HOMESTEAD OF HUGO
For profit - Corporation
124 Beds
BGM ESTATE
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#232 of 282 in OK
Last Inspection: January 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Homestead of Hugo has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #232 out of 282 facilities in Oklahoma places it in the bottom half of the state, and it is the second choice among two options in Choctaw County. The facility is showing signs of improvement, with issues decreasing from 26 in 2024 to just 1 in 2025, but it still faces serious challenges. Staffing is rated as average with a turnover of 57%, which is consistent with the state average, and they have concerning fines totaling $61,736, higher than 83% of Oklahoma facilities. Specific incidents of concern include failure to follow background screening policies for employees, jeopardizing resident safety, and neglecting to monitor a resident's respiratory status, leading to potentially life-threatening situations. While there are some improvements noted, families should weigh these serious weaknesses against the facility's efforts to enhance care.
- Trust Score
- F
- In Oklahoma
- #232/282
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 57% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $61,736 in fines. Higher than 74% of Oklahoma facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Oklahoma. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 45 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 18%
Review needed
26 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 26 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Oklahoma average (2.6)
Significant quality concerns identified by CMS
Staff Turnover: 57%
11pts above Oklahoma avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $61,736
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: BGM ESTATE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (57%)
9 points above Oklahoma average of 48%
The Ugly 45 deficiencies on record
3 life-threatening
Jun 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit MDS assessments data to CMS in the required timeframe for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit MDS assessments data to CMS in the required timeframe for 3 (#9, 49, 52, and #61) of 6 sampled residents reviewed for MDS assessments.
The administrator identified 51 residents resided in the facility.
Findings:
1. An undated Resident Face Sheet, showed Resident #52 was admitted to the facility on [DATE].
Resident #52's quarterly assessment, dated 04/23/25, was completed, but not submitted.
On 06/04 at 2:06 p.m., the MDS coordinator stated Resident #52's assessment should have been submitted by 04/30/25.
2. An udated Resident Face Sheet, showed Resident #9 was admitted to the facility on [DATE].
Resident #9's annual assessment, dated 04/23/25, was completed, but not submitted.
3. An undated Resident Face Sheet, showed Resident #49 was admitted to the facility on [DATE].
Resident #49's quarterly assessment, dated 04/23/25, was completed, but not submitted.
A CMS Submission Report, dated 06/02/25, showed Resident #9, 49, and #52's records were submitted late.
On 06/04/25 at 2:07 p.m., the MDS coordinator stated Resident #9 and Resident #49's assessments should have been submitted no later than 04/29/25.
4. An undated Resident Face Sheet, showed Resident #61 was admitted to the facility on [DATE].
Resident #61's assessment, dated 05/09/25, was still in progress.
On 06/05/25 at 9:02 a.m., the MDS coordinator stated the assessment, dated 05/09/25, for Resident #61 should have been completed by 05/18/25.
On 06/05/25 at 9:06 a.m., the MDS coordinator stated the assessment for Resident #61 had not been completed.
A CMS Submission Report, dated 06/09/25, showed Resident #61's record was submitted late.
Aug 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to develop a diabetes care plan for one (#2) of three residents whose care plans were reivewed.
The Resident Current Status Report, dated 08/1...
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Based on record review and interview, the facility failed to develop a diabetes care plan for one (#2) of three residents whose care plans were reivewed.
The Resident Current Status Report, dated 08/13/24, documented a census of 47 residents.
Findings:
Res #2 had diagnoses which included diabetes.
Physician's orders, dated 06/14/24 documented in part, Novolin R insulin .sliding scale: If blood sugar 0-200, give 0 units, if blood sugar is 201-250, give 5u, if blood sugar is 251-300, give 7u, if blood sugar is 301-350, give 10u, if blood sugar is 351-400, give 14u, if blood sugar is greater than 400, call MD before meals and at bedtime .
Res #2's blood sugar log documented blood sugars above 400 14 times.
Res #2's comprehensive care plan did not have a care plan focus for diabetes.
On 08/15/24 at approximately 3:30 p.m., the DON reported they were not able to locate a care plan for Res #2's diabetes. The adminisrtator and DON reported Res #2's diabetes should have been care planned and must have been overlooked.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to have sufficient direct care staffing levels for May through July which had the potential to affect all residents.
The Resident Current Stat...
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Based on record review and interview, the facility failed to have sufficient direct care staffing levels for May through July which had the potential to affect all residents.
The Resident Current Status Report, dated 08/13/24, documented a census of 47 residents.
Findings:
The Quality of Care Monthly Report documented the following days below the required staffing level:
May 2024:
Day Shift:
05/08/24 - 3.85 hours short
05/11/24 - 6.22 hours short
05/18/24 - 10.31 hours short
05/19/24 - 7.44 hours short
05/26/24- 11.44 hours short
Evening Shift:
05/11/24 - 9.21 hours short
05/18/24 - 7.12 hours short
05/25/24 - 8.33 hours short
June 2024:
Day Shift:
06/01/24 - 12.55 hours short
06/09/24 - 19.76 hours short
06/22/24- 25.16 hours short
06/23/24- 10.03 hours short
06/28/24 - 6.41 hours short
06/30/24 - 8.93 hours short
Evening Shift:
06/01/24 - 11.20 hours short
06/02/24 - 12.22 hours short
06/08/24 - 9.69 hours short
06/09/24 - 8.96 hours short
06/16/24 - 11.81 hours short
06/23/24 - 15.33 hours short
06/29/24 - 7.90 hours short
06/30/24 - 5.89 hours short
July 2024:
Day Shift:
07/04/24 - 6.37 hours short
07/20/24 - 7.60 hours short
07/21/24 - 12.59 hours short
07/27/24 - 12.78 hours short
07/28/24 - 19.84 hours short
Evening Shift:
07/14/24 - 5.22 hours short
07/27/24 - 14.14 hours short
07/28/24 - 13.22 hours short
On 08/15/24 at 2:25 p.m., the administrator reported they have had challenges with staffing and continue daily to try to acquire more staff.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure staff washed or sanitized their hands and change gloves as needed during the cleaning of a residents' perineal area to prevent potenti...
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Based on observation and interview, the facility failed to ensure staff washed or sanitized their hands and change gloves as needed during the cleaning of a residents' perineal area to prevent potential infection for one (#1) of three sampled residents reviewed for increased assistance with activities of daily living.
The administrator reported 52 residents resided in the facility.
A facility policy titled, Infection Control - Prevention and Control Program dated 03/2012, read in part, The intent of the program is to assure the home develops, implements, and maintains an Infection Prevention and Control in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility.
Resident #1 had diagnoses which included Alzheimer's Disease and muscle wasting and atrophy.
On 05/30/24 at 9:40 a.m., an observation of Resident #1 receiving perineal care was observed. CNA #3 and Employee #1 were observed transferring Resident #1 from a wheelchair to a bed. The two employees were gloved during the transfer. The two employees were observed to initiate perineal care without changing gloves. The employees removed the resident's pants and dirty briefs. Employee #1 cleaned the resident's vaginal area then with a new wipe the anal area. The staff members then placed a new brief on the resident and touched them at various parts of their body with the dirty gloves. The staff members then rearranged the bedding including the pillow with the dirty gloved hands. Employee #1 was observed touching their face with the gloved hand they had used to wipe the resident's vaginal and anal areas. The two staff members did not change their gloves or clean their hands during the care. There were no spare gloves observed in the room during the care. After the care was completed, the two were asked how they believed the care had gone. CNA #3 stated they had forgotten to bring a trash bag for the dirty items. They were asked how many times they had changed their gloves while they provided the care. They each stated they had forgotten to change gloves after handily potentially soiled items. Employee #1 stated they should have changed their gloves.
On 05/30/24 at 10:20 a.m., RN #2 [Regional RN] was informed of the care that had been provided to Resident #1. They stated the two staff members should have cleaned their hands prior to providing care and after handling the dirty items. They stated the two staff members did not follow infection control procedures.
Apr 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to provide bathing to residents as scheduled for two (#2 and #4) of four residents reviewed for bathing.
The administrator identified 50 resid...
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Based on record review and interview, the facility failed to provide bathing to residents as scheduled for two (#2 and #4) of four residents reviewed for bathing.
The administrator identified 50 resident residing in the facility.
Findings:
1. Res #2 had diagnoses which included psoriasis, skin changes, and moderate protein calorie malnutrition.
A physician order, dated 07/13/21, documented the resident required one person assist with bathing.
A quarterly assessment, dated 01/15/24, documented the resident required supervision to touch assist with bathing.
On 04/09/24 at 11:21 a.m., Res #2 stated they had asked for a bath on Sunday 04/07/24 and did not receive a bath.
Res #2 was scheduled to receive a shower or bath on Mondays, Wednesdays, and Fridays of each week. During March 2024 the resident received four showers out of 13 opportunities. One shower was on a scheduled shower day and the other three were not on scheduled days. The documentation on the shower sheets revealed eight refusals on scheduled days, and no documentation was provided for the remaining shower days.
The resident's scheduled shower sheets for April 2024 did not document the resident had a shower in April as of the 10th. The resident scheduled days would have been the 1st, 3rd, 5th, 8th, and 10th, of April. The documentation revealed on April 1st the resident refused a shower. There was not a shower sheet for April 3rd. On April fifth there was a shower sheet but did not documented if the resident had a shower or not that day, On April 7th, the date the resident stated they had requested a shower, the resident's name was on a shower sheet but there was no documentation of the resident receiving a shower.
2. Res #4 had diagnoses of hemiplegia and hemiparesis, muscle weakness, and lack of coordination.
A quarterly assessment, dated 02/06/24, documented the resident was dependent with bathing.
The shower sheets observed for Res #4 documented the resident did not receive a shower on their scheduled shower days for 03/23/24, 03/30/24 for March 2024.
On 04/10/24 at 1:38 p.m., CNA #2 stated at times they had to rush to get the showers done. CNA #2 stated if they did not get a shower on the scheduled day they tried to get it on the next day. CNA #2 stated they had to ask the resident three times and then report to the nurse if the resident refused to shower. CNA #2 stated sometimes the shower would be completed but did not get documented.
On 04/10/24 at 1:42 p.m., CNA #1 stated they had a shower chart they went by to know what resident was supposed to get a shower. CNA #1 stated they had two CNAs currently so they did three showers today because did not have the time to get all the showers completed. The CNA #1 stated if the shower sheet did not document a bath or refusal the resident probably did not receive a shower that day.
On 04/10/24 at 1:49 p.m., the DON stated by looking at the documentation the showers were not completed as scheduled.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure double portions were provided for one (#2) of four residents who were reviewed for nutrition.
The administrator identi...
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Based on observation, record review, and interview, the facility failed to ensure double portions were provided for one (#2) of four residents who were reviewed for nutrition.
The administrator identified 15 residents who had weight loss.
Findings:
Res #2 had diagnoses which included moderate protein calorie malnutrition.
A physician order, dated 08/02/23, documented the resident was to receive a regular diet with double portions.
A quarterly assessment, dated 01/15/24 documented the resident's weight was 209 pounds and had not had a loss or gain. The assessment documented the resident required supervision or touch assist with eating.
A dietary note, dated 04/08/24, documented the resident weight was 204.5 pounds with a BMI of 26.3, WNL. The note documented no significant weight changes. The resident's diet was documented as a regular diet with double portions and the resident's intake was 76 to 100% of their meal. The note documented to continue care.
On 04/09/24 at 11:21 a.m., Res #2 stated the food in the facility sucks and was delivered cold. Res #2 stated they had been hungry for a month.
On 04/09/24 at 11:33 a.m., the lunch meal service was observed. At 12:22 p.m., the kitchen ran out of taco meat and a test tray was not provided. [NAME] #1 stated they served all the residents but were out of taco meat. They were observed to not serve any resident double portions of food.
On 04/10/24 at 8:48 a.m., cook #1 stated they did not have any residents who received double portions of food with meals.
Res #2's meal card was observed it documented the resident was to receive a regular diet with thin liquids. Double portions was not documented on the meal card.
On 04/10/24 at 1:56 p.m., the DON reviewed Res #2's orders and stated they were not aware Res #2 was to receive double portions of food with their meals.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a sufficient number of staff to ensure residents received t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a sufficient number of staff to ensure residents received the needed care and services for two (#2, and #4) of four residents reviewed for staffing.
The administrator identified 50 resident residing in the facility.
Findings:
1. Res #2 had diagnoses which included psoriasis, skin changes, and moderate protein calorie malnutrition.
A physician order, dated 7/13/21, documented the resident required one person assist with bathing.
A quarterly assessment, dated 01/15/24, documented the resident required supervision to touch assist with bathing.
On 04/09/24 at 11:21 a.m., Res #2 stated they had asked for a bath on Sunday 04/07/24 and did not receive a bath.
Res #2 was scheduled to receive a shower or bath on Mondays, Wednesdays, and Fridays of each week. During March 2024 the resident received four showers out of 13 opportunities. One shower was on a scheduled shower day and the other three were not on scheduled days. The documentation on the shower sheets revealed eight refusals on scheduled days, and no documentation was provided for the remaining shower days.
