South Pointe Rehabilitation and Care Center
For profit - Limited Liability company
375 Beds
MGM HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#269 of 282 in OK
Photo by South Pointe Rehabilitation and Care Center
Photo by South Pointe Rehabilitation and Care Center
Photo by South Pointe Rehabilitation and Care Center
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
South Pointe Rehabilitation and Care Center received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranked #269 out of 282 facilities in Oklahoma, this places them in the bottom half of the state's nursing homes and #35 out of 39 in Oklahoma County, meaning there are very few local alternatives that are worse. Although the facility shows some improvement in its trend, reducing issues from 35 in 2024 to 20 in 2025, the staffing situation is only rated 2 out of 5 stars, and there is concerning RN coverage, being lower than 77% of similar facilities. With a high fine amount of $240,907, which is more than 88% of Oklahoma facilities, families should be aware of potential compliance issues. Specific incidents raise serious red flags: one included a resident being physically assaulted by an unknown person allowed into the facility, while another incident involved a resident smoking unsupervised, violating safety protocols. These findings highlight concerning lapses in safety and supervision that families should consider when evaluating this nursing home.
- Trust Score
- F
- In Oklahoma
- #269/282
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near Oklahoma's 48% average. Typical for the industry.
- Penalties ✓ Good
- $240,907 in fines. Lower than most Oklahoma facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Oklahoma. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 57 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 5%
Review needed
35 → 20 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 35 issues
2025: 20 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below Oklahoma average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Oklahoma average (2.6)
Significant quality concerns identified by CMS
Staff Turnover: 42%
Near Oklahoma avg (46%)
Typical for the industry
Federal Fines: $240,907
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: MGM HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 57 deficiencies on record
2 life-threatening 2 actual harm
Apr 2025
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to act upon grievances presented during residents council meetings or provide rationale as to why concerns could not be provided from the faci...
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Based on record review and interview, the facility failed to act upon grievances presented during residents council meetings or provide rationale as to why concerns could not be provided from the facility.
The DON identified 177 residents resided in the facility.
Findings:
A facility's policy titled Grievance/Missing Property, revised 04/26/23, read in part, Purpose: To provide an opportunity for Residents, Resident Representatives, and/or Families to present concerns or Grievances to the proper authorities at the Facility and to receive responses to the issue(s) raised.
On 04/28/25 at 11:37 a.m., resident council minutes were reviewed and no rationale was provided for the past 6 months from the facility staff.
On 04/28/25 at 1:11 p.m., the administrator stated no issues or concerns in resident's council meetings had not been addressed in the past 6 month (November 2024, December 2024, January 2025, Feburary 2025, March 2025 and, April 2025.)
On 04/28/25 at 1:12 p.m., the administrator stated resident council had requested lawn furniture since November 2024. Resident council had also expressed concerns with food temperatures and missing items in laundry rooms.
On 04/28/25 at 1:13 p.m. the administrator stated they were not doing resident council grievances as they should.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure residents had access to their personal funds during non banking hours for 2 (#27 and #39) of 3 sampled residents reviewed for person...
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Based on record review and interview, the facility failed to ensure residents had access to their personal funds during non banking hours for 2 (#27 and #39) of 3 sampled residents reviewed for personal funds.
The BOM identified 103 residents in the facility trust account.
Findings:
An undated resident trust fund policy and procedure, read in part, The resident or their legal guardian are the only ones who can designate what the monies are spent on and have the right to request their Resident Trust Fund Ledger at anytime .Residents shall be able to make withdrawals from their account at any time.
1. Resident #27's fund management service agreement, dated 03/09/23, read in part, I may make deposits to and withdrawals from my resident fund account at the facility.
A quarterly resident assessment, dated 03/12/25, showed Resident #27's cognition was intact (BIMS 15).
On 04/22/25 at 11:47 a.m., Resident #27 reported they had not been able to get their own money from their personal funds to give to their family member. They stated they had filed a grievance.
