YORK MANOR NURSING HOME
Non profit - Corporation
60 Beds
Independent
Data: November 2025
Trust Grade
38/100
#191 of 282 in OK
Photo by Google Maps
Photo by Larry Coke
Photo by Larry Coke
Photo by Larry Coke
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
York Manor Nursing Home in Muskogee, Oklahoma, has a Trust Grade of F, indicating significant concerns and a poor overall rating. It ranks #191 out of 282 facilities in the state, placing it in the bottom half, and #7 out of 10 in the county, meaning there are only three local options with lower rankings. While the facility's trend is improving, with issues decreasing from 19 in 2023 to 7 in 2025, the high turnover rate of 63% is concerning, although they do have good RN coverage, surpassing 91% of state facilities. Families should be aware of serious incidents such as a resident being left unattended in the shower, resulting in a fall and fracture, as well as concerns regarding proper hand hygiene practices among staff during meal service. Overall, while there are strengths in RN coverage and staffing ratings, the facility's poor trust grade and specific incidents of neglect raise significant red flags for potential residents and their families.
- Trust Score
- F
- In Oklahoma
- #191/282
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 63% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $9,750 in fines. Lower than most Oklahoma facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Oklahoma. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Bottom 33%
Needs review
19 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 19 issues
2025: 7 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Oklahoma average (2.6)
Below average - review inspection findings carefully
Staff Turnover: 63%
17pts above Oklahoma avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $9,750
Below median ($33,413)
Minor penalties assessed
Staff turnover is elevated (63%)
15 points above Oklahoma average of 48%
The Ugly 40 deficiencies on record
1 actual harm
Sept 2025
1 deficiency
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
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to include the actual and working hours of licensed and unlicensed staff on the daily posted staffing and failed to ensure disci...
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Based on observation, interview, and record review, the facility failed to include the actual and working hours of licensed and unlicensed staff on the daily posted staffing and failed to ensure disciplines were included on the nurse staffing data for 7 (09/08/25 through 09/14/25) of 7 days reviewed for posted nurse staffing.The DON identified 41 residents resided in the facility.Findings: On 09/15/25 at 3:18 p.m., a dry erase board was observed to show staff names, the shift, the date and the census. The dry erase board did not show the number of hours worked. The undated policy titled Nurse Staffing Information, read in part, The facility must post the following information on a daily basis.The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident are per shift: a. Registered nurses b. Licensed practical nurses or licensed vocational nurses (as defined under State Law) c. Certified nurse aides. A Daily Nursing Sign-In Sheet, dated 09/08/25, showed 19 staff worked the day shift. The sheet did not show the discipline for 17 of 19 employees. The Daily Nursing Sign-In Sheet showed eight staff worked the evening shift. The sheet did not show the discipline for five of the eight employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. A Daily Nursing Sign-In Sheet, dated 09/09/25, showed 15 staff worked the day shift. The sheet did not show the discipline for 12 of 15 employees. The Daily Nursing Sign-In Sheet showed nine staff worked the evening shift. The sheet did not show the discipline for six of the nine employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. A Daily Nursing Sign-In Sheet, dated 09/10/25, showed 15 staff worked the day shift. The sheet did not show the discipline for 12 of 15 employees. The Daily Nursing Sign-In Sheet showed eight staff worked the evening shift. The sheet did not show the discipline for six of the eight employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for three of the three employees. A Daily Nursing Sign-In Sheet, dated 09/11/25, showed 15 staff worked the day shift. The sheet did not show the discipline for 12 of 15 employees. The Daily Nursing Sign-In Sheet showed nine staff worked the evening shift. The sheet did not show the discipline for eight of the nine employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for three of the three employees. A Daily Nursing Sign-In Sheet, dated 09/12/25, showed 14 staff worked the day shift. The sheet did not show the discipline for 11 of 14 employees. The Daily Nursing Sign-In Sheet showed seven staff worked the evening shift. The sheet did not show the discipline for five of the seven employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. A Daily Nursing Sign-In Sheet, dated 09/13/25, showed ten staff worked the day shift. The sheet did not show the discipline for 9 of ten employees. The Daily Nursing Sign-In Sheet showed eight staff worked the evening shift. The sheet did not show the discipline for six of the eight employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. A Daily Nursing Sign-In Sheet, dated 09/14/25, showed 7 staff worked the day shift. The sheet did not show the discipline for six of seven employees. The Daily Nursing Sign-In Sheet showed eight staff worked the evening shift. The sheet did not show the discipline for six of the eight employees. The Daily Nursing Sign-In Sheet showed three staff worked the night shift. The sheet did not show the discipline for two of the three employees. On 09/15/25 at 3:20 p.m., the administrator stated they posted the daily staffing information was posted on the dry erase board and they maintained the information on the Daily Nursing Sign-In Sheets.
Jan 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a NOMNC form was provided to a resident within the mandated time frame for one (#10) of three sampled residents reviewed for benefic...
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Based on record review and interview, the facility failed to ensure a NOMNC form was provided to a resident within the mandated time frame for one (#10) of three sampled residents reviewed for beneficiary notices.
The ADON reported there had been five discharges from Medicare covered part A services in the past six months.
Findings:
A CMS form 10123 - NOMNC, signed 09/19/24, documented Resident #10's Medicare part A services would end on 09/20/24. The document did not have the resident's signature, but those of two staff members with a written statement that documented the resident's unwillingness to sign.
A CMS form 20052 - SNF Beneficiary Notification Review completed by the ADON documented Resident #10 had begun Medicare part A services on 08/28/24 and the last day covered was 09/20/24.
On 01/28/25 at 9:10 a.m., the ADON stated residents on CMS part A services were given NOMNC forms at least two days prior to the end of those services. They stated they and another staff member signed the document on 09/19/24 after the resident would not sign the form. They stated because the form was signed on 09/19/24, and the services were to end on 09/20/24, the document was late.
On 01/28/25 at 9:17 a.m. the DON stated the facility did not have a policy and procedure regarding beneficiary notices. They stated they instead used CMS guidelines.
CONCERN
(D)
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, record review, and interview, the facility failed to ensure infection control practices were followed for one (#26) of two sampled residents who were reviewed for wound care.
Th...
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Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed for one (#26) of two sampled residents who were reviewed for wound care.
The DON identified three residents who were currently receiving wound care treatments.
Findings:
An undated policy titled Hand Hygiene, read in parts, follow the facility's established hand hygiene procedures to prevent the spread of infection and disease to other staff, residents and visitors .Hands should be washed for at least twenty (20) seconds using soap and water under the following conditions .Before performing invasive procedures .Before handling clean or soiled dressings, gauze pads, etc .After handling used dressings, contaminated equipment, etc .Before putting on gloves .After removing gloves.
Resident #26 had diagnoses which included cerebral palsy, spina bifida, and a stage four pressure ulcer to the buttock.
A physician order, dated 10/18/24, documented the staff was to cleanse the wound to the right buttock with wound wash, pat dry, apply Medihoney and calcium alginate to the wound bed, and cover with an abdominal pad.
A discharge return anticipated, dated 12/06/24, documented the resident was independent for daily decision making and was dependent with most ADL care. The assessment documented the resident had a stage four pressure ulcer that was present upon admission.
On 01/27/25 at 9:08 a.m., LPN/charge nurse #1 gathered supplies from the treatment cart. The LPN donned a gown and gloves, entered the resident's room, and placed the supplies on the resident's bedside table. The LPN did not clean the bedside table or provide a barrier for the unclean surface. The LPN did not wash their hands before donning gloves. The LPN cleaned the wound with normal saline and padded the area dry with a piece of gauze. Using the same gloved hands the LPN picked up the Medihoney and calcium alginate dressing and applied it to the wound. The LPN then covered the dressing with an abdominal pad. The LPN removed their gloves and gathered the remaining supplies from the bedside table, exited the room, and placed the supplies on the treatment cart. The LPN did not wash their hands after removing their gloves or clean supplies returned to the treatment cart.
On 01/27/25 at 9:22 a.m., the LPN stated they should have washed their hands before donning gloves and after removing their gloves. The LPN stated they should have changed gloves between touching unclean areas and clean areas during care. The LPN stated supplies returned to the treatment cart should be cleaned before returning to the cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to provide written notices of transfer to residents transferred to acute care hospitals by the facility for three (#17, 27, and #45) of three ...
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Based on record review and interview, the facility failed to provide written notices of transfer to residents transferred to acute care hospitals by the facility for three (#17, 27, and #45) of three sampled residents reviewed for discharges and hospitalizations.
The ADON stated nine residents had transferred to an acute care hospital in the previous three months.
Findings:
An undated Transfer and Discharge policy, read in part, Preparation and orientation of the resident is essential to ensure safe and orderly transfer or discharge from the facility. Sufficient preparation means that the facility informs the resident where he/she is going and takes steps under its control to ensure safe transportation. The facility will involve the resident and the resident's family/representative in selecting the new residence. The policy did not include procedures which included notification in writing prior to transfer.
1. Resident #17 had diagnoses which included Parkinson's disease and dementia.
A nurse's note, dated 12/28/24 at 6:23 p.m., documented Resident #17 had been transferred to an acute care hospital following a fall.
A nurse's note, dated 01/05/25 at 7:22 p.m., documented Resident #17 had been transferred to an acute care hospital for altered mental status.
2. Resident #27 had diagnoses which included diabetes and heart failure.
A nurse's note, dated 12/06/24 at 7:11 a.m., documented Resident #27 had been transferred to an acute care hospital for confusion.
3. Resident #45 had diagnoses which included paranoid schizophrenia.
A nurse's note, dated 10/05/24 at 9:00 a.m., documented the resident had been transferred to an acute care hospital on for verbal and physical aggression.
On 01/28/25 at 10:17 a.m., the DON was asked to provide the written notices of transfer for Resident #17, 27, and #45. They stated they had never heard of a written notice of transfer until that day.
On 01/28/25 at 12:22 p.m., the DON stated the facility had not been providing written notices of transfers when residents had been transferred to hospitals. They stated they had searched through the documentation of residents who had been transferred and found no notices of transfers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to post nurse staffing in a prominent place accessible to residents and visitors.
The administrator identified 42 residents who resided in the ...
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Based on observation and interview, the facility failed to post nurse staffing in a prominent place accessible to residents and visitors.
The administrator identified 42 residents who resided in the facility.
Findings:
On 01/26/25 at 8:54 a.m., a tour of the facility was conducted. No nurse staff posting was observed.
On 01/27/25 at 1:40 p.m., the nurse staff posting for the facility was not observed. The DON stated they were not aware the nurse staff posting was not posted or needed to be posted.
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 observation, record review, and interview, the facility failed to ensure:
a. the deep fryer was cleaned after use; and
b. refrigerated items were labeled and dated for the residents.
The die...
