Oakland Manor Nursing and Rehabilitation Center LL
For profit - Limited Liability company
29 Beds
PIONEER HEALTHCARE MANAGEMENT
Data: November 2025
Trust Grade
65/100
#161 of 422 in MI
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Oakland Manor Nursing and Rehabilitation Center has a Trust Grade of F, indicating significant concerns about the facility's overall care quality. Ranked #161 out of 422 facilities in Michigan, they are in the top half, but this still reflects below-average performance in key areas. The facility is improving, having reduced the number of issues identified from 10 in 2022 to 7 in 2024. Staffing is a significant weakness, with a poor rating of 1 out of 5 stars and a concerning turnover rate of 61%, which is much higher than the state average. On the positive side, they have not incurred any fines and have an excellent quality measure rating of 5 out of 5 stars. However, there are serious issues to consider. For example, a resident with severe medical needs was not consistently weighed as required, leading to significant weight loss. Additionally, the kitchen environment was not adequately maintained, with standing water and pests present, which could affect food safety. Overall, families should weigh these strengths and weaknesses carefully when considering this facility for their loved ones.
- Trust Score
- C+
- In Michigan
- #161/422
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Michigan facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 38%
Needs review
10 → 7 violations
★★★★☆
4.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2022: 10 issues
2024: 7 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 61%
15pts above Michigan avg (46%)
Frequent staff changes - ask about care continuity
Chain: PIONEER HEALTHCARE MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (61%)
13 points above Michigan average of 48%
The Ugly 17 deficiencies on record
1 actual harm
Oct 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify, in writing, the reason for a discharge out of the facility ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify, in writing, the reason for a discharge out of the facility to a representative of the State Long term Care Ombudsman for two Residents (R15 and R17) of two residents reviewed for discharge.
Findings include:
Resident #15 (R15)
Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, revealed R15 was admitted to the facility on [DATE] and discharged from the facility on 7/31/24.
Review of facility report of discharges for month of July 2024 did not reveal R15 on the discharge report sent to the Ombudsman.
Resident #17 (R17)
Review of the MDS assessment, dated 9/2/24, revealed R17 was admitted to the facility on [DATE] and discharged from the facility on 9/2/24.
Review of facility report of discharges for the month of September 2024 did not reveal R17 on the discharge report sent to the Ombudsman.
During an interview on 10/30/24 at approximately 12:55 p.m., Social Worker C stated, R17 is not on the list for the ombudsman and should be.
Review of facility policy titled Transfer and Discharge date implemented 11/1/22, read in part . The facility will provide transfer/discharge notice to the resident/representative and Ombudsman as indicated .the Social Services Director, or designee will provide copies of notices . of transfer to the Ombudsman .such as in a list of residents on a monthly basis.
During an interview on 10/30/24 at approximately 3:20 p.m., the Nursing Home Administrator (NHA) stated, I know a list of discharges is supposed to be sent to the Ombudsman . It is something we missed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of the bed hold policy to resident or ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of the bed hold policy to resident or their representative prior to hospital transfer for one Resident (R17) of two residents reviewed for hospitalization, resulting in the potential of resident and/or resident representative being uninformed of the bed hold policy.
Findings include:
Resident #17 (R17)
Review of the Minimum Data Set (MDS) assessment, dated 9/2/24, revealed R17 was admitted to the facility on [DATE] and discharged from the facility to the hospital on 9/2/24.
During an interview on 10/30/24 Social Worker C stated, I don't know that I have a bed hold policy that was given to the resident or resident representative .it was not given to them, and I don't know what to tell you it just wasn't done .it was not given to R17 upon discharge.
Review of facility policy titled Bed Hold Notice Upon Transfer last reviewed/revised 3/13/24, read in part . At the time of transfer for hospitalization .the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy . the facility will keep a signed and dated copy of the bed hold notice information given to the resident and/or resident representative in the residents file.
During an interview on 10/30/24 at approximately 3:20 p.m., the Nursing Home Administrator (NHA) stated, I know a bed hold policy is supposed to be given upon discharge . It is something we missed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge summary for one Resident (R17) of two resident...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge summary for one Resident (R17) of two residents reviewed for discharge from the facility. This deficient practice resulted in the potential for compromised continuity of care.
Findings include:
Resident #17 (R17)
Review of the MDS (minimum data set) assessment, dated 9/2/24, revealed R17 was admitted to the facility on [DATE] and discharged from the facility on 9/2/24.
A Review of R17's Electronic Medical Record (EMR) revealed no discharge summary or recapitulation of stay was present in the record.
Review of facility policy titled Discharge Summary date implemented 11/1/22, read in part . It is the policy of this facility to ensure that a discharge summary is provided upon a residents discharge .the discharge summary provides necessary information to continuing care providers pertaining to the residents course of treatment while the resident was in the facility and the residents plan of care after discharge .It must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another.
During an interview on 10/30/24 at 1:30 p.m., RN/MDS (Registered Nurse/Minimum Data Set) A stated, I do the discharge summaries for the residents .I did not do a discharge summary for R17 .it was not done.
During an interview on 10/30/24 at approximately 3:20 p.m., the Nursing Home Administrator (NHA) stated, I know we are supposed to do a discharge summary . It is something we missed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received assistance with showering for one Re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received assistance with showering for one Resident #13 (R13) of one resident reviewed for ADL (activities of daily living) care, resulting in the potential for embarrassment, frustration, and unmet care needs.
Findings include:
Resident #13 (R13)
Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 9/20/24, with active diagnoses that included: diabetes mellitus, hypertension, and arthritis. R13 scored a 13 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of intact cognition. Further review of MDS assessment revealed the resident needed substantial/maximal assistance for showers/bathing.
During an interview on 10/29/24 at 10:51 a.m., R13 stated, I have only had one shower since being here .I got a shower last month and I look forward to getting a shower this month.
Review of the Electronic Medical Record (EMR) revealed that R13 had one shower since admission to the facility.
Review of facility shower schedule dated 8/14/24 revealed that R13 should be offered showers on Wednesday and Saturday.
During an interview on 10/30/24 at 9:45 a.m., RN/MDS (Registered Nurse/minimum Data Set) A stated, I am unable to find the charting in the EMR for the showers .
Review of facility policy titled Resident Showers date implemented 11/1/22, read in part . It is the policy of this facility to assist residents with bathing to maintain proper hygiene .residents will be provided showers as per request or as per facility schedule.
Review of facility policy titled Activities of Daily Living (ADLs) date implemented 11/1/22, read in part . Care and services will be provided for the following activities of daily living: bathing .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure weekly weights were completed for one Resident #4 (R4) of on...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure weekly weights were completed for one Resident #4 (R4) of one resident reviewed for nutritional needs. This deficient practice resulted in the potential for missed weight fluctuations.
Findings include:
Resident #4 (R4)
Review of R4's Minimum Data Set (MDS) assessment, dated 10/7/24 revealed admission to the facility on [DATE], with active diagnoses that included: diabetes mellitus, malnutrition, anxiety disorder, and depression. R4 scored a 14 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition.
During an interview on 10/29/24 at 1:03 p.m., R4 stated I don't get enough food or snacks. I have lost weight since being here . I have been weighing myself by the Activity room and have lost several pounds . I have told the staff, but they did not believe me and told me you have not lost weight.
Review of R4's Electronic Medical Record (EMR) revealed a Doctors order for weekly weights, R4 had an admission weight, and no subsequent weights had been completed.
During an interview on 10/30/24 at approximately 9:20 a.m., RN/MDS (Registered Nurse/Minimum Data Set) A stated, R4 had an admission weight but there were no other weights completed since then.
