting, kicking, pushing, scratching). The Care Plan listed a goal that…

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, policy review, and staff interview, the facility failed to hold hot foods at an adequate minimum temperature for 1 of 1 meal service observed. The facility reported a census of 39 residents. Findings include: The 2/24 facility Dietary Policies and Procedures with the subject of Food Temperatures stated the minimum temperature of hot foods was 135 degrees Fahrenheit. On 8/13/24 at 12:29 p.m., Staff D Dietary Aide served the last meal in the B Wing. Immediately after the service, he obtained the following temperatures: Sweet potatoes 119 degrees Fahrenheit Green Beans 120 degrees Fahrenheit Pork 130 degrees Fahrenheit. Pureed meatballs 96 degrees Fahrenheit. Pureed sweet potatoes 99 degrees Fahrenheit. Gravy 90 degrees Fahrenheit. Pureed green beans 108 degrees Fahrenheit. On 8/14/24 at 9:51 a.m. the Dietary Manager stated hot food should be held at a minimum temperature of 135 degrees Fahrenheit. She stated she stood around the corner while Staff D obtained the temperatures on 8/13/24. She stated the facility would order more lids and cover the food in order to…

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, policy review, and staff interviews, the facility failed to store and prepare food under sanitary conditions for 3 of 3 kitchen areas reviewed. The facility reported a census of 39 residents. Findings include: The facility undated [name redacted(name of detergent company)] Detergent Services policy stated (dishwasher) rinse temperatures should reach between 176 degrees Fahrenheit to 185 degrees Fahrenheit. The 2/24 facility Dietary Policies and Procedures with the subject of Good Safety and Sanitation Guidelines stated the facility would utilize the current food code for standards of practice for the dietary department to meet the needs of safe food handling and sanitation of the kitchen. The 2/24 facility Dietary Policies and Procedures with the subject of Personal Hygiene stated food service employees must wear a hair restraint to effectively keep hair from coming in contact with exposed food or clean equipment. The facility 8/14/24 Kitchenette Daily Cleaning List included direction for staff to clean the microwave and refrigerator. The initial main kitchen…

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 review of Quality Assurance and Performance Improvement(QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance(QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 39 residents. Findings include: The Centers for Medicare and Medicaid Services(CMS) 2567, dated 2/15/24, listed, in part, the following concerns: F812 QAPI Sign-In Sheets documented the facility had QAPI meetings on the following dates: 4/19/24 and 7/26/24. The current survey, conducted 8/12/24-8/15/24 also identified the above concern. The undated facility QAPI Plan stated the facility would address key issues to continuously improve services. The plan stated the QAA committee would prioritize areas that were problem-prone. On 8/15/24 at 8:59 am., the Administrator stated with regard to QA…

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, record review, staff interview, and policy review, the facility failed to ensure dignity was provided to residents with catheters by not placing the catheter bags in dignity bags for 2 of 4 residents reviewed for catheters (Residents #8 and #143). The facility reported a census of 39 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) of 13 indicating intact cognition. The MDS further documented the resident had diagnoses including neurogenic bladder, chronic kidney disease, congestive heart failure, and diabetes mellitus. The resident required assistance of staff for toileting, personal hygiene, bathing, and transfers. She had an indwelling catheter and was frequently incontinent of bowel. The Care Plan dated 7/3/24 revealed a focus area for Resident #8's need for an indwelling urinary catheter related to a neurogenic bladder with a goal the resident's catheter care would be managed…

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 clinical record review, policy review, and staff interviews, the facility failed to ensure residents remained free of physical abuse when a staff member hit a resident on the shoulder for 1 of 1 residents reviewed for abuse(Resident #23). The facility reported a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 6/13/24, listed diagnoses for Resident #23 which included diabetes, non-Alzheimer's dementia, and morbid obesity. The MDS stated the resident required substantial to maximal assistance for dressing and was dependent on staff for toileting hygiene, showering, and transfers. The MDS listed the resident's Brief Interview for Mental Status Score (BIMS) as 6 out of 15, indicating severely impaired cognition. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated July 2019, stated all residents had the right to be free from abuse and defined physical abuse to include hitting and slapping. Care Plan entries, dated 1/30/23, stated the resident had verbal behavioral symptoms directed toward…