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Based on observation, record review, and interview, the facility failed to ensure:
a. the deep fryer was cleaned after use; and
b. refrigerated items were labeled and dated for the residents.
The dietary manager identified 40 residents who received meals prepared by the kitchen and two residents who received nutrition via tube feeding.
Findings:
An undated policy titled Storage of Food in Refrigeration, read in parts, Food being returned to storage after cooking or preparation must be covered .All containers must be labeled with the contents and date food item was placed in storage .Previously cooked foods can be held in refrigeration of 41 degrees F or lower for up to 3 days and then must be discarded.
A cleaning schedule documented the deep fryer had not been cleaned the week of 01/20/25 through 01/26/25.
On 01/26/25 at 9:12 a.m., a kitchen tour was conducted. The deep fryer had dark grease and food particles around the outside edges of the fryer.
On 01/26/25 at 9:17 a.m., dietary cook #1 stated they had not used the deep fryer today. The cook stated the deep fryer did not look like it had been cleaned.
On 01/26/25 at 9:21 a.m., a sandwich bag containing six boiled eggs, dated 01/20/25, and an open box of candy (chocolate covered cherries) were observed in the refrigerator not labeled or dated.
On 01/26/25 at 4:10 p.m., the DM stated the deep fryer had been used three days ago and the staff did not clean it after use. The DM stated foods stored in the refrigerator should be placed in a container, labeled, and dated. The DM stated foods previously cooked should not be stored for more than 48 hours. The DM stated the boiled eggs had been discarded and the staff educated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
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 facility medical director participated in the quality as...
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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 facility medical director participated in the quality assessment and performance improvement program.
The ADON stated there were 42 residents residing at the facility.
Findings:
A document titled QAPI Plan for [NAME] Manor Nursing Center, dated 09/30/24, read in part, The goal of a QAPI plan is to provide guidance for performance improvement efforts and assistance with achieving he purpose, guiding principles and scope set in the QAPI program. This plan is a living document that should include input from representatives from all disciplines within the organization and needs to be reviewed and refined at least annually.
Thirteen documents titled QAPI Meeting & Agenda, dated on and between 01/25/24 and 12/30/24, documented pre-printed titles of attendees followed by handwritten signatures of those who attended individual QAPI meetings. Each of the forms had the pre-printed words Medical Director followed by a signature line. On each form the signature line for the medical director was blank.
On 01/29/25 at 10:09 a.m., the facility administrator stated the quality assurance committee met monthly. They stated they understood the medical director was supposed to participate in at least quarterly meetings. They stated the medical director was available for resident clinical issues throughout the year. They stated the medical director did not participate in the quality assessment and performance improvement program.
Oct 2023
17 deficiencies
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 observation, record review, and interview, the facility failed to ensure residents code status was documented correctly...
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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 residents code status was documented correctly throughout the residents' clinical records for one (#31) and a DNR consent form documented complete information for one (#3) of two residents reviewed for code status.
The Resident Census and Conditions of Residents form documented 42 residents resided in the facility.
Findings:
1. Res #31 had diagnoses which included mood disorder due to known physiological condition with major depressive episodes and Alzheimer's disease.
A care plan, dated [DATE], documented the resident had chosen not to execute an Advanced Directive at that time. The care plan documented Res #31 was a full code and wanted life sustaining measures. The care plan documented the Advance Directive wishes would be reviewed annually and was scanned into the residents EHR.
An advanced directive/DNR information acknowledgement form dated [DATE], documented the resident did not wish to have CPR.
A quarterly assessment, dated [DATE], documented the resident was intact with cognition.
A physician order, dated [DATE], documented the resident code status was a full code.
On [DATE] at 12:30 p.m., the social service director stated the Advance Directive form and the resident code status did not match in the EHR. The social service director stated they would ask the resident what their wishes were for their code status.
2. Res #3 had diagnoses which included schizoaffective disorder and disassociative indemnity disorder.
A care plan, dated [DATE], documented the resident had a DNR code status. The care plan documented Res #3 did not want life sustaining measures if their heart should stop or their breathing stopped. The care plan documented the social worker would review their advanced directive and DNR status with the resident at least annually.
A physician order, dated [DATE], documented the resident had DNR status.
A DNR form scanned into the EHR, dated [DATE], was signed by the resident. The DNR was signed by two witnesses but the DNR but did not document the witnesses addresses.
On [DATE] at 12:23 p.m., the social services director stated the DNR did not have the addresses of the witnesses and they were not sure if the DNR was a legal document or not because they were not a lawyer.
On [DATE] at 3:41 p.m., the DON stated a DNR form which documented witness signatures but not addresses was not a completed DNR form.
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to notify a representative of a discharge to the hospital for one (#96) of three residents sampled for discharges.
The Resident Census and Co...
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Based on record review and interview, the facility failed to notify a representative of a discharge to the hospital for one (#96) of three residents sampled for discharges.
The Resident Census and Conditions of Residents form documented 42 residents resided in the facility.
Findings:
Res #96 had diagnoses which included hypertensive heart and chronic kidney disease.
A nurse note, dated 8/29/23, documented the resident was awake but did not respond and was sent to the emergency department of a local hospital. The note did not document the resident's representative was notified of the transfer.
The resident's MDS assessments documented a Discharge Return Anticipated assessment on 08/29/23 and an Entry assessment on 08/31/23.
A Discharge Return Anticipated assessment, dated 09/14/23, documented the resident was severely impaired in cognition, had rejection of care and wandering, and required supervision to limited assistance with ADLs.
On 10/16/23 at 2:28 p.m., the ADON reviewed the note documented on 08/29/23 and confirmed the note did not document the resident's representative had been notified when the resident was sent to the emergency department. The ADON stated the resident's representative should have been notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure a significant change assessment was submitted to CMS within 14 days of completion for one (#7) of 21 residents whose assessments were...
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Based on record review and interview the facility failed to ensure a significant change assessment was submitted to CMS within 14 days of completion for one (#7) of 21 residents whose assessments were reviewed.
The Resident Census and Conditions of Residents form documented 42 residents resided in the facility.
Findings:
A significant change assessment for Res #7, dated 09/10/23, was completed in the EHR program and documented, Export Ready.
On 10/12/23 at 3:30 p.m., the ADON confirmed the significant change assessment had been completed on 09/14/23. They stated the program was having issues with the CAA section when completing assessments for about three weeks but it had been fixed for a while. The ADON stated they did not submit the assessments to CMS, the corporate MDS person did this offsite. The stated they had no way to know if assessments had been submitted to CMS or not. The ADON stated the assessment should have been submitted within 14 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a resident with a newly evident possible serious mental disorder was referred to OHCA for one (#12) of one sampled resident whose PA...
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Based on record review and interview, the facility failed to ensure a resident with a newly evident possible serious mental disorder was referred to OHCA for one (#12) of one sampled resident whose PASRR screening was reviewed.
The Resident Census and Conditions of Residents form documented a census of 42 residents.
Findings:
Res #12 had diagnoses which included CHF, dementia with behavioral disturbances, and major depressive disorder.
A PASRR level I, dated 06/18/09, documented the resident did not have a serious mental illness.
On 05/20/13 a new diagnosis of schizoaffective disorder was added to the resident's diagnoses.
A significant change assessment, dated 02/02/23, documented the resident was not considered by the state level II PASRR process to have serious mental illness and /or intellectual disability or related condition. The assessment documented the resident received an antipsychotic and an antidepressant for seven days during the look back period.
A quarterly assessment, dated 08/02/23, documented the resident was moderately impaired with cognition and required supervision with most ADLs. The assessment documented the resident received an antipsychotic and an antidepressant medication.
On 10/12/23 at 10:46 a.m., the MDS coordinator stated when a resident received a new diagnosis of a serious mental illness they had to call OHCA. The MDS coordinator could not find documentation of OHCA being contacted regarding the resident's new mental health diagnoses.
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 observation, record review, and interview, it was determined the facility failed to ensure baths were performed for one (#31) of three residents sampled for ADLs.
The Resident Census and Con...
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Based on observation, record review, and interview, it was determined the facility failed to ensure baths were performed for one (#31) of three residents sampled for ADLs.
The Resident Census and Conditions of Residents form documented a census of 42 residents.
Findings:
Res #31 had diagnoses which included mood disorder due to known physiological condition with major depressive episodes and Alzheimer's Disease.
A care plan, dated 05/17/21, documented the resident required assistance with ADLs. The care plan documented the caregivers would allow the resident a choice between a shower or a tub bath on the resident's scheduled shower days. The care plan documented the resident required assistance with bathing. The care plan documented the care givers would notify the nurse if a noticeable decline in the residents ability to perform ADLs. The care plan did not contain documentation the resident refused bathing.
A quarterly assessment, dated 08/23/23, documented the resident was intact with cognition and was independent to requiring supervision with ADLs. The assessment documented the resident received antipsychotic and antidepressant medications daily during the assessment period.
The bathing schedule for Res #31 documented the resident was scheduled to receive baths on Tuesday, Thursday, and Saturday on the three to eleven shift. The resident should have received 12 baths during the last 30 days.
The POC bathing task from September 19 to October 14 2023 documented the resident had two showers and refused four baths in the last 30 days.
On 10/11/23 at 10:05 a.m., Res #31 stated they could do most ADLs but the staff would help with a bath. The resident stated they could shave themselves. The resident was observed to smell of urine. The resident had whiskers, hair that was not combed, and their shirt was dirty. Res #31 stated they used a brief and was not wet right now. The resident had been laying on their bed with only a incontinent pad on the bed and the bed was observed to not have sheets. Res #31 stated the staff did put sheets on the bed but they just had not got to it on that day.
On 10/16/23 at 2:16 p.m., Res #31 was observed walking down the hall toward the dining room. The resident hair was not combed and sticking out from his head. The resident had on a dirty shirt and a jacket.
On 10/16/23 at 2:16 p.m., CNA #3 stated the resident was on the 3-11 shower list. CNA #3 stated there was a shower book which documented when the residents received their baths. CNA #3 stated when a resident received a shower they would document a bath in the POC system and on a bathing sheet. The CNA stated if a resident refused a bath they would go to another CNA and have them try. The CNA stated if the resident refused twice they would chart it as a refusal. The CNA stated the shower sheets were given to the charge nurse. CNA #3 stated the resident refused a bath for them some time ago. CNA #3 stated on their shift on shower days the bed was to be stripped, wiped down, and made up. The CNA stated every one would have their sheets changed on shower days and when needed. The CNA stated on Sundays they tried to do shaving and nail care for the residents who did not get showers.