Review of facility policy titled, Weight Monitoring last reviewed/revised 3/27/24, read in part . A weight monitoring schedule will be developed upon admission for all residents .newly admitted residents- monitor weight weekly for four weeks .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to maintain a pest free environment. This deficient practice had the potential to affect all residents in the facility. Findings...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to maintain a pest free environment. This deficient practice had the potential to affect all residents in the facility. Findings include:
On 10/29/24 at 9:00 AM, during a tour of the kitchen serving area with Dietary Manager G, there was standing water and cobwebs observed in the corner under the steam table. Several gnats were observed near the standing water and flying about the kitchen area. When queried, Dietary Manager G stated the water was from filling the wells of the steam table. No explanation was provided for the gnats observed in the kitchen area.
On 10/29/24 at 9:20 AM, several gnats were observed flying about in the hallway near the resident rooms.
According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to post the required nurse staffing information resulting in the inability of residents to determine the number of staff availab...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to post the required nurse staffing information resulting in the inability of residents to determine the number of staff available to provide resident care and had the potential to affect all 14 residents in the facility.
Findings include:
During an observation on 10/29/24 at approximately 8:15 a.m., the daily nursing staffing sheet for 10/28/24 was located near the entrance to the wing of the facility where residents did not have direct access to the required nurse staffing information.
During an observation on 10/30/24 at approximately 1:55 p.m., the daily nurse staffing sheet was not located or available for the residents to review.
During an interview on 10/30/24 at 2:03 p.m., the RN/MDS (Registered Nurse/Minimum Data Set) A stated, there is not a nursing staffing sheet located for the residents to view.
During an interview on 10/30/24 at 2:15 p.m., the Certified Nurse Assistant B acknowledged that the residents do not go out by the entrance to the wing of the facility and stated, The residents don't go out that way.
During an interview on 10/30/24 at approximately 3:20 p.m., the Nursing Home Administrator (NHA) acknowledged that there was not the required nursing staffing information available for the residents to view.
Feb 2022
10 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12
A review of the medical record revealed that R12 was admitted to the facility on [DATE] with diagnoses including se...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12
A review of the medical record revealed that R12 was admitted to the facility on [DATE] with diagnoses including sepsis, pneumonia, anemia, weakness, falls and orthostatic hypotension.
Review of the care plan revealed R12 was to be weighed upon admission, weekly time four and then monthly if weights were stable.
Review of the medical record only revealed weights for 12/16/21 (admission weight of 151.2 lbs), 1/4/22 (137.4 lbs), and 1/5/22 (137 lbs). On 2/23/22 surveyor requested a current weight for R12, it was 135.8 lbs.
Review of a Nutritional Assessment Progress Note dated 1/11/22, written by Certified Dietary Manager (CDM A) revealed, Significant Loss .(R12) has sustained a 9.4% in 20 days weight loss. No weights for 90 or 180 days .He is required 1:1 feeding .cbw (current body weight) is 137.
During an interview on 2/23/22 at 11:30 a.m. when asked if R12 has lost any weight recently and when did the weight loss occur CDM A stated that (R12) triggered for severe weight loss last month. We liberalized his diet, asked for weekly weights and he is on the nutritional supplement. I request for weekly weights from nursing if I don't get them then I don't.
During an interview on 02/24/22 at 9:45 a.m. when asked when they were notified of R12's weight loss, RD B replied, I am not sure. No weekly weights were completed. When asked who is involved in evaluating and addressing any underlying causes of nutritional risks or impairment, RD B replied, If I am notified of an impairment I reach out to the CDM and get their assessment and observations of the residents, intakes, and preferences. I review the chart and try to figure out what's going on. When asked if R12 lost any weight recently RD B replied, Yes. When asked when the weight loss occurred, RD B stated, I am not sure there was no weekly weights done. If there was I would have gotten it the next week.
R8
On 2/22/22 at 3:58 PM, a review of R8's clinical record was conducted and revealed an admission date of 12/7/21 with diagnoses that included: stroke, dysphagia, hemiplegia, heart disease, and repeated falls. R8's most recently completed MDS assessment dated [DATE] indicated they had moderately impaired cognition, did not exhibit any hallucinations, delusions, behaviors, or rejection of care, was non ambulatory and required extensive assistance from one staff member for activities of daily living.
A review of R8's documented weights in the electronic medical record revealed the following documented weights: 12/8/22 147 lbs, 1/4/22 138.6 lbs and 1/5/22 139.6 lbs. It was noted no weight had been documented for February 2022.
A review of R8's progress notes was conducted and revealed the following:
A progress note from Certified Dietary Manager (CDM) 'A' dated 1/10/22 that read, Significant Loss Nutritional Status .(R8) has an <sic> 5% weight loss for x30 days .Expect weightloss <sic> continue because of poor intake .
A progress note from CDM 'A' dated 1/25/22 that read, (R8) po (oral) intake continues to be <25% of all meals. Weightloss <sic> may be unavoidable due to poor intake. Will speak with the idt (interdisciplinary team) about a <sic> approach.
A progress note from Registered Dietician (RD) ' B' dated 1/28/22 that read, Weight Loss .significant weight loss x30days; <sic> weight down 8# (lbs) x30 days <sic. Weight loss was unplanned, unavoidable, likely r/t (related to) variable intakes .Intervention: Place on weekly weights x 2 weeks, Will add Med pass 2.0 (dietary supplement) 1x/day, (once per day) Notify MD .of weight loss .
A progress note from the Administrator dated 1/31/22 that read, At Risk: (R8) was discussed by IDT .Weight loss noted, RD made aware .
A progress note from the Administrator dated 1/31/22 that read, At Risk: (R8) was discussed by IDT members .Glucerna (dietary shake supplement) ordered due to poor intake .
On 2/22/22 at 4:22 PM, a review of R8's orders was conducted and did not reveal any active, completed, or cancelled orders for weekly weights, or Med Pass 2.0 supplement referenced in RD 'B's note on 1/28/22, or the Glucerna Shake supplement referenced in the Administrator's note on 1/31/22.
On 2/23/22 at 11:30 AM, an interview was conducted with R8's assigned nurse, Registered Nurse (RN) 'F'. They were asked if the nursing staff administered Med Pass 2.0 supplements and said they did. They explained there would be a physician's order and a place to document the administration on the medication administration record.
On 2/23/22 at 2:05 PM, CDM 'A' was observed to obtain a weight for R8. R8's weight was 137.8 pounds, showing an additional loss of 1.8 pounds since their last documented weight on 1/5/22 where they had previously been identified as having a significant weight loss over a thirty day period.
On 2/24/22 at 9:46 AM, an interview was conducted with RD 'B' regarding R8's significant weight loss. RD 'B' was asked about their recommendation for weekly weights referenced in their note on 1/28/22 and said CDM 'A' was responsible for making sure the weekly weights were done. RD 'B' was asked if they followed up to ensure CDM 'A' obtained the weights and said they were currently overseeing ten different buildings and they checked them monthly. RD 'B' was then asked about the order for Med Pass 2.0 and after reviewing the clinical record confirmed they had put the order in but somehow it had also been discontinued the same day, also by them. RD 'B' said they must have made a mistake when they put the order in. RD 'B' was then asked about the use of food acceptance records and said CDM 'A' monitored that. They were asked where CDM 'A' documented food acceptance and said they did not have a place for it to be documented. RD 'B' was asked if they sat in on the IDT meetings and said they did not, CDM 'B' went to the IDT meetings. RD 'A' said they remotely charted on residents, made recommendations, and e-mailed them to the CDM 'A' and the Director of Nursing, but they did not follow-up to check on their recommendations.