2. Resident #39's fund management service agreement, dated 02/21/21, read in part, I may make deposits to and withdrawals from my resident fund account at the facility.
A quarterly resident assessment, dated 03/26/25, showed Resident #39's cognition was severely impaired (BIMS 04).
On 04/22/25 at 12:59 p.m., family member #1 voiced concerns with whether or not Resident #39 was receiving their money.
On 04/24/25 at 1:55 p.m., the BOM stated there was a box kept at the front receptionist desk that held personal funds for the residents to access when needed. They stated each day residents could request funds. They stated the receptionist would fill out the appropriate form and give the resident's up to $50 at a time. They stated if it was over the $50 amount, they would print out a receipt and have the resident sign it so it could get scanned in. The BOM stated the receptionist was only there during working hours. The BOM stated after that, the box was placed in a safe.
On 04/24/25 at 1:11 p.m., the BOM stated the facilty had a receptionist on the weekend from 8:00 a.m. to 5:00 p.m. They stated the facility did not have a process in place for residents to access their funds during non banking hours.
On 04/24/25 at 1:42 p.m., the BOM stated residents had access to their funds seven days a week during the hours of 8:00 a.m. to 5:00 p.m.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure residents received quarterly statements for 2 (#27 and #39) of 3 sampled residents reviewed for personal funds.
The BOM identified ...
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Based on record review and interview, the facility failed to ensure residents received quarterly statements for 2 (#27 and #39) of 3 sampled residents reviewed for personal funds.
The BOM identified 103 residents in the facility trust account.
Findings:
An undated resident trust fund policy and procedure, read in part, An internal audit of the resident trust will be completed on a quarterly basis by the corporate office. The resident/legal guardian reserves the right to be informed of internal Resident Trust audits and the results of those audits.
A resident trust statements signature page, dated 01/01/25 through 03/31/25, showed a blank for the signature for Resident #27 and Resident #39.
1. Resident #27's fund management service agreement, dated 03/09/23, read in part, I will receive a statement of any account I have at least uarterly [sic].
A quarterly resident assessment, dated 03/12/25, showed Resident #27's cognition was intact (BIMS 15).
On 04/22/25 at 11:47 a.m., Resident #27 reported they had not been able to get their own money from their personal funds to give to their family member. They stated they had filed a grievance.
2. Resident #39's fund management service agreement, dated 02/12/21, read in part, I will receive a statement of any account I have at least uarterly [sic].
A quarterly resident assessment, dated 03/26/25, showed Resident #39's cognition was severely impaired (BIMS 04).
On 04/22/25 at 12:59 p.m., family member #1 voiced concerns with whether or not Resident #39 was receiving their money.
On 04/24/25 at 1:07 p.m., the BOM stated they were new to the position and now they were completing the resident trust statement list for quarterly statements. They stated they would have the residents sign they received the statement. They stated for residents who were unable to sign, they would place an m next to their name and the facility would mail the statement to the appropriate party. The BOM stated they were working on getting them in the mail yesterday and today. They stated the deadline was by the end of April for the quarter.
On 04/25/25 at 7:20 a.m., the BOM stated they did not have quarterly statements for the resident trust accounts. They stated the previous employee had left and the BOM would have been responsible for the quarterly statements and they were not provided.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to perform a background check for 1 (contract laborer #1) of 1 contracted employee.
The DON identified 176 residents resided in the facility....
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Based on record review and interview, the facility failed to perform a background check for 1 (contract laborer #1) of 1 contracted employee.
The DON identified 176 residents resided in the facility.
Findings:
The employee file for contracted laborer #1 did not have proof a background check was performed.
