Oakview Nursing & Rehabilitation Center

Based on observation, interview and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Observations revealed containers filled with a dark liquid that were opened, not dated, and/or labeled. This had the potential to affect 76 of 76 residents. Observation during the initial kitchen tour on 06/03/2024 at 11:15 AM, revealed five drink containers that were not labeled, dated, or had expired in the walk-in cooler. The findings include: Review of the facility's policy titled, Food Storage, Cold Foods, dated 05/2014 and revised 04/2018, revealed all time/temperature control for safety, foods frozen and refrigerated, would be appropriately stored in accordance with guidelines of the FDA's (US Food and Drug Administration's) food code. All foods should be stored, wrapped, or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. Observation of a walk-in cooler on 06/03/2024 at 11:15 AM, revealed two (2) containers of a dark liquid that were labeled with a created…

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 and interview it was determined the facility failed to have an effective pest control program to ensure the facility was free of pest. All 76 residents had the potential to be affected. Observation during the initial tour on 06/03/2024 at 11:15 AM, revealed rodent and bird droppings in the emergency food storage supply room. The findings include: The facility was unable to provide a specific policy related to pest control. The Administrator stated the facility followed the guidance from the State Operations Manual which defined an effective pest control program as a measure to eradicate and contain common household pest. Observation during the initial tour on 06/03/2024 at 11:15 AM, revealed the storage area for the facility's emergency food supply was housed in a detached building occupied by the maintenance department. Observation revealed the floor of the room was covered with white droppings. Further observation revealed rodent droppings on the boxes of food stored on the shelves. During an interview with the Dietary Manager on 06/05/2024 at 12:50 PM, she…

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 facility policy review, the facility failed to develop and implement an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible related to clean supplies stored with Biohazard Waste in an outside storage building. The findings include: Review of the facility's policy, Infection Control, effective 01/23/2024, noted the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the facility's infection control policies and practices included: a. Prevent, detect, investigate, and control infections in the facility; and b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. After an observation of Resident #74's (R74) wound care on 06/05/2024 at 10:22 AM with the Special Projects Director of Nursing, the nurse and the charge nurse went out…

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 facility policy review, it was determined the facility failed to ensure residents were assisted with/encouraged to perform hand washing before meals and the facility staff failed to avoid touching ready-to-eat foods with their bare hands during meals. This affected two (2) of three (3) halls observed. In addition, the facility did not maintain proper clean to dirty techniques in the laundry room, for one (1) of one (1) laundry room. Also staff failed to ensure proper dirty linen placement while providing incontinent care for Resident #43. Further observations revealed personal protective equipment (PPE) was not properly disposed of after use or before exiting residents' rooms who were on isolation for two (2) of two (2) residents observed on isolation. (Resident #10 and Resident #13) This deficient practice occurred during the COVID-19 pandemic, and had the potential to affect all residents. Findings included: 1. Review of the facility's policy titled, Hand Washing/Hand…

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, record review, and facility policy review, it was determined the facility failed to treat a resident with dignity by failing to close the privacy curtain during care and failed to address the resident in a dignified manner by calling the resident a feeder. This affected one (1) of three (3) sampled residents reviewed for dignity (Resident #43). Findings included: Review of the facility policy for, Resident Rights, with a last revision date of 08/16/2018, revealed under the Policy Statement, all residents had the right to be treated with dignity and respect. The policy also indicated the facility would promote and protect the residents' rights. 1. Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Osteoarthritis, and Adult Failure to Thrive. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/17/2021, revealed the resident had short- and long-term memory impairment and was totally dependent…

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, record review, and facility policy review, it was determined that the facility failed to notify the physician of a change in condition for one (1) of three (3) sampled residents reviewed for notification of changes in condition (Resident #41). Findings included: Review of the facility policy, titled, Change of Condition, dated 11/06/2019, was completed. The policy indicated that a significant change in the resident's physical, mental or psychosocial status would be relayed to the physician. Record review revealed Resident #41 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Diagnoses included multiple sclerosis, diabetes, colostomy, and pressure ulcers. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/16/2021, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the Nursing admission Skin Assessment, dated 07/05/2021, revealed that Resident #41 had no open areas.…

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, record review, and facility policy review, it was determined that the facility failed to develop a care plan for one (1) of twenty-four (24) sampled residents reviewed for care plans (Resident #24). Resident #24 did not have a care plan developed for activities. Findings included: Review of the facility policy, Comprehensive Care Plans, with a revision date of 07/19/2018, revealed the nurse/Interdisciplinary Team was responsible for the review and updating of care plans. Further review of the policy revealed the care plan should reflect the current status of the resident and be updated with changes in the resident's status. Record review revealed Resident #24 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's, Dementia, and Psychosis. Review of the admission Minimum Data Set (MDS) assessment, dated 06/04/2021, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), indicating the resident was interviewable. Review of Resident…

