ROSE MANOR NURSING CENTER
LOCATED: 1610 NORTH BRYAN AVENUE, SHAWNEE, OK 74804

ROSE MANOR NURSING CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES.

LEVEL OF HARM –ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interview, it was determined the facility failed to:

1. a) provide interventions according to the resident’s needs to prevent the development of an avoidable stage 3 pressure ulcer for one resident (#5),
2. b) identify the presence of a pressure ulcer prior to developing into a stage 3 and failed to identify the breakdown of the right heel for one resident (#5),
3. c) provide interventions according to the resident’s needs to prevent the development of an avoidable stage 2 pressure ulcer for one resident (#12), and
4. d) provide interventions to prevent the worsening of a stage 3 pressure ulcer for one resident (#5) and the worsening of a stage 2 to a stage 3 pressure ulcer for one (#12) of six sampled residents with pressure ulcers.

The facility’s failure to provide interventions according to the residents’ needs resulted in harm with the development and worsening of avoidable stage 3 pressure ulcers for two (#5 and #12) of six sampled residents with pressure ulcers. The facility identified nine residents with pressure ulcers.

The facility also failed to:

1. e) provide interventions to prevent the development of a stage one pressure ulcer; and accurately assess and identify the presence of a stage one pressure ulcer for one (#5) of six sampled residents with pressure ulcers.

These deficient practices had the potential to affect 48 residents identified by the facility who were at high risk for the development of pressure ulcers.

Resident #5 was readmitted to the facility on [DATE] following hospitalization for surgical repair of a fracture to the left femur. Other [DIAGNOSES REDACTED].

On 04/04/16 at 4:15 p.m., the resident was observed sitting in a Geri chair in the living area outside the assisted dining room. The resident was observed to receive help with the evening meal at 5:30, continuing to sit in the Geri chair and without being repositioned. At 6:25 p.m., the resident was assisted to her room from the dining room, still seated in the Geri chair.

At 7:15 p.m., the resident was assisted from the Geri chair to the bed utilizing a mechanical lift. CNAs (certified nurse aides) #1 and #3 removed the incontinent brief from the resident, which was observed to be heavily soiled with urine and feces. The lower edge of the dressing, which was intact over the coccyx, was soiled with feces. The resident’s buttocks were observed to be dark pink. The CNAs did not notify the nurse of the soiled dressing. The CNAs cleansed the resident’s soiled perineum and buttocks, applied a clean incontinent brief, repositioned the resident to her left side and adjusted the pillows and covers. The CNAs used the same gloves throughout the entire time.

The CNAs were asked what care the resident had received since they had arrived at 3:00 p.m. They stated they had provided no care for the resident since arriving at 3:00 p.m. They stated the resident had been up in the Geri chair since noon to eat lunch in the dining room, and no staff had checked the resident for incontinence or provided any type of repositioning since that time. They stated the staff working prior had not had time to lay the resident down after lunch to provide any personal care or repositioning. They stated they had been busy assisting other residents with personal care and assisting residents up for the evening meal since arriving at 3:00 p.m. They stated they were aware the resident needed to be checked for incontinence and incontinent care provided every two hours, as well as repositioning the resident every one to two hours due the presence of a pressure ulcer on the coccyx.

They were asked what care the resident needed. They stated the resident was incontinent of bowel and bladder, and unable to recognize or verbalize her needs, so she was to be checked for incontinence at least every two hours and incontinent care provided to keep her skin clean. They stated she needed to be repositioned from side to side every one to two hours, and heels were to be floated utilizing pillows so there was no pressure on the heels. They stated it was important to do these things so residents did not develop pressure ulcers.

Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.