The resident's scheduled shower sheets for April 2024 did not document the resident had a shower in April as of the 10th. The resident scheduled days would have been the 1st, 3rd, 5th, 8th, and 10th, of April. The documentation revealed on April 1st the resident refused a shower. There was not a shower sheet for April 3rd. On April fifth there was a shower sheet but did not documented if the resident had a shower or not that day, On April 7th, the date the resident stated they had requested a shower, the resident's name was on a shower sheet but there was no documentation of the resident receiving a shower.
2. Res #4 had diagnoses of hemiplegia and hemiparesis, muscle weakness, and lack of coordination.
A quarterly assessment, dated 02/06/24, documented the resident was dependent with bathing.
The shower sheets observed for Res #4 documented the resident did not receive a shower on their scheduled shower days for 3/23/24, 3/30/24 for March 2024.
On 04/10/24 at 1:38 p.m., CNA #2 stated at times they had to rush to get the showers done. CNA #2 stated if they did not get a shower on the scheduled day they tried to get it on the next day. CNA #2 stated they had to ask the resident three times and then report to the nurse if the resident refused to shower. CNA #2 stated sometimes the shower would be completed but did not get documented.
On 04/10/24 at 1:42 p.m., CNA #1 stated they had a shower chart they went by to know what resident was supposed to get a shower. CNA #1 stated they had two CNAs currently so they did three showers today because did not have the time to get all the showers completed. The CNA stated if the shower sheet did not document a bath or refusal the resident probably did not receive a shower that day.
3. Documents titled Homestead of [NAME] Daily Staffing Hours sheets were reviewed for February and March 2024. The facility had one day in February 2024 where they did not meet the staffing requirements. March sheets revealed 11 days the staffing requirements were not met.
On 04/10/24 at 2:09 p.m., the DON stated the facility did not have enough CNAs the first part of March. They stated the facility had to let a couple of them go and had some not shown up for work and/or just never came back. The DON stated staffing was challenging but they had some good staff who just needed leadership.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
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, record review, and interview, the facility failed to ensure:
a. infection control policy were implemented in the kitchen.
b. food was distributed in a sanitary manner.
The admini...
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Based on observation, record review, and interview, the facility failed to ensure:
a. infection control policy were implemented in the kitchen.
b. food was distributed in a sanitary manner.
The administrator identified 50 residents who received meals from the kitchen.
Findings:
An undated facility policy titled Employee Health Policy Agreement, read in part, Reporting: Symptoms of illness I agree to report to the manager when I have: 1. diarrhea 2. Vomiting .If you have any of the symptoms or illness listed above, you may be excluded*or restricted**from work .if an employee is on duty during the onset of symptoms, their immediate supervisor will release them to leave the facility until they are free of symptoms .
1. Times cards were reviewed for 03/16/24 for DA #1 and DA #2. DA #1 worked from 6:00 a.m., to 11:06 a.m.
DA #2's time card documented they had clocked in at 10:59 a.m. on 03/16/24 to relieve DA #1.
On 04/09/24 at 3:45 p.m., DA #1 stated on 03/16/24 I was sick and came to work sick. DA #1 stated the DM made them stay at work until someone came into relieve them. DA #1 stated they worked passing meals out to the residents.
On 04/09/24 at 3:40 p.m., the DM stated when the if kitchen staff came to work they sick they should have been sent home. The DM stated they had not had anyone sick at work who was made to stay and work.
On 04/10/24 at 8:43 a.m., [NAME] #2 stated a staff member had been sick in the kitchen and was throwing up. The cook stated they called the DM. The DM told [NAME] #2 to send the sick staff member home, so DA#2 was called in to work. [NAME] #2 stated the sick staff member did not stay at work until the relief staff got to work.
2. On 04/09/24 at 11:36 a.m., during meal service the following things were observed. [NAME] #2 was touching the rims of the glasses while serving them to the residents. [NAME] #2 was observed to touch the eating end of the silverware with bare hands.
The serving trays were observed to be wet.
On 04/09/24 at 11:47 a.m., [NAME] #1 was observed to leave the serving area, retrieve a can of tomato juice, poured it into a glass, and returned to serving the meals without removing their gloves or washing their hands.
On 04/09/24 at 12:02 p.m., the DM stated the kitchen staff should not have been touching eating areas of the silverware or drinking glasses. They stated the staff should not have been touching dirty items and returning to serve the food in the same gloves. The DM stated the trays should have been air dried completely before using them for service.
Jan 2024
19 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Abuse Prevention Policies
(Tag F0607)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/04/24 at 3:00 p.m., an Immediate Jeopardy situation was determined to be in existence related to the facility's failure to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/04/24 at 3:00 p.m., an Immediate Jeopardy situation was determined to be in existence related to the facility's failure to follow their abuse policy and ensure background screenings were completed for 7 of 46 employees.
On 01/04/24 at 3:05 p.m., the Oklahoma State Department of Health verified the existence of the Immediate Jeopardy situation.
On 01/04/24 at 3:10 p.m. the administrator was notified of the IJ situation.
On 01/04/24 at 5:31 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Completion Date 01/04/24 at 7:00 p.m. The Administrator will be educated over the telephone by the Regional Director on employee background checks. The Business Office Manager's employment will be terminated immediately.
Currently in progress: Reviewing all employee personnel records to verify criminal background checks are completed. Any employee without a criminal background check will not be allowed to return to work until completed. New hires will have criminal background checks performed before starting to work. The names of the employees that were sent home are (names withheld), Housekeeper #1 and Dietary Aide #1. The names of the employees that were not allowed to come to work were (names withheld), Dietary Aide #2, CNA #1, CNA #2, CNA #3, and CNA #4.
The IJ was lifted, effective 01/04/24 at 7:00 p.m., when all components of the plan of removal had been completed. The deficiency remained at a widespread level with potential for harm.
Based on record review and interview, the facility failed to follow their abuse policy and ensure background checks were completed for new hires.
The administrator identified 41 residents who resided in the facility.
Findings:
The Abuse Prevention Program policy, last revised August 2006, read in part, Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Comprehensive policies and procedures have been developed to aide our facility in preventing abuse .Our abuse prevention program provides policies and procedures that govern, as a minimum: a. Protocols for conducting employment background checks .
An Abuse - Reportable Events policy, dated 01/2018, read in part, .1. Screening: a. Pre-employment screening will be completed on all employees, to include: Criminal History Check, Background Check .
The Homestead of [NAME] Employee Roster provided by the OK-Screen & Detention Programs was compared to the facility employee roster. The following seven of 46 employees did not have background screenings:
a. Dietary Aide #2 hired on 10/11/23,
b. Housekeeping #1 hired on 12/01/22,
c. CNA #1 hired on 07/03/23,
d. CNA #2 hired on 06/26/23,
e. CNA #3 hired on 09/21/23,
f. CNA #4 hired on 05/19/23, and
g: Dietary Aide #1 hired on 09/26/23.
On 01/04/24 at 2:30 p.m., the business office manager reported they had not gotten to employee background checks. The business office manager reported all background checks should have been completed upon hire.
On 01/04/24 at 3:15 p.m., the administrator reported she thought the business office manager was doing her job and following protocol.
01/08/24 at 4:05 p.m., the administrator reported they thought the business office manager was following a check list for new hires. The administrator reported they had not followed up regarding background checks to ensure they were completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure DNR forms were dated and signed appropriately for two (#27 a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure DNR forms were dated and signed appropriately for two (#27 and #98) of 16 residents who were reviewed for advance directive/DNR status.
The administrator identified 41 residents who resided in the facility.
Findings:
1. Res #27 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, benign neoplasm, pain, and atrial fibrillation.
A physician order, dated 11/29/22, documented the resident's code status was DNR.
The care plan, dated 11/29/22, documented the resident had a signed DNR form. The care plan documented the staff was to verify the DNR and label the resident's chart with the physician order.
An undated form titled Certification of Physician documented the form was used by a physician to certify the incapacitated person without a representative would not have consented to use of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. The signature was not legible and was not printed per the form.
On 01/03/24 2:35 p.m., the resident was lying in bed. The resident's eyes were open but did not verbally respond to questions.
On 01/03/24 at 2:49 p.m., the administrator stated the DON was responsible for monitoring appropriate signage of DNR or POA forms. The administrator stated with no DON currently, they were responsible. The administrator reviewed the resident's clinical record and stated the DNR signed by the physician was not dated and the signature was not legible. The administrator stated they would not consider the form a legal document.
2. Res #98 was admitted to the facility on [DATE] with diagnoses which included diabetes, anxiety disorder, atrial fibrillation, and dementia.
A physician order, dated 12/26/23, documented the resident's code status was DNR.
An undated witnessed form titled OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM documented the form was signed by a representative. No documentation could be found regarding a POA for the resident.
On 01/03/24 at 2:49 p.m., the administrator reviewed the resident's clinical record and stated a POA form could not be located.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure an annual resident assessment was completed within the required timeframe for one (#8) of 15 sampled residents whose resident assess...
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Based on record review and interview, the facility failed to ensure an annual resident assessment was completed within the required timeframe for one (#8) of 15 sampled residents whose resident assessments were reviewed.
The administrator identified 41 residents who resided in the facility.
Findings:
Res #8 had a quarterly resident assessment completed on 08/14/23. Their annual resident assessment was due 11/14/23 but was not completed.
On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported Res #8's annual assessment should have been completed within the required timeframe. The Corporate RN #1 reported the MDS Coordinator's last day was 11/11/23 and there was no one in place initially to do MDS in the interim.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure MDS assessments accurately reflect the resident's status related to GDR attempts for one (#39) of five residents reviewed for unneces...
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Based on record review and interview the facility failed to ensure MDS assessments accurately reflect the resident's status related to GDR attempts for one (#39) of five residents reviewed for unnecessary medications.
The administrator identified 41 residents resided in the facility.
Findings:
Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia.
A quarterly assessment, dated 11/26/23, documented the resident was intact with cognition and required supervision with most ADLs. The assessment documented the resident received an antipsychotic and an antianxiety medication. The assessment documented the resident had not had a gradual dose reduction attempted.
A MRR, dated 02/08/23, documented the resident had an order for Zyprexa 5.0 mg BID. The MRR documented a request for a reduction attempt for Zyprexa to 2.5 mg in the a.m. and 5.0 mg in the evening.
The EHR documented on 02/17/23, the resident's Zyprexa was decreased to 2.5 mg in the morning and 5.0 mg at night.
On 01/04/24 at 11:59 a.m., the Corporate Nurse Consultant #1 stated the MDS was not correct for the GDR because the resident had a reduction on 02/17/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident received services to prevent an ADL...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident received services to prevent an ADL decline for one (#13) of two residents who were reviewed for ADL decline.
The administrator identified one resident with an ADL decline in the past three months.
Findings:
Res #13 was admitted to the facility on [DATE] with diagnoses which included anemia, dehydration, muscle wasting and atrophy multiple sites, lack of coordination, muscle weakness, and difficulty with walking.
The care plan, dated 05/19/23, documented the resident had a problem with ADL functions and required assistance with transfers, dressing, toileting, and personal hygiene. The care plan documented the resident needed physical therapy, occupational therapy, and speech therapy related to dehydration. The staff were to monitor progress, therapist and nursing to collaborate care, and provide services to maximize resident accomplishments.
A physical therapy Discharge summary, dated [DATE], documented the resident's case started 05/19/23 and completed on 08/04/23. The discharge summary documented the resident showed fair progress throughout treatment. The summary documented the resident participated well. The summary documented the resident was discharged to long term care with the highest functional level achieved.
A quarterly assessment, dated 08/23/23, documented the resident was severely impaired cognitively. The assessment documented the resident's functional status for bed mobility was extensive assist of one person, transfer status was limited assist with one person, dressing status was extensive assist with one person, eating status was supervision with setup, toilet use status was extensive assist of one, and hygiene status was extensive assist of one person.
A significant change assessment, dated 09/08/23, documented the resident was modified independent with daily decision making. The assessment documented the resident's functional status for bed mobility was extensive assist of two people, transfer status was identified as the activity did not occur, dressing status was extensive assist of two people, eating status was extensive assist of one person, toilet use status was extensive assist of one person, and hygiene status was extensive assist of two people.
On 01/08/24 at 10:39 a.m., the resident was observed lying in bed with a foley catheter to bedside. The resident required assistance of staff with positioning.
On 01/08/24 at 11:58 a.m., the corporate nurse stated the resident had a significant change assessment completed on 09/08/23. The nurse stated the resident had a decline. The nurse stated the resident had been discussed in the morning staff meeting on 08/30/23 regarding a decline. The nurse did not know why the resident was not receiving therapy or restorative services due to the decline.
On 01/08/24 at 4:57 p.m., the administrator stated there was some confusion if the resident was remaining in the facility. The administrator stated nothing was done when the resident had a decline.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to document, retain and make accessible to all residents and guests the required daily staffing information.
The administrator i...
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Based on observation, interview, and record review, the facility failed to document, retain and make accessible to all residents and guests the required daily staffing information.
The administrator identified 41 residents who resided in the facility.
Findings:
On 01/03/24 at 9:06 a.m. and throughout the investigation, a whiteboard at the east wing nursing station was observed to include the date and staff name and titles. There was no documentation of the facility name, census, or staffing hours worked.
There was no staffing board in the memory care unit.
