Oakview Medical Care Facility

Based on observation, interview, and record review, the facility failed to provide a process for visitors, staff, and residents to submit concerns and grievances anonymously potentially affecting 73 total residents. An observation on 4/7/26 at 2:00PM throughout the facility revealed there was not a concern or grievance form available outside of asking for one at the nurse's station and no box or location could be found to drop a grievance anonymously. In an interview on 4/7/26 at 2:50 PM Director of Social Services (DSS) C reported that grievances are not completed for residents unless a resident asks for one. DSS C reported that the facility did not have grievance forms outside of the nurse's station and if a person wanted one, they had to ask for it. In an interview on 4/7/26 at 3:17 PM the Director of Nursing Services (DONS) reported that grievances can be filled out by anyone, and the facility policy reflects that a grievance should be accessible to be submitted anonymously and at that time there was not a specific location for residents to file grievances anonymously. Review of…

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 assess a skin concern identified upon admission for 1 resident (R4) of 6 residents reviewed for skin and pressure ulcer concerns.Findings include:Review of an admission Record revealed R4 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, diabetes, and dependence on renal dialysis.Review of R4's Baseline Care Plan, dated 12/16/2025, revealed .spot on bottom, long time, (no change), hurts, barrier cream, wife places bandaid. Further review revealed no assessment of this chronic wound and no interventions specific to this wound.Review of a current Care Plan focus and interventions for R4, initiated 3/23/2026, revealed a stage 2 pressure ulcer on his right gluteus. Further review revealed R4 was noted to be at risk for pressure injuries but there were no mention or interventions pertaining to the chronic wound on his gluteus prior to identification of the stage 2 pressure ulcer.Review of R4's admission Assessment, dated…

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 This citation pertains to intake 2729237. Based on interview and record review, the facility failed to follow policies and procedures to report injuries of unknown origin for one (R2) of 4 residents reviewed for injuries.Findings include:Resident #2 (R2)Review of a Face Sheet revealed R2 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, Parkinsonism, and dementia. Review of an Incident Report titled Bruise dated 10/16/25 at 2:00 AM for R2 revealed: Incident Description: Nursing Description: purple discoloration noted to upper right arm. Resident Description: Resident does not recall any incident which could have caused bruising. Agencies/People Notified: Physician. No documentation to show the Abuse Coordinator was notified. Review of a Nursing Progress note dated 10/16/25 at 2:17 AM for R2 revealed: Large purple discoloration noted to right upper arm measuring 15cm (centimeters) x 6cm. Resident unable to recall any incident which may have caused the bruising. Message left in…

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 This citation pertains to intake 2729237. Based on interview and record review, the facility failed to follow policies and procedures to thoroughly investigate injuries of unknown for one (R2) of 4 residents reviewed for injuries of unknown origin.Findings include:Resident #2 (R2)Review of a Face Sheet revealed R2 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, Parkinsonism, and dementia. Review of an Incident Report titled Bruise dated 10/16/25 at 2:00 AM for R2 revealed: Incident Description: Nursing Description: purple discoloration noted to upper right arm. Resident Description: Resident does not recall any incident which could have caused bruising. No statements from staff documented and no thorough investigation of the root cause was completed. Review of a Nursing Progress note dated 10/16/25 at 2:17 AM for R2 revealed: Large purple discoloration noted to right upper arm measuring 15cm (centimeters) x 6cm. Resident unable to recall any incident which may have caused 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake 2729237. Based on interview and record review, the facility failed to follow policies and procedures and implement meaningful care plan interventions to prevent falls for one (R2) of 4 residents reviewed for falls.Findings include:Resident #2 (R2)Review of a Face Sheet revealed R2 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, Parkinsonism, and dementia. Review of a Witnessed Fall Incident Report dated 11/27/25 for R2 revealed: Housekeeping pulled cart up to the door of room [ROOM NUMBER] and found him standing up with his walker. Staff witnessed resident's foot get stuck in the wheel of his walker causing him to lose balance and fall. Resident unable to give description. Injuries Observed at Time of Incident: Skin Tear, Right hand (back). Staff statement from the Housekeeper: . I waited because his CNA (Certified Nursing Assistant) was in there doing care. (R2) was in his chair when (CNA) left the room after caring for him. When I turned 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, interview, and record review, failed to ensure 1) equipment was being maintained, 2) required information/reminders are being provided at hand sinks 3) maintain physical facilities in sanitary conditions and in good repair potentially effecting 69 residents that receive food/water from the facility. Findings include: The following observations were observed on 02/11/25 between 10:29 AM to 1:50 PM, during tour of the kitchen/facility with Directory of Dietary (DOD) A. Observation of the dish washing area revealed a large area of the flooring had low grout, resulting in a build-up of food residues/debris, standing water and grime between the floor tiles. Observation of the (Name of Living Center's) Kitchenette found, 1) An employee handwashing reminder sign was not provided at the hand sink. 2) Ice machine's water filter was not labeled/dated. Observation of the shared hallway kitchenette revealed, ice machine did not have a water filter installed. During an interview on 2/12/25 at 10:02 AM, Maintenance Director (MD) D revealed he was unsure of when maintenance…

