Oakridge Manor Nursing and Rehabilitation Center L

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were given the opportunity to make decisions about their treatment for one (R32) of two residents reviewed for advance directives, resulting in R32 becoming distressed, tearful, and withdrawn after the facility attempted to petition (send to the hospital involuntarily for a psychiatric evaluation) him to the hospital when he refused dialysis, continuously expressing frustration with having a feeding tube, and not being included in conversations about his care.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate assessments were completed for four (R41, R16, R15 and R18) of 13 residents reviewed for Minimum Data Set (MDS) assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and biologicals were appropriately stored in a safe/sanitary manner in one medication cart reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was accessible to the resident for one (R32) of three residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review the facility failed to assess, monitor and treat a skin tear for one (R16) of one resident reviewed for wounds.

Inspectors wroteThis citation pertains to Intake Number(s): MI00152212. Based on observation, interview, and record review, the facility failed to consistently monitor residents' skin according to physician's orders and appropriately implement preventative interventions for three (R15, R18, R23) of three residents reviewed for pressure ulcers, who had a history of or were at risk of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review facility failed to thoroughly investigate and do a root cause analysis of a fall; and failed to consistently implement fall/accident prevention interventions as recommended for one (R34) of one resident reviewed for falls. This deficient practice has the potential for further falls with/without injury and resulted in hospital transfer of R34 for evaluation after fall. R34 R34 was a long-term care resident of the facility, originally admitted to facility on 9/24/24. R34's admitting diagnoses included dementia, personality disorder, schizoaffective disorder, and drug induced movement disorder, and unsteady gait with history of falls. Based on Minimum Data Set (MDS) assessment dated [DATE], R34 had a Brief Interview for Mental Status (BIMS) score of 3/15 indicative of severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review facility failed to ensure a resident admitted with an indwelling catheter was assessed for removal; failed follow-up with urologist as ordered and failed to have orders for catheter care for one (R23) of two residents reviewed for urinary catheter. This deficient practice has the potential to cause Urinary Tract Infections (UTI) and loss of normal bladder function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and address a significant weight loss in a timely manner for one (R15) of one resident reviewed for nutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure irregularities identified by the consultant pharmacist and signed by the physician were completed for one (R16) of five residents reviewed for monthly medication regimen reviews.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate tracking and administration of the pneumococcal vaccinations for three (R143, R16 and R10) of five residents reviewed for vaccinations.

Inspectors wroteBased on observation and interview, the facility failed to provide 80 square feet per resident for 7 of 20 multiple resident rooms and failed to provide 100 square feet per resident for 3 of 4 single bed resident rooms, resulting in the potential for inadequate space and resident dissatisfaction with their living conditions. Findings Include: On 5/07/25 at 11:00 AM, the following Medicare/Medicaid resident rooms were observed: Room # Square Ft. Beds 102 227 3 103 93 1 107 222 3 109 222 3 110 231 3 111 83 1 203 93 1 204 230 3 205 224 3 207 225 3 The health and safety of the residents were not affected by the room size. Interviews revealed residents had no problems with their rooms.

Inspectors wroteThis citation pertains to Intake MI00145936. Based on interview and record review, the facility failed to protect the one resident (R902)'s right to be free from physical abuse a resident (R903).

Inspectors wroteThis citation pertains to Intake Number MI00145339 Based on interview, and record review, the facility failed to complete a comprehensive admission assessment for one resident (R701) of three residents reviewed for assessments.

Inspectors wroteThis citation pertains to Intake Number MI00145339 Based on observation, interview, and record review, the facility failed to complete an assessment for incontinence for one (R701) of three residents reviewed for incontinence care.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and implement interventions to address changes in range of motion (ROM) for one (R14) of two residents reviewed for limited ROM, resulting in R14 developing contractures in three fingers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered and/or documented per professional standards of practice for three (R198, R196, R3 and R14) residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment free from hazards. This deficient practice had the potential to affect multiple residents who reside on the first floor.