On 04/25/25 at 9:11 a.m., the HR specialist stated they did not know contract laborer #1 provided services in the facility until recently. The HR specialist stated the contracted laborer never returned the contract agreement they were to sign or provided information for their background check. The HR specialist did not know when the contracted laborer started working in the facility. The HR specialist stated they should know when the contracted laborer started but they did not get out of the office much and there was a general lack of communication among the administrative staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to report an allegation of abuse for 1 (#79) of 4 sampled residents to the Oklahoma State Department Health for alleged abuse within 2 hours a...
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Based on record review and interview, the facility failed to report an allegation of abuse for 1 (#79) of 4 sampled residents to the Oklahoma State Department Health for alleged abuse within 2 hours after the allegation was made.
The DON identified 177 residents resided in the facilty.
Findings:
A facility's policy titled Abuse Prevention, dated 10/21/22, read in part, In addition, the facility will follow Section 1150B of the Social Security /Act's time limits for reporting a reasonable suspicion of crime (immediately but no later than 2 hours if abuse or seriously bodily injury .
Resident #79's diagnoses which included major depressive disorder, seizures, suicidal ideations, and bipolar disorder.
A incident report, dated 04/22/25 at 5:00 a.m., showed Resident complains of being slaps[sic] them on their buttocks every time incontinent care is done by a 10-6 staff member.
A transaction report, dated 04/22/25, showed Incident report dated 04/22/25 at 5:00 a.m. for Resident #79 was faxed to the Oklahoma State Department of Health on 04/22/25 at 2:37 p.m.
On 04/28/25 at 4:17 p.m., the DON stated the incident report for Resident #79 was not reported within the 2 hour timeframe.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure physician ordered abdominal girth measurement amounts were completed for 1 (#21) of 1 sampled resident reviewed for non...
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Based on observation, record review and interview, the facility failed to ensure physician ordered abdominal girth measurement amounts were completed for 1 (#21) of 1 sampled resident reviewed for non pressure skin conditions.
The DON identified one residents with orders to measure abdominal girth resided in the facility.
Findings:
On 04/25/25 at 9:38 a.m., LPN #3 was observed measuring Resident #21's abdominal girth. They placed the measuring tape across the mid section of the abdomen and stated it measured 53 inches.
A physician order policy, last reviewed 09/28/22, read in part, Physician Orders that are missing required components, are illegible or unclear must be clarified prior to implementation.
A quarterly resident assessment, dated 02/12/25, showed Resident #21's cognition was intact (BIMS 15).
A physician order, dated 02/25/25, showed daily girth/abdomen measurement one time a day for increased girth/abdomen.
A nurse progress note, dated 03/02/25, showed the resident's girth measurement was 48.2 inches.
A nurse progress note, dated 03/16/25, showed the resident's girth measurement was 43 inches. There was no measurement amount documented between the 03/02/25 and the 03/16/25 measurement.
A nurse progress note, dated 03/24/25, showed the resident's girth measurement was 47.5 inches. There was no measurement amount documented between the 03/16/25 and the 03/24/25 measurement.
A nurse progress note, dated 03/26/25, showed the resident's girth measurement was 48 inches.
A nurse progress note, dated 03/31/25, showed the resident's girth measurement was 47.5 inches. There was no measurement amount documented between the 03/26/25 and the 03/31/25 measurement.
The March 2025 TAR showed staff initials and a checkmark for completion daily for the daily girth/abdomen measurement order. There were no values of the measurement located on the TAR.
A nurse progress note, dated 04/01/25, showed the resident's girth measurement was 47.4 inches.
A nurse progress note, dated 04/07/25, showed the resident's girth measurement was 49 inches. There was no measurement amount documented between the 04/01/25 and the 04/07/25 measurement.
A nurse progress note, dated 04/08/25, showed the resident's girth measurement was 49 inches.
A nurse progress note, dated 04/14/25, showed the resident's girth measurement was 48 inches. There was no measurement amount documented between the 04/08/25 and the 04/14/25 measurement.
A nurse progress note, dated 04/15/25, showed the resident's girth measurement was 49 inches. This was the most recent measurement amount documented.
