Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakview Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not consistently ensure that providers responded to pharmacist recommendations for gradual dose reductions (GDR) and drug regimen reviews (MRR) for several residents receiving psychotropic and other medications. In multiple cases, documentation of provider review or rationale for declining GDRs was missing, and repeated pharmacist requests went unaddressed, contrary to facility policy.
Three residents, including individuals with respiratory failure, lung cancer, COPD, and cognitive impairment, were not offered or administered the appropriate pneumococcal vaccines as required by CDC guidelines. In each case, either consent was obtained but the vaccine was not given, or the opportunity to consent or refuse was not provided when residents became eligible. The DON reported a lack of knowledge regarding the vaccine schedule and had not proactively identified residents due for immunization.
A resident with a history of stroke and hip fracture, requiring substantial assistance for transfers, requested to be moved from a recliner to a wheelchair. Despite multiple requests and reminders to staff, the resident waited over an hour before being assisted, expressing frustration at not being listened to. Staff interviews confirmed delays and acknowledged that residents should not have to wait this long for assistance, as facility policy requires residents to be treated with dignity and respect.
A resident admitted with a Stage 2 pressure ulcer on the right heel experienced deterioration to a Stage 3 ulcer and developed new pressure ulcers due to inadequate monitoring and intervention by the facility. The facility failed to follow up with a wound clinic, and documentation and communication regarding the resident's condition were insufficient. Staff were inconsistent in their awareness and documentation of the resident's pressure injuries, and facility policies on pressure ulcer prevention and physician notification were not effectively implemented.
The facility failed to revise care plans for three residents, leading to deficiencies in addressing their medical needs. A resident's care plan did not include prophylactic antibiotics despite their use, another resident's wandering concerns were initially omitted, and a third resident's care plan lacked identification of pressure injuries. These oversights were acknowledged by staff and attributed to a new staff member's inexperience in care plan management.
The facility failed to include antiplatelet medication and seizure management in the care plans for two residents. One resident, with moderately impaired cognition, was prescribed Clopidogrel Bisulfate and Aspirin EC, but the care plan did not reflect this. Another resident, with intact cognition, was prescribed Phenytoin Sodium for seizures, yet the care plan did not address this. The MDS Coordinator acknowledged these oversights.
A resident with multiple diagnoses did not receive prescribed medications due to a nurse's error, despite the medications being delivered to the facility. The facility's policy requiring administration per physician order was not followed, leading to a deficiency.
A facility failed to timely initiate antibiotics for a UTI and lacked a clear process for catheter change frequency for a resident with an indwelling catheter. The resident had severely impaired cognition and neurogenic bladder. Inconsistencies in catheter change dates and unclear physician orders were noted, with the Corporate Nurse acknowledging the confusion. Additionally, there was a delay in administering the antibiotic Levofloxacin after a UTI was identified.
A resident with severely impaired cognition did not receive prescribed medications, including a diuretic, antibiotic, and blood pressure medications, due to a failure in delivery from the pharmacy. Facility staff acknowledged issues with prompt medication delivery for new admissions, and documentation indicated the medications were not administered as per physician orders.
Failure to Ensure Timely Provider Response to Pharmacist Drug Regimen Review and Gradual Dose Reduction Recommendations
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews (MRR) and gradual dose reduction (GDR) recommendations made by the consulting pharmacist were consistently and timely addressed by the attending providers for multiple residents. In several cases, the pharmacist identified the need for GDRs for psychotropic and other medications, but the facility was unable to provide documentation that these recommendations were reviewed or acted upon by the prescriber. For example, for one resident with moderate cognitive impairment receiving antidepressant medication, the facility could not produce documentation of a provider's response to a GDR recommendation made in September, and only provided a response dated much later, after repeated requests. Other residents with varying degrees of cognitive impairment and complex medication regimens, including antipsychotics, antidepressants, anxiolytics, and hypnotics, also had GDR recommendations from the pharmacist that were not addressed in a timely manner or lacked provider rationale when GDRs were declined. In some instances, the pharmacist had to repeat GDR requests due to lack of response, and the facility's own documentation confirmed that GDRs for certain residents were not addressed for multiple months. Interviews with facility staff, including the DON, revealed that there was an ongoing issue with providers not documenting rationales for declining GDRs and that unresolved GDRs were sometimes escalated to the medical director or nurse practitioner. Facility policies required that any drug regimen irregularities identified by the pharmacist be reported in writing to the provider, medical director, and DON, and that the provider's response, including rationale for no change, be documented in the medical record. Despite these policies, the facility did not ensure that provider responses to pharmacist recommendations were consistently documented, nor that rationales for declining GDRs were provided, resulting in a deficiency related to the management and oversight of unnecessary medications.