On 01/08/24 at 4:00 p.m. the Corporate RN #1 reported the staffing board did not have the required components and 18 months of staffing records were not retained.
On 01/08/24 at 4:55 p.m. the administrator reported they were not aware of the requirements for posted staffing or retention of staffing records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure menus were followed for one of one meal servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure menus were followed for one of one meal service observed.
The administrator identified 39 resident who receive their meals from the facility kitchen.
Findings:
Res #43's annual assessment, dated 09/18/23, documented the resident's cognition was intact.
On 01/02/24 at 12:26 p.m., Res #43 was observed in the dining room eating lunch. The resident stated the food was good today; the barbeque chicken was just messy. Res #43 stated the only problem they had was when they ask for food from the alternate menu the facility sometimes did not have it.
The fall/winter 2023-2024 week 3 day 19 menu for 01/04/24 documented taco soup, shredded cheese, corn, lettuce and tomato chopped, tortilla chips, salsa, and a fruit cup.
On 01/04/24 at 3:31 p.m., DA #1 was working in the kitchen preparing the evening meal. DA #3 was on break at this time. DA #1 stated they were having chicken fingers, mashed potatoes and gravy, spinach with eggs, rolls, and ice cream for the evening meal.
On 01/04/23 at 4:29 p.m., DA #1 stated they did not have the ingredients to make the taco soup or tomatoes and the [NAME] #1 had told them to make the chicken fingers instead. DA #1 stated they did not have corn dogs for the alternate menu either.
On 01/04/24 at 4:33 p.m., during evening meal service it was observed the residents who receive a puree meal did not receive any form of bread with their meal. Also some meals were observed to go out to the 100 and 200 hall and some residents did not receive a roll or any kind of bread with their meal.
On 01/05/24 at 12:48 p.m., [NAME] #1 stated most of the time they were able to follow the menu. [NAME] #1 stated they did not have [NAME]-slaw for the meal today and did not have the taco soup last night. [NAME] #1 stated they did not have the items to make the taco soup. [NAME] #1 stated the administrator ordered the food for the menu items. [NAME] #1 stated they were not sure if they had corn dogs or not. She stated they do run out because the main thing the residents ask for are the corn dogs. [NAME] #1 stated they had to substitute this week a lot because they did not have the items to prepare the menu.
On 01/08/24 at 2:09 p.m., the administrator stated the facility should have followed the menu and the residents should receive the food listed on the menu. The administrator stated they did the food ordering for the facility and was not aware they had ran out of things for the menus.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure quarterly resident assessment were completed within the required timeframe for 12 (#5, 6, 23, 26, 30, 31, 35, 36, 37, 39, 42 and #44...
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Based on interview and record review, the facility failed to ensure quarterly resident assessment were completed within the required timeframe for 12 (#5, 6, 23, 26, 30, 31, 35, 36, 37, 39, 42 and #44) of 15 sampled residents whose resident assessments were reviewed.
The administrator identified 41 residents who resided in the facility.
Findings:
A review of resident assessments was conducted with the following results:
a. Res #5's annual resident assessment was completed on 07/31/23. A quarterly resident assessment was due on 10/31/23 but was not completed.
b. Res #6's annual resident assessment was completed on 08/25/23. A quarterly resident assessment was due on 11/25/23 but was not completed.
c. Res #23's annual resident assessment was completed on 08/06/23. A quarterly resident assessment was due on 11/06/23 but was not completed.
d. Res #26's annual resident assessment was completed on 08/16/23. A quarterly resident assessment was due on 11/16/23 but was not completed.
e. Res #30's quarterly resident assessment was completed on 08/13/23. A quarterly resident assessment was due on 11/13/23 but was not completed.
f. Res #31's annual resident assessment was completed on 08/05/23. A quarterly resident assessment was due on 11/05/23 but was not completed.
g. Res #35's quarterly resident assessment was completed on 08/25/23. A quarterly resident assessment was due on 11/25/23 but was not completed.
h. Res #36's quarterly resident assessment was completed on 08/24/23. A quarterly resident assessment was due on 11/24/23 but was not completed.
i. Res #37's quarterly resident assessment was completed on 08/08/23. A quarterly resident assessment was due on 11/08/23 but was not completed.
j. Res #39's annual resident assessment was completed on 08/26/23. A quarterly resident assessment was due on 11/26/23 but was not completed.
k. Res #42's annual resident assessment was completed on 08/22/23. A quarterly resident assessment was due on 11/22/23 but was not completed.
l. Res #44's quarterly resident assessment was completed on 08/28/23. A quarterly resident assessment was due on 11/28/23 but was not completed.
On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported the quarterly resident assessment should have been completed within the required timeframe. The Corporate RN #1 reported the MDS Coordinator's last day was 11/11/23 and there was no one in place initially to do MDS in the interim.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia.
A care plan, dated 12/01/21, docu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia.
A care plan, dated 12/01/21, documented the resident was at risk for adverse consequences related to receiving antipsychotic medication to treat delusional disorder and dementia with behaviors.
A PASRR I, dated 08/29/22, documented the resident had a serious mental illness. The PASRR documented a PASRR II was not needed this stay per administrator.
A quarterly assessment, dated 11/26/23, documented the resident was intact with cognition and required supervision with most ADLS. The assessment documented the resident received an antipsychotic and an antianxiety medication.
On 01/04/24 at 8:30 a.m., the administrator stated they did not make medical decisions and that the PASRR was completed by the last DON. The administrator stated according to the documentation of the resident having a serious mental illness OHCA should have been contacted.
3. Res #41 admitted to the facility on [DATE] with the following diagnoses bipolar disorder, depression, and dementia with behavioral disturbance.
A PASRR I , dated 07/12/23, documented the resident did not have a serious mental illness.
A quarterly assessment, dated 09/30/23, documented the resident was severely impaired with cognition, and requires extensive assistance with ADLs. The assessment documented the resident received an antipsychotic and an antidepressant medication.
On 01/04/24 at 8:23 a.m., the administrator stated the resident had the bipolar diagnosis on admission. The administrator stated the PASRR I was not filled out correctly and bipolar should have been listed as a serious mental illness on the PASRR I. The administrator stated the resident primary diagnosis was unspecified dementia.
Based on record review and interview, the facility failed to ensure a level ll PASRR referral was made to the Oklahoma Health Care Authority for three (#6, 39, and #41) of 16 residents who were reviewed for PASARR.
The administrator identified 41 residents who resided in the facility.
Findings:
1. Res #6 was admitted the facility with diagnoses which included moderate intellectual disabilities, depression, and bipolar disorder.
A PASRR level l form, dated 01/27/23, documented the resident was admitted to the facility as a skilled resident. The form documented if the resident remained in the facility more than 30 days and as a long term care resident the would need to be updated.
On 01/04/24 at 8:42 a.m., the administrator reviewed the resident's clinical record and stated per the PASRR level l completed a referral to the Oklahoma Health Care Authority should have been made when the resident remained in the facility longer than 30 days. The administrator stated a referral was not made to the Oklahoma Health Care Authority for a PASRR level ll when the resident remained in the facility more than 30 days and became a long term care resident with a diagnosis of a serious mental illness.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure there was RN coverage eight hours daily, seven days a week and failed to ensure a DON was employed.
The administrator identified 41...
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Based on record review and interview, the facility failed to ensure there was RN coverage eight hours daily, seven days a week and failed to ensure a DON was employed.
The administrator identified 41 residents who resided in the facility.
Findings:
Upon entrance and throughout the investigation there was no RN in the DON position. The administrator identified 12/23/23 as the last day a DON worked in the facility.
The administrator provided a list of RN coverage from 12/23/23 through 01/08/24.
There was no documented RN coverage for the following dates: 12/24/23, 12/27/23, 12/28/23, and 01/01/24.
On 01/08/24 at 4:50 p.m., the administrator reported they unfortunately did not have RN coverage for three days in December and one day in January. The administrator stated they were in the process of hiring a DON.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review, and interview, the facility failed to provide MRRs for twelve months for five (#1, 6, 27, 39, and #41) out of five residents reviewed for unnecessary medications.
The administ...
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Based on record review, and interview, the facility failed to provide MRRs for twelve months for five (#1, 6, 27, 39, and #41) out of five residents reviewed for unnecessary medications.
The administrator identified 41 residents resided in the facility.
Findings:
A policy dated November 2018, read in part, .MEDICATION REGIMEN REVIEW .The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly .
1. Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia.
A care plan, dated 12/01/21, documented the resident was at risk for adverse consequences related to receiving antipsychotic medication to treat delusional disorder and dementia with behaviors.
A quarterly assessment, dated 11/26/23, documented the resident was intact with cognition and required supervision with most ADLS. The assessment documented the resident received antipsychotic and antianxiety medication.
The corporate nurse provided MRRs for January, February, April, and July of 2023. The other eight months were not provided. Twelve months of pharmacy reviews were asked for during the survey.
On 01/04/24 at 9:30 a.m., the Corporate Nurse Consultant #1 stated that the MRRs provided were all that they could find.
2. Res #41 admitted to the facility and had the following diagnoses bipolar disorder, depression, anxiety disorder and dementia with behavioral disturbance.
A quarterly assessment, dated 09/30/23, documented the resident was severely impaired with cognition, and requires extensive assistance with ADLs. The assessment documented the resident received an antipsychotic and an antidepressant medication seven days out of the look back period.
The corporate nurse provided MRRs for July and September of 2023. The other ten months were not provided. Twelve months of pharmacy reviews were asked for during the survey.
On 01/08/24 at 1:59 p.m., the Corporate Nurse Consultant #1 stated no other medication reviews were found for the resident.
3. Res #1 was admitted to the facility with diagnoses which included heart failure, acute respiratory disease, diabetes, conversion disorder with seizures, cerebral infarction, and anxiety disorder.
The facility provided MRRs for February, March, and April of 2023 for the resident. The facility could not provide MRRs for January, May, June, July, August, September, October, November, or December of 2023 for the resident.
4. Res #6 was admitted to the facility with diagnoses which included ventricular tachycardia, depression, and bipolar disorder.
The facility provided a MRR for February 2023 for the resident. The facility could not provide MRRs for January, March, April, May, June, July, August, September, October, November, or December of 2023 for the resident.
5. Res #27 was admitted to the facility with diagnoses which included cerebral infarction, anxiety disorder, depression, pain, and atrial fibrillation.
The facility provided MRRs for January, March, and July of 2023 for the resident. The facility could not provide MRRs for February, April, May, June, August, September, October, November, or December of 2023 for the resident.
On 01/04/24 at 9:35 a.m., the corporate nurse stated they were unable to locate all the monthly medication regimen reviews for the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure unnecessary psychotropic medications were not administered for one (#39) of five sampled residents reviewed for unnece...
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Based on observation, record review, and interview, the facility failed to ensure unnecessary psychotropic medications were not administered for one (#39) of five sampled residents reviewed for unnecessary medication.
The administrator identified 41 residents resided in the facility.
Findings:
1. Res #39 had diagnoses which included delusional disorders, anxiety disorders, and dementia.
A care plan, dated 12/01/21, documented the resident was at risk for adverse consequences related to receiving antipsychotic medication to treat delusional disorder and dementia with behaviors. The care plan documented to attempt to give the lowest dose possible.
A MRR, dated 07/12/23, documented the resident was currently receiving Ativan 1 mg BID for anxiety and requested to an attempt to reduce Ativan to 0.5 mg BID for anxiety. The physician agreed and signed the MRR but did not date the MRR and the MRR was not noted. The Ativan was not decreased for the resident and the current order was for Ativan 1 mg BID.
A discontinued medication order for Ativan 0.5 mg administer 1 mg BID was in place from 04/17/23 to 08/16/23.
A physician order, dated 08/16/23, documented Ativan 0.5 mg administer 1 mg BID.
A quarterly assessment, dated 11/26/23, documented the resident was intact with cognition and required supervision with most ADLS. The assessment documented the resident received an antipsychotic and an antianxiety medication.
On 01/03/24 at 3:49 p.m., the resident's MAR for January 2023 was reviewed. The order documented on the MAR was Ativan 0.5 mg administer 1 mg BID for anxiety.
On 01/03/24 at 4:10 p.m., LPN #2 retrieved the resident's Ativan medication from the medication cart. LPN #2 stated this was the medication the resident was receiving. Observed the Ativan medication card which documented Ativan 1 mg administer BID.
The resident had received the higher dose of Ativan for 145 days from July 12, 2023 to January 4, 2024.
On 01/04/24 at 9:44 a.m., the Corporate Nurse Consultant #1 stated the Ativan had not been reduced from the July MRR request. The resident was still currently getting Ativan 1 mg BID.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure a dietary manager was hired for the facility.
The administrator identified 39 residents who received meals from the ki...
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Based on observation, record review, and interview, the facility failed to ensure a dietary manager was hired for the facility.
The administrator identified 39 residents who received meals from the kitchen.
Findings:
On 01/02/24 at 9:39 a.m., during the initial tour of the kitchen, there were two staff working in the kitchen. [NAME] #1 stated they were the acting DM because the facility did not currently have a DM.
On 01/05/24 at 12:50 p.m., [NAME] #1 stated the facility had a dietitian that come to the facility once a month.