The April 2025 TAR showed staff initials and a checkmark for completion daily for the daily girth/abdomen measurement order. There were no values of the measurement located on the TAR.
An order summary report, dated 04/25/25, showed Resident #21's diagnoses included abscess of the liver and stage three chronic kidney disease.
On 04/23/25 at 11:13 a.m., Resident #21 stated staff were measuring their abdomen in the morning and weighed them to make sure it doesn't swell up. They stated they had a softball size mass in their liver that was removed, and they were monitoring them to ensure there were no more concerns with their liver.
On 04/25/25 at 9:28 a.m., LPN #3 stated the staff did not have an option to put the amount of the abdominal girth measurement on the TAR.
On 04/25/25 at 9:29 a.m., LPN #3 stated they did not have a value to compare the measurement to. They stated the value they were wanting them to compare was the daily weights. LPN #3 stated that was what they gathered from the report. LPN #3 stated they took a tape measure from the manager's office to measure Resident #21's abdomen. They stated they measured from the highest mid area of the abdomen.
On 04/25/25 at 9:43 a.m., LPN #3 stated today the resident was 53 inches. They stated they wanted it to be between 53 and 60. They stated if it went above that, they would notify the physician.
On 04/25/25 at 10:25 a.m., the DON stated unit manager #2 had reported they were monitoring Resident #21's abdominal girth due to everything that was going on with their wound and gallstones. They stated the unit manager would notify the physician if it got bigger, but I see there are no parameters.
On 04/25/25 at 10:26 a.m., the DON stated the order should say when to notify the physician.
On 04/25/25 at 10:27 a.m., the DON stated in order to generate a field to document the measurement value on the TAR, staff had to physically add it. They stated it did not automatically come up and staff would have to add supplementary documentation. The DON stated they just added it. They stated staff could also document in a progress note.
On 04/25/25 at 10:28 a.m., the DON stated staff would not know if there was an increase in the resident's girth size if they were not documenting a value each day.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a PRN order for an anti-psychotic drug was limited to 14 days for 1 (#92) of 5 sampled residents reviewed for unnecessary medication...
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Based on record review and interview, the facility failed to ensure a PRN order for an anti-psychotic drug was limited to 14 days for 1 (#92) of 5 sampled residents reviewed for unnecessary medications.
The DON identified 177 residents resided in the facility.
Findings:
A policy titled PSYCHOTROPIC MANAGEMENT GUIDELINES, dated 07/26/23, read in part, PRN medications will be ordered for no longer than 14 days.
Resident #92's order summary report, dated 04/2025, showed the resident had diagnoses which included senile degeneration of the brain and unspecified psychosis not due to a substance or known physiological condition.
Resident #92's physician's order, dated 02/25/25, showed lorazepam (antianxiety medication) 2 mg/ml, give 0.5 ml by mouth every two hours as needed for agitation and restlessness.
The end date for the lorazepam order showed indefinite.
The March and April 2025 MAR, showed the resident received the lorazepam 12 times outside of the 14 days.
On 04/28/25 at 12:45 p.m., the DON stated the lorazepam was ordered on 02/25/25. They stated the order did not have an end date. The DON stated the PRN order had to be limited to 14 days and re-evaluated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure labs were obtained as ordered for:
a. 1 (#24) of 1 sampled resident reviewed for dialysis; and
b. 1 (#92) of 5 sampled residents re...
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Based on record review and interview, the facility failed to ensure labs were obtained as ordered for:
a. 1 (#24) of 1 sampled resident reviewed for dialysis; and
b. 1 (#92) of 5 sampled residents reviewed for unnecessary medications.
The DON identified 177 residents resided in the facility and three residents received dialysis services.
Findings:
1. In the electronic health record, Resident #24's diagnosis sheet, dated 04/24/05, showed diagnoses which included renal dialysis and atrial fibrillation.