On 10/16/23 at 2:31 p.m., CNA #4 stated the resident's shower was on 3-11 shift but the resident refused a lot. CNA #4 stated the resident was incontinent and smelled of urine frequently. CNA #4 stated the staff encouraged the resident to shower but they refused to at times. The CNA stated the resident would hang up their dirty clothes in their room. CNA #4 stated the resident changed his pants today but would not change his shirt and jacket. CNA #4 stated Thursday of last week we got the resident to take a bath. CNA #4 stated the staff always let the nurse know when a resident was refusing care. The CNA stated they charted on the POC the when the resident refused care. The CNA stated the resident had the right to refuse.
On 10/16/23 at 2:53 p.m., the ADON stated the nurse should have been getting the bathing sheets and charting refusal of care. The ADON stated they would look in the notes for documentation.
The facility did not provide documentation the resident had refused their baths/showers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to administer oxygen according to physician orders for one (#3) of one resident reviewed for respiratory care.
The Resident Cen...
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Based on observation, record review, and interview, the facility failed to administer oxygen according to physician orders for one (#3) of one resident reviewed for respiratory care.
The Resident Census and Conditions of Residents form documented 10 residents received respiratory treatments.
Findings:
Res #3 had diagnoses which included schizoaffective disorder and dissociative identity disorder.
A care plan, dated 08/08/22, documented the resident received oxygen therapy. The care plan documented to administer the medication as ordered by the physician and monitor and document side effects and effectiveness. The care plan documented the resident often refused to wear oxygen.
A physician order, dated 03/29/23, documented oxygen at 2 L per nasal cannula while sleeping due to severe sleep apnea.
A quarterly assessment, dated 08/05/23 documented the resident was intact with cognition and required supervision with most ADLs. The assessment documented the resident received oxygen therapy.
The October TAR documented the resident used oxygen 2L at HS.
On 10/10/23 at 3:16 p.m., Res #3 was observed sitting in the bed awake with the head of the bed raised and oxygen in use at 3L per nasal cannula.
On 10/16/23 at 3:42 p.m., the DON stated they should have assessed the resident to see when the resident needed the oxygen during the day and if the resident needed oxygen they should call the physician and get an order.
On 10/16/23 at 3:45 p.m., the resident was observed sitting on the side of the bed and was asked the surveyor if they could go take their shower now. Res #3 stated they had just took their oxygen off. The oxygen concentrator was observed off at that time. The concentrator was turned on and the oxygen was set at 1.5L . The resident stated they turn the oxygen to whatever liter they wanted.
On 10/16/23 at 3:54 p.m., LPN #2 stated the resident did not wear the oxygen too much during the day. LPN #2 stated they were not aware the resident changed the L flow amount of their oxygen. LPN #2 stated they have to go check the oxygen to make sure what the setting was on. LPN #2 looked at the order and stated it documented to use the oxygen at night. LPN #2 stated a PRN oxygen order should have been obtained and staff should check the resident pulse oxygen level.
On 10/16/23 at 3:59 p.m., the DON stated the staff were going to educate and supervise the resident regarding their use of oxygen. The DON stated resident did not always know they can administer to high and to low a dose of oxygen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure residents with a diagnosis of post traumatic stress disorder received culturally competent trauma informed care in ord...
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Based on observation, record review, and interview, the facility failed to ensure residents with a diagnosis of post traumatic stress disorder received culturally competent trauma informed care in order to eliminate or mitigate triggers which could cause re-traumatization of the resident for one (#39) of one resident reviewed for behavior.
The Resident Census and Conditions of Residents form documented 34 residents had psychiatric diagnoses and two had behavioral needs.
Findings:
Res #39 had diagnoses which included chronic post-traumatic stress disorder and recurrent major depressive disorder.
An annual assessment, dated 08/12/23, documented the resident was independent with most ADLs, had no issues with their mood, and had no behaviors.
On 10/11/23 at 10:12 a.m., the resident was observed sitting in her room on her bed. The resident stated they received medications in the morning to help with their depression but it did not help much.
The resident's care plan was reviewed and did not document a plan of care to mitigate the resident's possible triggers for the diagnosis of post traumatic stress disorder.
On 10/16/23 at 10:29 a.m., the ADON/MDS coordinator stated this residents post-traumatic stress disorder was related to their history related to incarceration as well as other life events. The ADON reviewed the resident's care plan and confirmed the plan did not document a plan of care related to post-traumatic stress disorder. The ADON stated they were not aware of what the triggers for this resident would have been.
On 10/16/23 at 10:48 a.m., the ADON stated the resident had been admitted with the diagnoses but the physician who admitted the resident no longer worked at the facility. The ADON stated the resident had not opened up to them to discuss what may cause a re-traumatization and the facility had not developed a plan to address their needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to review the risks and benefits of side rails with the resident or resident representative and obtain an informed consent prior...
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Based on observation, record review, and interview, the facility failed to review the risks and benefits of side rails with the resident or resident representative and obtain an informed consent prior to installation for two (#13 and #28) of two sampled residents reviewed for side rails.
The administrator identified 15 residents in the facility had bed rails on their beds.
Findings:
A undated policy titled Bed Rails, read in part, .The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation .1. The facility will assess the resident's need for bed trails and all factors involved, including alternatives. Alternatives to bed rails will always be attempted before consideration of bed rail application. Documentation in the resident's record will reflect this assessment and related information, including how the alternatives failed to meet the resident's assessed needs .the facility must obtain informed consent from the resident or if applicable, the resident representative for use of bed rails .
1. Res #13 had diagnoses which included diabetes mellitus, anxiety disorder, and schizophrenia.
A quarterly assessment, dated 07/06/23, documented the resident was intact with cognition and was independent with most ADLs.
A quarterly assessment, dated 10/06/23, documented the resident was intact with cognition.
A side rail assessment, dated 10/06/23, documented the resident had not expressed a desire to have side rails raised while in bed for their own safety and/or comfort. The assessment documented the resident was able to get in and out of bed independently and did not use side rails for positioning or support.
A side rail consent or a physician order for side rails were not found in the EHR for the resident.
The care plan was reviewed and did not document a plan for side rails for the resident.
On 10/10/23 at 2:56 p.m., the resident's bed was observed to have side rails at the foot of the bed in the up position. Res #13 stated the rail on the bed will not go down and they wished it would. Res #13 stated they did not use the rail that was attached to the bed.
On 10/13/23 at 10:15 a.m., the bed rail was observed in up position at the foot of the resident's bed.
On 10/13/23 at 10:18 a.m., LPN #1 stated they did not think the resident needed a side rail on the bed.
On 10/13/23 at 10:20 a.m., CNA #1 and CNA #2 stated stated the resident was independent, could get out of be on their own, and did not need a side rail for assistance.
On 10/13/23 at 10:25 a.m., the ADON stated they were not aware the resident had a side rail on the bed.
On 10/13/23 at 10:33 a.m., maintenance #1 stated they were new to the facility. They stated the side rails were checked at least once to twice a week. They stated the maintenance supervisor would have the records.
On 10/13/23 at 11:22 a.m., the ADON stated they were still looking for the consents for the bed rails. The ADON stated there was a consent tab and if the resident did have any consents they would be there.
2. Res #28 had diagnoses which included cerebral palsy, spina befida, and immobility syndrome.
A consent or a physician order for side rails was not found in the resident's EHR.
A quarterly assessment, dated 09/18/23, documented the resident was intact with cognition and required limited assistance with bed mobility and total assistance with transfers. The assessment documented the resident had bed rails in the restraint section.
The care plan was reviewed and did not contain a plan for side rails for the resident.
A side rail assessment for Res #28, dated 09/18/23, documented the resident had expressed a desire to have side rails raised while in bed for their own safety and/or comfort. The assessment documented the resident was not able to get in or out of bed independently.
On 10/10/23 at 2:41 p.m., the resident's bed was observed to have two bed rails in the up position. Res #28 stated they did not use the bed rails and the rails were already on the bed when they moved in.
On 10/13/23 at 10:16 a.m., the bed was observed to have side rails up on both sides of his bed and the resident was out of the room.
On 10/13/23 at 11:22 a.m., the ADON stated they were still looking for consents for bed rails.
A side rail assessment for Res #28, dated 10/13/23, documented the resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort. The assessment documented the resident was not able to get in or out of bed independently.
A nurse note, dated 10/13/23, documented they were unable to locate a signed informed consent for bedrails. The note documented the physician was notified and received verbal order to continue.
On 10/16/23 at 9:46 a.m., the ADON stated they were not able to find a bed rail consent for the resident so the resident signed a new one on 10/13/23.
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 F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week and failed to ensure an RN was designated to ...
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Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week and failed to ensure an RN was designated to serve as the DON.
The Resident Census and Conditions of Residents form documented 42 residents resided in the facility.
Findings:
Documents titled Shiftkey Schedule documented an RN was not present in the building on the dates of 09/03/23, 09/04/23, or 09/06/23.
On 10/16/23 at 6:30 p.m., the administrator confirmed there was not on RN in the building on the dated listed above.
On 10/16/23 at 7:13 p.m., the administrator stated the previous DON had left the facility employ in August and the facility went without an RN/DON during this time. The administrator stated the facility had an RN in the building most days but there were three days were there was also no RN in the facility.
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
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure the attending physician documented they had reviewed a consultant pharmacist's recommendation or provide a rational fo...
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Based on observation, record review, and interview, the facility failed to ensure the attending physician documented they had reviewed a consultant pharmacist's recommendation or provide a rational for disagreeing with a request to reduce a medication for one (#23) of five residents whose medications were reviewed.
The Resident Census and Conditions of Residents form documented 42 residents resided in the facility.
Findings:
Res #23 had diagnoses which included schizoaffective disorder - bipolar type, anxiety disorder, insomnia, and depressive episodes.
A consultant pharmacist recommendation, dated 12/14/22, asked the physician to consider a reduction of Latuda 40 mg, Zyprexa 10 mg, Risperidone 3 mg BID (antipsychotic medications), and Topamax 50 mg (a antiseizure medication). The physician responded pt stable; no change on 12/28/22.
A consultant pharmacist recommendation, dated 03/07/23, asked the physician to consider a reduction of the resident's dose of Trazodone (an antidepressant medication). The form did not document a response from the physician.
A care plan, reviewed on 07/18/23, documented the the facility was to consult with pharmacy and the physician to consider dosage reduction when clinically appropriate.
A quarterly assessment, dated 09/22/23, documented the resident was intact in cognition and received insulin, antipsychotics, antianxiety, and antidepressant medications daily during the assessment period.
On 10/12/23 at 2:48 p.m., the resident was observed sitting on a sofa in the common area. The resident was clean and without odor. When the resident spoke there was little inflection of their voice.
On 10/12/23 at 4:02 p.m., the ADON and DON reported they were unable to find a physician response to the consultant pharmacist recommendation from 03/07/23. The DON confirmed a good time to attempt a reduction in a medication was when the resident was stable so the phrase of stable was not a good rational to not attempt a decrease in a resident's medications.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure significant medication errors did not occur for one (#23) of five residents whose medications were reviewed.