On 01/05/24 at 1:08 p.m., [NAME] #1 stated they did not want the DM position. [NAME] #1 stated they had not had a DM for several months but was not sure of the date. [NAME] #1 stated the administrator interviewed someone for the DM position today.
On 01/08/24 at 1:55 p.m., the dietitian stated they were in the facility once a month for as long as they need them, about six hours. The dietitian stated they were not filling in as the facilities DM while they were without one.
The facility records documented the dietary managers last day was 09/01/23.
On 01/08/24 at 2:12 p.m., the administrator stated [NAME] #1 did not want to be the DM but they had worked at the facility for a long time. The administrator stated as of right now they do not have a DM but the job was offered to someone today.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to have an effective administration to use its resources effectively and efficiently to attain or maintain the highest practicab...
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Based on record review, observation, and interview, the facility failed to have an effective administration to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to:
a. ensure DNR forms were dated and signed;
b. ensure background checks were completed for new hires;
c. ensure an annual resident assessment was completed within the required timeframe.;
d. ensure quarterly assessments were completed within the required timeframe;
e. ensure resident assessments were transmitted to CMS within the required timeframes;
f. ensure MDS assessments were accurate;
g. ensure a level II PASRR referral was made to the Oklahoma Health Care Authority;
h. ensure a resident received services to prevent an ADL decline;
i. ensure there was RN coverage eight hours daily, seven days a week;
j. ensure a DON was employed;
k. ensure daily staffing information was documented, accessible, and retained;
l. ensure MRRs were provided for twelve months;
m. ensure unnecessary psychotropic medications were not administered;
n. ensure a dietary manager was hired for the facility;
o. ensure menus were followed;
p. ensure food was stored, prepared, and served in accordance with professional standards;
q. ensure a facility assessment was updated annually;
r. ensure a full time qualified social worker was employed; and
s. ensure equipment was sanitized between residents.
The administrator identified 41 residents who resided in the facility.
Findings:
1. On 01/03/24 at 2:49 p.m., the administrator stated the DON was responsible for monitoring appropriate signage of DNR or POA forms. The administrator stated with no DON currently, they were responsible.
2. On 01/04/24 at 2:30 p.m., the business office manager reported they had not gotten to employee background checks. The business office manager reported all background checks should have been completed upon hire.
On 01/04/24 at 3:15 p.m., the administrator reported she thought the business office manager was doing her job and following protocol.
01/08/24 at 4:05 p.m., the administrator reported they thought the business office manager was following a check list for new hires. The administrator reported they had not followed up regarding background checks to ensure they were completed.
3. On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported Res #8's annual assessment should have been completed within the required timeframe. The Corporate RN #1 reported the MDS Coordinator's last day was 11/11/23 and there was no one in place initially to do MDS in the interim.
4. On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported the quarterly resident assessment should have been completed within the required timeframe. The Corporate RN #1 reported the MDS Coordinator's last day was 11/11/23 and there was no one in place initially to do MDS in the interim.
5. On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported the MDS coordinator's last day was 11/11/23 and none of the facility staff had login credentials with QIES to obtain reports and transmit resident assessments.
6. On 01/04/24 at 11:59 a.m., the cooperate nurse consultant #1 stated the MDS was not correct for the GDR the resident had a reduction on 02/17/23.
7. On 01/04/24 at 8:23 a.m., the administrator stated the resident had the bipolar diagnosis on admission. The administrator stated the PASRR I was not filled out correctly and bipolar should have been listed as a serious mental illness on the PASRR I. The administrator stated the resident primary diagnosis was unspecified dementia.
On 01/04/24 at 8:30 a.m., the administrator stated according to the documentation of the resident having a serious mental illness OHCA should have been contacted.
On 01/04/24 at 8:42 a.m., the administrator reviewed the resident's clinical record and stated per the PASRR level l completed a referral to the Oklahoma Health Care Authority should have been made when the resident remained in the facility longer than 30 days. The administrator stated a referral was not made to the Oklahoma Health Care Authority for a PASRR level ll when the resident remained in the facility more than 30 days and became a long term care resident with a diagnosis of a serious mental illness.
8. On 01/08/24 at 11:58 a.m., the corporate nurse stated the resident had a significant change assessment completed on 09/08/23. The nurse stated the resident had a decline. The nurse stated the resident had been discussed in the morning staff meeting on 08/30/23 regarding a decline. The nurse did not know why the resident was not receiving therapy or restorative services due to the decline.
On 01/08/24 at 4:57 p.m., the administrator stated there was some confusion if the resident was remaining in the facility. The administrator stated nothing was done when the resident had a decline.
9. Upon entrance and throughout the investigation there was no RN in the DON position. The administrator identified 12/23/23 as the last day a DON worked in the facility.
On 01/08/24 at 4:50 p.m., the administrator reported they unfortunately did not have RN coverage for three days in December and one day in January. The administrator stated they were in the process of hiring a DON.
10. On 01/08/24 at 4:00 p.m. the Corporate RN #1 reported the staffing board did not have the required components and 18 months of staffing records were not retained.
On 01/08/24 at 4:55 p.m. the administrator reported they were not aware of the requirements for posted staffing or retention of staffing records.
11. The corporate nurse provided MRRs for January, February, April, and July of 2022. The other eight months were not provided. Twelve months of pharmacy reviews were asked for during the survey. On 01/04/24 at 9:30 a.m., the cooperate nurse consultant #1 stated that the MRRs provided were all that they could find.
12. On 01/04/24 at 9:44 a.m., the cooperate nurse consultant #1 stated the Ativan had not been reduced from the July MRR request. The resident was still currently getting Ativan 1 mg BID. They stated we both looked at the order on the current MAR.
13. On 01/02/24 at 9:39 a.m., during initial tour of the kitchen there were two staff members working. [NAME] #1 stated they were the acting DM because the facility did not currently have a DM.
On 01/08/24 at 1:55 p.m., the dietitian stated they were in the facility once a month for as long as they need them, about 6 hours. The dietitian stated they were not filling in as the facilities DM while they are without one.
14. On 01/08/24 at 2:09 p.m., the administrator stated the facility should have followed the menu and the residents should receive the food listed on the menu. The administrator stated they did the food ordering for the facility and were not aware they had ran out of things for the menus.
15. On 01/02/24 at 9:45 a.m., [NAME] #1 the acting DM stated the items in the refrigerators should be labeled and dated and not open to air.
On 01/02/24 at 9:48 a.m., the freezer was observed with ice all over the boxes of food, the ceiling, door, and floor. [NAME] #1 the acting DM stated they had been working on the freezer but it had been that way a while.
On 01/04/23 at 3:39 p.m., observed DA #1 preparing the puree the lid for the food processor was broken. DA #1 was using both pieces to cover the container while making the puree.
On 01/05/24 at 12:48 p.m., [NAME] #1 stated they the lid for the food processor had been broken for a month or two the administrator had ordered one and they were waiting for it to come in. [NAME] #1 stated they did not check the sanitizer yesterday morning for the dish machine. [NAME] #1 stated the staff working 01/04/24 should have been able to check the sanitizer in the three compartment sink and the dish machine. [NAME] #1 stated the glasses, bowl, and trays should have been air dried before stacking. [NAME] #1 stated when anyone enters the kitchen they should put on a hair net and wash their hands. The cook stated the staff should wash their hands after touching anything dirty.
On 01/08/24 at 2:09 p.m., the administrator stated they were ordering a new door for the freezer. The administrator then stated the company told them they could put a strip around the door. The administrator stated they did not know the date the freezer would be fixed but were on a list. The administrator stated every staff should know how to check the sanitizer. The administrator stated the staff should wash their hands when something dirty was touched and the items should be air dried before use.
16. On 01/08/24 at 4:40 p.m., the administrator was asked when the facility assessment was dated. The administrator stated they thought the assessment had been updated with COVID in 2020. The administrator stated the facility assessment did not have a date. There was no way to prove when the facility assessment was updated or reviewed. The administrator stated the facility assessment was reviewed last January when they were getting ready in 2023 survey but there is not a date on it.
On 01/08/24 at 4:52 p.m., the administrator stated they started working at the facility in 2010 and the lock unit was the first thing they got up and running in 2011. The administrator stated they did not see the locked unit on the facility assessment.
17. On 01/08/24 at 4:38 p.m., the administrator stated the social service director did not have a degree. The administrator identified the facility was licensed for 124 beds. The administrator stated the facility did not currently have a qualified social worker.
18. On 01/03/24 at 11:00 a.m. the Corporate RN #1 reported the equipment should have been cleaned/sanitized after each use.
On 01/08/24 at 5:00 p.m., the administrator reported the equipment should have been cleaned/sanitized after each use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure a facility assessment was updated annually.
The administrator identified 41 residents resided in the facility.
Findings:
Review of ...
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Based on record review and interview, the facility failed to ensure a facility assessment was updated annually.
The administrator identified 41 residents resided in the facility.
Findings:
Review of the facility assessment did not contain a date of when the assessment was formed, updated, or last reviewed.
On 01/08/24 at 4:40 p.m., the administrator was asked when the facility assessment was dated. The administrator stated they thought the assessment had been updated with COVID in 2020. The administrator stated the facility assessment did not have a date. There was no way to prove when the facility assessment was updated or reviewed. The administrator stated the facility assessment was reviewed last January when they were getting ready in 2023 survey but there is not a date on it.
On 01/08/24 at 4:52 p.m., the administrator stated they started working at the facility in 2010 and the lock unit was the first thing they got up and running in 2011. The administrator stated they did not see the locked unit on the facility assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to employ the services of a qualified social worker on a full times basis.
The administrator identified 41 resident resided in the facility. ...
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Based on record review and interview, the facility failed to employ the services of a qualified social worker on a full times basis.
The administrator identified 41 resident resided in the facility.
Findings:
On 01/08/24 at 4:36 p.m., the social service/activities director was out of the facility at this time buying cigarettes for the residents.
On 01/08/24 at 4:38 p.m., the administrator stated the social service director did not have a degree. The administrator identified the facility was licensed for 124 beds. The administrator stated the facility did not currently have a qualified social worker.
On 01/08/24 at 5:04 p.m., the employee file for the social service director was reviewed. The social service director did not have the credentials required for 124 bed facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure equipment was sanitized between residents.
The administrator identified 41 residents who resided in the facility.
Find...
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Based on observation, record review, and interview, the facility failed to ensure equipment was sanitized between residents.
The administrator identified 41 residents who resided in the facility.
Findings:
An Equipment and Supplies Used During Isolation policy, last revised on October 2009, read in part, .When possible, dedicate the use of non-critical resident-care equipment items such as stethoscope, sphygmomanometer .thermometer to a single resident (or cohort of residents) to avoid sharing between residents. If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident.
On 01/04/24 at 8:50 a.m., CMA #1 was observed to enter Res #12's room to take their vital signs and administer their medication. Equipment brought into the room was a wrist blood pressure cuff and pulse ox. Equipment was taken out of the room and placed on the medication cart after use without being sanitized.
On 01/04/24 at 9:00 a.m., CMA #1 was observed to enter Res #1's room to take their vital signs. Res #1 was in transmission based precautions for COVID. Equipment brought into the room was a wrist blood pressure cuff and pulse ox previously used in Res #12's room. Equipment was taken out of the room and placed on the medication cart after use without being sanitized.
On 01/04/24 at 9:15 a.m. CMA #1 was observed to enter Res #44's room to take their vital signs and administer their medication. Equipment brought into the room was a wrist blood pressure cuff and pulse ox used previously used in Res #12 and #1's room. Equipment was taken out of the room and placed on the medication cart after use without being sanitized.
On 01/04/24 at 9:25 a.m. CMA #1 was observed to enter Res #5's room to take their vital signs and administer their medication. Res #5 was in transmission based precautions for COVID. Equipment brought into the room was a wrist blood pressure cuff and pulse ox previously used in Res #12, 1 and #44's room. Equipment was taken out of the room and placed on the medication cart after use without being sanitized.
On 01/04/24 at 9:35 a.m. CMA #1 was observed to go back into Res #1's room to take their vital signs. Res #1 was in transmission based precautions for COVID. Equipment brought into the room was a wrist blood pressure cuff and pulse ox previously used in Res #12, 5 and #44's room. Equipment was taken out of the room and placed on the medication cart after use without being sanitized.
The residents on transmission based precautions did not have designated equipment for use in their room only.
On 01/03/24 at 11:00 a.m. the Corporate RN #1 reported the equipment should have been cleaned/sanitized after each use.
On 01/08/24 at 5:00 p.m., the administrator reported the equipment should have been cleaned/sanitized after each use.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure resident assessments were transmitted to CMS within the required timeframes.
The administrator identified 41 residents who resided ...
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Based on record review and interview, the facility failed to ensure resident assessments were transmitted to CMS within the required timeframes.
The administrator identified 41 residents who resided in the facility.
Findings:
An Electronic Transmission of the MDS policy, last revised on October 2010, read in part, .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data .
The facility was unable to provide QIES transmission reports, but was able to provide transmission records from their EHR system.
Transmission records from 09/06/23 though 01/03/24 were reviewed. 69 of 98 MDS/Resident assessments were submitted late.
