Flint Ridge Nrsg & Rehab Ctr

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to ensure appropriate treatment and services to maintain or improve the resident's ability to carry out activities of daily living. This affected one (Resident #93) of three residents reviewed for falls. The facility census was 75.

Inspectors wroteBased on observations, interviews and facility policy review, the facility failed to perform hand hygiene during medication administration. This affected nine residents (#19, #30, #36, #46, #49, #59, #65, #76, and #83) of 15 residents receiving medications during afternoon medication administration and had the potential to affect all 28 residents residing on the Main Unit hallway. The facility census was 80. Findings Include: An observation on 08/28/25 from 11:45 A.M. to 12:25 P.M. revealed Registered Nurse (RN) #234 completed noon medication administration on the Main Unit hallway. RN #234 prepared and administered medication for Resident #52, returned to the medication cart to begin preparation of medications for Resident #83 without sanitizing or washing hands. [...]

Inspectors wroteBased on observation, staff interview, resident interview, and policy review, the facility failed to ensure meals were kept at appropriate temperatures while serving food. This affected two residents (Resident #35 and #61) and had the potential to affect 69 out of 76 residents, with five residents who received nothing by mouth (NPO) diets. The facility census was 76.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to prepare, store, and serve food in a manner that to prevent contamination. This had the potential to affect 71 out of 76 residents with five residents being on nothing by mouth (NPO) diets. The facility census was 76.

Inspectors wroteBased on record review and interview the facility failed to complete a baseline care plan timely for one resident (#73) of five sampled for unnecessary medications and failed to complete a baseline care plan for one resident (#29) of one sampled for bowel and bladder incontinence. The facility census was 76.

Inspectors wroteBased on record review and interview the facility failed to ensure care plan conferences were held for two residents (#18 and #53) of two residents sampled for care planning. The facility census was 76.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review, the facility failed to ensure timely activities of daily living (ADL) assistance for Resident #14. Additionally, the facility failed to ensure Resident #38 had adequate ADL assistance with his fingernails. This affected two (Resident #14 and #38) of four residents reviewed for ADL's. The facility census was 76.

Inspectors wroteBased on record review, family interview, staff interview, and policy review, the facility failed to ensure a comprehensive wound management program to promote healing of Resident #35's pressure ulcer. This affected one (Resident #35) out of three residents reviewed for pressure ulcers. The facility census was 76.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to ensure there was follow-up care and monitoring for Resident #38's contracted wrist. This affected one (Resident #38) out of one residents reviewed for positioning and mobility. The facility census was 76.

Inspectors wroteBased on observation, interview, record review and manufacturer;s instruction review the facility failed to ensure the resident environment was free of potential accident hazards. This affected one resident (#46) of three sampled for accidents. The facility census was 76.

Inspectors wroteBased on record review, interview and policy review, the facility failed to obtain physician ordered laboratory studies to ensure therapeutic medication levels were achieved. This affected one resident (#17) of five reviewed for unnecessary medications. The facility census was 76.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure antibiotic use was appropriate. This affected one (Resident #40) of three residents reviewed for urinary tract infections (UTI). The facility census was 76.

Inspectors wroteBased on closed medical record review, policy review and interview, the facility failed to prevent a severe weight loss for Resident #2, a resident who received all nutrition via enteral feedings. This affected one resident (#2) of three residents reviewed for nutrition. The census was 72. Actual Harm occurred on 08/03/24 when Resident #2 was assessed to sustain a 10.55% weight loss (with the weight loss occurring between 07/30/24 and 08/03/24). The dietician was not notified and no new nutritional interventions were implemented. The resident continued to lose weight resulting in a 13.8% severe weight loss within 30 days of admission.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure Resident #37 was comprehensively assessed for pain and failed to develop an individualized pain management program to timely identify and prevent pain associated with the resident's pressure ulcers. This affected one resident (#37) of one resident reviewed for pain management. The census was 72. Actual Harm occurred on 09/05/24 when Resident #37 was observed yelling and moaning during pressure ulcer (wound) care. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility map accounted for all resident rooms and resident rooms provided a safe environment for residents. This affected five residents (#67, #68, #73, #97 and #99) of 25 residents residing on the Serenity Hall. The facility census was 72.

Inspectors wroteBased on observation, dietary meal card review, and interview, the facility failed to provide ordered serving size and ensure whole milk was available for the breakfast meal. This affected seven residents (#19, #28, #41, #54, #71, #73 and #83) who were to receive whole milk and had the potential to affect any resident receiving meals from the kitchen except for seven residents (#17, #23, #67, #74, #78, #84 and #86) who did not receive anything by mouth. The census was 72.