The Resi...
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Based on observation, record review, and interview, the facility failed to ensure significant medication errors did not occur for one (#23) of five residents whose medications were reviewed.
The Resident Census and Conditions of Residents form documented 42 residents resided in the facility.
Findings:
Res #23 had diagnoses which included type two diabetes mellitus with hyperglycemia.
A physician order, dated 07/13/19, documented the facility was to administer Novolin N (a type of insulin) 20 units daily for a diagnosis of diabetes.
A physician order, dated 10/28/22, documented the facility was to administer Novolog by sliding scale daily for a diagnosis of type two diabetes with other diabetic ophthalmic complication.
A quarterly assessment, dated 09/22/23, documented the resident was intact in cognition and received insulin daily during the assessment period.
A review of the May 2023 TAR did not document the resident's insulin doses were given on 05/10/23 and 05/31/23.
A review of the July 2023 TAR did not document the resident's insulin doses were given on 07/05/23 and 07/31/23.
A review of the September 2023 TAR did not document the resident's insulin doses were given on 09/23/23.
A review of the October 2023 TAR did not document the resident's insulin doses were given on 10/04/23 and 10/07/23.
On 10/12/23 at 2:40 p.m., the ADON and DON reviewed the resident's September and October TAR and stated they could not confirm the resident's insulin had been administered.
On 10/12/23 at 2:48 p.m., the resident was observed sitting on a sofa in the common area. The resident stated they did not refuse to have their finger stick blood sugar done or insulin given. The resident stated sometimes the staff did not get around to doing it. When asked if this has happened recently the resident stated it happened twice last week.
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 F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to prepare food in a form which met the individual needs of residents for one (#10) of one resident reviewed for a mechanically altered diet.
Th...
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Based on observation and interview, the facility failed to prepare food in a form which met the individual needs of residents for one (#10) of one resident reviewed for a mechanically altered diet.
The Resident Census and Conditions of Residents form documented a nine resident in the facility with mechanically altered diets and one resident who required tube feedings.
Findings:
An undated policy titled Therapeutic Diets, read in part .Mechanically altered diet means one in which the texture of a diet is altered .
Res #10 had diagnoses which included COPD, schizophrenia, and Alzheimer's Disease.
A physician order, dated 10/17/19, documented a regular diet, mechanical soft texture, regular consistency.
A care plan, updated 08/18/20, documented the resident was edentulous and received a regular mechanical diet. The care plan documented Res #10's swallow study precautions are as followed remain up right for minimum of 45 minutes after po intake and elevate HOB at all times. The swallow study precautions were to be upright at 90 degrees, multiply swallow x 2 after each bite to clear their throat and encourage the resident to take small bites, no food or drink 1 to 2 hours prior to bedtime. The care plan documented the resident had a history of refusing encouragement with swallowing techniques. The care plan documented the care givers would encourage the resident to clear throat, and remain upright.
An annual assessment, dated 08/29/23, documented the resident was moderately impaired with cognition and was independent with eating. The assessment documented the resident had coughing or chocking during meals or when swallowing. The assessment documented the resident had a mechanically altered diet.
On 10/12/23 at 12:16 p.m., while observing meal service the mechanical soft diets were observed to have the pork roast which was long and stringy with some chunked pieces. [NAME] #2 stated the mechanical soft diets received the roast which was being served they had one puree meal only. The cook stated the meat had not been altered in a food processor.
On 10/12/23 at 3:47 p.m., the dietitian stated the mechanical altered diet should have been ground with a gravy on top. They stated the facility had altered the meat from what the regular diet was served but it had not been altered enough to be safe for Res #10.
On 10/12/23 at 2:44 p.m., the DM stated they were not aware the meat was not ground for the mechanical altered diets and the meat should have been chopped up.
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 F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure residents on the resident trust fund had the right to manage their own financial affairs for three (#1, 37, and #38) o...
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Based on observation, record review, and interview, the facility failed to ensure residents on the resident trust fund had the right to manage their own financial affairs for three (#1, 37, and #38) of three residents reviewed for trust funds.
The facility administrator reported 39 residents were on the trust fund.
Findings:
On 10/10/23 at 4:23 p.m., Res #38 stated they were on the trust fund and could only get money on Fridays. The resident stated they had asked to have access to it on other days and were told they had to wait until Friday.
On 10/10/23 at 6:05 p.m., Res #37 stated they were on the trust fund and could only get money on Fridays.
On 10/11/23 at 10:29 a.m., Res #1 stated they could get money from the trust fund on Fridays. The resident stated they though they might have been able to get money every other day but they had only tried to get money on Fridays.
On 10/13/23 at 10:16 a.m., the administrator stated residents could get their money Monday through Friday but not on the weekends. The administrator stated currently the residents came on Fridays to get some of their cash so they would have money for the weekends. The administrator stated the population of the facility did not have the cognitive ability to keep up with or manage their funds. The administrator stated they understood it was a resident right to have access to their money whenever they want it but stated the residents in this facility were different and did not understand. The administrator stated they felt they had to help the residents manage their money.
On Friday, 10/13/23 at 1:00 p.m., a line of residents was observed outside of the administrator's office waiting to receive money from their trust fund.
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 F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to ensure quarterly statements were provided to the residents who were on the trust fund for one (#27) of three residents reviewed for trust fu...
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Based on record review and interview the facility failed to ensure quarterly statements were provided to the residents who were on the trust fund for one (#27) of three residents reviewed for trust funds.
The administrator reported 39 residents were on the trust fund.
Findings:
On 10/10/23 at 6:05 p.m., Res #27 stated they were on the trust fund and used to receive quarterly statements but had not received one for a while. The resident stated the person who used to provide them no longer worked at the facility.
On 10/13/23 at 10:16 a.m., the administrator stated quarterly statements were mailed to the seven or so residents who wanted them. The administrator stated they would tell others in the trust fund what their balance was if they wanted to know, but did not have documentation of this.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for three (#12, 23, and #28) of 16 sampled residents whose assessmen...
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Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for three (#12, 23, and #28) of 16 sampled residents whose assessments were reviewed.
The Resident Census and Conditions of Residents form documented a census of 42 residents.
Findings:
1. Res #28 had diagnoses which included cerebral palsy, chronic total occlusion of artery of the extremities, and immobility syndrome.
A quarterly assessment, dated 09/18/23, documented in the restraints section P that bed rails were used daily.
On 10/10/23 at 2:41 p.m., two quarter bed rails were observed in the up position on the resident's bed. The resident was not in the bed. The resident was observed in their wheelchair in the room. The resident stated they did not use the bed rails and they were on the bed already. Res #28 stated they did not know why the rails were on the bed.
On 10/13/23 at 9:02 a.m., the MDS coordinator stated the bed rails are not used as a restraint for the resident they were used to assist in positioning. The MDS coordinator stated the MDS entry was not accurate.
2. Res #12 had diagnoses which included schizoaffective disorder, CHF, and diabetes mellitus.
A quarterly assessment, dated 08/02/23, documented the resident was moderately impaired with cognition and required supervision with most ADLs. The assessment documented A GDR was clinically contraindicated 10/26/22,
A consultant pharmacist medication review, dated 10/18/22, requested to decrease trazodone (an antidepressant medication). The physician response, dated 10/26/23, documented the physician disagreed with the response by documenting the resident was stable at that time.
On 10/13/23 at 9:00 a.m., the MDS coordinator stated they were not aware antipsychotics were the only medications they were to capture for a GDR and GDR contraindication. The MDS coordinator stated a correction for the GDR section of the MDS had been completed with the correct date.
3. Res #23 had diagnoses which included schizoaffective disorder type, anxiety disorder, depressive episodes, and extrapyramidal disorder.
Physician orders, dated 02/24/22, documented the facility was to administer lorazapam (an antianxiety medication) to the resident TID.
A consultant pharmacist review of Res #23's records, dated 05/16/23, asked to consider a reduction of lorazepam from TID. The pharmacist review documented the physician agreed with the request to reduce the resident's dose of lorazepam to BID on 06/12/23.
An annual assessment, dated 07/03/23, documented the resident was intact in cognition and received antipsychotics, antianxiety, and antidepressant medications daily during the assessment period. The assessment documented the resident received antipsychotics on a daily basis and the last GDR of an antipsychotic was attempted on 06/12/23.
A quarterly assessment, dated 09/22/23, documented the resident was intact in cognition and received antipsychotics, antianxiety, and antidepressant medications daily during the assessment period. The assessment documented the resident received antipsychotics on a daily basis and the last gradual dose reduction of an antipsychotic was attempted on 06/12/23.
On 10/12/23 at 3:30 p.m., the ADON/MDS coordinator stated they had confused the term psychotropic medications with antipsychotics and the assessments were coded incorrectly for gradual dose reductions.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure:
a. dirty linens were stored properly.
b. proper PPE was present in the laundry room.
c. a program was designed to help prevent the de...
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Based on observation and interview, the facility failed to ensure:
a. dirty linens were stored properly.
b. proper PPE was present in the laundry room.
c. a program was designed to help prevent the development of Legionnaires' disease and Pontiac fever cased by Legionella bacteria.
The Resident Census and Conditions of Residents form documented a census of 42 residents.
Findings:
1. On 10/16/23 at 4:09 p.m., the laundry in the facility was observed not to have eye protection or a clothing cover in the laundry room. Two barrels of dirty laundry were observed in the hallway outside of the laundry and near the kitchen door, one with the lid not secure on the barrel of soiled laundry .
On 10/16/23 at 4:44 p.m., Laundry #1 stated they were not aware of any goggles or a clothing protector in the laundry room. The laundry staff member stated the two barrels in the hall contained dirty laundry and they brought it back there to get it off the halls.
On 10/16/23 at 4:54 p.m., the DM who was also over laundry at that time stated they were not aware of PPE was needed in the laundry room. The DM stated there was some PPE around the corner from the laundry room. The DM stated the dirty barrels should not have been in the hall. The DM stated they should have stayed in the dirty barrel room until they were ready to wash the laundry.
2. On 10/16/23 at 5:15 p.m., the administrator stated they had a Legionella policy and was not sure if it had been implemented.
On 10/16/23 at 5:20 p.m., the maintenance supervisor stated they had not even really heard of Legionella. They stated they had some books and two days of training had been working at the facility a few months. The maintenance supervisor stated they kept the air conditioners flushed out weekly and had not seen a policy for Legionella.
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 and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
The Resident Census and Conditio...
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Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
The Resident Census and Conditions of Residents form documented 42 residents resided in the facility with one resident who required tube feedings.
Findings:
1. On 10/10/23 at 4:59 p.m., the DM was observed to enter the facility from outside and started passing catsup to several of the residents in the dining room. The DM was not observed to perform hand hygiene.