On 01/08/23 at 3:00 p.m., the Corporate RN #1 reported the MDS coordinator's last day was 11/11/23 and none of the facility staff had login credentials with QIES to obtain reports and transmit resident assessments.
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 record review, observation, and interview the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety.
The administrator identified...
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Based on record review, observation, and interview the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety.
The administrator identified 39 residents who receive their meals from the kitchen.
Findings:
On 01/02/24 at 9:39 a.m., an initial tour of the kitchen was completed. Observations made in the refrigerators were peaches in cups not dated and labeled, two sandwiches in plastic bags were not dated or labeled, a glass of juice not covered, sliced cheese open to air and not dated or labeled, and hamburger patties wrapped up not labeled or dated.
On 01/02/24 at 9:45 a.m., [NAME] #1 the acting DM stated the items in the refrigerators should be labeled and dated and not open to air.
On 01/02/24 at 9:48 a.m., the freezer was observed with ice all over the boxes of food, the ceiling, door, and floor. [NAME] #1 the acting DM stated they had been working on the freezer but it had been that way a while.
On 01/04/23 at 3:38 p.m., DA #1 was observed to touched the trash can lid with her hand and did not wash her hands.
On 01/04/23 at 3:39 p.m., observed DA #1 preparing the puree. The lid for the food processor was broken. DA #1 was using both pieces to cover the container while making the puree.
On 01/04/23 at 3:40 p.m., DA #1 stated the lid got cracked in August and a few weeks ago the lid got broke. She thought they had ordered a new lid. At this time DA #1 touched her nose by her mask and continued with making the puree. The smaller piece of the lid was observed to fall into the puree, DA #1 retrieved the part of the lid from the puree and served the puree.
On 01/04/23 at 3:43 p.m., the small drinking glasses were observed on the storage rack upside down and observed to be wet on the inside of the glasses. The serving trays were observed stacked on a cart and the trays were stacked wet.
On 01/04/23 at 3:47 p.m., the freezer door was observed not closed completely. DA #1 stated they would have to knock the ice off the freezer door to get it to shut.
On 01/04/23 at 3:48 p.m., the maintenance man and DA #3 were observed to come in the back door or the kitchen. The maintenance man walked through the kitchen and out another door. DA #3 did not wash their hands when they entered the kitchen for work.
On 01/04/23 at 3:55 p.m., DA #1 was observed to wash the food processor container in the three compartment sink. DA #1 was asked to check the sanitizer in the sink water and the dish machine. The dish machine did not register any sanitizer nor did the sanitizer in the sink.
On 01/04/23 at 4:08 p.m., the bowls DA #1 was going to serve the spinach in were observed to be wet on the inside. DA #1 was asked at that time if the bowls were wet. DA #1 stated the bowls were wet and should be air dried before using them the bowls were not used at this time.
On 01/04/23 at 4:14 p.m., DA #3 was washing dishes in the dish machine trying to get the sanitizer to register. DA #3 switched the container of sanitizer to the dish machine and the sanitizer registered at 50 PPM. DA #3 did not wash her hands before going through the clean trays to see which ones were dry and taking the other to place in the rack to air dry.
The log for the dish machine sanitizer was observed blank for 01/04/24.
On 01/05/24 at 12:48 p.m., [NAME] #1 stated they the lid for the food processor had been broken for a month or two the administrator had ordered one and they were waiting for it to come in. [NAME] #1 stated they did not check the sanitizer yesterday morning for the dish machine. [NAME] #1 stated the staff working 01/04/24 should have been able to check the sanitizer in the three compartment sink and the dish machine. [NAME] #1 stated the glasses, bowl, and trays should have been air dried before stacking. [NAME] #1 stated when anyone enters the kitchen they should put on a hair net and wash their hands. The cook stated the staff should wash their hands after touching anything dirty.
On 01/08/24 at 2:09 p.m., the administrator stated they were ordering a new door for the freezer. The administrator then stated the company told them they could put a strip around the door. The administrator stated they did not know the date the freezer would be fixed but were on a list. The administrator stated every staff should know how to check the sanitizer. The administrator stated the staff should wash their hands when something dirty was touched and the items should be air dried before use.
Nov 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
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 record review and interview, the facility failed to ensure a resident received the necessary services to maintain groom...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received the necessary services to maintain grooming and personal hygiene for one (#1) of four residents sampled for assistance with bathing.
The administrator stated 44 residents lived in the facility.
Findings:
Res #1 was admitted on [DATE] and had diagnoses which included congestive heart failure, muscle wasting, and pain in the thoracic spine.
An admission assessment, dated 09/24/23, documented the resident was severely impaired in cognition, required extensive assistance with hygiene, and bathing did not occur.
A facility document, titled CNA SKIN SHEET, dated 09/26/23, documented the resident had received a bed bath.
A nurse note, dated 10/01/23, documented the resident had received a partial bath.
The EHR documented Res #1 was discharged on 10/20/23.
On 11/15/23 at 3:30 p.m., Corporate Nurse Consultant #1 stated there were only two documents for bathing related to Res #1. The corporate nurse stated no other baths were documented during the resident's stay.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
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 record review and interview, the facility failed to ensure a resident with wounds received the necessary assessments, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident with wounds received the necessary assessments, treatments, and services for one (#1) of three residents reviewed for pressure ulcers and other wounds.
The administrator stated 44 residents lived in the facility.
Findings:
Res #1 was admitted on [DATE] and had diagnoses which included congestive heart failure, muscle wasting, and pain in the thoracic spine.
An admission nursing note, dated 09/21/23, documented the resident had a small open area, which they documented as a stage II, on their buttocks. The note did not document measurements of the area or if the resident's physician had been notified of the open area.
A review of the resident's EHR did not document a treatment was put in place on 09/21/23 for care of the open area.
The resident's care plan, dated 09/21/23, did not document a plan of care related to pressure ulcers.
An admission assessment, dated 09/24/23, documented the resident was severely impaired in cognition and had one stage II pressure ulcer which was present on admission. The CAA triggered pressure ulcers for care planning.
A skin assessment, dated 09/27/23, documented the resident had a stage II pressure ulcer, measuring 1.0 x 0.5 x 0.1 cm. The assessment documented the physician was notified and an order for Calmoseptine twice a day to the left buttock was ordered.
The EHR did not document any other skin or wound assessment after 09/27/23.
The EHR documented the resident was discharged to home on [DATE].
On 11/15/23 at 1:57 p.m., the DON stated the nurse who had admitted the resident no longer worked at the facility. The DON stated per the note on 09/21/23 it did not appear the physician had been notified of the presence of a wound on the resident's buttocks.
On 11/15/23 at 2:20 p.m., Corporate Nurse Consultant #1 stated they had identified skin assessments were not taking place the last time they were in the facility. They stated Res #1 had been discharged by then. The corporate nurse stated when they discovered it the had the facility do a skin assessment sweep and asked the administrator to plan an action to correct the issue. The corporate nurse stated the lack of skin assessments was caused by a bathing schedule flaw, where the weekly skin assessments by CNA's were documented, which had been corrected.
On 11/15/23 at 3:10 p.m., the administrator stated the skin assessment sweep had been completed on 11/03/23. The administrator stated the facility had not completed a formal in-service for staff but had been informally letting staff know about the updated bathing schedule. The administrator stated they had started monitoring to ensure the plan of action was working.
May 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure one (#1) resident in the Memory Care Unit was allowed reasonable access to the use of a telephone and a place where calls could be m...
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Based on interview and record review, the facility failed to ensure one (#1) resident in the Memory Care Unit was allowed reasonable access to the use of a telephone and a place where calls could be made without being overheard.
The Resident Current Status Report, dated 05/30/23, documented a census of 16 residents in the Memory Care Unit.
Findings:
A Resident Rights policy, last revised 08/09, read in parts, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .Use a telephone in privacy .Residents are entitled to exercise their rights and privileges to the fullest extent possible.
A progress note, dated 02/13/23 at 1:59 p.m., read in parts, . had an appointment at the podiatrist this morning she complained the entire time over there because he was going to make her miss her phone call to her husband then we stopped to get a snack and saw we where going to make it back around 1pm she starts screaming about if that other resident has the phone or gets a phone call im going to yank it from her because she knows she gets the phone at 1:00 .
A progress note, dated 04/28/23 at 12:28 p.m., read in parts, .[Recorded as Late Entry on 04/30/23 12:29] RESIDENT ASKED [Administrator, name omitted] ABOUT GETTING HER PHONE CALL TO HER HUSBAND AT 3PM, SINCE HE GOT A JOB WORKING AT NIGHT .
A progress note, dated 05/28/23 at 4:00 p.m., read in parts, .SPOKE WITH HER SISTER [name omitted], [Administrator, name omitted] SAID SHOULD [sic] COULD SPEAK TO HER ONCE A DAY .
A progress note, dated 05/29/23 at 12:59 a.m., read in parts, . BEEN IN ROOM MOST OF SHIFT AROUND 12 MN CNA HEARD PHONE RINGING [Res #1, name omitted] HAD IT HID IN HER ROOM WAS SISTER ON PHONE THEN STARTED BEGGING NOT TO TELL ON HER PHONE IS IN LOCK UP NOW .
On 05/30/23 at 4:00 p.m., Res #1 reported they were allowed one telephone call per day at 1:00 p.m. The resident reported they were only allowed to use the telephone at the nurses' station and were not provided a private area to talk on the telephone. The resident reported the staff monitored their telephone calls and listened to their conversations. Res #1 reported none of the residents in the Memory Care Unit were allowed to use the telephone from 6:00 p.m. to 6:00 a.m. The resident reported the staff placed the telephone inside the locked medication room after 6:00 p.m. and would not allow residents to make calls until the next morning. Resident #1 reported the telephone at the nurses' station was the only telephone they had access to.
On 05/31/23 at 10:15 a.m., during a telephone interview, the surveyor asked CNA #1 if telephone use in the Memory Care Unit was restricted, CNA #1 reported they aren't allowed to use the phone from 6:00 p.m to 6:00 a.m., we are supposed to put the phone up where they can't get it. When the surveyor asked how long the phone use had been restricted in the Memory Care Unit, CNA #1 reported it had been that way for months. When asked if residents were allowed privacy during their telephone use, the CNA reported, no, most of the time the nurses are listening, especially if it is Res #1 [name ommitted].
On 05/31/23 at 10:34 a.m, during a telephone interview, the surveyor asked CNA #2 if telephone use in the Memory Care Unit was restricted, CNA #2 reported Res #1 had not been allowed to use the telephone for a couple of days. CNA #2 reported at 6 p.m, they take the phone and no body can use them after 6 p.m.
On 05/31/23 at 10:40 a.m., the surveyor recieved a telephone call from CNA #1, the CNA reported there was a meeting the other day and now Res #1 can't call her husband at all.
On 05/31/23 at 11:15 a.m, the surveyor asked the Administrator if residents in the Memory Care Unit had access to a telephone in a location where they could have private conversations. The Administrator reported all of the residents had access to the telephone at the nurses' station except for Res #1.The Administrator reported prior to 05/24/23, Res #1 had been allowed one phone call per day at 1:00 p.m. The Administrator reported on 05/24/23 they had taken Res #1's telephone privileges away because the resident's husband had made threats against the facility while on the telephone with the resident. The Administrator reported they felt they had made the right decision due to the safety of residents and staff. The surveyor asked the Administrator if they were aware the telephone use in the Memory Care Unit was restricted between 6:00 p.m. and 6:00 a.m., the Administrator reported they were not aware of the restriction and would in-service staff on the right for residents to have access to the telephone.
May 2023
2 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Respiratory Care
(Tag F0695)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An IJ situation was determined to be in existence related to the facility failing to ensure a resident's respiratory status was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An IJ situation was determined to be in existence related to the facility failing to ensure a resident's respiratory status was assessed, monitored, and interventions were put in place to prevent hospitalization. The staff failed to notify the physician of significant changes in condition and call Emergency Medical Services.
On 01/17/23, staff documented Res #1 had an oxygen saturation of 44% and 64%. The staff documented they gave Res #1 a breathing treatment prior to calling EMS. There was no physician notification documented.
A physician's order on 01/21/23, read in part, .maintain O2 sat above 90%.
On 02/20/23 at 4:49 a.m., staff documented the resident's oxygen saturation was 79%, the staff administered a breathing treatment, the oxygen saturation rose to 88%. There was no physician notification documented.
On 02/20/23 at 7:15 a.m., staff documented the resident's oxygen saturation was 91%, the respiratory rate was 36, and lung sounds were diminished. There was no physician notification or call to EMS documented.
On 02/21/23 Res #1 was diagnosed with bacterial pneumonia.
On 04/29/23 at 1:52 p.m., staff documented Res #1 was very short of breath, a breathing treatment was started, the oxygen saturation was 83%. There was no physician notification or call to EMS documented.
On 04/29/23 at 5:40 p.m., staff documented the oxygen saturation was 85%. There was no physician notification or call to EMS documented.
On 04/29/23 at 10:35 p.m., staff documented, cpap in place and 02 @ 2 l/m via cpap. Patient resp at 20 with SP02 69%. Patient's granddaughter present and requesting patient be sent to CMH ER. Nurse has been monitoring 02 and trying to determine if cpap is operating properly. Removed cpap and 02 admin via n/c @ 2 l/m . Staff failed to call EMS immediately.
