The discovery occurred during a February inspection when regulators documented that the facility failed to properly manage Resident 103's wound care. The maggot infestation in the right heel wound represented such a severe breakdown in basic medical care that inspectors classified it as immediate jeopardy, the most serious level of nursing home violations.
The Administrator and Director of Nursing were notified of the immediate jeopardy finding on February 7 at 3:18 PM, according to inspection records.
But the wound care failure was not the only life-threatening violation inspectors uncovered. They also found that Oak View had created a dangerous situation where a resident with moderate cognitive ability could have received unwanted life-saving measures due to conflicting medical orders in their electronic records.
Resident 424, who scored 8 on a cognitive assessment indicating moderate intact cognition, told inspectors on the day of the survey, "I want to die, I don't want them to save me."
The resident's electronic medical record showed Full Code status, meaning staff would perform CPR and other life-saving interventions. But buried in the same record was a signed Do Not Resuscitate order from both the resident's responsible party and a physician. The resident's responsible party confirmed during a telephone interview that the resident wished to be DNR.
When inspectors asked nursing staff about the resident's code status, they received conflicting information that revealed how the system had broken down.
Licensed Practical Nurse 2 checked the electronic medical record when asked to confirm Resident 424's code status and stated the resident was Full Code. Two other nurses, Licensed Practical Nurse 1 and Registered Nurse 1, explained their emergency protocol: "If there was a code, we would go to PointClickCare and verify the code status. We will check vitals and start CPR. We then would call out for a Code Blue and then continue to monitor with CPR until EMS comes and takes over."
The Director of Nursing acknowledged the problem during her interview, confirming that Resident 424 had conflicting code statuses and stating she would need to look into it. The MDS Nurse told inspectors that the care plan should be updated to match the physician's orders.
This meant that if Resident 424 had experienced a medical emergency, nursing staff following the electronic record would have performed CPR and other life-saving measures directly against the resident's expressed wishes and legal DNR order.
The facility's own policy on advance directives required that once advance directive information is received, it must be confirmed in the resident medical record and communicated to care plan team members. The policy also mandated that the attending physician be notified so appropriate orders could be documented.
None of this had happened properly for Resident 424.
Oak View's immediate response included conducting a full audit of all current residents on the same day the immediate jeopardy was identified. The Director of Nursing reviewed every resident from 4:30 PM to 8:00 PM to validate that advance directive preferences matched the orders in the electronic system and care plans. No other residents were found to have the same problem.
The facility also provided immediate training to licensed nurses, medical records personnel, and social services employees on the advanced directives policy and how to transcribe orders correctly.
But the inspection revealed additional care failures beyond the immediate jeopardy violations. Inspectors found that another resident was not receiving ordered medical equipment designed to prevent pressure sores.
Resident 11, who had lived at Oak View since 2007 with Alzheimer's disease and other conditions, had physician orders for bilateral heel boots while in bed every shift and a wedge cushion while in bed every shift. The heel boot order was dated January 29, and the wedge cushion order was dated January 3.
During observations on February 4, inspectors found Resident 11 lying in bed with heels elevated on a pillow, but no heel boots were present and no wedge was in the bed as ordered by the physician. A second observation that afternoon revealed the same missing equipment.
Certified Nursing Assistant 6 explained the problem during an interview: "R11 did not have her heel booties on 02/04/25 and 02/05/25 because I could not find them. I had to go to the linen closet and get her another pair. I did not know about the wedge. I am glad you told me. I will ask about that."
The nursing assistant's response revealed gaps in both equipment management and staff knowledge of physician orders. Registered Nurse 3 confirmed that staff expectations required CNAs to ensure heel boots were found and placed on residents, with the boots to be washed every three days unless visibly soiled.
The facility's own policy on physician orders stated that orders should be followed as written, and physicians should be notified if orders cannot be followed for any reason. The Director of Nursing confirmed this expectation, stating that she should be made aware if doctor's orders cannot be followed.
Oak View's plan to address the immediate jeopardy violations included daily monitoring of advance directive changes during clinical meetings five times a week for 12 weeks. The Director of Nursing or a designee would report findings to the Quality Assurance committee monthly with additional follow-up as needed until substantial compliance was achieved.
The Medical Director was notified of the immediate jeopardy on the day it was identified. An emergency meeting was held with the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Clinical Resource, and Clinical Market Lead to address the plan of removal and interventions.
Federal inspectors verified that the immediate jeopardy was removed the following day at 11:15 AM, but the underlying problems that led to maggots in a resident's wound and life-threatening confusion about a resident's end-of-life wishes had already exposed the human cost of systemic care failures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak View Health and Rehabilitation from 2025-02-11 including all violations, facility responses, and corrective action plans.
Additional Resources
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