Based on observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring for weight loss for three (R6, R8, and R12) of four residents reviewed for nutrition, resulting in significant and/or severe weight loss and the potential for further clinical compromise.
Findings include:
According to the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss dated 2/24/22, .The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe .3 months - 7.5% weight loss is significant; greater than 7.5% is severe .6 months - 10% weight loss is significant; greater than 10% is severe .The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes .The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition .Evaluating the resident's response to interventions should be based on defined criteria for improvement/worsening of nutritional status; for example, stabilization of weight .food/fluid intake .Recognizing the emergence of new risk factors; for example, pressure ulcers .
Resident #6:
On 2/22/22 at 9:53 AM, R6 was observed lying in bed, facing the door. The resident's body frame was noted to be very thin. Upon approach, resident was very confused.
Review of the clinical record revealed R6 was admitted into the facility on [DATE] with diagnoses that included: unspecified protein-calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, expressive language disorder, underweight, transient cerebral ischemic attack, aphasia, and dysphagia.
According to the Minimum Data Set (MDS) assessment dated [DATE], R6 had severe cognitive impairment, weighed 115, had no unplanned weight loss/gain, and received a mechanically altered diet.
On 2/22/22 at 2:30 PM, review of the available weights documented for R6 revealed an admission weight on 11/11/21 was 114.6 pounds (lbs). The most recent weight documented on 1/5/22 read 105.6 lbs (a loss of 9 lbs/7.85% in less than three months).
Review of the most recent nutritional assessment dated [DATE] by Certified Dietary Manager (CDM 'A') read, .Nutritional Status Underweight. (R6) po intake is fair at this time. His current diet is regular, thin liquid. He also requires an mech soft chopped texture. He receives a mighty shake tid (three times a day) with all meals. He did receive a diet upgrade. His bmi (body mass index) is 15.59. His cbw (current body weight) is 105.60/1/4/22. He does have an ulcer .He stain <sic> a 5.5% weight loss in 30 day on 1/4/22, no weights for x90 or x180 days. Will continue to montior <sic>.
Review of the nutritional assessment dated [DATE] by Registered Dietician (RD 'B') read, .Nutritional status underweight; significant weight loss x 30 days and admission weight; weight down 6# (pounds) x 30 days and 9# since admission. Weight loss was unplanned, unavoidable, likely r/t (related to) variable intakes, 50% of meals, had PNA (pneumonia), pressure ulcer healing .R hip pressure ulcer stage 2- will recommend MVT (multivitamin) and prostat TID (nutritional supplement three times a day) .Intervention: Place on weekly weights x 2 weeks . There were no additional weights obtained or documented since 1/5/22.
On 2/23/22 at 9:50 AM, an interview was conducted with the [NAME] President of Operations (Staff 'H') who was assisting administration during this survey. When asked about what the facility's process was for monitoring weights, Staff 'H' reported it would be done weekly for four weeks and a re-weight would occur if the weight obtained was more than or less than five pounds from the previous weight.
On 2/24/22 at 9:11 AM, CDM 'A' was asked to obtain a weight for R6. At that time, CDM 'A' reported they had obtained a weight yesterday (following concerns with lack of resident weights identified during survey) but that had not been put into the electronic clinical record yet. CDM 'A' was asked to observe a current weight with R6 and indicated they would be able to do that now. R6's current weight was 110.2 lbs.
On 2/24/22 at 9:25 AM, an interview and record review were conducted with CDM 'A'. When asked about the facility's process for monitoring resident's nutritional status and weights, CDM 'A' reported they were the primary person and there was also a corporate dietician that assisted. When asked to review R6's weight variance reports, CDM 'A' confirmed the last documented weight was 105.6 on 1/5/22. The CDM also confirmed the weight on 12/16 was also 105.6 lbs and the weight previous to this was 111.8 lbs. CDM 'A' confirmed there was no re-weight done following the weight loss beyond five lbs on 12/16. CDM 'A' reported the nurse should've notified them of the weight variance to obtain a re-weight and address interventions at that time. The next weight following the weight on 12/16/21 was not obtained until 1/4/22 (which was 105.2). A re-weight was done on 1/5/22 which documented 105.6. When asked about what interventions were implemented following the significant weight loss identified on 1/5/22 and a new pressure ulcer identified on 1/3/22, CDM 'A' reported they had sent an email to RD 'B' and the Director of Nursing (DON) on 1/5/22. CDM 'A' could not explain why they had not been notified of R6's weight loss identified by nursing on 12/16/21. When asked what was done following the notification to RD 'B' on 1/5/22, CDM 'A' reported they had an email response (which was offered to be viewed by CDM 'A') from RD 'B' on 1/28/22 which included multiple recommendations. When asked the delayed response, CDM 'A' was unable to offer an explanation and further reported the goal for the RD is to come in once a month to see the residents but that didn't work out as they worked mostly remotely and covered 10 buildings. CDM 'A' reported the recommendation from RD 'B' on 1/28/22 included weekly weights for two weeks. When asked about their assessment on 2/15/22 and if they had identified a lack of follow up with RD 'B's recommendation for weekly weights was not completed, CDM 'A' was unable to offer any further explanation. CDM 'A' was asked how it was determined R6's weight loss was unavoidable and CDM 'A' reported when the resident came in he was only eating about 25% and then had weight loss. When asked if they had determined if there was any difficulty eating/chewing, or food dislikes or any other contributing factors or clinical rationale from the physician to be able to identify wt loss was unavoidable, CDM 'A' responded, I see what you mean.
CDM 'A' further reported their process for monitoring residents' weights was to do weekly for four weeks, then monthly if stable. When asked who monitored the resident's food/fluid intake and where that would be documented, CDM 'A' reported that was not documented and that they kept track of that information since they did all the meal tray set up and they were able to see what was eaten when the trays came back.
When asked how nursing staff became aware which residents needed to be weighed, CDM 'A' reported they used to give nursing staff a sheet of which residents needed to be weighed but that they had not done that in a while. When asked what was the reason that had not been done, CDM 'A' did not offer any further explanation.
At that time, CDM 'A' was asked to review R6's weights and acknowledged they had not identified the weight loss from 12/16/21 until R6's weight was obtained on 1/4/22. CDM 'A' further reported R6 should have been on weekly weights. When asked who was responsible for ensuring weights were done or following up if they were not, CDM 'A' reported that was the nursing staff's responsibility.
On 2/24/22 at 9:50 AM, an interview and record review were completed with RD 'B'. When asked about their position with the facility, RD 'B' reported they covered 10 facilities (mostly) remotely and became full-time in October 2021. When asked about their process for monitoring resident's nutritional status, weights, etc., they reported they oversee the CDM and for at-risk residents such as those on tube feeding, dialysis or had pressure ulcers.
When asked about the delayed response to CDM 'A's email notification of R6's significant weight loss on 1/5/22, RD 'B' reported, Honestly I was stuck at another building. Had talked in meantime and put plan together. When asked who was responsible to ensure weights were being obtained and monitored, RD 'B' reported typically the CDM lets nursing know, I communicate with CDM and monitor weights at the beginning of the month, the CDM talks to DON and the DON, CDM and Administrator follow up.
When asked if they participated in the at-risk meetings, RD 'B' reported the CDM was the designated person from dietary for those meetings. When asked if they participated in any quality assurance meetings to identify concerns with nutritional processes, RD 'B' reported the CDM was involved in those meetings as well.
When asked if they had recommendations, how did those get implemented, RD 'B' reported they would send an email to the CDM and DON of items recommended and the DON would put an order in for the recommendations as the CDM did not have access to order entry.