On 04/30/23 Res #1 was transferred from the local hospital to a higher level of care with an elevated troponin and myocardial infarction.
On 05/01/23 at 4:45 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.
On 05/01/23 at 4:55 p.m., the Administrator and DON were notified of the IJ situation.
On 05/01/23 at 7:30 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented:
IJ Plan of Removal for Respiratory Assessment, Monitoring, and Interventions
Completion Date 5-1-23 at 8:30 p.m.
All staff will be educated with a sign in sheet that are currently working in the facility. Any remaining staff that aren't at the facility will be called and educated over the telephone. Employee name and time of call will be documented. Any staff we are unable to contact for educational training will not be allowed to clock in until education is completed.
Resident Change of Condition-Physician Notification
Clinical Staff Education will be completed on the following items:
Respiratory Assessment
Pulse Oximeter
CPAP/BIPAP Support
COPD Clinical Protocol
Currently in progress: Reviewing all residents with respiratory diagnosis, oxygen therapy, CPAP/BIPAP to ensure appropriate physician orders and interventions are in place. SBARS will be completed on any residents with a change of condition. The change of condition will be documented, physician will be notified, and time of notification will be documented. Care plans will be updated with any changes made to current orders.
On 05/01/23 at 7:30 p.m., the Administrator and DON were notified the immediacy was lifted effective 05/01/23 at 7:30 p.m. and the deficiency remained at a harm level.
On 05/03/23, facility staff were interviewed and were able to state they had been educated on respiratory assessment, pulse oximetry, CPAP/BIPAP support, COPD Clinical Protocol, Resident Change in Condition, and physician notification. Care plans had been updated to reflect identified residents' need for oxygen therapy, CPAP/BIPAP, and monitoring of respiratory status.
The Resident Census and Conditions of Residents, dated 05/01/23 the DON identified four residents with oxygen therapy.
Findings:
1. Res #1 was admitted with diagnoses which included COPD, chronic dyspnea, and C02 retention.
A care plan, last reviewed/revised on 01/12/23, documented in part, .resident has episodes of shortness of breath and is at risk for respiratory distress/failure .assess respiratory status ie: breath sounds, respiratory rate, skin color, etc. notify MD of abnormal .monitor for sob .report to MD .notify MD of any changes in condition .
A progress noted, dated 01/17/23 at 6:04 a.m., documented, sob o2 sat keep going down 44 and 64 alert with confusion weak gave albuterol breathing treatment o2 sat kept going down called 911 was here in few minutes left enroute to [hospital, name omitted] for eval daughter (name omitted) called and notified of sending to ER don notified.
A physician's order, dated 01/21/23, documented, obtain 02 sat q shift. Maintain above 90%.
A quarterly assessment, dated 02/08/23, documented Res #1 required oxygen therapy.
A progress note, dated 02/20/23 at 4:49 a.m., documented, o2 sat went down to 79 breathing treatment given up to 88-90 down head of bed up 02 at 2 liters via nc . o2 sat 88 will continue to monitor.
A progress note, dated 02/20/23 at 7:15 a.m., documented, Vs: 91% 2l/m n/c, 36 resp, 88hr neb treatment given with rate to 24 post. Diominished [sic] breath sounds bilaterally.
A physician's order, dated 02/23/23, documented, 0xygen at 2 liters via mask continuously.
A Clinical Report, dated 04/12/23 at 4:48 p.m., documented Res #1 was taken to the hospital by family.
A progress note, dated 04/12/23 at 11:54 p.m., documented, hospital called said they were going to admit her to hospital for hypoxia.
A hospital Discharge summary, dated [DATE], documented Res #1 was admitted on [DATE] and discharged on 04/14/23 with diagnoses which included hypoxia and acute exacerbation of COPD. The summary documented to notify the physician of shortness of breath.
A progress note, dated 04/29/23 at 1:52 p.m., documented in parts, .CNA .ASKED ME TO . CHECK ON THIS RESIDENT D/T HER BECOMING VERY SOB . STARTED BREATHING TX, .TRIED TO TRANSFER RESIDENT SHE BECAME VERY WEAK,02 WAS 83% WITH 02 3LITER . WILL CONT TO MONITOR .
A progress note, dated 04/29/23 at 5:40 p.m., documented in parts, .O2 85% with O2 @ 2L .
A progress note, dated 04/29/23 at 11:35 p.m. [late entry] documented in parts, . 02 @ 2 l/m via cpap. Patient resp at 20 with SP02 69% . Nurse has been monitoring 02 and trying to determine if cpap is operating properly. Removed cpap and 02 admin via n/c @ 2 l/m . transported patient to . ER.
A Medical Necessity for Ambulance Services, dated 04/29/23 (no time), documented Res #1 was transferred to higher level of care for the services of a cardiologist and admission to an Intensive Care Unit due to an elevated troponin, hypoxia, and hypercapnia.
A hospital document, with no title, dated 04/30/23 at 1:59 a.m., documented the resident's admitting diagnoses as COPD, Hypoxia, and NSTEMI.
On 05/01/23 at 3:45 p.m., Corp RN #1 reported the staff should have notified the physician on 01/17/23 when the resident's sat was 44% and 64%, on 02/20/23 when the resident's sat was 79% and 88%, and the respiratory rate was 36, on 04/29/23 when the resident's sat was 85%, and on 04/29/23 when the resident's sat was 69%.
On 05/01/23 at 3:55 p.m., the ADON reported the staff should have notified the physician on 01/17/23 when the resident's sat was 44% and 64%, on 02/20/23 when the resident's sat was 79% and 88%, and the respiratory rate was 36, on 04/29/23 when the resident's sat was 85%, and on 04/29/23 when the resident's sat was 69%.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician was notified of a change in condition for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician was notified of a change in condition for one (#1) of three residents reviewed for change in condition.
The Resident Census and Conditions of Residents, dated 05/01/23, documented a census of 49.
Findings:
Res #1 was admitted with diagnoses which included COPD, chronic dyspnea, and C02 retention.
A care plan, last reviewed/revised on 01/12/23, documented in part, .resident has episodes of shortness of breath and is at risk for respiratory distress/failure .assess respiratory status ie: breath sounds, respiratory rate, skin color, etc. notify MD of abnormal .monitor for sob .report to MD .notify MD of any changes in condition .
A progress noted, dated 01/17/23 at 6:04 a.m., documented, sob o2 sat keep going down 44 and 64 alert with confusion weak gave albuterol breathing treatment o2 sat kept going down called 911 was here in few minutes left enroute to [hospital, name omitted] for eval daughter (name omitted) called and notified of sending to ER don notified.
A physician's order, dated 01/21/23, documented, obtain 02 sat q shift. Maintain above 90%.
A quarterly assessment, dated 02/08/23, documented Res #1 required oxygen therapy.
A progress note, dated 02/20/23 at 4:49 a.m., documented, o2 sat went down to 79 breathing treatment given up to 88-90 down head of bed up 02 at 2 liters via nc will continue to monitor b/p 152/87 p 89 20 temp 97.6 o2 sat 88 will continue to monitor.
A progress note, dated 02/20/23 at 7:15 a.m., documented, Vs: 91% 2L/M n/c, 36 resp, 88 hr neb treatment given with rate to 24 post. Diminished breath sounds bilaterally.
A physician's order, dated 02/23/23, documented, oxygen at 2 liters via mask continuously.
A Clinical Report, dated 04/12/23 at 4:48 p.m., documented Res #1 was taken to the hospital by family.
A progress note, dated 04/12/23 at 11:54 p.m., documented, hospital called said they were going to admit her to hospital for hypoxia.
A hospital Discharge summary, dated [DATE], documented Res #1 was admitted on [DATE] and discharged on 04/14/23 with diagnoses which included hypoxia and acute exacerbation of COPD. The summary documented to notify the physician of shortness of breath.
A progress note, dated 04/29/23 at 1:52 p.m., documented in parts, .CNA .ASKED ME TO . CHECK ON THIS RESIDENT D/T HER BECOMING VERY SOB . STARTED BREATHING TX, .TRIED TO TRANSFER RESIDENT SHE BECAME VERY WEAK,02 WAS 83% WITH 02 3 LITER . WILL CONT TO MONITOR .
A progress note, dated 04/29/23 at 5:40 p.m., documented in parts, .O2 85% with O2 @ 2L .
A progress note, dated 04/29/23 at 11:35 p.m. [late entry] documented in parts, . 02 @ 2 L/m via CPAP. Patient resp at 20 with SP 02 69% . Nurse has been monitoring 02 and trying to determine if CPAP is operating properly. Removed CPAP and 02 admin via N/c @ 2 L/M . transported patient to . ER.
A Medical Necessity for Ambulance Services, dated 04/29/23 (no time), documented Res #1 was transferred to higher level of care for the services of a cardiologist and admission to an Intensive Care Unit due to an elevated Troponin (a blood test for heart attack), hypoxia (decreased oxygen), and hypercapnia (increased carbon dioxide).
A hospital document, with no title, dated 04/30/23 at 1:59 a.m., documented the resident's admitting diagnoses as COPD, Hypoxia, and NSTEMI (heart attack).
On 05/01/23 at 3:45 p.m., Corp RN #1 reported the staff should have notified the physician on 01/17/23 when the resident's sat was 44% and 64%, on 02/20/23 when the resident's sat was 79% and 88%, and the respiratory rate was 36, on 04/29/23 when the resident's sat was 85%, and on 04/29/23 when the resident's sat was 69%.
On 05/01/23 at 3:55 p.m., the ADON reported the staff should have notified the physician on 01/17/23 when the resident's sat was 44% and 64%, on 02/20/23 when the resident's sat was 79% and 88%, and the respiratory rate was 36, on 04/29/23 when the resident's sat was 85%, and on 04/29/23 when the resident's sat was 69%.
Feb 2023
7 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Res #39 was admitted with diagnoses which included vascular dementia and cardiac pacemaker.
A physician's order, dated [DATE]...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Res #39 was admitted with diagnoses which included vascular dementia and cardiac pacemaker.
A physician's order, dated [DATE], documented in part, .Full code.
A physician's order, dated [DATE], documented in part, Admit to homestead of [NAME] hospice services .
The Hospice admission Consent was signed on [DATE].
A Physician Order Report, dated [DATE] to [DATE], documented in parts, .start date [DATE] . Full code .
A Hospice Care Plan Conference Summary dated [DATE], documented Res #39 was a DNR.
A care plan, last revised on [DATE], documented in parts, . I choose to be a FULL CODE .My wishes will be honored through the next review date . If my heart should stop beating or I should stop breathing, I want all life support measures to be taken
A physician's order, dated [DATE], and signed by the physician on [DATE], documented in parts . Code Status: DNR .
On [DATE] at 2:00 p.m., the Corporate Administrator reported the lack of a physician's order for the DNR status was discovered on [DATE] during chart reviews. The Corporate Administrator reported the physician's order for the DNR status should have been obtained and documented on [DATE].
On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #51's physician was notified for a change in condition.
On [DATE] at 2:00 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.
On [DATE] at 2:20 p.m., the Administrator was notified of the IJ situation.
On [DATE] at 5:23 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health.
The facility's plan of removal, dated [DATE] at 5:23 p.m., read in parts, .All staff will be educated with a sign in sheet that are currently working in the facility. Any remaining staff that aren't at the facility will be called and educated over the telephone. Employee name and time of call will be documented. Resident Change of Condition-Physician Notification Policy. Clinical Staff Education will be completed with everyone that is currently working in the facility. Staff that aren't at the facility will be called and educated over telephone. Time of call will be documented. Resident Assessments, SBAR, Physician Notification. Currently in progress: Nurse Assessments are being completed on all residents for change of condition, decline in function, and appropriate interventions. A SBAR will be completed on any residents with a change of condition. The change of condition will be documented, physician will be notified, and time of notification will be documented.
The IJ was lifted, effective [DATE] at 7:00 p.m., when all components of the plan of removal had been completed. The deficiency remains at an isolated level with a potential for harm.
Based on record review and interview, the facility failed to ensure:
a. the physician was notified of a change in condition for one (#51) of one resident reviewed for a change in condition;
b. a diabetic protocol was followed for two (#1 and #16) of five residents reviewed for diabetic care; and
c. a physician's order was obtained for a DNR for one (#39) of one resident whose code status was reviewed.
The Resident Census and Conditions of Residents, dated [DATE], documented a census of 53.
Findings:
1. Res #51 was admitted with diagnoses which included diabetes and hypertension.
A Condition Change, Of the Resident (Observing, recording and Reporting), policy undated, documented in parts, .observe, record and report any condition change to the attending physician so proper treatment will be implemented .
[Recorded as Late Entry on [DATE] at 1:11 p.m.] A progress note, dated [DATE] at 8:00 a.m., read in parts, Resident had vomited scant amount of greenish clear emesis . There was no documentation of physician notification for Res #51's change in condition.
A progress note, dated [DATE] at 11:34 a.m., read in parts, Went into room to check resident FSBS (finger stick blood sugar), he was acting strange with covers over his face, noted that his BS registered HI, he was waving his hands around up in the air, his skin was cool and clammy and eyes rolling, also drenched in sweat, not making any sense .got charge nurse (name withheld), EMS was called, moved resident to floor to cont to CPR .they intubated .continued CPR, no pulse, EMS called and spoke to ER Dr. and was called at 11:59 .