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 observations, staff interviews, and facility policy review, the facility failed to ensure sanitary conditions of a food service area, failed to monitor and record resident refrigerator temperatures according to facility schedule, failed to ensure all staff entering kitchenettes wore a hair covering during food service, and failed to cover all food and drinks transported through the hallway to resident rooms to prevent contamination. The facility further failed to serve one resident, on a pureed texture diet, all menu items when side dish and dessert were omitted for 1 of 1 meal services observed. The facility reported a census of 39 residents. Findings Include: On 2/12/24 at 10:40 AM, observation of the C-Wing kitchenette refrigerator, which contained resident food and drinks, noted with splatters of liquid and crumbs collected on shelves. A log of refrigerator temperatures located on the outside of the kitchenette refrigerator had various shifts and entire days without a temperature recording. The steam table lids had spots of crusted food, water spots, and crumbs across…

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 observations, staff interview, and facility policy review, the facility failed to cover clean linen carts in compliance with infection control protocol while transported through 2 of 2 hallways. The facility reported a census of 39 residents. Findings include: 1. On 2/12/24 from 2:10 PM to 2:35 PM, observed a clean linen cart, with all but one side covered, being pushed through C-Wing Hallway as various staff passed through the area. Noted inside the cart were folded bed pads, clean sheets, and towels. The clean linen cart pushed by a Certified Nursing Assistant (CNA) from room to room as it remained uncovered and frequently left unattended throughout the 25 minutes of continuous observation. On 2/13/24 from 2:28 PM to 2:47 PM, observed a clean linen cart with all but one side covered, pushed through C-Wing Hallway as various staff passed through the area. The exposed side contained clean folded bed pads, wash clothes, and towels. The clean linen cart pushed by a CNA from room to room, remained uncovered and frequently left unattended throughout 19 minutes of continuous…

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 clinical record review, observations, staff interviews and facility policy review the facility failed to serve 2 out of 16 resident in the dining room (DR) in a dignified manner when meals served on trays (Residents # 12 and 17). The facility reported a census of 39 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #12 dated 12/21/23, included diagnoses of Alzheimer's Disease, and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severely impaired cognition. The MDS identified Resident #12 required partial or moderate assistance for eating. The Care Plan for Resident 12 dated 7/7/23, directed to provide adaptive equipment per the dietary list. The Dietary Seating Chart dated 2/6/24, failed to include a tray for Resident #12 while eating. 2. The MDS Assessment for Resident #17 dated 2/1/24, included diagnoses of non-Alzheimer's dementia, depression and dysphagia (difficulty swallowing). The MDS showed short and long term memory problems, severely impaired decision making skills.…

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 clinical record review, staff interview, and Facility Assessment Tool review, the facility failed to include anti-depressant and diuretic medications in Care Plan for one of five residents (Resident #2) reviewed for unnecessary medications. The facility reported a census of 39 residents. Findings Include: The Medication Administration Record (MAR), dated February 2024, revealed current orders for Furosemide (diuretic) 40 milligrams (mg) one tablet daily for Chronic Diastolic Heart Failure, initiated on 11/28/23, and Trazodone (antidepressant) 50 mg one tablet at bedtime for generalized anxiety disorder, initiated on 11/27/23. The Care Plan, revised on 2/12/24, lacked a focus areas to inform care needs and the side effects related to anti-depressant and diuretic medications. The Minimum Data Set (MDS), dated [DATE], revealed Resident #2 required both anti-depressant and diuretic medications. Diagnoses included: Heart failure and anxiety disorder. On 1/15/24 at 1:15 PM, the Director of Nursing (DON)…

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 clinical record review, observations, resident interview, and Call Light Log review, the facility failed to answer resident call lights in a timely manner resulting in long wait times for 2 of 39 residents reviewed for call light response time (Residents #1 and #3). The facility reported a census of 39 residents. Findings Include: 1. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (intact cognition). Resident required substantial/maximal staff assistance for transfers and dependence on staff for toileting hygiene. Resident #3 diagnoses included: End Stage Renal Disease, Neurogenic bladder, arthritis, seizure disorder, anxiety disorder, and depression. The Care Plan, revised on 01/03/24, revealed focused areas related to risk of falling and deterioration in ability to perform activities of daily living. On 2/12/24 at 10:57 AM, Resident #3 reported waiting a long time for help in the mornings and stated it often took greater than 15…

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.