On 2/24/22 at 10:48 AM, an interview was conducted with the DON. When asked about who was responsible for making sure the weights were obtained as needed, or if they were not, who was overseeing this process, the DON reported the CDM was to give a list to nursing staff and the nurses assigned CNAs to obtain and that information was given back to the CDM. When asked if they were aware of any concerns that weights were not being done as recommended or per facility policy, the DON reported I have not been notified. When asked if they had participated in any of the at-risk meetings, the DON reported, The DON further reported that they had not been at these meetings since they had been pulled to work at another facility and that out of the past six weeks, they had been gone about four weeks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure three residents (R#'s 8, 13, and 16) were treated in a dignified manner, of three residents reviewed for dignity. Find...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure three residents (R#'s 8, 13, and 16) were treated in a dignified manner, of three residents reviewed for dignity. Findings include:
A review of a facility provided policy titled, Resident Rights with a revision date of October 2021 was conducted and read, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .
R8
On 2/22/22 at 9:15 AM, R8 was observed up in the hallway eating their breakfast. It was observed R8 had an indwelling urinary catheter. It was observed the urinary collection bag was hanging under the seat of their wheelchair and had not been placed in a privacy bag, making the drainage bag visible to resident's staff, and visitors.
On 2/22/22 at 10:16 AM, R8 remained up in the hallway in their wheelchair with their urinary catheter drainage bag visible.
On 2/22/22 at 11:27 AM, R8 was observed in their wheelchair in the dining room. It was observed the urinary catheter drainage bag remained under the seat of the wheelchair, visible, not in a privacy bag.
On 2/22/22 at 3:58 PM, a review of R8's care plans was conducted, and it was revealed R8 had a care plan approach dated 12/7/21 for their urinary catheter that read, .Store collection bag inside a protective dignity pouch .
R8, R13, and R6
On 2/22/22 from 12:40 PM until 1:00 PM an observation was made of the lunch meal in the facility's dining room. The following was observed:
At 12:40 PM, R13, R8, and R16 were observed seated together at a table in the dining room. R8 and R16 were observed to have their lunch meals in front of them and were eating. R13 was not observed to have a meal served to them.
At 12:45 PM, R13 was reaching at R8's meal tray and was observed to take a half finished juice cup from R8's tray and began to drink it, finishing it. R13 then grabbed the fork from R8's tray and began feeding herself R8's food.
At 12:50 PM, R13 still did not have a lunch meal and R16 was observed to give them some crackers from their meal tray. R13 was observed to eat the crackers.
At 12:55 PM, R13 received their meal tray, and R8 and R16 were observed to be finished with their meal.
On 21/24/22 at 11:04 AM, the observations of R8's catheter bag and the lunch observation were shared with the facility's Director of Nursing (DON). They indicated R8's catheter bag should have been placed in a privacy bag and during meals, residents seated together should be served their meals together.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to properly assess and document a resident's skin status ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to properly assess and document a resident's skin status for one (R6) of one resident reviewed for pressure ulcers, resulting in the increased potential for delayed healing and/or worsening of the wound.
Findings include:
According to the facility's policy titled, Pressure Ulcer Treatment Level III dated 2/22/22, .Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough .Stage II Pressure Ulcer Interventions/Care Strategies .Follow-up if wound does not improve in 2-3 weeks, notify physician. Consider a skin consult with a wound specialist .The following information should be recorded in the resident's medical record .The type of treatment and resident response .Any change in the resident's condition .All assessment data (i.e., color, size, pain, drainage, etc.) when inspecting the wound .Report other information in accordance with facility policy and professional standards of practice.
Review of the clinical record revealed R6 was admitted into the facility on [DATE] with diagnoses that included: unspecified protein-calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, and expressive language disorder.
According to the Minimum Data Set (MDS) assessment dated [DATE], R6 had severe cognitive impairment, did not have a pressure ulcer but was at risk of developing pressure ulcers/injuries, and had a pressure reducing device for the bed.
Review of R6's weekly skin assessments since admission revealed there was a change in the resident's skin condition identified on 1/3/22 by Nurse 'H' at 11:07 AM which read, .Pressure Ulcer - R (right) hip . There were no other identifying descriptions of the wound and the section for risk factors was left blank. The proceeding assessments also completed by Nurse 'H' on 1/10, 1/17, 1/24, 2/7, 2/15 and 2/21 all noted the same as on 1/3. None of these assessments had any other identifying description or details of the wound.
Further review of R6's clinical record revealed conflicting assessment status of the pressure ulcer wound. A wound consultation from Wound Nurse Practitioner (NP 'C') dated 2/4/22 (most recent) documented a status as Wound #1 Right, Lateral Hip is a Stage 2 Pressure Injury Pressure Ulcer and has received an outcome of Resolved . There was no further documentation that NP 'C' had been notified of any changes in R6's skin condition following their assessment on 2/4/22, or that the attending physician had been notified of any changes in R6's skin condition as of this review.
Further review of R6's clinical record revealed the facility did not address ongoing skin assessments that identified the condition of the wound, whether there had been any changes to the pressure ulcer, or that the physician had been notified (as indicated in their policy). This was not identified until after it was brought to the facility's attention during the survey.
Review of R6's physician orders for the right hip pressure ulcer included:
Cleanse R hip with wound cleaner and apply dry dressing. Every Shift 07:00 AM - 07:00 PM, 07:00 PM - 07:00 AM (ordered 1/3/22 - d/c'd 1/30/22).
Cleanse R hip with wound cleaner and apply dry dressing. Once A Day Every Other Day 07:00 PM - 07:00 AM (ordered on 1/30/22 and remained current as of 2/23/22).
On 2/22/22 at 1:31 PM, Nurse 'H' was attempted to be contacted for an interview by phone. There was no return call by the end of the survey.
On 2/23/22 at 9:30 AM, the Administrator reported that the Director of Nursing (DON) had worked the midnight shift and would likely not be in the facility today and the Administrator would be available for any clinical follow-up.
On 2/23/22 at 11:40 AM, an interview and record review was conducted with the Administrator. When asked about R6's right hip pressure ulcer, the Administrator reported that had been resolved and confirmed the documentation from NP 'C' on 2/4/22. Upon review of the weekly skin assessments following 2/4/22, the Administrator confirmed they all identified that R6 had a right hip pressure ulcer without any details or descriptions of the condition of the skin/wound. When asked how it could be determined if the weekly skin assessments were being completed accurately if they all documented R6 had a right hip pressure ulcer, despite NP 'C's documentation the wound had resolved as of 2/4/22, the Administrator reported the nurses should be including wound descriptions and details with these assessments and would follow-up. There was no additional follow-up in regard to R6's pressure ulcer by the end of the survey.
On 2/23/22 at 12:14 PM, an interview was conducted with R6's assigned nurse (Nurse 'D'). When asked about R6's skin condition, Nurse 'D' reported they had only been working at the facility for a few days but was aware there was an open area to R6's right hip.
On 2/23/22 at 1:40 PM, an observation of R6's skin was completed with Nurse 'D' and Certified Nursing Assistant (CNA 'E'). R6 was observed lying on their right side, facing the door and agreed to observation of their right hip wound. Nurse 'D' and CNA 'E' were able to have R6 roll to their left side Nurse 'D' proceeded to remove the undated dressing that was secured over the resident's right hip. Nurse 'D' reported the dressing they removed was the same one they had placed on the resident yesterday. When asked how it could be determined that was the same dressing since it was not dated, Nurse 'D' was unable to offer any explanation. Upon removal of the dressing, there was brownish colored drainage on the dressing. Upon cleaning the wound area with normal saline, the resident responded Ouch and Nurse 'B' stated Sorry, I know that burns a little. Nurse 'D' obtained wound measurements using a paper ruler and reported the size of the wound was 1.5 centimeters (cm) in length by .5 cm in width. The base of the wound appeared pink in color.
