The interdisciplinary team at Northern Oaks Living & Rehabilitation Center had identified the resident as needing a floor mat beside her bed as part of her fall prevention strategy. But when federal inspectors arrived for a complaint investigation in November, they found the mat stored away from her room.
The administrator acknowledged the care plan violation during interviews with inspectors. He stated he did not think there were any negative consequences from the floor mat not being beside the resident's bed when she was in bed, despite his facility's own policies requiring such interventions for high-risk patients.
This represents a breakdown in the facility's interdisciplinary care planning system. The administrator explained that the IDT consisted of department heads including the medical director, the MDS coordinator, the director of nursing and himself. He stated the IDT communicated interventions to nurses who were expected to report those interventions to certified nursing assistants.
But somewhere in that chain of communication, the resident's safety measure disappeared.
The facility's comprehensive care planning policy, revised in December 2023, requires the interdisciplinary team to develop care plans that include measurable objectives and timeframes to meet residents' medical, nursing, mental and psychosocial needs identified in comprehensive assessments. The policy specifically states that care plans must include instructions needed to provide effective and person-centered care that meets professional standards of quality care.
For fall prevention specifically, Northern Oaks maintains a detailed policy revised in January 2022. The policy requires completion of a Fall Risk Evaluation on admission to determine each resident's risk for sustaining a fall. Residents with high risk factors identified in the evaluation must have individualized care plans developed with measurable objectives and timeframes.
The policy states that care plan interventions will be developed to prevent falls by addressing risk factors and will consider the particular elements of the evaluation that put the resident at risk.
Yet the administrator told inspectors he expected the IDT to monitor that direct care staff followed the care plans, suggesting a system that had failed in this case. The floor mat intervention had been identified, planned, and documented. It simply wasn't implemented.
The administrator stated he felt the care plan should reflect what the resident's care needs were and felt the interventions should be followed. His acknowledgment underscored the gap between policy and practice that inspectors documented.
When residents sustain falls at Northern Oaks, facility policy requires licensed nurses to complete physical assessments with results documented in medical records. The policy mandates investigation to determine probable causal factors, review by the interdisciplinary team, and updates to residents' care plans.
But the prevention measures that might avoid such incidents in the first place weren't being consistently implemented, according to the inspection findings.
The facility's baseline care plan policy requires development within 48 hours of admission that includes minimum healthcare information necessary to properly care for each resident. Comprehensive care plans must be reviewed and revised by the IDT after each assessment, including both comprehensive and quarterly review assessments.
The administrator clarified during the inspection that he understood the system's requirements. He knew the IDT was responsible for developing interventions. He knew nurses were expected to communicate those interventions to nursing assistants. He knew the interventions were supposed to be followed.
What he couldn't explain was why a simple floor mat, identified as necessary for a high-risk resident's safety, ended up in storage instead of beside her bed.
The inspection focused on this specific case but highlighted broader questions about care plan implementation at the facility. If a straightforward intervention like placing a floor mat couldn't be consistently executed, what other care plan requirements might be falling through the cracks?
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But for the resident whose safety mat remained in storage, the failure represented a complete breakdown of the individualized care planning process that nursing homes are required to provide.
The administrator's statement that he didn't think there were negative consequences from the missing floor mat contradicted his facility's own fall prevention policies, which specifically identify such interventions as necessary for high-risk residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northern Oaks Living & Rehabilitation Center from 2025-11-07 including all violations, facility responses, and corrective action plans.
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