Inspectors wroteBased on observation and interview the facility failed to ensure expired medical supplies were removed, maintain daily log of refrigerator temperatures, and provide refrigerated medication at recommended temperature between 36-42-degree Fahrenheit (F) resulting in the potential for the decreased efficacy of medical supplies and medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for three (R38, R43 and R6) of three residents reviewed for dignity.

Inspectors wroteBased on interview and record review, the facility failed to evaluate, and clarify the residents advance directive code status for one resident (R4) of one resident reviewed for hospice services.

Inspectors wroteThis Citation pertains to Intake MI00142276. Based on record review and interview, the facility failed to provide a notification for transfer to the hospital for one resident (R19) resulting in R19's responsible party was not informed for the reason of transfer and admission to the hospital.

Inspectors wroteBased on record review and interview, the facility failed to document within the medical record for two residents (R19, R20) that an identified irregularity identified from the medication regimen review (MMR) was acknowledged by the Physician/Prescriber to prevent adverse consequences related to medication therapy.

Inspectors wroteBased on interview and record review, the facility failed to obtain a Physician ordered laboratory (lab) test for one resident (R27) of one resident reviewed for laboratory diagnostics, resulting in the potential for abnormal lab results to go unreported to the Physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented and staff were educated on proper procedures for two (R15 and R27) residents.

Inspectors wroteBased on observation and interview, the facility failed to provide 80 square feet per resident for 16 of 20 multiple resident rooms and failed to provide 100 square feet per resident for 4 of 4 single bed resident rooms, resulting in the potential for inadequate space and resident dissatisfaction with their living conditions. Findings Include: On 4/22/24 at 2:00 pm, the following Medicare/Medicaid resident rooms were observed: Room # Square Ft. Beds 101 222 3 102 227 3 103 93 1 104 230 3 105 224 3 107 222 3 108 221 3 109 222 3 110 231 3 111 83 1 201 222 3 202 227 3 203 93 1 204 230 3 205 224 3 207 225 3 208 234 3 210 221 3 211 221 3 214 83 1 The health and safety of the residents were not affected by the room size. Interviews revealed residents had no problems with their rooms.

Inspectors wroteThis citation pertains to intake: MI00141572. Based on interview and record review, the facility failed to thoroughly follow-up and communicate resolutions on grievances expressed by one resident (R901) of one resident reviewed for grievances resulting in frustration and ongoing concerns with communication.

Inspectors wroteThis citation pertains to intake: MI00141572. Based on interview and record review the facility failed to ensure that a resident received the anti-viral treatment consistently as ordered by the physician and failed to follow up with the physician or practitioner when the ordered medication was not administered for one (R901) of two Residents reviewed for quality of care resulting in potential to result in complications from an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions to prevent pressure ulcers were implemented and identify and treat two new pressure ulcers for one (R24) of two residents reviewed for pressure ulcers, resulting in the development of pressure ulcers to the outside of both knees, one which had green purulent drainage and caused the resident pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the exterior trash/refuse area in a sanitary manner, resulting in the increased potential for odors and the attraction of pests and rodents. This deficient practice had the potential to affect all residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program and plan that ensured an interdisciplinary approach to have identified, developed, and implemented appropriate plans of action to correct quality deficiencies, resulting in the reoccurrence of deficient practices related to the facility's physician services and facility's failure to develop and implement policies and procedures that identified high-risk problems within the facility, ensure data collection for all departments within the facility, and failed to establish procedures that focus on high-risk problems, resident safety and quality of care. This deficient practice had the potential to affect all 44 residents that resided within the facility at the time of survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, comfortable, homelike environment for all 23 residents who resided on the second floor, including R10, R30, R5, R17, R24, R2, and R37.