On 10/10/23 at 5:07 p.m., DA #1 was observed in the kitchen during meal service. DA #1 was observed to have gloves on and wiped their upper lip and did not change gloves or wash their hands before serving a meal out the window pass.
On 10/10/23 at 5:11 p.m., the DM was observed passing tarter sauce in the dining room with gloves on. The DM was observed to place a hand on the cart at the pass then told the kitchen staff a resident wanted more shrimp. The DM then was observed to touch a bowl by the rim, moved something on the table, and then placed the resident's plate in front of them on the table. The DM was not observed to change gloves or perform hand hygiene. The DM continued to serve tarter sauce in the same gloves.
On 10/10/23 at 5:15 p.m., the DM was observed to retrieve a glass from the cart at the door, take it to a resident while taking the foil off the top of the glass, and held it by the rim.
On 10/10/23 at 5:18 p.m., CMA #1 was observed assisting a resident to eat. CMA #1 was observed to scratch the back of their own hand and continue to feed the resident. Hand hygiene was not observed.
On 10/10/23 at 5:21 p.m., the DM was observed to enter the kitchen to retrieve an item in the refrigerator. The DM was not observed to wash their hands when entering the kitchen or before returning to the dining room with bologna for a resident. The DM was observed to put on gloves and served more tarter sauce on the residents' plates.
On 10/10/23 at 5:24 p.m., CNA #5 was observed to look at their phone and place the phone back into the pocket on the scrub top then place both hands in their pockets. CNA #5 was not observed to use hand hygiene before serving a meal to a resident. CNA #5 pulled her hands out of the pockets on her scrubs right before taking a tray for a resident. CNA #5 placed the tray on the cart at the door got back in line and placed their hands back in their pockets. The CNA was observed to move their hair back and place her hand back in their scrub pockets, then took a tray and delivered to a resident in the dining room without performing hand hygiene.
On 10/10/23 at 5:31 p.m., CNA #5 was observed at the pass looking at their phone and then delivered the tray to a resident. Hand hygiene was not observed.
On 10/10/23 at 5:33 p.m., the DM was observed to entered the kitchen without hand washing and was observed to open the refrigerator. The DM then returned to the dining with strawberry milk, touched the resident on the back with their gloves on, and used her thumb and wiped their own face. The DM was not observed to change gloves or perform hand hygiene before serving tarter sauce to more residents.
On 10/12/23 at 2:34 p.m., the DM stated the staff should perform hand hygiene after every time a meal was served . The DM stated they should wash their hands when entering the kitchen. The DM stated the staff should not be on their phone or having their hands in their pockets when serving meals. The DM stated when a staff member was assisting a resident to eat they should be wearing gloves.
2. On 10/10/23 at 1:50 p.m., an initial tour of the kitchen was made. A package of ham steaks and two packages of bologna were observed in the sink thawing.
On 10/10/23 at 1:52 p.m., the DM stated the meat should have been thawing under running water or in a pan. The DM was observed to place the ham in the bottom of the refrigerator. A pork loin/roast was observed thawing on the bottom shelf of the refrigerator.
On 10/12/23 at 11:00 a.m., [NAME] #2 was observed on their phone in the kitchen. They were observed to place the phone back in the pocket on their scrub top and then dipped up rice to puree. [NAME] #2 did not wash her hands before preparing the puree.
On 10/12/23 at 11:13 a.m., [NAME] #1 was observed to enter the kitchen, open the ice machine, and then return to the dining room. The cook did not wash her hands when she entered the kitchen.
On 10/12/23 at 11:14 a.m., [NAME] #2 was observed to wash out the food processor, run it through the dish machine, then put the lid back on the chicken stock, and then wiped the counter with a sanitizer cloth. [NAME] #2 was then observed to touch the trash can lid and then open the oven door without washing her hands.
On 10/12/23 at 11:16 a.m., [NAME] #2 was asked to check the the dish machine sanitizer. At that time the sanitizer was checked by the cook three times and did not register any sanitizer. At 11:20 a.m., the DM rechecked the sanitizer and it did not register. The DM stated the facility was getting a new dish machine.
The dish machine sanitizer log was reviewed and did not contain documentation the sanitizer had been checked on 10/12/23.
On 10/12/23 at 11:26 a.m., the DM and [NAME] #1 started sanitizing and rinsing the dishes that had been washed that morning in the dish machine in the three compartment sink.
On 10/12/23 at 11:50 a.m., the DM was observed to stack the plates for service while the plates were still wet.
On 10/12/23 at 12:02 p.m., [NAME] #2 was observed to wash two scoops and sanitized them then use a towel to dry them before service. The plates, glasses, and silverware were observed to still be wet during food service. The trays the meals were served on had not been re-sanitized and used for service.
On 10/12/23 at 2:30 p.m., the DM stated the dish machine was now working and they would be checking it daily to make sure the sanitizer was working properly. The DM stated the company was in the facility two to three weeks ago and worked on the sanitizer to the dish machine. The DM stated the documentation for checking the dish machine was probably not accurate and there was no way of knowing how long the sanitizer was not working. The DM stated the dishes should have all air dried and should not have been used still wet.
Mar 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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview, The facility failed to follow physician orders for one (#4) of four residents reviewed for oxygen therapy.
The DON reported eleven residents who re...
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Based on record review, observation, and interview, The facility failed to follow physician orders for one (#4) of four residents reviewed for oxygen therapy.
The DON reported eleven residents who resided in the facility received oxygen therapy.
Findings:
Res #4 had diagnoses which included bradycardia, right bundle branch block, SOB, and history of COVID-19.
A physician order, dated 11/18/21, documented oxygen at 2 to 4 L per NC continuously for SOB to maintain oxygen sat greater than 90%.
A care plan revised 09/09/22, documented the resident's oxygen was to be set at 2 to 4 L per NC continuously for SOB. The care plan documented O2 tubing was to be changed every week and change the filter on the oxygen concentrator yearly on 08/30.
An annual assessment, dated 12/06/22, documented the resident was severely impaired with cognition and required extensive assistance with ADLs. The assessment documented the resident received oxygen therapy and hospice.
A TAR entry, dated 03/03/23, documented the resident's O2 sat was 95% and LPN #1 initialed that the resident was on continuous oxygen.
On 03/03/23 at 11:08 a.m., Res #4 was sitting in a chair in his room which he shared with his wife. The oxygen concentrator was observed close to the resident, was running and set at 1.5 L. There was not any tubing connected to the oxygen concentrator and the resident was not receiving any oxygen at that time. The resident was not observed in any distress. The resident was asked where his oxygen tubing was and he did not know. The resident's wife stated he did not wear the oxygen tubing that much.
On 03/03/23 at 11:16 a.m., the DON was asked to come to the residents room. The DON observed the oxygen concentrator without tubing. The DON stated the resident did not have oxygen tubing. She stated the resident's wife liked to pack things up and may have it somewhere. She stated she would get him more tubing and call the hospice to let them know the resident did not wear the oxygen all the time.
On 03/03/23 at 1:00 p.m., LPN #1 stated she checked the resident's O2 sat this morning and it was good and he was not on his O2. LPN #1 stated the resident will not leave the O2 on a lot of the time and his wife packed things up all the time. She stated hospice had been in today to see the resident.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, it was determined the facility failed to maintain an infection prevention and control program to prevent the spread of infections. The facility fail...
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Based on record review, observation, and interview, it was determined the facility failed to maintain an infection prevention and control program to prevent the spread of infections. The facility failed to ensure signage was posted visible at entrance and staff were wearing masks during the time when their county transmission rate was high for COVID-19.
The DON identified 45 residents who resided in the facility.
Findings:
The CDC guidelines titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic read in parts, .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection. Ensure everyone is aware of recommended IPC practices in the facility. Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can let help ensure people know that they reflect current recommendations. Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria:
1) a positive viral test for SARS-CoV-2
2) symptoms of COVID-19, or
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP)) .
When SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients .
On 03/02/23, the CDC COVID Data Tracker documented Muskogee county's COVID-19 transmission rate as high.
On 03/02/23 at 3:45 p.m., upon arrival to the facility no visible signage was observed at the front entrance to inform and alert visitors and staff of the current infection control measures. The DON was observed not wearing mask while assisting a resident. During the survey staff members were observed without mask on or masks not being worn properly while providing care to residents.
On 03/03/23 at 9:15 a.m. through 10:18, CNA #1, CNA #2, CNA #3, and CMA #1 stated they were aware staff should be wearing a mask when caring for residents when the county's transmission rate was high.
On 03/03/23 at 9:30 a.m., the DON stated the signage was on the entrance door the other day but someone must have moved the signage. She also stated she did not use the front entrance door to enter the facility so she did not know that it was no longer posted.
On 03/03/23 at 11:34 a.m., the IP stated she was aware the county was high for COVID. She stated the staff should be wearing masks when around the residents.
Nov 2022
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on record review, observation, and interview, the facility failed to ensure residents were free from neglect for one (#1) of three residents reviewed for abuse and neglect. The facility failed t...
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Based on record review, observation, and interview, the facility failed to ensure residents were free from neglect for one (#1) of three residents reviewed for abuse and neglect. The facility failed to prevent a resident from having been left unattended in the shower room which resulted in a fall that caused a right fibula fracture. The deficient practice was determined to be past-noncompliance since the facility identified the situation and implemented interventions to prevent the recurrence of the situation.
The Resident Census and Conditions of Residents documented 41 residents resided in the facility.
Findings:
An undated facility policy titled Shower/Tub Bath, documented the following: Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower.
Res #1 was admitted with diagnoses which included hypertension, unspecified psychosis not due to a substance or known physiological condition, and schizoaffective disorder-bipolar type.
A quarterly assessment, dated 09/04/22, documented the resident was cognitively intact, independent with most ADLs, and required extensive assistance with bathing.
An OSDH initial incident report, Form 283, dated 10/04/22, documented Certain Injuries for Res #1. The report documented the residents had a fall in the shower room and was sent to the ER for evaluation.
An in-service training report, dated 10/05/22, documented 51 staff members were educated on resident shower safety, never leaving a resident unattended in the shower, and never moving an injured resident until EMS arrives and takes over care.
An OSDH final incident report, Form 283, dated 10/06/22, documented Certain Injuries for the resident. The report documented the following: On 10/03/22 at 9:30 a.m., the resident sustained a fall in the shower room. The resident was sent to the ER via EMS and was evaluated. The resident returned to the facility via EMS on 10/03/22 at 3:18 p.m., with a diagnosis of closed fracture of right fibula. The resident was not care planned to shower independently. The resident stated after her shower she was getting dressed and was trying to put her bra on when she fell. Res #1 stated CNA #1 was not in the shower room with her when she was showering or when she fell. The Activities Director was in the hall at the time of resident's fall and stated CNA #1 had passed her heading into the shower room and when the CNA opened the shower room door, she told the Activities Director to get the nurse. CNA #1 self-terminated prior to the investigation being completed and she had been reported to the CNA board for neglect of a resident.
