Inspection Reports for
Oakview Nursing & Rehabilitation

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.

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.

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 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.

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.

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 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.