On 2/24/22 at 10:50 AM, an interview was conducted with the DON. When asked about their facility's process for monitoring resident's changes in status such as pressure ulcers, the DON reported they had at-risk meetings weekly and would be discussed as an interdisciplinary team. When asked who was responsible for overseeing the pressure ulcers, they reported that would be the DON. The DON further reported that they had not been at these at-risk meetings since they had been pulled to work at another facility and that out of the past six weeks, they had been gone about four weeks. When asked about the process of monitoring changes in resident's skin condition and documentation of the details of the wounds, the DON reported Nurse 'H' was responsible for doing their wound assessments and coordinated with NP 'C'. The DON was unable to offer any further explanation as to the conflicting documentation of R6's right hip pressure ulcer status, or lack of documentation of the wound details.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure complete assessment following a fall with injur...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure complete assessment following a fall with injury to ensure appropriate interventions were in place or consider new interventions to prevent future fall occurrences for one (R6) of one resident reviewed for falls.
Findings include:
According to the facility's policy titled, Falls and Fall Risk, Managing dated 2/24/22, .Monitoring Subsequent Falls and Fall Risk .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .
According to the facility's policy titled, Assessing Falls and Their Causes dated 2/24/22, .After a Fall .the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred .Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident .The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found .After a fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms .and will document the results of this effort .When a resident falls, the following information should be recorded in the resident's medical record .Appropriate interventions taken to prevent future falls .
On 2/22/22 at 9:53 AM, R6 was observed lying in bed, facing the door. The resident's bed was noted to be in an elevated position from the floor (not carpeted) which did not have any type of a floor mat.
Review of the clinical record revealed R6 was admitted into the facility on [DATE] with diagnoses that included: unspecified protein-calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, expressive language disorder, underweight, transient cerebral ischemic attack, aphasia, and dysphagia.
According to the Minimum Data Set (MDS) assessment dated [DATE] documented R6 had no communication concerns, had severely impaired cognition, and had one fall without injury.
Review of the fall care plan initiated 11/10/21 identified R6 was at risk for falling R/T (related to): weakness and debility, attempts to perform unassisted transfers, fall risk score, impaired cognition; (R6) has been using his bed control to raise the bed up high and not keeping in low position despite frequent reminders to keep the bed low. There was no documentation that these interventions were reviewed until 2/22/22.
Review of the progress notes revealed R6 had two falls since admission on [DATE] and on 2/23/22.
An entry on 2/7/22 at 3:08 PM by Nurse 'H' read, .Resident was observed by staff lying on floor of bedroom on R (right) side .Abrasions noted below R knee and side of L (left) knee .
Review of the clinical record revealed there was no documentation that the facility had reviewed R6's fall to investigate the potential cause or identify if interventions were appropriate, or if new interventions were needed.
Review of R6's facility event reports provided by the facility included two documents (dated 2/7/22 and 2/23/22). Review of the event report for 2/7/22 which had been completed by Nurse 'H' documented R6 had an unwitnessed fall in their room which resulted in abrasions. The section of the form which read Care Plan Reviewed was marked No. There was no documentation of what interventions had been in place at the time of the fall, consideration of any new interventions or any interviews with staff. There was no additional documentation available for review in the clinical record.
On 2/22/22 at 1:31 PM, Nurse 'H' was attempted to be contacted for an interview by phone. There was no return call by the end of the survey.
On 2/23/22 at 1:15 PM, an interview was conducted with the Administrator. At that time, the Administrator reported the Director of Nursing (DON) was not currently available, or at the facility and would be able to assist with questions regarding R6's falls. When asked about what their process was for reviewing events such as falls, and what they did to prevent future occurrences, or identify the root cause or any specific details at the time of the fall, the Administrator reported they should have discussed that in their weekly at-risk meeting. The Administrator was asked to review the clinical record and confirmed there was no documentation that an at-risk meeting was completed for R6 following the fall on 2/7/22, or whether interventions had been reviewed. The Administrator reported the DON might have additional documentation and would follow up. There was no additional documentation provided by the end of the survey.
On 2/24/22 at 10:50 AM, an interview was conducted with the DON. When asked about R6's falls and whether they could provide any documentation that the resident's fall on 2/7/22 had been assessed, the DON reported they had at-risk meetings weekly and would be discussed as an interdisciplinary team. The DON further reported that they had not been at these at-risk meetings since they had been pulled to work at another facility and that out of the past six weeks, they had been gone about four weeks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the administration of the influenza (flu) and pneumococcal (...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the administration of the influenza (flu) and pneumococcal (pneumonia) vaccines to two residents (R#'s 6 and 8) who wished to receive the vaccine, of five residents reviewed for vaccines. Findings include:
A review of a facility provided policy titled, Immunization and Vaccination revised September 2021 was conducted and read, .1. Residents/patients will receive recommended immunizations .1. Soon after admission, the staff will review each resident's immunization status. 2. Based on appropriate assessment of the resident/patient and relevant information the physician will order appropriate immunizations .
On 2/23/22 at 9:28 AM, a review of R6's clinical record revealed they admitted to the facility on [DATE] and signed a document titled, FLU AND PNEUMONIA VACCINE CONSENT with a check mark that indicated they wished to receive the annual flu vaccine and the pneumonia vaccine.
On 2/23/22 at 9:30 AM, a review of R8's clinical record revealed they admitted to the facility on [DATE] a document titled, FLU AND PNEUMONIA VACCINE CONSENT had been signed with a check mark that indicated they wished to receive the annual flu vaccine and the pneumonia vaccine.
On 2/23/22 at 9:43 AM, evidence that either R6 or R8 had received the vaccine was not available in the electronic medical record. In absence of the Director of Nursing (DON), the facility's [NAME] President of Operations was requested to provide evidence the vaccines had been received. At 10:15 AM, The [NAME] President of Operations reported neither R6 or R8 had received the vaccines and they were not sure why.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure a remote control for the bed and call light cord were maintained in safe, operating condition for one (R17) of one resi...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure a remote control for the bed and call light cord were maintained in safe, operating condition for one (R17) of one resident reviewed for environment.
Findings include:
Review of the facility's policy titled, Equipment Management dated 2/24/22 read, .In the event that any equipment stops functioning as expected, the equipment will be removed from service, tagged as broken, taken out of the patient care area, and a work order will be submitted to the facility maintenance manager .If a piece of equipment malfunctions, remove the equipment from the resident care area with any supplies or accessories attached .Prior to use, the maintenance manager will inspect the cord and plug of any electrically powered .equipment .
On 2/22/22 at 9:21 AM, R17 was observed lying in bed with the head of the bed slightly elevated. Upon approach, the resident was also observed to have oxygen being delivered via nasal cannula and was visibly upset. R17 was observed repeatedly attempting to press the button on the bed remote to raise the head of the bed, without success. R17 handed the remote to this surveyor to see if able to get the bed remote to work, but the button to raise the bed was not functioning. During this time, R17 was very short of breath and reported they needed the head of the bed up to be able to breathe easier. The nurse was informed of the resident's concern with the bed remote.
On 2/22/22 at 12:51 PM, R17 was observed attempting to reach out to eat their lunch meal without success. The head of the bed remained in the slightly lower position as observed earlier. R17 asked to try the bed remote again and the button still did not work. The resident was asked to press their call light button, which they did. At that time, the call light button was observed to have exposed wires between the cord and the end of the call light button. Resident reported they liked to have the call light button kept directly on their abdomen area on top of the sheets so they could reach it.