Resident #24's Physician Order, read in part, revised 02/07/24 A1C Now AND EVERY 3 MONTHS (FEBRUARY, MAY, AUGUST, NOVEMBER). (A lab test that measures the average level of sugar in your blood over the past 2-3 months.)
Labs services for Resident #24 was due for the month of Feburary 2025 and was not found.
On 04/23/25 at 2:37 p.m., the DON stated the last A1C they had for Resident #24 was November 2024.
On 04/24/25 at 11:21 a.m., LPN #4 stated they did not know how Resident #24's labs got missed.
On 04/24/25 at 2:27 p.m., the director of nurses stated she did not think they had a policy.
2. Resident #92's physician's order, dated 01/24/25, showed Keppra level monthly for a total of three months starting on the 27th and ending on the 27th every month for seizures, and Keppra medications.
A laboratory report for Keppra level, dated 01/28/25, showed a collection date of 01/27/25.
There was no documentation the Keppra level was obtained for 02/2025 and 03/2025.
Resident #92's order summary report, dated 04/2025, showed the resident had a diagnosis of seizures.
On 04/28/25 at 1:37 p.m., the ADON stated the Keppra level was not obtained for 02/2025 and 03/2025.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to:
a. notify the physician of missing labs for 1 (#24) of 1 residents reviewed for dialysis.
b. develop a lab policy.
The DON identified 177...
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Based on record review and interview, the facility failed to:
a. notify the physician of missing labs for 1 (#24) of 1 residents reviewed for dialysis.
b. develop a lab policy.
The DON identified 177 residents resided in the facility.
Findings:
Resident #24's diagnosis sheet, dated 04/24/25, showed a diagnosis of renal dialysis.
Resident #24's Physician Order, read in part, revised 02/07/24 A1C Now AND EVERY 3 MONTHS (FEBRUARY, MAY, AUGUST, NOVEMBER). (A lab test that measures the average level of sugar in your blood over the past 2-3 months.)
Labs services for Resident #24 was due for the month of Feburary 2025 and was not found.
On 04/23/25 at 2:37 p.m., the DON stated the last A1C they had for Resident #24 was November 2024.
On 04/24/25 at 11:21 a.m., LPN #4 stated they did not know how Resident #24's labs got missed.
On 04/24/25 at 2:23 p.m., the director of nurses stated we just notified the physician today.
On 04/24/25 at 2:27 p.m., the director of nurses stated they did not think they had a policy for laboratory services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 residents were educated and offered the opportunity to creat...
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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 residents were educated and offered the opportunity to create an advance directive for 5 (#46, 55, 77, 94, and #175) of 35 sampled residents reviewed for advance directives.
The DON identified 177 residents who resided in the facility.
Findings:
1. Resident #46 was admitted to the facility on [DATE].
A review of Resident #46's electronic health records showed no advance directive information had been provided.
2. Resident #55 was admitted to the facility on [DATE].
A review of Resident #55's electronic health records showed no advance directive information had been provided.
3. Resident #77 was admitted to the facility on [DATE].
A review of Resident #77's electronic heath record showed no advanced directive information had been provided.
4. Resident #94 was admitted to the facility on [DATE].
A review of Resident #99's electronic heath record showed no advanced directive information had been provided.
5. Resident #175 was admitted to the facility on [DATE].
A review of Resident #175's electronic heath record showed no advanced directive information had been provided.
On 04/23/25 at 9:19 a.m., the DON stated the advance directive acknowledgement form was not completed on many residents because prior to March, they were just asking them about advance directives and putting the DNR in the chart if they had one.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 resident assessments were coded to reflect the status for 3 ...
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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 resident assessments were coded to reflect the status for 3 (#105, 126, and #175) of 35 sampled residents reviewed for resident assessments.
The DON identified 177 residents resided in the facility.
Findings:
1. Resident #105's care plan, dated 4/24/25, showed the resident had diagnoses which included dementia, heart failure and chronic obstructive pulmonary disorder.