On 11/03/22 at 1:12 p.m., Res #1 was observed lying in bed with a fiberglass cast to the right lower leg. The resident stated she lost her balance while trying to dress after showering which caused the fall. The resident stated the CNA had left the room prior to the fall for 1-2 minutes but returned to help immediately when she fell.
On 11/03/22 at 2:15 p.m., the Activities Director stated she was a witness to the event as stated in the incident report. She stated CNA #1 walked past her in the hall, walking towards the shower room. She stated having observed CNA #1 stop at the doorway of the shower room and screamed for help. She reported having notified the nurse in charge and then observed the nurse and CNA #1 attend to Res #1 in the shower room after the fall. The Activities Director stated she was certain the CNA was not in the shower room supervising the resident when the fall occurred but the CNA should have been according to facility policy.
On 11/03/22 at 4:22 p.m., the DON stated CNAs are expected to be in the room with residents at all times during a shower/bath according to policy. The DON stated the CNA should have been in the shower room with Res #1 at the time of the fall.
Aug 2022
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to offer advanced directives for one (#34) of five sampled residents reviewed for advanced directives.
The Resident Census and Conditions of R...
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Based on record review and interview, the facility failed to offer advanced directives for one (#34) of five sampled residents reviewed for advanced directives.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 11 residents had advanced directives.
Findings:
An undated Living Will/Advance Directives/Life-Sustaining Treatment Orders policy, read in parts, Residents will be given the option of completing a Living Will or Advance Directive if they have not already done so. This option will be presented to a resident on admission to the facility .The Living Will or Advance Directives will then be noted on the resident's medical record .
Resident #34 had diagnoses which included, COPD, schizophrenia, and extrapyramidal and movement disorder.
There was no documentation Resident #34 had been offered advance directives.
On 08/01/22 at 2:12 p.m., LPN #1 was asked if Resident #34 had been offered advanced directives. They stated there was no documentation filed in the resident's hard chart.
On 08/02/22 at 10:37 a.m., SS was asked to locate advance directives for Resident #34. They reviewed the resident's file and was not able to locate documentation where Resident #34 had been offered advance directives.
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 accurately reflected the residents' status for one (#21) of 13 whose assessments were reviewed.
The Resident C...
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Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for one (#21) of 13 whose assessments were reviewed.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 43 residents resided in the facility.
Findings:
Res #21 had diagnoses which included bipolar disorder with psychotic features.
A physician order, dated 06/02/22, documented Invega Sustenna (antipsychotic medication) 234 MG inject 1 dose intramuscularly one time a day every 28 days related to bipolar disorder with psychotic features.
A quarterly assessment, dated 06/07/22, documented the resident was not on an antipsychotic medication.
On 08/02/22 at 2:46 p.m., the MDS/care plan coordinator stated they missed the antipsychotic medication on the assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 a serious mental health diagnosis was refer...
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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 a serious mental health diagnosis was referred to the OHCA for one (#35) of one resident sampled for PASRR evaluations.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 43 residents resided in the facility.
Findings:
Resident #35 was admitted to the facility on [DATE] and had diagnoses which included bipolar II disorder.
A PASRR level I, dated 04/01/15, documented the resident did not have a serious mental illness.
On 08/02/22 at 4:14 p.m., the RN consultant stated anytime the resident had a serious mental illness the question regarding serious mental illness should be marked as so on the PASRR level I.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#43) of one sampl...
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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 discharge summary was completed for one (#43) of one sampled resident reviewed for discharge summaries.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 43 residents resided in the facility.
Findings:
Resident #43 was admitted to the facility on [DATE] with diagnoses which included COPD, heart failure, hemiplegia, and hemiparesis following cerebral infarction affecting the right dominant side
A nurses note, dated 05/25/22 at 11:16 a.m., documented a family member of the resident picked them up and transported them to another nursing home. It was documented the resident's family member signed for their medications and their medications and medication list was to be turned over to the nursing home on arrival.
There was no documentation a discharge summary had been completed.
On 08/03/22 at 12:01 p.m., the administrator was asked if a discharge summary had been completed for the resident.
On 08/03/22 at 12:41 p.m., the administrator stated a discharge summary was not completed for the resident and it should have been.
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
Based on record review and interview, the facility failed to ensure the physician was notified of a significant weight loss and/or gain for two (#17 and #34) of three sampled residents reviewed for we...
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Based on record review and interview, the facility failed to ensure the physician was notified of a significant weight loss and/or gain for two (#17 and #34) of three sampled residents reviewed for weight loss and/or gain.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 43 residents resided in the facility.
Findings:
1. Resident #17 had diagnoses which included, schizoaffective disorder, and unspecified dementia.
A Speech Pathology Report Mobile Modified Barium Swallow, dated 05/18/22, read in parts, .Impressions and Recommendations .Diet recommendations .PO with compensatory strategies .PO liquid: Nectar Small sips, recc consider PEG .PO Diet: Puree Small bites, 1:1 assist, PEG recc .Follow up Modified Barium Swallow .in 3-4 months or sooner to check for safest diet and dysphagia status .
A physician's order summary report, dated August 2022, read in parts, .Regular diet Pureed texture, Nectar consistency, MAY USE STRAWS 05/19/22 .Weight weekly every day shift every Mon for monitor .02/14/20 .
A dietary note, dated 07/22/22, read in parts, .Nutritional Assessment for Weight Loss and Wounds. Wt (7/18) 116.6#. -2.8% x 1 mo., -9.6% x 3 mo., -12.3% x 6 mo. Trigger for significant loss .Fed by staff Avg. meal intake 25%-50% with most in range of approximately 25% .Recommend: increase Mighty Shake with meals to TID. Will notify physician regarding continues significant weight loss .
A nurse's note, dated 08/01/22, read in parts, 09:00 [9:00a.m.,] This nurse spoke with .APRN this shift regarding resident not eating and holding food in mouth. Received new order to obtain a GI consult Will call GI Dr to set up appointment .
An undated, Nutrition Evaluation Report/Recommendation, read in parts, .In review of the resident's medical record on July 22, 2022 following recommendations related to nutritional care were identified. Wt (7/18) 116.6#. -2.8% x 1 mo., -9.6% x 3 mo., -12.3% x 6 mo. Continued significant wt loss .Avg. meal intake 25% .Recommend Increase Might Shake with meals to TID .Physician accepts . The nutrition evaluation report/recommendation was signed by the APRN on 08/02/22.
On 08/04/22 at 10:01 a.m., the DON was asked when was the recommendation to start mighty shakes had been implemented. The stated on 08/02/22. The DON was asked the reason it take so long to get the mighty shakes implemented. They stated, We did not get [resident] recommendation until that day.
On 08/04/22 at 10:01 a.m., the DON was asked when had the physician been notified about the significant weight loss. They stated, On 08/02/22 that's when we got [dietician] recommendation and the physician was notified. The DON was asked was there documentation the physician had been notified about the resident's poor appetite/refusing meals since 07/26/22. They stated stated, Not until the first of August. The DON was asked how often residents were seen by the physician. They stated, The NP comes every week and the doctor comes one time a month. The DON was asked when had Resident #17 been seen by the doctor. They stated, Looks like it was 06/06/22 when [Resident] was last seen by the doctor.
On 08/04/22 at 10:14 a.m., the DON asked LPN #3 if Resident #17 had been seen by the NP recently. They stated, Resident #17 wasn't seen by the NP, the NP just gave the order to see GI.
2. Resident #34 had diagnoses which included, COPD, schizophrenia, and extrapyramidal and movement disorder.
A physician's order summary report, dated 07/18/22, read in part, .Daily weight, Notify PCP if weight gain of 3lbs or more one time a day .
A weight list documented Resident #34 weighed 291.0 lbs on 07/23/22 and 296.0 lbs on 07/24/22.
A nurse's note, dated 07/24/22, read in part, . resident did gain over 3 lbs. was given an extra lasix via mar .
There was no documentation the PCP was notified of resident's weight gain of 3 lbs or more.
On 08/02/22 at 3:54 p.m., the DON was asked if the physician had been notified about the weight gain on 07/24/22.
On 08/03/22 at 10:06 a.m., the DON stated the RN consultant called the PCP's office and they were not aware of the resident's weight gain on 07/24/22.
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 record review and interview, the facility failed to ensure comprehensive care plans were developed for two (#31 and #33) of 13 sampled residents reviewed for care plans.
The Resident Census a...
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Based on record review and interview, the facility failed to ensure comprehensive care plans were developed for two (#31 and #33) of 13 sampled residents reviewed for care plans.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 43 residents resided in the facility.
Findings:
1. An annual assessment, dated 06/27/22, documented Resident #31 had mood state and dehydration/fluid maintenance as care plan decisions on the CAA.
There was no documentation mood state and dehydration/fluid maintenance were care planned.
On 08/02/22 at 4:04 p.m., the MDS/care plan coordinator was asked when the last comprehensive assessment had been completed for the resident. They stated 06/27/22. They were asked to review the resident's assessment and care plan. They were asked if mood state and dehydration/fluid maintenance had been care planned. They stated they did not see it and it should have been care planned. They stated care plans should be reviewed and updated as needed with a comprehensive assessment.
2. An annual assessment, dated 07/02/22, documented Resident #33 had dehydration/fluid maintenance as a care plan decision on the CAA.
There was no documentation dehydration/fluid maintenance was care planned.
On 08/03/22 at 10:10 a.m., the MDS/care plan coordinator was asked when the last comprehensive assessment had been completed for the resident. They stated 07/02/22. They were asked to review the resident's assessment and care plan. They were asked if dehydration/fluid maintenance had been care planned. They stated it was not and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 update care plans for three (#21, 28, and #38) of 13 sampled reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update care plans for three (#21, 28, and #38) of 13 sampled residents reviewed for care plans.
The Resident Census and Conditions of Residents report, dated [DATE], documented 43 residents resided in the facility.
Findings:
1. Resident #21 had a diagnoses which included diabetes mellitus.
A physician order, dated [DATE], documented to inject 10 unit of Lantus (insulin) subcutaneously one time a day.
A care plan, initiated on [DATE], documented the resident had diabetes mellitus and required medication. It was documented the nurse would administer Lantus 10 units subcutaneously one time a day in morning and 18 units subcutaneously at bedtime as ordered by the physician.
On [DATE] at 2:46 p.m., the MDS/care plan coordinator stated they updated the resident's care plan in June and did not update the Lantus on the care plan. They stated the 18 units of Lantus was discontinued on [DATE].
2. Resident #28 had diagnoses which included CHF, COPD, and atrioventricular block second degree.
A care plan, dated [DATE], documented the resident had chosen not to execute an advanced directive. It was documented the resident was a full code and wanted life sustaining measures. It was documented the resident had chosen to have CPR, Peg tube, IV fluids, and antibiotics.