On 2/22/22 at 1:01 PM, Certified Nursing Assistant (CNA 'J') responded to the activated call light. CNA 'J' attempted to press the bed control button to raise the head of the bed and reported it would not move. When asked if that was the first time they had an issue with the bed remote, CNA 'J' reported no but could usually get it to work if the button was pressed down for a while. CNA 'J' was observed to push the button and after several attempts the bed raised up slightly then stopped. When asked if this had been reported previously, CNA 'J' reported no as they were usually able to get it to go if you kept trying. When asked if that had been reported to any facility staff, they reported no.
On 2/22/22 at 1:10 PM, an interview was conducted with the Administrator. When asked who the facility's Maintenance Director was in regard to ensuring resident equipment was maintained, they reported for big things they called the hospital and fix it but for things like beds, they would call their supervisor and they'd send someone. When asked how they became aware of issues with resident care equipment and what their process was for monitoring to ensure they were functioning safely and properly, the Administrator reported there was a log at the desk it would be noted in and when they were doing rounds. When informed of the observation of R17's non-functioning bed remote and exposed wires on their call light button, the Administrator reported they were just in their room yesterday and was not aware of those concerns. The Administrator further reported they were frequently in R17's room but was not aware of these concerns and also reported staff had access to a computer at the nursing station but no one had reported this previously. The Administrator reported they would follow up.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure the use of hair and beard restraints by kitchen staff, failed to ensure food items were covered, labeled, and dated, a...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure the use of hair and beard restraints by kitchen staff, failed to ensure food items were covered, labeled, and dated, and failed to ensure potentially hazardous food items were held at the proper temperature. These deficient practices had the potential to affect all residents that consume food from the kitchen. Findings include:
During an initial tour of the kitchen on 2/22/22 from 8:50 AM-9:30 AM, the following items were observed:
Dietary Staff I was observed at the steam table inside the kitchen and was not wearing a hair restraint. When queried, Dietary Staff I confirmed she should have been wearing a hair restraint. On 2/22/22 at 11:30 AM, Certified Dietary Manager (CDM) A was observed bringing the lunch items into the kitchen, taking food temperatures, and placing the food items onto the steam table. CDM A was observed with a beard but was not wearing a beard restraint.
Observation of a sign posted on the kitchen door noted the following: Hair nets and beard guards must be worn at all times in the kitchen.
According to the 2013 FDA Food Code section 2-402.11 Effectiveness, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
In the reach-in refrigerator, there was a 3 pound can of tomato soup, which was opened and uncovered. There was a pan of chili that was unlabeled and undated.
According to the 2013 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306
According to the 2013 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
The handwashing sink next to the steam table was covered up with 3 steam table lids.
According to the 2013 FDA Food Code section 5-205.11 Using a Handwashing Sink, 1. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. 2. (B) A HANDWASHING SINK may not be used for purposes other than handwashing.
In the refrigerator located in the therapy room, there was a foil covered plate of an unknown meat that was undated. CDM A stated, Everything needs to be dated or it gets thrown out.
According to the Facility policy Foods Brought by Family/Visitors revised 10/26/21, 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator designated for resident use. Containers will be labeled with the resident's name, the item and the use by date.
On 2/22/22 at 11:30 AM, CDM A was observed unloading the lunch food items, which had been transferred in an insulated container from another facility. The internal temperatures of the food items were measured as follows:
Pan of tuna sandwiches: 59-60 degrees Fahrenheit
Pan of chicken salad sandwiches: 58 degrees Fahrenheit
Pan of cucumber/tomato salad: 57 degrees Fahrenheit
Tuna puree: 83 degrees Fahrenheit
Vegetable puree: 87 degrees Fahrenheit
Puree soup: 101 degrees Fahrenheit
According to the 2013 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: 1. (1) At 57ºC (135ºF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54ºC (130ºF) or above; or 2. (2) At 5ºC (41ºF) or less.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program that identified deficiencies, and then developed and im...
Read full inspector narrative →
Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program that identified deficiencies, and then developed and implemented appropriate plans of action to correct quality deficiencies related to weight monitoring for residents with weight loss. This deficient practice has the potential to affect all residents that resided in the facility.
Findings include:
During an interview on 2/24/22 at 1:35 p.m., when asked if the QAPI program had identified that there was a problem with resident weights not being completed timely, the NHA stated that the CDM (Certified Dietary Manager) will request weights sometimes in the meeting, but it was not identified as a problem and there was no process for improvement of this issue.
During this same interview the QAPI plan was reviewed with NHA. This review of the QAPI plan failed to reveal how concerns are measured, improvement areas are identified, how correction actions would be implemented and then how the facility would assess the effectiveness of the corrective actions. The NHA was not able to provide this information during the QAPI task interview.
Review of the facility's policy entitled, Quality Assessment/ Process Improvement Plan Revised 1/18/22, revealed the following, .The primary purposes of the Quality Assessment and Performance Improvement (QAPI) Plan are: 1. to provide a means to identify and resolve present and potential negative outcomes related to resident care and safety . and .4. to establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcomes .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation had two deficient practices.
Deficient Practice #1
Based on observation, interview, and record review the facility...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation had two deficient practices.
Deficient Practice #1
Based on observation, interview, and record review the facility failed to implement appropriate infection control practices including: proper personal protective equipment (PPE) use in transmission-based precaution rooms and proper transmission-based precaution education for visitors for one resident (R121), proper PPE use during COVID-19 specimen collection from staff and residents, and proper hand hygiene and glove use for three residents (R's 18, 171, and 6) of nine residents reviewed for infection control, resulting in the potential for the spread of infection. This deficient practice had the potential to affect all 19 residents who resided in the facility. Findings include:
A review of the facility policy for transmission based precautions was reviewed, however; the provided policy did not include specific directives for caring for COVID-19 unvaccinated residents.
A review of the Center for Disease Controls guidance at https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html updated on 10/25/21 was reviewed and read, For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2, (COVID-19) maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a gown .
A review of a facility policy titled, Handwashing/Hand Hygiene revised 1/27/21 was conducted and read, .Use an alcohol-based hand rub .or alternatively, soap .and water for the following situations: .b. before and after direct contact with residents; .m. After removing gloves; .9. The use of gloves does not replace hand washing/hand hygiene .
R121, 18, and 171
On 2/22/22 at 9:20 AM, Licensed Practical Nurse (LPN) 'CC' was observed to don personal PPE required for entry into R121's droplet isolation room. A sign on the door indicated a gown, gloves, eye protection and an N95 mask were required to enter the room. As LPN 'CC' donned the PPE, it was observed they placed an N95 face mask over the KN95 mask they were already wearing.
On 2/22/22 at 9:40 AM, LPN 'D' was observed to exit R18's room with a pair of blue examination gloves on. LPN 'D' proceeded down the hallway to a linen cart and remove a washcloth from the clean linen cart, wearing the examination gloves. LPN 'D' then re-entered R18's room with the gloves on and the washcloth in their hand. LPN 'D' gave the washcloth to R18 and exited the room. As LPN 'D' was exiting the room they were observed to doff the gloves and dispose of them in the garbage receptacle on the medication cart in the hallway.
On 2/22/22 at 10:38 AM, LPN 'CC' was observed in R121's room with an N95 mask placed over the top of a KN95 mask.
On 2/23/22 at 10:00 AM, Social Worker 'FF' was observed in R121's contact isolation room. A sign outside of R121's room indicated a gown, gloves, eye protection, and N95 mask were required for entry. Social Worker 'FF' was observed to have a surgical mask covering their nose and mouth. When Social Worker 'FF' exited the room they were interviewed about what PPE was required to enter the room. They said they were supposed to have had on an N95 mask, but they just didn't grab one.