A progress note, dated 04/12/25, showed a nurse confirmed there was a new open wound on Resident #105's left buttock that was not there the week before.
A quarterly MDS assessment, dated 04/15/25, showed Resident #105 had no wounds.
On 04/28/25 at 1:25 p.m., MDS #2 stated they would expect the MDS to catch the wound and put it somewhere, once staff determined what kind of wound it was.
On 04/28/25 at 2:55 p.m., the DON stated it was expected the MDS assessments be accurate.
2. Resident #175's care plan, dated 4/24/25, showed the resident had diagnoses which included severe intellectual disabilities and metabolic acidemia noted at birth.
A progress note, dated 3/17/25 at 10:27 a.m., showed the nurse found no [NAME] tube (a low profile gastrostomy tube used for delivering nutrition). The note showed the physician sent Resident #175 to ER for replacement.
A progress note, dated 3/17/25 at 4:27 p.m., showed Resident #175 returned from the ER with no peg tube in place and no new orders.
A quarterly assessment, dated 04/09/25, showed peg tube as present even though it was not.
On 04/23/25 at 9:07 a.m., LPN #2 stated Resident #175 was not on a feeding tube because they pulled it out on 3/17/25. LPN #2 stated Resident #175 ate well and their family stated they were the happiest they have ever been.
On 04/24/25 at 12:27 p.m., MDS #1 stated Resident #175 does not have a peg tube. The quarterly assessment was coded inaccurately.
3. Resident #126's care plan, dated 04/16/2025, showed the resident had diagnoses which included unspecified dementia and abnormalities of gait and mobility.
A fall incident report, dated 03/05/25, showed the resident was found face down on the floor. The report showed the resident was assessed and assisted back in bed.
A fall incident report, dated 03/21/25, showed the resident was observed laying on the fall mat on their left side. The report showed the resident was assisted into their wheelchair.
Resident #126's quarterly resident assessment, dated 03/26/25, showed the resident had no falls since admission/entry or reentry or the prior assessment.
On 04/24/25 at 2:14 p.m., MDS #2 stated the 03/26/25 quarterly resident assessment showed the resident had no falls.
On 04/24/25 at 2:15 p.m., MDS #2 stated the assessment should have captured the fall on 03/05/25 and 03/21/25.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide in between meal snacks for 1 (Hall 3) of 1 halls reported during resident council meeting.
The administrator reported 174 residents w...
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Based on observation and interview, the facility failed to provide in between meal snacks for 1 (Hall 3) of 1 halls reported during resident council meeting.
The administrator reported 174 residents were provided meals from the kitchen.
Findings:
A policy titled Meals and Snacks, dated 11/27/23, read in part, Meal service shall be provided to residents on a regularly scheduled basis according to facility established times. Nutritional Services shall be delivered to the nursing units by nutritional services personal. Nursing shall be responsible for distributing snacks to the residents.
On 04/28/25 at 2:37 p.m., it was observed on hallway 3, no snacks were offered or distributed to residents.
On 04/28/25 at 2:38 p.m., Resident #24 was visiting on hallway 3 and stated they did not get a 2:00 p.m. snack.
On 04/28/25 at 2:46 p.m., Resident #79 stated they did not get a snack.
On 04/28/25 at 3:16 p.m., the DON stated the snacks were not getting offered or distributed to the residents.
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 and interview, the facility failed to serve the noon day meal in a manner that minimized the risk of infection/cross contamination for 174 or 174 residents who ate meals prepared ...
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Based on observation and interview, the facility failed to serve the noon day meal in a manner that minimized the risk of infection/cross contamination for 174 or 174 residents who ate meals prepared from the kitchen.
The adminstrator identified 174 residents who ate meals from the facility kitchen.
