White Oak Manor-Shelby

Inspectors wroteBased on observations, record review, and resident, staff, and Nurse Practitioner interviews, the facility failed to provide care in a safe manner when staff were assisting a resident (Resident #1) with right side weakness and vascular dementia with incontinence care. The resident fell off the side of the bed onto the floor. The resident complained of mild pain to her right knee and right arm and was provided her as needed pain medication and an order was received for in-house x-rays of the right side. Resident #1's right wrist began to show some mild swelling, and she continued to complain of pain, scheduled pain medication was administered, and she was transferred to the hospital for treatment. A hospital x-ray (imaging test for body's internal structures) revealed Resident #1 had suffered a fractured right wrist and right knee during the fall. [...]

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of restraints (Resident #8), infections (Resident #15), and falls with major injury (Resident #35). This deficient practice was identified for 3 of 5 sampled residents.

Inspectors wroteBased on record review, observation, resident and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan for 1 of 6 residents whose comprehensive care plans were reviewed (Resident #30).

Inspectors wroteBased on record review, staff and Nurse Practitioner interviews, the facility failed to provide care in a safe manner when Resident #1, who had a history of falls, slid out of a standard wheelchair onto the floor. The standard wheelchair was not the wheelchair Resident #1 was care planned to use when out of bed. Resident #1 later complained of pain and an x-ray revealed a femur fracture. Resident #1 was transferred to the hospital and diagnosed with a femur and knee fracture. The deficient practice occurred for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1). [...]

Inspectors wroteBased on record review, Resident Representative, and staff interviews, the facility failed to provide dignity for a cognitively impaired resident who waited for incontinence care to be provided. Resident #1 was severely cognitively impaired and Resident Representative stated that Resident #1 would have felt awful and embarrassed when left in wet brief without incontinence care. This deficient practice affected 1 of 3 resident sampled for dignity and respect (Resident #1).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to establish policies and procedures for standard and transmission-based precautions and failed to implement Enhanced Barrier Precautions (EBP) when providing urinary catheter care for 1 of 3 staff members reviewed for infection control practices (Nurse Aide #1).

Inspectors wroteBased on staff interviews the facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Control Program. The deficient practice had the potential to affect 105 of 105 residents at the facility.

Inspectors wroteBased on observations, record review, resident, and staff interviews the facility failed to provide nail care for a dependent resident for 1 of 3 residents (Resident #2) reviewed for activities of daily living (ADL).

Inspectors wroteBased on record review, resident interview, and staff interviews the facility failed to safely transfer a resident when Nurse Aide (NA) #3 and NA #4 transferred Resident #240 resident from the bed to the wheelchair. During the transfer the resident reported pain and stated her knee had popped. Resident #240 was sent to the emergency room (ER) and x-ray results indicated a right horizontal fracture involving the superior patella (a break in the upper part of the kneecap) with large knee joint effusion. Resident #240 was discharged back to the facility the same day with an immobilizer and a follow up appointment with .This occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #240).

Inspectors wroteBased on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure evening and weekend group activities were planned for the facility to meet the needs of residents who expressed that it was important to them to attend group activities for 4 of 4 residents reviewed for activities (Resident #17, #23, #43, and #75).

Inspectors wroteBased on record reviews, staff, Nurse Practitioner and Pharmacist interviews the facility failed to obtain a routine medication from the pharmacy for administration which caused a resident to miss 28 doses of the medication for 1 of 5 residents (Resident #46) reviewed for unnecessary medication.

Inspectors wroteBased on observations, resident and staff interviews the facility failed to provide evening snacks to residents when requested for 4 of 4 residents (Resident #17, #23, #43, and #75) reviewed for frequency of snacks. This practice had the potential to affect other residents who requested or desired an evening snack.

Inspectors wroteBased on record review and resident and staff interviews the facility failed to treat a resident in a dignified manner when staff assisted a resident onto the commode and left the resident. This deficient practice was for 1 of 3 residents reviewed for dignity (Resident #3). Resident #3 required extensive 1 person assist with transfers and toileting, and due to the long wait, transferred himself back to his wheelchair causing feces to get onto his clothes and wheelchair which made him feel very upset and mad.

Inspectors wroteBased on record review and staff interviews the facility failed to develop comprehensive care plans in the areas of anticoagulant (blood thinning) medication use for 2 of 2 residents whose comprehensive care plans were reviewed (Resident #4 and Resident #31).

Inspectors wroteBased on record review, staff, Nurse Practitioner and Pharmacist interviews the facility failed to clarify orders for monitoring blood pressure and pulse for the administration of an antihypertensive medication. This occurred for 1 of 5 residents reviewed for unnecessary medication (Resident #46).

Inspectors wroteBased on observations, record review, Medical Director and staff interviews, the facility failed to protect a resident's right to be free from neglect when staff pushed a resident with diabetes in her wheelchair without shoes, and when the resident asked the staff person to stop because her foot was hurting, the staff kept pushing the wheelchair and the resident sustained an open area to her great left toe and an abrasion to her left heel due to her foot being caught under the wheelchair footrest and being dragged during the transport. The left great toe had to be treated for one month before it healed. This was for 1 of 1 resident reviewed for neglect (Resident #6). Immediate Jeopardy began on 11/14/22 when Transport Driver #1 continued to transport Resident #6 in her wheelchair after she told him to stop pushing her down the hall because he was dragging her foot and it hurt. [...]

Inspectors wroteBased on record review, resident and staff interviews the facility failed to follow their neglect policy in the areas of reporting immediately to administration, conducting a thorough investigation and protecting residents. Transport driver #1 pushed Resident #6 from her room to the front lobby of the facility with her foot caught underneath the footrest of the wheelchair. Resident #6 stated to Transport driver #1 to stop however he kept pushing despite the resident being in pain resulting in an injury to the resident's foot. The incident was not immediately reported to Administration staff. The lack of reporting, investigating and protecting put all residents at risk for serious harm. This occurred for one of one resident reviewed for abuse (Resident #6). Immediate Jeopardy began on 11/14/22 an alleged perpetrator was allowed to continue to work without any corrective action. [...]

Inspectors wroteBased on record review, and interviews with staff, Nurse Practitioner (NP) and Medical Director (MD), the facility failed to provide wound care to an unstageable sacral pressure ulcer on 3 consecutive days, 12/08/22, 12/09/22, and 12/10/22 for 1 of 3 residents (Resident #154) reviewed for pressure ulcers.