On 2/23/22 at 11:25 AM, LPN 'D' was observed in the dining room wearing a pair of blue surgical gloves carrying a temporal no-touch thermometer. LPN 'D' was then observed from the hallway to enter R18 and R171's room. LPN 'D' obtained R18's temperature wearing the surgical gloves. They were then observed to move over to R171 and obtain their vital signs. LPN 'D' was not observed to doff the gloves or perform hand hygiene in between resident contact for R18 and R171.
COVID-19 Specimen Collection
On 2/22/22 at 11:47 AM, Staff 'EE' was observed pulling down their pink mask and performing their own COVID-19 nasal swab test at the nursing desk. There was no other staff nearby or in the area. When asked about their process for testing and if that was usually done at the nursing desk, Staff 'EE' stated, Typically it's under nurse supervision. I thought they (Nurse) was here but must've got a pharmacy delivery. When asked to clarify if the tests where usually done at the nursing station, Staff 'EE' stated, Yes, but not if there's any residents around. I'll throw this one out and get another. When asked what type of testing they were doing, they reported, The twice weekly for vaccinated (staff).
On 2/23/22 at 12:25 PM, Registered Nurse (RN) 'F' was observed administering COVID-19 rapid tests to two visitors and Dr. 'GG' in the facility's lobby. RN 'F' was not observed to don an isolation gown, N95 mask, or eye protection during the nasal swab specimen collection from the two visitors and Dr. 'GG'.
On 2/23/22 at 1:19 PM, an interview was conducted with the facility's Administrator regarding the observations of the COVID-19 testing by staff. The Administrator indicated only nurses were supposed to perform the testing for COVID-19 and it should be done prior to entering the resident care area. The Administrator was then asked what PPE should staff wear when performing COVID-19 testing. The Administrator said that when they performed testing on staff they wear a gown, gloves, and surgical mask. They were asked if they wore eye protection and said they wore glasses, so no they did not wear any additional eye protection. It was brought to the Administrator's attention the observation of Staff 'EE' obtaining their own specimen at the nursing station, and RN 'F' obtaining COVID-19 nasal swab specimens from visitors and Dr. 'GG' wearing only a surgical mask and gloves. At that time, the administrator was asked to provide the facility policy, or guidance they used for PPE use when collecting COVID-19 specimens, no policy or guidance was received by the end of the survey.
R6
According to the facility's policy titled, Pressure Ulcer Treatment Level III dated 2/22/22, .Wash hands before treatment .Apply gloves .Remove soiled dressing and place in opened plastic bag. Also remove soiled gloves and place in the plastic bag .Wash hands .Apply gloves .Clean area with normal saline .Open package and remove dressing, maintaining sterility .Apply dressing/treatment .Remove and discard gloves .Wash and dry your hands thoroughly .
Review of the clinical record revealed R6 was admitted into the facility on [DATE] with diagnoses that included: unspecified protein-calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction, and expressive language disorder.
Review of R6's weekly skin assessments since admission revealed there was a change in the resident's skin condition identified on 1/3/22 by Nurse 'H' at 11:07 AM which read, .Pressure Ulcer - R (right) hip .
On 2/23/22 at 1:40 PM, an observation of R6's skin was completed with Nurse 'D' and Certified Nursing Assistant (CNA 'E'). R6 was observed laying on their right side, facing the door and agreed to an observation of their right hip wound. Nurse 'D' and CNA 'E' were able to have R6 roll to their left side Nurse 'D' proceeded to remove the undated dressing that was secured over the resident's right hip. Nurse 'D' reported the dressing they removed was the same one they had placed on the resident yesterday. When asked how it could be determined that was the same dressing since it was not dated, Nurse 'D' was unable to offer any explanation. Upon removal of the dressing, there was brownish colored drainage on the dressing. Using the same gloves used to remove the soiled dressing, Nurse 'B' began to clean the wound area with normal saline. R6 responded Ouch and Nurse 'B' stated Sorry, I know that burns a little. Nurse 'D' was not observed to change gloves, use hand sanitizer, or wash hands prior to cleaning R6's wound. Nurse 'D' obtained wound measurements using a paper ruler and reported the size of the wound was 1.5 centimeters (cm) in length by .5 cm in width. The base of the wound appeared pink in color. Nurse 'D' then opened the clean wound dressing with the same soiled gloves and placed on top of the resident's bed sheet. Nurse 'D' then removed their soiled gloves, used hand sanitizer, and donned new gloves. Upon pulling the wound dressing from the packaging, the sticky portion pulled on and ripped the glove on Nurse 'D's right hand. Nurse 'D' proceeded to place the dressing over R6's wound with the same ripped glove.
On 2/24/22 at 10:49 AM, an interview was conducted with the facility's Director of Nursing/Infection Control Preventionist. They were asked what PPE was required to enter a droplet isolation room and reported staff should wear an isolation gown, N95 mask, gloves, and eye protection. They were also made aware of LPN 'D' wearing gloves in the hallway and not performing hand hygiene or changing gloves in between caring for residents. The DON acknowledged the concerns and said gloves should not be worn in the hallway, hand hygiene should be done in between glove use and gloves should be changed in between residents. The DON was then asked about the process for completing wound care treatments and reported the nurses should wash hands and switch gloves. When informed of the infection control practices during R6's wound care with Nurse 'D', the DON acknowledged the concerns and reported they were not in accordance with their policy and standards of practice and would follow-up.
Deficient Practice #2
Based on interview and record review the facility failed to ensure a comprehensive infection control program that consistently included monthly summaries, infection rates, line listings of resident infections, determination of whether infections were acquired from the hospital or in the facility, whether infections met criteria for the use of antibiotics, mapping for trends or outbreaks, pharmacy reports, lab reports, and departmental surveillance. This deficient practice had the potential to affect all 19 residents who resided in the facility. Findings include:
A review of an undated facility provided policy titled, Infection Control was conducted and read, This facility's Infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infection .2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility .
On 2/24/22 12:22 PM a review of the facility's infection control program data was reviewed. It was noted no infection control data (monthly summary, line listings of resident infections, mapping, pharmacy reports, lab reports, or departmental surveillance) for January 2022 was provided. At that time the Director of Nursing (DON)/Infection Control Preventionist was asked about the January 2022 data and said they had been pulled to two other sister facilities and was told by the Administrator they had until February 25, 2022, to compile the data.
A review of the December 2021 program data revealed only a monthly summary. The data did not include any line listings or whether the infections met the McGeer's criteria (a set of symptom/diagnostic criteria to justify the use of antibiotics), mapping, pharmacy reports, lab reports, or departmental surveillance.
A review of the November 2021 data included a monthly summary and a line listing of resident infections, however; the line listings were incomplete and did not show resident admission dates, whether the infections were acquired in-house or from the community, or whether the infections met the criteria for antibiotic use. The data did not include the use of any mapping, pharmacy reports, lab reports, or departmental surveillance.
A review of the October 2021 data only included a pharmacy report of antibiotics prescribed to four residents. The data did not contain a monthly summary, line listings, mapping, lab reports, or departmental surveillance.