A progress note, dated [DATE] at 11:36 a.m., read in parts, upon being called to the resident's room EMS notified of need for transfer with a noted change in mental status. skin pale, diaphoretic, temp 96.6. fsbs HI, ems notified of change in status. upon ems arrival resident became unresponsive agonal, pulse thready with no bp palpable, sat will not pick up. connected to aed per ems and intubated with oral tube per ems. vital signs cease .
A progress note, dated [DATE] at 12:11 p.m., documented the physician was notified of Res #51's death.
On [DATE] at 12:32 p.m., RN #2, stated they had observed the resident on [DATE] at 8:00 a.m., RN #2 stated Res #51 had vomited a small amount of greenish fluid and they did not think it was important. RN #2 stated they did not notify the physician.
2. Res #1 was admitted with diagnoses which included diabetes.
A Sliding Scale For Regular Insulin protocol for the patients of Dr. (name withheld), read in parts, .Blood Sugar >350 Call Doctor
Res #1 had a blood sugar over 350 nine times between [DATE] and [DATE].
There was no documentation Res #1's physician was notified of the blood sugar results over 350.
On [DATE] at 12:30 p.m., RN #2 reported the sliding scale protocol for Res #1 should have been followed and the physician notified of blood sugar results over 350.
Res #16 was admitted with diagnoses which included diabetes.
An Obtaining a Fingerstick Glucose Level policy, dated 10/10, read in parts, .The blood sugar results .Report results promptly to the .Attending Physician .
A physician's order, dated [DATE], read in parts, .if blood sugar is greater than 400, call MD.
On [DATE] at 11:12 a.m., Res #16's blood sugar registered as 441 and 12 units of Regular insulin was given.
On [DATE] at 11:14 a.m., RN #1 stated the blood sugar registered as 441 and the physician was to be notified and the blood sugar to be rechecked in two hours.
On [DATE] at 3:30 p.m., Res #16 reported the nurse had not rechecked their blood sugar.
On [DATE] at 3:35 p.m., there was no documentation the physician was notified or the blood sugar was rechecked.
On [DATE] at 3:42 p.m., RN #1 reported they had not rechecked the blood sugar or notified the physician and had reported the blood sugar to LPN #1 to follow up.
On [DATE] at 3:44 p.m., LPN #1 reported they were aware of Res #16's blood sugar of 441 and they had not notified the physician or rechecked the blood sugar.
On [DATE] at 3:49 p.m., the ADON reviewed the health record and reported the blood sugar had not been rechecked and the physician had not been notified as ordered.
On [DATE] at 4:14 p.m., the corporate administrator reported the blood sugar should have been rechecked and the physician notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure resident assessments were accurate regarding weight loss for one (#30) of one resident reviewed for weight loss.
The DON identified ...
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Based on record review and interview, the facility failed to ensure resident assessments were accurate regarding weight loss for one (#30) of one resident reviewed for weight loss.
The DON identified five residents who had weight loss in the last six months.
Findings:
Res #30 was admitted with diagnoses which included CVA.
A Registered Dietician progress note, dated 10/11/22 at 2:10 p.m., read in parts, Oct wt 118.6 .underweight. Sig wt loss 8.1%/3mo .
A quarterly assessment, dated 10/29/22, did not document the significant weight loss.
A quarterly assessment, dated 01/29/23, documented in parts, .Loss of 5% or more in the last month .on physician-prescribed weight-loss regime .
On 02/06/23 at 10:58 a.m., RN #2 reported the significant weight loss should have been documented on the quarterly assessment for 10/29/22 and Res #30 was not on a physician-prescribed weight-loss regime and it should not have been documented on the assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to revise a care plan with fall interventions for one (#30) of one resident reviewed for falls.
The DON identified 15 residents who had falls ...
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Based on record review and interview, the facility failed to revise a care plan with fall interventions for one (#30) of one resident reviewed for falls.
The DON identified 15 residents who had falls in the last six months.
Findings:
A Fall - Evaluation and Prevention policy, dated 03/15, read in parts, .It is the policy of this facility to evaluate residents for their fall risk and develop interventions for prevention .Review all falls immediately .review of nurses note documentation and care plan updating. Fall interventions are to be reviewed for appropriateness, to ensure that they are a new intervention, and to ensure that they have been implemented .
Res #30 was admitted with diagnoses which included difficulty walking, lack of coordination, and muscle weakness.
A nursing note, dated 09/14/22 at 1:17 a.m., read in parts, .slipped and fell on .buttock .put bedside commode beside bed .
A nursing note, dated 10/20/22 at 2:15 p.m., read in parts, .resident found in .room floor .
A comprehensive care plan, dated 01/17/23 at 2:50 p.m., was not revised with fall interventions for the falls on 09/14/22 and 10/20/22 for Res #30.
On 02/06/23 at 11:05 a.m., RN #2 reported the falls on 09/14/22 and 10/20/22 for Res #30 should have been care planned to include fall interventions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician of a change in condition for one (#51) of thre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician of a change in condition for one (#51) of three residents whose records were reviewed for a change in condition.
The Resident Census and Conditions of Residents report, dated [DATE], documented a census of 53 residents.
Findings:
Res #51 was admitted with diagnoses which included diabetes and hypertension.
A Condition Change, Of the Resident (Observing, recording and Reporting), policy undated, documented in parts, .observe, record and report any condition change to the attending physician so proper treatment will be implemented .
[Recorded as Late Entry on [DATE] at 1:11 p.m.] A progress note, dated [DATE] at 8:00 a.m., read in parts, Resident had vomited scant amount of greenish clear emesis . There was no documentation of physician notification for Res #51's change in condition.
A progress note, dated [DATE] at 11:34 a.m., read in parts, Went into room to check resident FSBS (finger stick blood sugar), he was acting strange with covers over his face, noted that his BS registered HI, he was waving his hands around up in the air, his skin was cool and clammy and eyes rolling, also drenched in sweat, not making any sense .got charge nurse (name withheld), EMS was called, moved resident to floor to cont to CPR .they intubated .continued CPR, no pulse, EMS called and spoke to ER Dr. and was called at 11:59 .
A progress note, dated [DATE] at 11:36 a.m., read in parts, upon being called to the resident's room EMS notified of need for transfer with a noted change in mental status. skin pale, diaphoretic, temp 96.6. fsbs HI, ems notified of change in status. upon ems arrival resident became unresponsive agonal, pulse thready with no bp palpable, sat will not pick up. connected to aed per ems and intubated with oral tube per ems. vital signs cease .
A progress note, dated [DATE] at 12:11 p.m., documented the physician was notified of Res #51's death.
On [DATE] at 12:32 p.m., RN #2, stated they had observed the resident on [DATE] at 8:00 a.m., RN #2 stated Res #51 had vomited a small amount of greenish fluid and they did not think it was important. RN #2 stated they did not notify the physician.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to provide showers for two (#40 and #45) of three residents reviewed for showers.
The Resident Census and Conditions of Residen...
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Based on record review, observation, and interview, the facility failed to provide showers for two (#40 and #45) of three residents reviewed for showers.
The Resident Census and Conditions of Residents, dated 01/30/23, documented six residents were dependent for bathing.
Findings:
Res #40 was admitted with diagnoses which included chronic kidney disease, diabetes, and muscle weakness.
A quarterly assessment, dated 11/25/22, documented Res #40 was cognitively intact and required extensive assistance with bathing.
A bathing sheet, dated December 2022, documented Res #40 received four of 13 scheduled showers.
A bathing sheet, dated January 2023, documented Res #40 received seven of 13 scheduled showers.
A care plan, reviewed 01/24/23, read in part, .Bathing extensive .give shower .
On 01/30/23 at 10:34 a.m., Res #40 reported they were not receiving showers three times a week as scheduled. Res #40 stated there were not enough staff to ensure their showers were given.
Res #45 was admitted with diagnoses which included atrial fibrillation and dementia.
A care plan, reviewed 05/18/22, read in parts, .Bathing .Assist X1 .
A quarterly assessment, dated 11/25/22, documented Res #45 required assistance with bathing.
A bathing sheet, dated December 2022, documented Res #45 received six of 13 scheduled showers.
A bathing sheet, dated January 2023, documented Res #45 received six of 13 scheduled showers.
On 02/04/23 at 1:47 p.m., an unnamed nursing staff member reported Res #40 and #45 were scheduled showers three times a week and the showers had not been given as scheduled.
On 02/04/23 at 1:50 p.m., an unnamed nursing staff member reported Res #40 and #45 were scheduled showers three times a week and the showers had not been given as scheduled.
On 02/04/23 at 1:52 p.m., the ADON reported Res #40 and #45 were scheduled a shower three days a week. The ADON reviewed the bathing sheets for December 2022 and January 2023 and stated the showers had not been given.
On 02/04/23 at 1:54 p.m., the DON reported the showers had not been given as scheduled.
On 02/04/23 at 2:28 p.m., the corporate administrator reported the showers had not been given as scheduled.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to provide sufficient staff to care for the needs of the residents.
The Resident Census and Conditions of Residents, dated 01/30/23, documente...
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Based on record review and interview, the facility failed to provide sufficient staff to care for the needs of the residents.
The Resident Census and Conditions of Residents, dated 01/30/23, documented a census of 53 residents.
Findings:
An undated facility assessment read in parts, Direct Care Staff 1:6 days, 1:8 evenings, 1:15 nights. Total licensed or certified.
The Quality of Care report, dated October 2022, documented 30 of 31 days were not staffed per the facility assessment.
The nursing schedule, dated October 2022, documented 30 of 31 days were not staffed per the facility assessment.
The Quality of Care report, dated November 2022, documented 16 of 30 days were not staffed per the facility assessment.
The nursing schedule, dated November 2022, documented 16 of 30 days were not staffed per the facility assessment.
The Quality of Care report, dated December 2022 documented 10 of 31 days were not staffed per the facility assessment.
On 01/30/23 at 10:34 a.m., Res #40 reported they had not received showers three times a week as scheduled. The resident reported it was due to not enough staff.
On 01/30/23 at 11:10 a.m., Res #45 reported at times their call lights did not get answered in a timely manner. Res #45 reported they had waited up to an hour for their call light to be answered.
On 01/30/23 at 2:10 p.m., a call light on 300 hall was activated.
On 01/30/23 at 2:41 p.m., the call light on 300 hall was answered.
On 02/04/23 at 1:47 p.m., an unnamed staff member reported there was not enough staff.
On 02/04/23 at 1:50 p.m., an unnamed staff member reported there was not enough staff to ensure showers were given as ordered.
On 02/04/23 at 1:52 p.m., an unnamed staff member reported showers should have been given as scheduled but there was not enough staff.
On 02/06/23 at 9:49 a.m., the DON reported for the months of October, November, and December, the facility had not been adequately staffed.
On 02/06/23 at 9:49 a.m., the Administrator reported for the months of October, November, and December, the facility had not been adequately staffed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to ensure food was prepared and stored in a sanitary manner.
The Resident Census and Conditions of Residents report, dated 01/30...
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Based on record review, observation, and interview, the facility failed to ensure food was prepared and stored in a sanitary manner.
The Resident Census and Conditions of Residents report, dated 01/30/23, documented 51 residents received meals from the kitchen.
Findings:
A policy titled Food Preparation and Service, dated 07/14, read in parts, .Foods will not be thawed at room temperature .
A policy titled Preventing Foodborne Illness-Employees Hygiene and Sanitary Practices, dated 10/08, read in parts, .food service employees will be trained in the proper use of utensils .
On 01/30/23 from 9:20 to 9:45 a.m., a turkey breast was observed sitting on the food preparation counter to thaw.
On 01/30/23 from 9:24 to 9:45 a.m., common scoops were observed in the flour and sugar bins.
On 02/04/23 from 10:40 to 10:50 a.m., during puree preparation, cook #1 was observed repeatedly using the blender bowl and blade without placing them in the dishwasher between uses.
On 01/30/23 at 9:45 a.m., the DM reported the turkey breast should not have been left at room temperature to thaw and the common scoops should not have been left in the food storage bins.
On 02/04/23 at 10:55 a.m., cook #1 stated they were unaware the blender bowl and blade had to be placed into the dishwasher between uses.
On 02/04/23 at 11:10 a.m., the administrator reported the turkey breast should not have been left at room temperature to thaw and the common scoops should not have been left in the food storage bins. The administrator reported the blender bowl and blade should have been placed into the dishwasher between uses.
Jan 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 a gradual dose reduction (GDR) for an antipsyc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a gradual dose reduction (GDR) for an antipsychotic medication was initiated for one resident (#10) of five reviewed for unnecessary medications.
The DON reported 11 residents who received antipsychotic medications.
Findings:
Resident (Res) #10 was admitted on [DATE] and had diagnoses which included epilepsy and psychotic disorder with delusions.
A policy and procedure, Consultant Pharmacist Reports, revised January 2018, documented in parts .recommendations are acted upon and documented by the facility staff. The Director of Nursing or designated licensed nurse address and document recommendations .