Failure to Offer and Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to offer or administer the pneumococcal vaccine to three out of five residents reviewed for immunizations, despite having policies in place to assess and vaccinate residents according to CDC recommendations. In one case, a resident with respiratory failure and lung cancer, who had intact cognition, consented to receive the pneumococcal vaccine upon admission, but there was no documentation that the vaccine was administered. The administrator confirmed that staff did not follow through with obtaining an order for the vaccine, despite the resident's family member consenting to vaccination. Another resident with acute and chronic respiratory failure and COPD, also with intact cognition, had previously received both Prevnar 13 and Pneumovax but had not been offered or administered a pneumococcal conjugate vaccine (PCV15, PCV20, or PCV21) as recommended five years after the last dose. The clinical record lacked documentation that the vaccine was offered or refused in the years following eligibility, and the resident only recalled being offered the vaccine on admission and again during the survey process. A third resident, with iron deficiency anemia, moderate intellectual disability, and a history of blood clots, had received Pneumovax but had not been offered a pneumococcal conjugate vaccine after becoming eligible. The resident's guardian had consented to other vaccinations but was not given the opportunity to consent or refuse the pneumococcal conjugate vaccine. The DON, responsible for immunization tracking, reported only recently learning the pneumococcal vaccine schedule and had not run reports to identify eligible residents until prompted by the surveyor.
Failure to Timely Assist Resident with Transfer Request, Compromising Dignity and Respect
Penalty
Summary
A resident with a history of cerebral infarction and a left hip fracture, who required substantial to maximal assistance for transfers and had intact cognition, requested to be moved from her recliner to her wheelchair. During a continuous observation, the resident made her request to a CNA during a water pass, and the CNA responded that she would assist the resident 'in a little bit.' Despite completing the water pass in the same pod, the CNA did not return to assist the resident and instead engaged in other activities, including speaking with staff and helping another resident with a puzzle. The resident remained in her recliner for over an hour after her initial request, repeatedly expressing her desire to be moved and her frustration at not being listened to. When a nurse entered the room, the resident again requested to be moved, and the nurse stated she would inform the CNA. The CNA eventually returned with the non-mechanical lift but again delayed the transfer, telling the resident she would assist her 'in a little bit.' The resident was finally transferred to her wheelchair more than an hour after her initial request. Interviews with staff confirmed that the resident required an assist of two with a non-mechanical lift and that there was only one such lift available for three pods. Staff acknowledged that the resident should not have had to wait so long for assistance and that, according to facility policy, residents should be treated with dignity and respect, including timely responses to their requests. The Director of Nursing also stated that residents should be moved when they request, regardless of how recently they were transferred.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate monitoring, assessment, and intervention for a resident with a pressure ulcer present on admission, leading to the deterioration of the existing ulcer and the development of new pressure ulcers. The resident was admitted with a Stage 2 pressure ulcer on the right heel, which worsened to a Stage 3 ulcer by a later date. The clinical record indicated that the resident experienced pain and was referred to a wound clinic, but the right heel ulcer was not assessed or treated during the first clinic appointment. The facility did not follow up with the clinic, resulting in the right heel ulcer progressing to a Stage 3 with necrotic tissue, and new pressure ulcers developing on the left heel and bilateral buttocks. The facility's documentation and communication regarding the resident's condition were inadequate. The admission assessment failed to identify pressure injuries, and subsequent nursing progress notes lacked detailed assessments and measurements of the wounds. The facility's care plan did not document the presence of pressure ulcers or unhealed skin impairments, and there was a lack of timely notification to the primary care provider about the resident's worsening condition. Staff interviews revealed inconsistencies in the awareness and documentation of the resident's pressure injuries, with some staff unaware of the wounds until the survey. The facility's policies on pressure ulcer prevention, skin checks, and physician notification were not effectively implemented. The policies required timely assessments, documentation, and communication with healthcare providers, but these were not consistently followed. The facility's failure to adhere to its policies and procedures contributed to the resident's pressure ulcers worsening and new ulcers developing, ultimately leading to the resident being sent to the emergency department for suspected cellulitis and sepsis.
Care Plan Deficiencies in Addressing Resident Needs
Penalty
Summary
The facility failed to ensure proper revisions to the care plans of three residents, leading to deficiencies in addressing their specific medical needs. For Resident #45, the care plan did not include the use of prophylactic antibiotics, despite the resident having an indwelling catheter and being on cephalexin for prophylaxis. This oversight was acknowledged by the MDS Coordinator, who confirmed that prophylactic antibiotics should have been included in the care plan. Resident #29's care plan initially failed to address wandering concerns, despite the resident's history of ambulating outside unsupervised and the subsequent placement of a wander guard for safety. The resident expressed a desire to go outside independently, but staff interventions were necessary to ensure safety. The facility's Administrator noted that the staff member responsible for care plans was new, which contributed to the omission of wandering concerns and interventions in the care plan. For Resident #9, the care plan lacked identification of pressure injuries or unhealed wounds, despite the presence of a Stage 2 pressure injury on the right heel and other skin impairments noted in the clinical records. The MDS Coordinator confirmed that wounds and pressure injuries should have been included in the care plan, as per the facility's policy on pressure ulcer prevention. This omission highlights a failure to incorporate necessary interventions into the resident's plan of care.