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, record review, and facility policy review, it was determined the facility failed to ensure a resident had scheduled care conferences with involvement from the resident representative. This affected one (1) of two (2) residents reviewed for participation in care planning. (Resident #48). Findings included: Review of the facility's policy, Comprehensive Care Plan, last reviewed 04/14/2021, revealed the comprehensive care plan will be developed with participation from the resident, resident's family, or resident representative. The nurse/interdisciplinary team was responsible for the review and updating of care plans. The care plan should reflect the status of the resident and be updated with changes with resident's status .at least quarterly. Record review revealed the facility admitted Resident #48 on 04/28/2020 with diagnoses which included Alzheimer's Disease, Major Depression Disorder, and Parkinson's Disease. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/22/2021, revealed the facility assessed Resident #48's cognition as severely impaired…

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, record review, and facility policy review, it was determined that the facility failed to provide supervision and verbal cueing to complete oral hygiene for one (1) of three (3) sampled residents reviewed for activities of daily living (Resident #13). Findings included: Review of the facility policy, Oral Care, with a revision date of 07/08/2018, indicated under Section 3, Paragraph E, that a resident that appeared to be able to care for self may forget to care for teeth. Section 7 indicated staff should make sure the resident brushed their teeth. Record review revealed Resident #13 was admitted to the facility on [DATE], with diagnoses which included Unspecified Dementia with Behaviors, Vascular Dementia, and Cognitive Communication Deficit. Review of the Annual Minimum Data Set (MDS) assessment, dated 05/12/2021, revealed Resident #13 had adequate hearing, but impaired vision with no glasses. The resident was identified as moderately cognitively impaired. Limited assistance was…

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, record review, and facility policy review, it was determined the facility failed to ensure two (2) of two sampled residents received nail care and foot care (Resident #43 and Resident #68). Staff failed to provide Resident #68 with adequate nail care and Resident #43 with adequate nail and foot care. Findings included: 1. Review of the facility's policy, Nail Grooming, last reviewed 07/24/2018, revealed Regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and as needed. Record review revealed the facility admitted Resident #68 on 10/29/2019 with diagnoses that included obsessive compulsive disorder, excoriation (skin-picking) disorder, functional quadriplegia (paralysis of four limbs), and intracranial injury. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/13/2021, revealed the facility was unable to assess Resident #68's cognition, and a staff assessment…

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 an observation, interview, record review, and facility policy review, it was determined the facility failed to provide activities per resident's preferences for one (1) of three (3) sampled residents reviewed for activities (Resident #24). Findings included: Review of the facility policy, Activity Program, dated 07/25/2017, indicated the facility would provide an on-going Activities program designed to support residents in their choice of activities. 5. Individualized and group activities are provided that - a. Reflect the schedules choices and rights of the residents. Record review revealed Resident #24 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's dementia and psychosis. Review of the admission Minimum Data Set (MDS) assessment, dated 06/04/2021, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), indicating mild cognitive impairment. Review of Resident #24's Comprehensive Care Plan, revealed no entries related to preferences…

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, it was determined the facility failed to obtain orders for an indwelling urinary catheter, failed to obtain orders for catheter care, and failed to secure an indwelling urinary catheter for one (1) of one (1) sampled residents reviewed who had an indwelling urinary catheter (Resident #3). Findings included: Interview with the Corporate Clinical Consultant, on 08/13/2021 at 12:56 PM, revealed the facility used the Lippincott Nursing Manual as their policy and procedure manual. Per the 10th edition of the Clinical Nursing and Skills Technique, an indwelling urinary catheter should be secured to reduce the risk of urethral trauma, urethral erosion, or accidental removal. Record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Cerebral Infarction, Anemia, and Congestive Heart Failure. Review of the admission Minimum Data Set (MDS) assessment, dated 05/03/2021, revealed Resident #3 was…

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, it was determined the facility failed to maintain a medication error rate of less than five (5%) percent. Two (2) errors were made in twenty-five (25) opportunities, for a medication error rate of eight (8%) percent. Findings included: Review of the facility policy, The facility's Medication Administration General Guidelines, with a review date of 09/2018, indicated under Procedures, Paragraph 5b, that long-acting, extended-release, or enteric-coated dosage forms should generally not be crushed, and an alternative should be sought. 1. Record review revealed Resident #29 was admitted to the facility on [DATE], with diagnoses which included Hypertension, Heart Disease, and Dementia with Behaviors. Review of Resident #29's Physician Orders, included Divalproex DR (a delayed release medication used as a mood stabilizer for this resident) 250 milligrams, one (1) tablet to be given by mouth during the morning medication pass. Observation of medication administration…

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, record review, and facility policy review, it was determined the facility failed to provide pneumococcal vaccines for two (2) of five (5) sampled residents reviewed for pneumococcal vaccinations (Resident #54 and Resident #15). Findings included: Review of the facility policy, Vaccination of Residents, revised 2019, revealed all residents would be offered vaccines that aid in preventing infectious diseases unless the vaccine were medically contraindicated, or the resident has already been vaccinated. 1. Record review revealed Resident #54 was admitted to the facility on [DATE]. Further review of Resident #54's record revealed immunization consents indicated Resident #54 had requested the pneumococcal vaccine on 06/11/2021. There was no documented evidence Resident #54 received the vaccination. Interview with the Director of Nursing (DON), on 08/13/2021 at 1:12 PM, revealed pneumonia shots were given whenever the request was made. If a consent was signed, an order was sent to the pharmacy. 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.