A care plan, dated 03/19/20, documented in parts .reduce zyprexa and attempt a gradual dose reduction .
A physician order, dated 10/20/20, documented Res #10 was to receive zyprexa (an antipsychotic medication) 2.5 mg in the morning and 5 mg in the evening.
A pharmacy recommendation, dated 09/21/21, documented the pharmacist requested to decrease zyprexa from 2.5 mg in the a.m. and 5 mg in the p.m. to 2.5 mg twice a day. The physician agreed with the recommendation and signed the document.
A significant change assessment, dated 10/25/21, documented the resident was severely impaired with cognition, required extensive to total dependence with activities of daily living, and received antipsychotic medications seven out of seven days of the look back period.
On 01/03/22 at 11:30 a.m., Res #10 was observed in bed asleep.
On 01/04/22 at 9:31 a.m., Res #10 was observed in bed asleep.
On 01/04/22 at 11:40 a.m., the ADON reviewed the recommendation and reported the physician order had not been changed for the GDR attempt and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
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 perform laboratory services for one resident (#10) of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform laboratory services for one resident (#10) of five reviewed for laboratory services.
The Administrator reported a census of 54 residents.
Findings:
Resident (Res)#10 was admitted [DATE] and had diagnoses which included epilepsy and psychotic disorder with delusions.
A care plan, dated 03/19/20, documented in part .monitor labs.
A physician order, dated 03/20/20, documented Res #10 was to receive valproic acid (an anti-seizure medication) 250 mg twice a day.
A physician order, dated 03/20/20, documented Res #10 was to receive laboratory test for a valproic acid level every March, June, September, and December.
Laboratory results were reviewed and a valproic acid level was not documented for Res #10 for the month of June 2021.
Laboratory results, dated 09/17/21, documented the valproic acid levels were low.
A significant change assessment, dated 10/25/21, documented the resident was severely impaired with cognition, required extensive to total dependence with activities of daily living, and received antipsychotic medications seven out of seven days of the look back period.
On 01/04/22 at 11:16 a.m., the ADON reported Res #10's laboratory valproic acid levels was not done for the month of June 2021 and should had been completed as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the care plan was implemented and physician notified when blood glucose levels were elevated for two residents (#27 an...
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Based on observation, interview, and record review, the facility failed to ensure the care plan was implemented and physician notified when blood glucose levels were elevated for two residents (#27 and #48) of two observed during medication administration pass.
The DON reported nine residents required blood glucose testing with insulin administration per sliding scale.
Findings:
A physician standing order, dated 04/21/21, documented in parts .sliding scale insulin premeals only, if blood sugar is .>350 mg/dl, give sliding scale and recheck every two hours until below 300 mg/dl.
1. Resident (Res) #27 had diagnoses which included diabetes mellitus and chronic kidney disease.
A physician order, dated 02/13/20, documented in parts . Novolin R Regular Insulin .per Sliding Scale; If Blood Sugar is less than 80, call MD. If Blood Sugar is 80 to 100, give 15 Units. If Blood Sugar is 101 to 150, give 25 Units. If Blood Sugar is 151 to 200, give 27 Units. If Blood Sugar is 201 to 250, give 29 Units. If Blood Sugar is 251 to 300, give 31 Units. If Blood Sugar is 301 to 350, give 33 Units. If Blood Sugar is 351 to 400, give 35 Units. If Blood Sugar is greater than 400, give 37 Units subcutaneously Before Meals at 06:00, 11:00, 16:00.
An annual assessment, dated 11/20/21, documented the resident was cognitively intact and had received insulin seven of seven days.
A care plan, revised 12/07/21, documented in parts .Problem: Resident had the potential for hypo/hyperglycemia related to diabetes mellitus. Goals: resident will have blood glucose within acceptable range and absence of signs of hypoglycemia or hyperglycemia. Approach: Monitor for signs of hyperglycemia (blood glucose > 140 mg/dl .
On 01/04/22 at 11:15 a.m., Res #27 was observed awake and lying in bed watching television.
On 01/04/22 at 11:18 a.m., during medication administration observation, LPN #1 was observed to perform a blood glucose monitoring via finger stick for Res #27. LPN #1 reported the blood glucose registered as HI. LPN #1 reported HI indicated the blood glucose was over 600 mg/dl. LPN#1 administered Novolin Regular insulin 37 units per sliding scale orders SQ right lower abdomen. LPN#1 stated the physician was aware the resident always had high blood glucose levels. LPN #1 stated she would report the HI blood glucose to the RN.
On 01/04/22 at 1:15 p.m., Res #27 reported staff had not rechecked their blood glucose. The resident reported they did not feel like the blood glucose was high.
The FSBS log book and progress notes were reviewed and did not contain documentation of a follow up blood glucose or physician notification of the HI blood glucose.
01/05/22 at 9:06 a.m., the DON reported the residents FSBS was not reported to an RN and should have been immediately rechecked and the physician should have been notified of the HI blood glucose.
2. Resident (Res) #48 had diagnoses which included diabetes mellitus and chronic kidney disease.
A physician order, dated 04/08/21, documented Novolin R Regular Insulin per sliding scale; If blood sugar is less than 60, call MD. If blood sugar is 201 to 250, give 3 Units. If blood sugar is 251 to 300, give 6 Units. If blood sugar is 301 to 350, give 9 Units. If blood sugar is 351 to 400, give 12 Units. If blood sugar is greater than 400, give 15 Units subcutaneous before meals and at bedtime. Special instructions: if greater than 401 give 15 units and refer to prn order.
A physician order, dated 04/08/21, documented Novolin R Regular Insulin 15 units injection as needed. Special Instructions: recheck FSBS 2 hours after first dose, administer 15 units if FSBS has not decreased and recheck in 2 hours. If FSBS remains high, contact MD.
A care plan, revised 12/16/21, documented in parts .Problem: Resident has potential for possible side effects related to diabetes mellitus. Goals: Resident will have blood glucose ranging between 70-140 and absence of signs of hypoglycemia or hyperglycemia. Approach: Administer medications: Humulin R sliding scale Evaluate/record/report effectiveness/adverse side effects .
A quarterly assessment, dated 12/18/21, documented the resident was cognitively intact and had received insulin seven of seven days.
On 01/04/22 at 11:00 a.m., resident #48 was observed lying in bed.
On 01/04/22 at 11:05 a.m., during medication administration observation, LPN #1 was observed to perform a blood glucose monitoring via finger stick for Res #48. LPN #1 reported the blood glucose was 570 mg/dl. LPN #1 administered Novolin Regular insulin 15 units per sliding scale orders SQ lower right abdomen. LPN #1 stated the physician was aware the resident always had high blood glucose levels. LPN #1 stated they would report the elevated blood glucose to the RN.
On 01/04/22 at 1:15 p.m., Res #48 reported staff had not rechecked their blood glucose. The resident stated the staff will recheck it at 4 p.m.
The FSBS log book and progress notes were reviewed and did not contain documentation of a follow up blood glucose or physician notification of the 570 mg/dl blood glucose.
01/05/22 at 9:06 a.m., the DON reported the residents FSBS was not reported to an RN and should have been immediately rechecked, rechecked after 2 hours, and treated if still high as ordered. The DON stated the physician should have been notified of the elevated blood glucose.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less the 5% for two residents (#20 and #21) of six residents observed during medication ...
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Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less the 5% for two residents (#20 and #21) of six residents observed during medication pass. A total of 27 opportunites were observed with two errors. Total error rate was 7.41%.
The Administrator reported a census of 54 residents.
Findings:
1. Resident #20 was admitted to the faciltiy on 11/03/18 with diagnoses that included hypertension.
A physician order, dated 04/22/21, documented to administer carvedilol (an antihypertensive medication) 3.125 mg 1/2 tab to equal 1.5625 twice a day for hypertension.
On 01/04/22 at 8:05 a.m., CMA #1 was observed preparing the morning medications for Res #20. CMA #1 was observed to place one whole tab of carvedilol into the medication cup. CMA #1 attempted to administer the medication to Res #20. This surveyor ask CMA #1 to step out into the hall. CMA #1 was asked to read the order again and compare it to the medication label. CMA #1 stated the medication label and the physicians' order does not match. CMA #1 stated I should have given half a tab of carvedilol.
2. Res #21 had diagnoses which included rheumatoid arthritis.
A physician order, dated 05/10/18, documented to administer mobic (an anti-inflammatory medication) 7.5mg one table once a day in the morning.
On 01/05/22 at 9:48 a.m., during observation of the medication administration pass, CMA #1 was observed to administer medications for Res #21. Res #21 was observed asking CMA #1 if they had received mobic with the morning medication. CMA #1 stated the medication was ordered but had not been delivered.
On 01/05/22 at 9:55 a.m., CMA #1 stated the medication had not been given. CMA #1 stated the medication had been ordered but would not be delivered until late in the evening from the pharmacy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (#20) of four were free from sign...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (#20) of four were free from significant medication errors.
The Administrator reported a census of 54 residents.
Findings:
Resident (Res) #20 was admitted to the facility on [DATE] and had diagnoses that included hypertension.
A Medication administration general guidelines policy and procedure, revised 11/2018, documented in parts .Check #2: Prepare the dose-the dose is removed from the container and verified against the label and the MAR by reviewing the five rights .right resident, right drug, right dose, right route, and right time .
A physician order, dated 04/22/21, documented to administer carvedilol (an antihypertensive medication) 3.125 mg 1/2 tab to equal 1.5625 twice a day for hypertension.
An annual assessment, dated 10/30/21, documented the Res #20 was cognitively intact.
A care plan, revised 11/23/21, documented in parts Problem: Resident has potential for complications related to hypertension. Approach: Administer carvedilol 1.5625 twice a day .
On 01/04/22 at 8:05 a.m., CMA #1 was observed preparing the morning medications for Res #20. CMA #1 was observed to place one whole tab of carvedilol into the medication cup. CMA #1 attempted to administer the medication to Res #20. This surveyor ask CMA #1 to step out into the hall. CMA #1 was asked to read the order again and compare it to the medication label. CMA #1 stated the medication label and the physicians' order does not match. CMA #1 stated I should have given half a tablet of carvedilol instead of a full tablet. CMA #1 was asked how many carvedilol had been dispensed? CMA #1 stated 30. CMA #1 was asked how many carvedilol remained? CMA #1 stated two.
On 01/04/22 at 8:40 a.m., the DON reported they had reviewed the physicians' order for Res #20 and the order read carvedilol 3.125 mg give 1/2 tab to equal 1.5625 mg twice a day. The DON reviewed the label on the medication card and stated the label reads carvedilol 3.125 mg give one tab daily. The DON reported the carvedilol order started on 4/22/21 and according to the MAR the staff had been administering one whole tab twice a day and was a medication error.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure a dietary manager was employed full time in the dietary department.
The Administrator reported 54 residents received m...
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Based on observation, interview, and record review, the facility failed to ensure a dietary manager was employed full time in the dietary department.
The Administrator reported 54 residents received meals from the kitchen.
Findings:
On 01/03/22 at 9:25 a.m., upon initial tour of the kitchen, there was no DM observed in the kitchen.
On 01/03/22 at 9:40 a.m., a dietary aide reported there was no dietary manager.
On 01/04/22 at 11:00 a.m., during the follow up observation, the kitchen log books were reviewed and failed to staff a DM.
On 01/04/22 at 11:30 a.m., cook #1 reported there had not been a DM staffed for months.
On 01/04/22 at 11:53 a.m., the Administrator stated there was not a DM and had no plan to hire a DM.
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
- "What changes have you made since the serious inspection findings?"
- "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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s), Special Focus Facility, $61,736 in fines, Payment denial on record. Review inspection reports carefully.
- • 45 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $61,736 in fines. Extremely high, among the most fined facilities in Oklahoma. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Homestead Of Hugo's CMS Rating?
CMS assigns HOMESTEAD OF HUGO an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Oklahoma, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Homestead Of Hugo Staffed?
CMS rates HOMESTEAD OF HUGO's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 57%, which is 11 percentage points above the Oklahoma average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Homestead Of Hugo?
State health inspectors documented 45 deficiencies at HOMESTEAD OF HUGO during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 42 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Homestead Of Hugo?
HOMESTEAD OF HUGO 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 BGM ESTATE, a chain that manages multiple nursing homes. With 124 certified beds and approximately 53 residents (about 43% occupancy), it is a mid-sized facility located in HUGO, Oklahoma.
How Does Homestead Of Hugo Compare to Other Oklahoma Nursing Homes?
Compared to the 100 nursing homes in Oklahoma, HOMESTEAD OF HUGO's overall rating (1 stars) is below the state average of 2.6, staff turnover (57%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Homestead Of Hugo?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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 Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Homestead Of Hugo Safe?
Based on CMS inspection data, HOMESTEAD OF HUGO has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Oklahoma. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Homestead Of Hugo Stick Around?
Staff turnover at HOMESTEAD OF HUGO is high. At 57%, the facility is 11 percentage points above the Oklahoma 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 Homestead Of Hugo Ever Fined?
HOMESTEAD OF HUGO has been fined $61,736 across 3 penalty actions. This is above the Oklahoma average of $33,696. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Homestead Of Hugo on Any Federal Watch List?
HOMESTEAD OF HUGO is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.