Inspectors wroteBased on interview and record review, the facility failed to operationalize their abuse prohibition policy to ensure contracted nursing staff had appropriate background checks and fingerprints done before working in the facility for 13 of 13 contracted staff reviewed for criminal background checks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided to three residents (R's 13, 17, 30) of three residents reviewed met professional standards of nursing practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician visits/assessments were completed and documented for four (R's: 2, 28, 29, 38 & 39) of six residents reviewed for physician visits, resulting in the lack of documentation and increased potential for coordination of care due to lack of documentation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely physician visits for five (R2, R38, R29, R39 and R27) of five residents reviewed for frequency of physician visits.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to consistently acknowledge and respond to the pharmacist consultant's recommendations for three residents (R's 16, 24 & 29) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dress one (R5) of one resident reviewed for dignity, in clean clothing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (R24) of one resident reviewed for accommodation of needs had their call light accessible to them.

Inspectors wroteBased on interview and record review the facility failed to implement the facility's policy on an Against Medical Advice (AMA) discharge to ensure a safe discharge for one (R43) of two residents reviewed as a closed record.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure a level I Preadmission Screening (PAS)/Annual Resident Review (ARR) Mental Illness/Intellectual Disability/Related Conditions Identification was completed accurately and sent to local community mental health for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one (R27) of four residents reviewed for PASARRs. This deficient practice resulted in the potential for the resident to be excluded from receiving necessary care and services appropriate to meet their mental health and intellectual disability needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop comprehensive care plans which addressed targeted behaviors and symptoms for the use of antipsychotic medication for one (R29) of five residents reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (R5) of one resident reviewed for activities of daily living (ADLs) received a shower on a regular basis.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate administration of tube feeding formula in accordance with the physician order for one (R25) of one resident reviewed for tube feeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who was a trauma survivor received care and services that accounted for experiences and identified and implemented interventions to mitigate triggers for one (R29) of one resident reviewed for trauma informed care, resulting in the potential for re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma and lack of individualized care plan interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medically related social services to address mood, behavior, psychosocial well-being and/or trauma-informed care for two (R29 and R42) of five residents reviewed for social services, resulting in the increased potential for ongoing unaddressed physical, mental and psychosocial needs of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document administration of a controlled medication; pull medication from the back up supply when it was not available for administration; ensure medications were ordered timely and accurately; and failed to verify medications delivered by the pharmacy matched the physicians order for one (R30) resident.

Inspectors wroteR38 On 5/16/23 at 9:36 AM and multiple observations throughout the survey, R38 was observed either sitting or lying on the bed, or self propelling himself in a wheelchair. At each of these observations, the interactions with R38 revealed the resident was alert, and readily initiated conversation with staff and peers. There were no observations of any hallucinations, delusions or paranoia. Review of the clinical record revealed R38 was admitted into the facility on 9/24/22 and readmitted [DATE] with diagnoses that included: psychoactive substance abuse with unspecified psychoactive substance-induced disorder, bipolar disorder and major depressive disorder. According to the MDS assessment dated [DATE], R38 was cognitively intact and received antipsychotic medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory reports were contained in the clinical record for one (R29) of two residents reviewed for laboratory services, resulting in the increased potential for inability to effectively monitor changes in resident's condition due to lack of supporting documentation.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective Antibiotic Stewardship program that included consistent implementation of protocols for appropriate antibiotic administration and ensured that infection criteria were met for two (R24 and R46) of seven residents reviewed for antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate tracking and administration of the pneumococcal vaccinations for residents residing in the facility for two (R10 and R20) of five residents reviewed for pneumococcal vaccinations.

Inspectors wroteBased on observation and interview, the facility failed to provide 80 square feet per resident for 16 of 20 multiple resident rooms and failed to provide 100 square feet per resident for 4 of 4 single bed resident rooms, resulting in the potential for inadequate space and resident dissatisfaction with their living conditions. Findings Include: On 5/16/23 at 2:00 pm, the following Medicare/Medicaid resident rooms were observed: Room # Square Ft. Beds 101 222 3 102 227 3 103 93 1 104 230 3 105 224 3 107 222 3 108 221 3 109 222 3 110 231 3 111 83 1 201 222 3 202 227 3 203 93 1 204 230 3 205 224 3 207 225 3 208 234 3 210 221 3 211 221 3 214 83 1 The health and safety of the residents were not affected by the room size. Interviews revealed residents had no problems with their rooms.