Care Plan Deficiencies for Antiplatelet and Seizure Management
Penalty
Summary
The facility failed to include the use of antiplatelet medication and seizure management in the comprehensive care plans for two residents. For one resident, the Minimum Data Set (MDS) assessment indicated moderately impaired cognition, and the resident was prescribed Clopidogrel Bisulfate and Aspirin EC. Despite the resident receiving these medications consistently, the care plan did not reflect the use of antiplatelet medication. The MDS Coordinator acknowledged this oversight during an interview. For another resident, the MDS assessment showed intact cognition, and the resident was prescribed Phenytoin Sodium for possible seizure activity. The medication was added following adjustments made in the hospital, and the resident was to follow up with neurology. However, the care plan did not address the seizure disorder or the medications prescribed for it. The MDS Coordinator confirmed that the seizure disorder and related medications should have been included in the care plan.
Medication Administration Error Due to Nurse Omission
Penalty
Summary
The facility failed to administer medications as prescribed for a resident, leading to a deficiency in meeting professional standards of quality. The resident, who was admitted with diagnoses including hypokalemia, paroxysmal atrial fibrillation, hypotension, and adult failure to thrive, did not receive their prescribed medications on the day of admission. The medications included Metoprolol Tartrate for hypertension, Levetiracetam for alcohol use, and Potassium Chloride for hypokalemia. The Medication Administration Record (MAR) indicated that these medications were not administered because they were marked as not available from the pharmacy. Upon further investigation, it was revealed that the medications were indeed delivered to the facility, but the nurse responsible for administering them omitted them in error. The nurse consultant confirmed that the medications were delivered together, and the omission was not due to a delay from the pharmacy. The facility's policy on medication administration, which requires medications to be administered per physician order, was not followed in this instance, resulting in the deficiency.
Deficiency in Timely Antibiotic Initiation and Catheter Change Process
Penalty
Summary
The facility failed to ensure timely initiation of an antibiotic for the treatment of a urinary tract infection (UTI) and did not have a clear process for the frequency of urinary catheter changes for a resident with an indwelling catheter. The resident, who had severely impaired cognition, was noted to have an indwelling catheter due to neurogenic bladder. The care plan included interventions such as assessing the need for the catheter quarterly, maintaining a closed system, and providing catheter care twice daily and as needed. The clinical records revealed inconsistencies in catheter change dates and a lack of clarity in physician orders regarding the frequency of catheter changes. The catheter was changed on various dates, but there was no consistent schedule, and the facility's policy did not specify how frequently catheters should be changed. This lack of clarity was acknowledged by the Corporate Nurse during an interview. Additionally, there was a delay in initiating antibiotic treatment for a UTI. A urine sample was obtained and sent for analysis, but the antibiotic Levofloxacin was not administered until several days later. This delay in treatment was documented in the resident's Medication Administration Record, indicating a gap between the identification of the UTI and the start of antibiotic therapy.
Medication Availability Deficiency for Resident
Penalty
Summary
The facility failed to ensure the availability of necessary medications for a resident, identified as Resident #45, who was one of three residents reviewed for medication availability. The resident, who had severely impaired cognition as indicated by a score of 4 out of 15 on the Brief Interview for Mental Status (BIMS) exam, did not receive several prescribed medications, including a diuretic, an antibiotic, and blood pressure medications, because they were not delivered from the pharmacy. This issue was documented in the Orders-Administration Notes and the Medication Administration Record (MAR) for July 1, 2024, where the medications were marked with a code indicating other/see progress notes. Interviews with facility staff, including the MDS Coordinator, Administrator, and Corporate Nurse, revealed concerns about the promptness of medication delivery for new admissions. The Health Status Note from July 1, 2024, indicated that the resident did not receive any medications that day due to the pharmacy's failure to deliver them, and a call was placed to the pharmacy to address the issue. The facility's policy on Medication Administration, revised in April 2023, states that medications should be administered per physician order, highlighting a deviation from this policy in the case of Resident #45.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southeast Iowa Regional Medical - Klein Center | 0.7 mi | ★★★★★ | 2 | 1 |
| Henderson County Ret Center | 13.8 mi | ★★★★★ | 0 | 0 |
| Azria Health Prairie Ridge | 14.3 mi | ★★★★★ | 19 | 0 |
| New London Specialty Care | 15.1 mi | ★★★★★ | 6 | 0 |
| West Point Care Center Inc | 15.8 mi | ★★★★★ | 4 | 0 |
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