On 2/24/22 at 1:27 PM, an interview was conducted with the facility's Administrator regarding the lack of documentation for the infection control program and the Administrator acknowledged the concern.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to track and securely document the COVID-19 vaccination status for 20 Staff members (Registered Dietician 'B', Registered Nurse '...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to track and securely document the COVID-19 vaccination status for 20 Staff members (Registered Dietician 'B', Registered Nurse 'F', Licensed Practical Nurses 'K', 'L', 'M', 'N', 'O', 'P', and 'Y', and Certified Nursing Aides 'Q', 'R', 'S', 'T', 'U', 'V', 'W', 'X', 'Z', 'AA', and 'BB') of 71 staff members reviewed for COVID-19 vaccination status, and implement additional precautions for personal protective equipment (PPE) use for COVID-19 vaccine exempt staff in accordance with their COVID-19 vaccination of facility staff policy for two staff members (Dietary Aide 'I' and Activity Director 'DD') of two staff members reviewed for COVID-19 exemptions. This deficient practice had the potential to affect all 19 residents who resided in the building. Findings include:
A review of a facility provided policy titled, VACCINATION POLICY effective January 27, 2022, was conducted and read, .The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provided any care, treatment, or other services for the facility and/or its's residents: (i) Facility employees; (ii) Licensed practitioners; .(iv) Individuals who provide care, treatment, or other services for the facility and/or it's residents, under contract or by other arrangement .Employees, who meet criteria for exempt status, and are not fully vaccinated must use a NIOSHapproved <sic> N95 or equivalent or higher level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with residents .
COVID-19 Staff Vaccination:
On 2/22/22 at 9:44 AM, an entrance conference was conducted with the facility's Administrator. At that time, they were requested to provide the staff COVID-19 vaccination status for all of their employees.
On 2/22/22 at approximately 1:00 PM, a review of the facility provided COVID-19 staff vaccination matrix was conducted and it was brought to the Administrator's attention that both the Licensed Practical Nurses (LPNs) currently working were not listed on the vaccination matrix.
On 2/22/22 at approximately 2:30 PM, the COVID-19 staff vaccination matrix was returned by the Administrator and was noted to include the two LPN's that were working the day shift. At that time, the Administrator was asked if the matrix was completed and accurate and they indicated it was.
On 2/23/22 at 8:58 AM, a review of the facility provided matrix for COVID-19 staff vaccination status received on 2/22/22 at 2:30 PM was conducted and documented the facility had 51 total staff. The matrix indicated 42 staff were fully vaccinated, 1 staff was partially vaccinated, and 6 staff had granted exemptions. It was noted the vaccination status of staff added up to 49, but the facility reported they had a total of 51 employees.
A facility provided staff roster was cross referenced against the facility provided COVID-19 staff vaccination matrix and it was noted Registered Dietician 'B' and Registered Nurse 'F' were not listed on the staff vaccination matrix.
A facility provided schedule of staff who worked in the facility from January 27, 2022, to February 19, 2022, was reviewed and compared to the facility provided staff vaccination matrix and 18 total contracted staff from the schedule were not documented on the vaccination matrix. The staff included LPN's 'K', 'L', 'M', 'N', 'O', 'P', and 'Y', and Certified Nursing Aides 'Q', 'R', 'S', 'T', 'U', 'V', 'W', 'X', 'Z', 'AA', and 'BB'.
On 2/23/22, at 10:30 AM, the COVID-19 staff vaccination matrix was discussed with the facility's [NAME] President of Operations. They were asked about why the staff vaccination status (49 staff) did not add up to the total number of reported staff (51 staff) and said they would have it corrected. An updated vaccination matrix was not received by the end of the survey.
On 2/24/22 at 10:49 AM, an interview was conducted with the facility's Director of Nursing (DON)/Infection Control Preventionist regarding the reviewed staff schedules and the staff COVID-19 vaccination matrix. The DON reported the schedule provided were the staff that worked in the facility and said the facility's Administrator had taken over tracking the staff's vaccination status.
On 2/24/22 at 1:27 PM, an interview was conducted with the facility's Administrator regarding concerns with the employee staff roster, working schedules, COVID-19 staff vaccination status for all staff and the miscalculations on the provided vaccination matrix and they acknowledged the concern.
Appropriate PPE use for COVID-19 exempt staff:
On 2/22/22 and 2/23/22, and 2/24/22 multiple observations of Dietary Aide 'I' revealed they were wearing a surgical mask over their mouth and nose.
On 2/23/22 at 1:15 PM, Dietary Aide 'I' was observed in the hallway with a meal tray prepared for delivery to a resident on droplet isolation precautions. Dietary Aide 'I' was observed to have a surgical mask covering their nose and mouth. At that time, Certified Dietary Manager 'A' was overheard to remind Dietary Aide 'I' to ensure they put on all the proper PPE to enter the room, which included changing their mask from a surgical mask to an N95 mask.
On 2/23/22 at 8:58 AM, a review of the facility provided matrix for COVID-19 staff vaccination status was conducted and revealed Dietary Aide 'I' and Activity Director 'DD' both had facility approved COVID-19 vaccination exemptions.
On 2/23/22 at 2:30 PM, and 3:58 PM, Activity Director 'DD' was observed wearing a KN95 mask over their mouth and nose.
On 2/24/22 at 8:51 AM, an interview was conducted with Activity Director 'DD'. They were observed to be wearing a KN95 mask and at that time, they were asked about what additional infection control precautions they were taking given their COVID-19 vaccination exemption. Activity Director 'DD' said they were tested for COVID-19 twice a week and they were expected to maintain social distancing and wear an N95 mask. At that time, they were asked about their KN95 mask and said they thought it was an N95 mask. When asked where they got their mask, they reported a nursing staff member had given it to them.
On 2/24/22 at 10:49 AM, an interview was conducted the facility's DON/Infection Control Preventionist. They were asked about what additional infection control measures COVID-19 vaccine exempt staff were expected to practice. It was reported that per the facility policy, COVID-19 vaccine exempt staff were to test twice weekly, maintain social distancing to the best of their ability, and wear an N95 mask. At that time, it was brought to their attention that Dietary Aide 'I' and Activity Director 'DD' were not observed to be wearing N95 masks. The DON acknowledged the concern and said they would look into it.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Michigan facilities.
Concerns
- • 17 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Oakland Manor Nursing And Rehabilitation Center Ll's CMS Rating?
CMS assigns Oakland Manor Nursing and Rehabilitation Center LL an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Michigan, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Oakland Manor Nursing And Rehabilitation Center Ll Staffed?
CMS rates Oakland Manor Nursing and Rehabilitation Center LL's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Michigan average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Oakland Manor Nursing And Rehabilitation Center Ll?
State health inspectors documented 17 deficiencies at Oakland Manor Nursing and Rehabilitation Center LL during 2022 to 2024. These included: 1 that caused actual resident harm, 15 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Oakland Manor Nursing And Rehabilitation Center Ll?
Oakland Manor Nursing and Rehabilitation Center LL is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PIONEER HEALTHCARE MANAGEMENT, a chain that manages multiple nursing homes. With 29 certified beds and approximately 20 residents (about 69% occupancy), it is a smaller facility located in Pontiac, Michigan.
How Does Oakland Manor Nursing And Rehabilitation Center Ll Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Oakland Manor Nursing and Rehabilitation Center LL's overall rating (4 stars) is above the state average of 3.1, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Oakland Manor Nursing And Rehabilitation Center Ll?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Oakland Manor Nursing And Rehabilitation Center Ll Safe?
Based on CMS inspection data, Oakland Manor Nursing and Rehabilitation Center LL has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Oakland Manor Nursing And Rehabilitation Center Ll Stick Around?
Staff turnover at Oakland Manor Nursing and Rehabilitation Center LL is high. At 61%, the facility is 15 percentage points above the Michigan average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Oakland Manor Nursing And Rehabilitation Center Ll Ever Fined?
Oakland Manor Nursing and Rehabilitation Center LL has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Oakland Manor Nursing And Rehabilitation Center Ll on Any Federal Watch List?
Oakland Manor Nursing and Rehabilitation Center LL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.