Inspectors wroteBased on observation, policy review and interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents except seven residents (#17, #23, #67, #74, #78, #84 and #86) who did not receive anything by mouth. The census was 72.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to provide a dignified meal experience. This affected one resident (#24) of four residents observed during meal service in the dining room. The census was 72.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to provide written notice before a resident's room was changed. This affected one resident (#99) of three residents reviewed for room changes. The facility census was 72.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to provide assistance with meals as needed. This affected one resident (#37) of four residents sampled. The census was 72.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to timely develop and implement comprehensive, individualized and effective pressure ulcer care and treatment to promote the healing of pressure ulcers for Resident #37, who was admitted to the facility with multiple pressure ulcers present. This affected one resident (#37) reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. The census was 72.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure oxygen tanks were safely transported. This affected two residents (#57 and #89) observed with oxygen. The facility identified 13 residents utilized oxygen.

Inspectors wroteBased on closed medical record review, policy review, and interview, the facility failed to implement enteral feeding recommendations timely. This affected one resident (#2) of three residents reviewed for enteral feedings. The facility identified 13 residents who received nothing by mouth. The census was 72.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure residents received oxygen per physician orders. This affected one resident (#57). The facility identified 13 residents that were ordered to receive oxygen. The census was 72.

Inspectors wroteBased on medical record review, policy review and interview, the facility failed to maintain accurate medical records. This affected three residents (#2, #28, and #37) of five sampled residents. The census was 72.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure infection protocols were implemented when facility staff failed to ensure gloving and hand washing was completed during incontinence care and indwelling catheter supplies were maintained off the floor. This affected two residents (#28, #37). The census was 72.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy for wound care, this facility failed to ensure residents assessments were accurate to refect a pre-existing skin injury during admission assessments. This affected one (Resident #141) of four residents reviewed for skin care and prevention. The facility census was 70.

Inspectors wroteBased on medical record review, and staff interview, this facility failed to ensure residents receiving antibiotics were monitored for effectiveness including obtaining and monitoring vital signs. This affected one (Resident #141) of the four residents reviewed for antibiotic use. The facility census was 70.

Inspectors wroteBased on medical record review, staff interview, and facility policy for medication administration, this facility failed to ensure residents thyroid medication was administered at the scheduled time. This affected one (Resident #41) of the four residents reviewed for accurate medication administration. The facility census was 70.

Inspectors wroteBased on medical record review, staff interview, and facility policy for charting and documentation, this facility failed to ensure information documented in residents medical records were accurate to reflect care provided. This affected one (Resident #41) of four residents reviewed for accurate medical record documentation. The facility census was 70.

Inspectors wrote2. Review of the medical record for Resident #5 revealed an admission date of 11/14/21. Medical diagnoses included schizoaffective disorder (09/15/22), bipolar disorder (07/18/21), obsessive-compulsive disorder (07/18/21), anxiety disorder (07/18/21), major depressive disorder (07/18/21), and mild intellectual disabilities (07/18/21). Review of the annual MDS 3.0 assessment, dated 07/15/23, revealed Resident #5 had intact cognition and scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #5 required extensive assistance from two staff to complete Activities of Daily Living (ADLs). Review of Resident #5's PASRR, dated 01/28/22, revealed the document did not include Resident #5's diagnosis of anxiety disorder, obsessive-compulsive disorder, or schizoaffective disorder. The document also did not include Resident #5's use of anti-anxiety medication. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected three (Residents #5, #13, and #30) of three residents reviewed for Pre-admission Screening and Resident Review (PASRR). The census was 76.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident care plans were revised to reflect changes in advanced directives. This affected one (Resident #7) out of 18 residents reviewed for advanced directives. The facility census was 76.

Inspectors wroteBased on medical record review, staff interviews, and facility policy review, the facility failed to ensure dietary recommendations to address weight loss were implemented in a timely manner. This affected one (Resident #64) of four residents reviewed for nutrition. The facility census was 76.

Inspectors wroteBased on medical record review, staff interviews, and facility policy review, the facility failed to ensure medications were administered according to the physician ordered parameters. This affected two residents (Resident #30 and Resident #34) out of six residents reviewed for unnecessary medications. The facility census was 76.