A physician order, dated [DATE], documented the resident had a DNR.
On [DATE] at 3:38 p.m., Resident #28 stated they did not want CPR.
On [DATE] at 10:02 a.m., the MDS/care plan coordinator stated they changed the care plan for the resident on [DATE] when she went through every residents care plan for code status.
3. Resident #38 had diagnoses which included COPD, dementia, and drug induced subacute dyskinesia.
A care plan, initiated [DATE] and last updated [DATE], documented the resident was able to toilet self, turn and reposition self. It was documented the resident needed supervision with the assistance of one staff member for dressing and bathing.
A significant change assessment, dated [DATE], documented the resident required extensive assistance with bed mobility, transfer, dressing, and toilet use. It was documented the resident was totally dependent on staff for bathing.
On [DATE] at 9:37 a.m., CNA #1 stated Resident #38's amount of assistance needed changed day to day. They stated the resident was fully dependent in the shower and staff helped her to dress. They stated they encouraged the resident first and if the resident was not able to perform the task they would assist.
On [DATE] at 9:49 a.m., the MDS/care plan coordinator stated Resident #38 had always needed assistance. They stated the resident needed supervision with the assistance of one staff member.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #6 had diagnoses which included depression and psychotic disorder.
On [DATE] at 2:12 p.m., Resident #6's chart was r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #6 had diagnoses which included depression and psychotic disorder.
On [DATE] at 2:12 p.m., Resident #6's chart was reviewed for advanced directives and a DNR. There was a red dot observed on the spine of the resident's hard chart.
On [DATE] at 2:22 p.m., LPN #2 was asked how staff knew what residents had DNR's. They stated, It's the ones with the red dots on the charts, and on their doors by their names they have red dots by their names too I think.
On [DATE] at 2:31 p.m., LPN #3 was asked what the red dots indicated by the residents names on their doors. They stated it's the residents who have had falls or are a fall risk.
On [DATE] at 2:59 p.m., CNA #3 was asked how would they know if a resident was found unresponsive to start CPR. They stated, I would ask the nurse. CNA #3 was asked what if the nurse was not available. They stated, I would check for a DNR in the [NAME] or our POC. CNA #3 started looking for DNR documentation for Resident #6 in the EHR [NAME] and POC. They were not able to locate documentation.
On [DATE] at 3:02 p.m., CNA #1 was asked how they would know to start CPR. They stated there should be a list at the nurses station. The EHR [NAME] was reviewed with CNA #1 for Resident #6. The [NAME] documented the resident chose not to have life saving measures/CPR.
On [DATE] at 3:30 p.m., the DON was asked how the CNA's would know to start CPR. They stated, The CNA would not start CPR they would notify the nurse. They stated the CNA's know to go look in the hard chart. The DON was asked where it was located in the chart. They stated they look for a DNR. They stated it would be located behind the demographic sheet behind the advanced directives.
On [DATE] at 3:34 p.m., the Administrator stated they should just go have a nurse look on the chart. They stated there should be a better system in place.
On [DATE] at 3:35 p.m., the DON was asked if there was any other way for staff to identify a resident with a DNR. They stated the red dots on the chart was not their policy. They stated the nurses did it for a quick guide. The DON was asked what the red dots next to the names on the door indicated. They stated the red dots indicated falls since admission. The DON was asked to observe a door with a red name label. They stated the red tag indicated the resident was a DNR.
On [DATE] at 3:35 p.m., the DON was asked to review Resident #6's white name label on their door. They stated the label should be red. They stated the red label was not policy, but something put into place. They stated the CNA's have access to the charts.
2. Resident #28 admitted had diagnoses which included CHF, COPD, and atrioventricular block second degree.
A physician's order dated, [DATE], documented the resident had a DNR.
A care plan, dated [DATE], documented the resident had chosen not to execute an advanced directive. It was documented the resident was a full code and wanted life sustaining measures. It was documented the resident had chosen to have CPR, Peg tube, IV fluids, and antibiotics.
A quarterly resident assessment, dated [DATE], documented the resident's cognition was intact.
A DNR form, dated [DATE], documented the DNR was signed by the physician.
On [DATE] at 12:14 p.m., LPN #1 stated a DNR list was at nurses station and the residents who had DNR's would have a mark by their name and the rest were full codes. They stated there would be a red dot on the outside of the hard chart. Resident #28 did not have a mark by their name and there was not a red dot observed on their hard chart.
On [DATE] at 2:15 p.m., CNA #2 stated the red dot on the residents name by their door indicated they were a DNR.
On [DATE] at 2:42 p.m., a red dot was observed by Resident #28's name on their door.
On [DATE] at 3:32 p.m., LPN #4 stated she had worked at the facility for five years and knew which residents had DNR's. LPN #4 was asked if Resident #28 had a DNR. They stated Resident #28 was not a DNR. They looked in the EHR and stated Resident #28 was a DNR. LPN #4 was asked if the resident was on the DNR list at the nurses station. They stated the resident was not on the list as a DNR. LPN #4 was asked what the red dot on the hard chart indicated. They stated they thought the red dots on the chart indicated fall risks. LPN #4 looked in the resident's hard chart and found an advanced directive and a DNR dated [DATE]. The advance directive documented Resident #28 wanted life sustaining treatment. LPN #4 stated the resident went back and forth, but if they coded tonight they would be a DNR.
On [DATE] at 3:37 p.m., LPN #5 stated they preferred to look in the orders to find if the resident was a DNR. They stated if they did not have time to look in the chart they would go off the red dots on the doors for DNR.
On [DATE] at 3:38 p.m., Resident #28 was asked about their code status. They stated they did not want CPR.
Based on record review, observation, and interview, the facility failed to have an effective system to denote a residents resuscitation status for two (#6 and #28) of 16 sampled residents reviewed for advance directives.
The Resident Census and Conditions of Residents report, dated [DATE], documented 43 residents resided in the facility.
Findings:
An undated CARDIO PULMONARY RESUSCITATION policy, read in parts, .The CPR .status for every resident will be known to staff for assuring the proper response in the event of a sudden cessation of life .If the resident has a DNR .order, the charge nurse will put a red piece of paper (8 /2 x 11) .in a plastid [sic] sheet protector and place in the front of the medical record as the first document. Only the charts of the DNR residents will be so flagged, all others will be presumed to be of resuscitate status. If there are any changes in the resuscitation status during the course of the resident's stay, a new physicians order must be obtained and this information communicated to the interdisciplinary team. A master list of residents with DNR will be kept by the social worker and available to nursing staff .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
On 08/02/22 at 3:19 p.m., the pharmacist was asked where staff documented side effects for psychotropic medications. They stated, It is on the treatment sheets. They were asked what was the policy for...
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On 08/02/22 at 3:19 p.m., the pharmacist was asked where staff documented side effects for psychotropic medications. They stated, It is on the treatment sheets. They were asked what was the policy for monitoring side effects. They stated, I don't know we, just follow the state regs [regulations] on that.
On 08/02/22 at 4:01 p.m., the pharmacist provided a copy of a medication policy and procedure. They stated there was no specific monitoring. They stated all drugs were monitored for side effects.
On 08/02/22 at 3:37 p.m., the DON and RN consultant were asked if residents were monitored for side effects for the use of psychotropic medications. They stated, Yes. They were asked where side effects were documented. The DON stated anything out of the ordinary should be documented a progress not. They stated if they had issues they would look at the medications and notify the physician accordingly.
Based on record review and interview, the facility failed to ensure side effect monitoring for psychotropic medications were completed for two (#21 and #38) of five sampled residents reviewed for unnecessary medications.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 38 residents who received psychoactive medications.
Findings:
A Specific Medication Administration Procedure policy, effective July 2015, read in parts .To administer medications in a safe and effective manner .Monitor for side effects or adverse drug reactions immediately after administration and throughout each shift .
1. Resident #21 had diagnoses which included bipolar disorder with psychotic features, depression, insomnia, anxiety disorder, and suicidal ideations.
A care plan, dated 03/22/22, documented Resident #21 had bipolar disorder current episode mixed severe with psychotic features, depression, EPS, anxiety, and history of suicidal ideations. It was documented the resident required psychotropic medication and monitoring.
Physician's orders, dated 06/02/22, documented to administer Celexa (antidepressant medication) 40 mg by mouth daily, Ambien (hypnotic medication) 5 mg by mouth at bedtime, and Invega Sustenna (antipsychotic medication) one dose Intramuscular one time every 28 days.
A physician's order, dated 07/25/22, documented to administer Zyprexa (antipsychotic medication) 5 mg by mouth at bedtime.
There was no documentation side effects were being monitored for the use of psychotropic medications.
2. Resident #38 had diagnoses which included schizoaffective disorder, bipolar type, dementia with behavioral disturbances, and anxiety disorder.
A physician's order, dated 02/24/22, documented to administer Risperdal (antipsychotic medication) 2 mg by mouth two times a day.
There was no documentation side effects were being monitored for the use of a psychotropic medication.
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 record review, observation, and interview, the facility failed to ensure a medication administration error rate of less than 5% for two (#34 and #37) of four sampled residents who were observ...
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Based on record review, observation, and interview, the facility failed to ensure a medication administration error rate of less than 5% for two (#34 and #37) of four sampled residents who were observed during medication pass. Three errors were observed during 49 opportunities of medication administration. This resulted in a medication error rate of 6.12%.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 43 residents resided in the facility.
Findings:
A Specific Medication Administration Procedures policy, effective July 2015, read in parts, .To administer medications in a safe and effective manner .Review 5 Rights (3) times: .Check MAR/TAR for order .Check the label against the order on the MAR .
1. Resident #37 had diagnoses which included tachycardia and allergy.
A physician's order summary, dated August 2022, read in parts, Artificial Tears Solution [lubricant eye drop] Instill 1 drop in left eye four times a day for Dry eyes related to Allergy 06/10/2019 .Propranolol HCL [beta blocker medication] Tablet 10 MG Give 1 tablet by mouth two times a day related to TACHYCARDIA .Obtain my pulse prior to administering and hold in[sic] < [less than] 60 06/29/2018 .
On 08/03/22 at 7:48 a.m., CMA #1 was observed to obtain B/P and pulse for Resident #37. They documented the resident's B/P as 90/54 and pulse as 98. CMA #1 reported the findings to the nurse and was instructed to hold Resident #37's Propranolol. CMA #1 was observed to administer one drop of Artificial Tears solution in Resident #37's right eye.
On 08/03/22 at 8:00 a.m., CMA #1 was asked what was the order on the eye drop vial. They stated administer one drop in left eye. CMA #1 was asked which eye the drop was put in. They stated, The right eye, I got my rights and lefts messed up.
