Inspection Reports for
Oakview Nursing & Rehabilitation

Incident #3027891-I

The facility was found to be in substantial compliance.

No deficiencies are cited in this document. The facility is certified in compliance based on acceptance of the Plan of Correction.

Complaint #2716820-C and facility reported incident #2799491-I.

The facility failed to report an allegation of abuse in a timely manner for 1 of 4 residents reviewed. Staff did not report suspected abuse to the state agency as required, resulting in a deficiency.

The facility failed to report allegations of abuse in a timely manner for Resident #2 despite multiple staff being aware of the concerns. Staff did not follow the facility's abuse reporting policy, and the Administrator confirmed the failure to report the abuse allegation to the department on January 13, 2026. The facility provided dependent adult abuse training to staff on January 29, 2026.

Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility will be certified in compliance effective August 22, 2025.

The visit included investigation of Complaints #1804304-C, #1804307-C and Facility Reported Incident 1084309-I.

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. The facility was not using the updated CMS forms as required.

The facility will be certified in compliance effective April 11, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.

Complaint #127430-C was substantiated based on observations, clinical record review, and interviews indicating failure to prevent wandering and unsafe resident interactions.

The facility failed to prevent one resident from wandering into another resident's room and putting their hand on that resident, indicating inadequate supervision and assistance devices to prevent accidents. The investigation included clinical record review, observations, and staff and resident interviews.

Complaint investigation for incident #124525-I; facility found to be in substantial compliance.

The facility was found to be in substantial compliance.

The facility was found to be in substantial compliance based on the accepted Plan of Correction, and certification in compliance is effective as of August 27, 2024.

The facility reported incident #122661-M was substantiated during the investigation.

The facility was found to have multiple deficiencies including failure to ensure dignity in catheter care, physical abuse by staff, inadequate food temperature control, unsanitary food preparation areas, and failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program.

The facility failed to ensure residents remained free from physical abuse when a staff member punched a resident in the left shoulder after an altercation. The incident involved Resident #23, who had severe cognitive impairment and required substantial assistance.

The facility will be certified in compliance effective March 5, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.

The facility was found deficient in several areas including resident rights related to dignity and respect during dining, care plan revisions for medication management, sufficient nursing staff response times, food safety and sanitation practices, and infection prevention and control procedures.

Investigation involved multiple complaints and self-reported incidents; facility found in substantial compliance.

The facility was found to be in substantial compliance following the investigation.

The facility was found to be in compliance based on the accepted plan of correction; no specific deficiencies or findings are detailed in this document.

The investigation of complaints #104909-C and #105641-C was conducted and both complaints were not substantiated.

The facility was found deficient in multiple areas including failure to implement abuse/neglect policies, failure to report injuries of unknown source timely, failure to investigate alleged violations thoroughly, failure to revise care plans timely, and failure to provide proper catheter care. The facility also failed to include all relevant staff statements in investigations and did not complete mandatory abuse training within required timeframes.

This visit was a follow-up to a complaint survey. All deficiencies identified in the complaint survey were corrected.

All deficiencies were corrected and the facility was found to be in substantial compliance effective May 13, 2022.

Complaint #104403-C was substantiated. Facility Self-Reported Incident #104404-I was substantiated.

The complaint and incident were substantiated. Deficiencies were found related to failure to notify physician and responsible party timely about resident changes and injuries, failure to obtain treatment orders timely, and failure to ensure hot liquid safety in the dining room. The facility reported a census of 36 residents.

The facility failed to provide timely and accurate assessment and treatment for a serious burn injury caused by spilled hot coffee. Staff served hot coffee without nursing supervision, failed to notify the physician and family promptly, and used another resident's topical treatment without authorization. The burn worsened due to inadequate supervision and delayed treatment orders. The facility also failed to maintain a safe environment and proper meal service supervision, resulting in Immediate Jeopardy to resident safety.

The facility was found to have multiple deficiencies including failure to meet professional standards in medication administration, inadequate catheter care, failure to post correct nurse staffing information, improper food portioning and preparation, inadequate infection prevention and control practices, and failure to ensure proper use of personal protective equipment.

Complaints #91476 and #92150 and a Facility Self-Reported Incident #922812 were investigated and found not substantiated.

The complaints and self-reported incident were investigated and found to be not substantiated.

The facility was found to be in compliance with the CMS and CDC recommended practices to prepare for COVID-19.