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 follow professional standards of nursing practice for medication administration for 4 of 18 residents (Resident #29, #40, #42, and #49), reviewed for the provision of nursing services, resulting in lack of vital sign assessments prior to medication administration and medications administered outside of physician ordered parameters. Findings: Resident #29 (R29) Review of an admission Record revealed R29 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension and atrial fibrillation (abnormal beating of the heart) Review of R29's Order Summary dated 12/16/24 revealed, Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth two times a day .Hold if SBP (systolic blood pressure/top number) is less than 100, or DBP (diastolic blood pressure/bottom number) is less than 50 or HR (heart rate) is less than 60. To be administered at 9:00 Am and 9:00 PM. Review of…

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 update a care plan to reflect current treatment for 1 resident (R13) of 18 residents reviewed for accuracy of care plans. Findings include: Review of an admission Record revealed R13 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke) and dementia. Review of R13's Physician's Orders active 2/11/2025 at 1:37 PM revealed R13 had a urinary catheter and was being treated for a pressure ulcer on her coccyx. Review of R13's nursing Progress Note, dated 1/10/2025 at 11:22 AM, revealed a urinary catheter was inserted per the physician because her coccyx wound was not healing. Review of R13's current Care Plan, active 2/12/2025, revealed her coccyx wound was documented as healed. Further review revealed no urinary catheter care plan. In an interview on 2/12/2025 at 2:03 PM, Wound Registered Nurse (RN) H reported R13's care plan should have been updated to reflect her coccyx wound as active when it reopened 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 observation, interview, and record review, the facility failed to follow standards of practice for medication storage and labeling. Finding: During an observation on 02/11/25 at 10:02 AM, the treatment cart sat unlocked and unattended and contained prescription medications including insulin pens. A partially used humalog insulin pen that was prescribed to the resident in room [ROOM NUMBER]-2 was not dated to indicate when it had been opened. During an observation on 02/11/25 at 10:16 AM, the green hall medication cart's narcotic box was unlocked and a drinking straw had been intentionally placed through the back hinge of the narcotic box so that it would not latch and lock. During an interview at the same time, Registered Nurse (RN) J indicated that this was not an acceptable practice and that this should not have been done. During an observation on 02/11/25 at 10:39 AM a small plastic medication cup that contained chocolate pudding and a spoon, sat unattended and uncovered on the green hall medication…

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 follow professional standards of nursing practice for medication administration for 1 of 18 residents (Resident #4), reviewed for the provision of nursing services, resulting in medications being administered outside of the physician ordered parameters. Findings: Resident #4 (R4) Review of an admission Record revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension, atrial fibrillation (abnormal beating of the heart), and heart disease. Review of R4's Physician Order dated 4/6/23 revealed, amLODIPine Besylate Oral Tablet 2.5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Hold of SBP (systolic blood pressure/top number) is < (less than)100 or HR (heart rate) < (less than) 60. Review of R4's September Medication Administration Record revealed R4's amlodipine was administered outside parameters (heart rate less…

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 provide complete and comprehensive assessments and notify the provider and guardian of a resident's reported seizure activity 1 of 18 residents (Resident #7) reviewed for quality of care. Findings: Resident #7 (R7) Review of an admission Record revealed R7 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: seizure disorder. Review of a Minimum Data Set (MDS) assessment for R7, with a reference date of 1/5/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R7 was cognitively intact. Review of R7's Order Summary revealed R7 had current orders for Lacosamide 100 mg twice a day, Zonisamide 200 mg twice a day, and Oxcarbazepine 300 mg twice a day for her seizure disorder. Review of R7's Care Plans revealed, Dx. (diagnosis) of Seizure disorder with treatment at an acute Hospital for repeated seizures .Date Initiated:…

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.