Inspectors wroteBased on observation, record review, facility policy and procedure and interview, the facility failed to maintain acceptable infection control practices including proper procedures for residents in droplet isolation and/or quarantine to prevent the spread of infection including COVID-19. This affected five residents (#37, #212, #311, #312 and #313) and had the potential to affect all 66 residents residing in the facility.

Inspectors wroteBased on observation, medical record review and interview the facility failed ensure comprehensive and individualized care plans were developed for all residents. This affected four residents (#7, #25, #32 and #47) of 21 sampled residents who care plans were reviewed.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to promote Resident #311's dignity when staff failed to ensure the resident's urinary drainage collection bag was covered and not visible to other residents/staff/visitors. This affected one resident (#311) of one resident reviewed for dignity.

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to notify the physician when Resident #19 experienced a significant weight loss. This affected one resident (#19) of 21 sampled residents.

Inspectors wroteBased on observation, record review, interview and facility policy review the facility failed to ensure residents were provided with personal privacy. This affected three residents (#5, #19 and #212) of three residents reviewed for privacy.

Inspectors wroteBased on observation, record review and interview the facility failed to comprehensively assess Resident #25's behavior patterns. This affected one resident (#25) of 21 sampled residents.

Inspectors wroteBased on observation, resident record review, interview interview and policy review this facility failed to ensure resident assessments were accurate to reflect each residents specific care needs. This affected one resident (#32) of 21 residents reviewed for assessments.

Inspectors wroteBased on medical record review and staff interview the facility failed to refer a resident with a newly evident serious mental disorder to the appropriate State-designated authority for a Preadmission and Resident Review (PASRR) Level II assessment/determination upon change in status. This affected one resident (#7) of one resident reviewed for PASRR.

Inspectors wroteBased on observation, medical record review and staff interview the facility failed to ensure Resident #59's baseline plan of care addressed the resident's bruising and skin tears. This affected one resident (#59) of 21 sampled residents who care plans were reviewed.

Inspectors wroteBased on medical record review and staff interview the facility to revise Resident #47's plan of care to reflect the resident's incontinence of bladder. This affected one resident (#47) of 21 sampled residents whose care plans were reviewed.

Inspectors wroteBased on observation, medical record review and interview the facility failed to ensure Resident #5 and Resident #47, who required staff assistance for activities of daily living received timely and adequate personal care/shaving assistance to maintain good hygiene. This affected two residents (#5 and #47) of five residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement individualized and meaningful activities to meet the total care needs of Resident #11 and Resident #53. This affected two residents (#11 and #53) of three residents reviewed for activities.

Inspectors wroteBased on observation, record review and interview the facility failed to assess and monitor Resident #59 related to bruising and skin tears. This affected one resident (#59) of two residents reviewed for skin conditions.

Inspectors wroteBased on observation, medical record review and staff interview the facility failed to ensure Resident #7 received proper treatment to maintain vision and hearing abilities. This affected one resident (#7) of one resident reviewed for communication.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to adequately and comprehensively assess pressure ulcers for Resident #47 and Resident #59 upon admission and/or re-admission to the facility. This affected two residents (#47 and #59) of four residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure the resident environment remained free of accident hazards related to smoking. This affected one resident (#34) of two residents reviewed for accidents.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to implement timely and effective interventions to ensure Resident #19 maintained acceptable parameters of nutritional status, such as body weight. This affected one resident (#19) of three residents reviewed for nutrition.

Inspectors wroteBased on observation, record review and interview the facility failed to implement a comprehensive and individualized plan for Resident #11, who had a diagnosis of dementia to ensure the resident received the appropriate treatment and services to attain or maintain her highest practicable physical, mental, and psychosocial well-being. This affected one resident (#11) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review and staff interview the facility failed to ensure pharmacy recommendations for Resident #7 and Resident #38 were addressed timely by the physician. This affected two residents (#7 and #38) of three residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure medications were administered only when necessary and with adequate and appropriate monitoring including laboratory testing to monitor for effectiveness and optimal dose. This affected two residents (#7 and #38) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review and interview the facility failed to implement behavioral interventions, including non pharmacological approaches prior to administering psychoactive medications and failed to timely evaluate the effectiveness of psychoactive medications for Resident #11. This affected one (Resident #11) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on record review and interview the facility failed to ensure physician ordered laboratory testing was completed as ordered and/or failed to ensure the physician was promptly notified of resident laboratory results which fell outside the clinical reference ranges. This affected two residents (#5 and #7) of five residents reviewed for unnecessary medication use.