On 08/03/22 at 9:05 a.m., LPN #3 was asked if CMA #1 reported resident #37's BP and pulse to them this morning. They stated, Yes. LPN #3 was asked if CMA #1 was told to hold Residents #37's Propranolol. They stated they asked CMA #1 to hold the Propranolol since their blood pressure was low. They stated they had standing orders to hold if any resident had a B/P below 100/60. LPN #3 was asked what the physician's order said when to hold the medication. They stated, Hold if pulse below 60, indication for use tachycardia LPN #3 was asked what the resident's heart rate was. They stated 98. LPN #3 was asked if the medication should have been held. They stated, No.
There was no physician's order to hold the medication if Resident #37's B/P was below 100/60.
On 08/03/22 at 9:11 a.m., CMA #1 was asked the reason Resident #37's Propranolol was not administered during the medication pass. They stated the nurse instructed them to hold it. CMA #1 was asked what the order said when to hold the medication. They stated to obtain pulse and hold if less than 60. CMA #1 was asked what was Resident #37's heart rate. They stated 98. CMA #1 was asked if the medication should have been held. They stated, No it should have been given, but I did what my nurse told me. CMA #1 was asked if they were aware of the hold for pulse less than 60. They stated, No.
2. Resident #34 had diagnoses which included COPD, schizophrenia, and extrapyramidal and movement disorder.
A physician's order summary, dated August 2022, read in part, .Benztropine Mesylate [anticholinergic medication] Tablet 1 MG Give 1 mg by mouth two times a day .
On 08/03/22 at 8:02 a.m., CMA #1 was observed to administer Benztropine 0.5 mg one tablet to Resident #34.
The August 2022 MAR documented CMA #1 administered one Benztropine Mesylate 1 mg on 08/03/22.
On 08/03/22 at 9:11 a.m., CMA #1 was asked how many Benztropine tablets were administered to Resident #34 this morning. They stated one. CMA #1 was asked what was the physicians' order. They stated Benztropine 1 mg. They stated the resident should have received two instead of one. CMA #1 stated it was a medication error.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
2. Resident #11 had diagnoses which included, COPD, and other nonspecific abnormal finding of lung field.
A physician's order summary, dated August 2022, read in part, .Ipratropium-Albuterol Solution...
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2. Resident #11 had diagnoses which included, COPD, and other nonspecific abnormal finding of lung field.
A physician's order summary, dated August 2022, read in part, .Ipratropium-Albuterol Solution [breathing treatment] 0.5-2.5 (3) MG/3ML 1 vial inhale orally four times a day .
On 08/01/22 at 1:43 p.m., the tubing on Resident #11's nebulizer machine was dated 06/16/22.
On 08/02/22 at 1:45 p.m., Resident #11's nebulizer tubing was dated 08/02/22.
3. Resident #34 had diagnoses which included COPD and dyspnea.
A physician's order summary, for August 2022, read in part, .Ipratropium-Albuterol solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally as needed for Dyspnea TID PRN 09/20/2021 .
The July 2022 TAR documented Resident #34 received a breathing treatment on 07/09/22 and 07/10/22.
On 08/01/22 at 12:06 p.m., the tubing on Resident #34's nebulizer machine was dated 06/16/22.
On 08/02/22 1:59 p.m., LPN #2 was asked where it was documented when a residents nebulizer mask/tubing were changed. They stated they thought they did it once a week. LPN #2 then asked LPN #3 how often the tubing was changed. LPN #3 stated it was done on the 11-7 shift. LPN #2 stated, If they don't do it the first of the week, I'm not sure I will have to go find out.
On 08/02/22 at 2:04 p.m., LPN #2 stated, The CMA's change the tubing out one time a week and they have a book.
On 08/02/22 2:44 p.m., CMA #2 was asked if Resident #34's nebulizer tubing was changed today. They stated, Yes. CMA #2 was asked if they could recall what the date was on the tubing removed. They stated, No. CMA #2 was asked how often was tubing change. They stated one time a week. CMA #2 was asked to review the document titled MAINTENANCE ON OXYGEN AND HHN EQUIPMENT, dated 06/01/22 to 06/29/22, for Resident #11. CMA #2 was asked if there was documentation Resident #11's nebulizer tubing had been changed since 06/29/22. They stated, I couldn't tell you.
CMA #2 was asked if Resident #11's tubing had been changed today. They stated, Yes. CMA #2 was asked if they recalled the date on the tubing. They stated, No. CMA #2 was asked if the date was 06/16/22. They stated it was probably right. CMA #2 was asked to review the policy and procedure for HHN tubing and mask and when it was supposed to be changed. They stated, I don't remember that.
Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for three (#11, 34, and #35) of four residents observed for infection control.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 43 residents resided in the facility.
Findings:
An undated, Respiratory Treatment Nebulizer (Hand Held) policy, read in parts, .EQUIPMENT CARE/INFECTION CONTROL .Nasal cannula or mask and tubing are to be changed every 48 hours .
1. Resident #35 had diagnoses which included a wound.
A physician order, dated 08/05/21, documented to cleanse stasis ulcer to right BKA stump with wound cleanser pat dry with 4x4. It documented to apply Bactroban ointment (antibacterial) to wound and cover with a Telfa island dressing every day and prn. It documented to apply to R stump topically every 12 hours as needed for soilage.
A quarterly assessment, dated 07/15/22, documented the resident's cognition was intact and they had one stage II pressure ulcer.
A weekly skin audit report, dated 07/05/22, documented a pin point wound to stump with scant yellow drainage.
A physician's order, dated 07/15/22, documented contact isolation for MRSA right stump wound.
A physician's order, dated 08/01/22, documented to administer Doxycycline (antibiotic medication) by mouth two times a day for right stump wound infection for three weeks.
A weekly skin assessment, dated 08/02/22, documented wound measured 0.75 cm x 0.5 cm x no depth with drainage.
On 08/01/22 at 12:36 p.m., a sign was observed on Resident #35's door to their room. It documented to please report to nurses station before entering the room.
On 08/03/22 at 4:13 p.m., LPN #1 was observed to perform wound care for Resident #35. LPN #1 did not use the proper PPE for contact precaution while performing the wound care. They did not perform hand hygiene or change their gloves between cleaning the wound and treatment.
On 08/03/22 at 4:24 p.m., Res #35 stated they receive wound care everyday and have for the past three years.
On 08/03/22 at 4:26 p.m., LPN #1 stated they were not sure, but thought Resident #35 was no longer on contact precautions. They stated they did not use hand hygiene or change their gloves after cleaning the wound and before treatment of the wound.
On 08/04/22 at 10:05 a.m., the RN consultant stated they believed Resident #35 was still on contact precautions. They stated staff should wear gloves, mask, and gown before performing the resident's wound care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to offer pneumococcal immunizations to two (#1 and #25) of five sampled residents reviewed for immunizations.
The Resident Census and Conditi...
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Based on record review and interview, the facility failed to offer pneumococcal immunizations to two (#1 and #25) of five sampled residents reviewed for immunizations.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 43 residents resided in the facility.
Findings:
A Influenza Vaccine/Pneumococcal Vaccine policy, revised 12/03/01, read in parts, .The company encourages each resident to be vaccinated for protection against the pneumococcal disease .A physician's order must be obtained .Each resident will be assessed to determine the eligibility for vaccination .The assessment and administration of the vaccine will be recorded in the resident's medical record .Those residents who are not vaccinated will have the reason documented in the medical record .The same procedure will be used to assess the resident and administer to the resident the pneumococcal vaccine .
1. Resident #1 had diagnoses which included Parkinson's disease and GERD.
There was no documentation the resident had been offered a pneumococcal immunization.
2. Resident #25 had diagnoses which included anemia and hypertension.
There was no documentation the resident had been offered a pneumococcal immunization.
On 08/03/22 at 11:34 a.m., the DON was asked if the pneumococcal immunization had been offered to Resident #25. The DON stated there was no documentation of the resident having one.
On 08/03/22 at 11:36 a.m., the DON was asked if the pneumococcal vaccination had been offered to Resident #1. The DON stated there was no documentation in the EHR a pneumococcal immunization was offered. The DON stated they would look in the hard chart.
On 08/03/22 at 12:38 p.m., the DON was asked if they were able to locate documentation pneumococcal vaccinations were offered to Resident #1 and Resident #25. They stated they had not. The DON was asked what was the policy for offering pneumococcal vaccinations. They stated they knew the pneumococcal vaccination was offered on admission.
On 08/03/22 at 2:12 p.m. the DON stated the pharmacy was contacted and had not sent the pneumococcal vaccination because of the residents' ages. The DON was asked the reason the physician was not contacted regarding whether to offer he pneumococcal vaccination due to the residents' ages. They stated, We just did not offer it.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to designate a RN to serve as the DON on a full-time basis.
The Resident Census and Conditions of Residents report, dated 08/02/22, documente...
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Based on record review and interview, the facility failed to designate a RN to serve as the DON on a full-time basis.
The Resident Census and Conditions of Residents report, dated 08/02/22, documented 43 residents resided in the facility.
Findings:
A nursing verification report, undated, documented the DON was an LPN.
There was no documentation the DON was a RN.
On 08/01/22 at 9:45 a.m., the administrator stated the DON was a LPN. They stated they had a RN as a consultant since the DON was a LPN.
On 08/02/22 at 4:12 p.m., the administrator was asked when the DON was hired. They stated they were designated in their role on 02/03/22. They stated they were full-time and the RN consultant worked at least eight hours a week either from home or in the facility. The administrator was referred to the federal regulation on designating a RN as the DON on a full-time basis.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 40 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (38/100). Below average facility with significant concerns.
- • 63% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is York Manor's CMS Rating?
CMS assigns YORK MANOR NURSING HOME an overall rating of 2 out of 5 stars, which is considered 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 York Manor Staffed?
CMS rates YORK MANOR NURSING HOME's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 63%, which is 17 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 York Manor?
State health inspectors documented 40 deficiencies at YORK MANOR NURSING HOME during 2022 to 2025. These included: 1 that caused actual resident harm and 39 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates York Manor?
YORK MANOR NURSING HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 60 certified beds and approximately 41 residents (about 68% occupancy), it is a smaller facility located in MUSKOGEE, Oklahoma.
How Does York Manor Compare to Other Oklahoma Nursing Homes?
Compared to the 100 nursing homes in Oklahoma, YORK MANOR NURSING HOME's overall rating (2 stars) is below the state average of 2.6, staff turnover (63%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting York Manor?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can 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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is York Manor Safe?
Based on CMS inspection data, YORK MANOR NURSING HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Oklahoma. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at York Manor Stick Around?
Staff turnover at YORK MANOR NURSING HOME is high. At 63%, the facility is 17 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 York Manor Ever Fined?
YORK MANOR NURSING HOME has been fined $9,750 across 1 penalty action. This is below the Oklahoma average of $33,176. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is York Manor on Any Federal Watch List?
YORK MANOR NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.