On 04/22/25 at 12:15 p.m., cook #1 was observed to plate food from the steam table to be served to residents. With gloved hands, the cook touched the counter, shelving, and utensils other kitchen staff had touched as well. [NAME] #1 was observed to use their gloved hands to hold plated food in position by placing their gloved fingers on the plate and pushing the food together to one side of the plate. The cook then used their gloved hands to place a roll on the residents' plates.
On 04/22/25 at 12:25 p.m., the dietary manager stated the kitchen staff were to use serving utensils and tongs to plate food and not their gloved hands.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 pneumococcal vaccines were offered to residents for 3 (#105,...
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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 pneumococcal vaccines were offered to residents for 3 (#105, 123, and #133) of five sampled residents reviewed for vaccines.
The DON identified 177 residents resided in the facility.
Findings:
The pneumococcal vaccine policy, last reviewed 04/28/22, read in part, The opportunity to receive the Pneumococcal Vaccine will be extended to all Residents. The Facility will provide pertinent information regarding the Risks/Benefits of receiving the Vaccine .Residents will be offered the Pneumococcal Vaccine upon Admission.
1. An admission record, dated 04/24/25, showed Resident #105 admitted to the facility on [DATE].
There was no documentation Resident #105 had been offered a pneumococcal vaccine.
2. An admission record, dated 04/24/25, showed Resident #123 admitted to the facility on [DATE].
There was no documentation Residents #123 had been offered a pneumococcal vaccine.
3. An admission record, dated 04/24/25, showed Resident #133 admitted to the facility on [DATE].
There was no documentation Residents #133 had been offered a pneumococcal vaccine.
On 04/24/25 at 11:11 a.m., the IP stated they sent out letters to families of resident's who could not answer for themselves if they wanted to receive a vaccine. They stated for residents who could, they would ask them if they wanted to receive a vaccine.
On 04/24/25 at 11:13 a.m., the IP stated immunizations were documented in the resident's clinical record. They stated it documented whether the resident or family agreed or declined the vaccine.
On 04/24/25 at 11:14 a.m., the IP stated Resident #105 received a pneumonia vaccine on 11/02/98 and would be due for another pneumonia vaccine.
On 04/24/25 at 11:33 a.m., the IP stated Resident #123 received the influenza vaccine at the hospital but not the pneumonia vaccine.
On 04/24/25 at 11:37 a.m., the IP stated Resident #133 had not received a pneumonia vaccine.
Mar 2025
6 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/27/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/27/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident #12 from mental and physical abuse.
On 02/25/25 at 3:02 p.m., Resident #12 was interviewed and stated on 01/23/25 at 6:00 p.m. a person came to door 2 (hall 200) pounding on the door. Resident #12 stated CMA #1 let this person in and they immediately staring cussing and making a move to hit CMA #1. Resident #12 stated they took off down towards them and asked the unknown person what they were doing. Resident #12 stated the person took two swings at them and on the second swing hit them on the face. Resident #12 stated it hurt like the [NAME]. Resident #12 stated ever since then, I don't feel safe. Resident #12 stated, It could happen again. Resident #12 stated
they did not know who the person was, but they were delivering medications for a company and the administrator and DON would know who they were. Resident #12 stated the cops were called and charges were pressed. Resident #12 stated they needed security at the doors.
The Abuse Prevention Policy, dated 10/21/22, read in part, The facility is committed to protecting the facility from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents .Abuse: Willful infliction of injury .with resulting physical harm, pain, mental anguish or emotional distress.
An Incident Note, dated 01/23/25, showed around 6:30 p.m., LPN #2 witnessed a confrontation between Resident #12 and the med-delivery person. The note showed LPN #2 saw the person flip their hands towards Resident #12's face. The note showed LPN #2 and other staff asked the person to leave the facility. The note showed the police, resident's family, and DON were notified.
An unlabeled document, dated 01/24/25, showed Resident #12 stated they were not afraid, but did not feel safe. Resident #12 stated they felt like security needed to be put in place at night time. This note was signed by the social service supervisor.
There was not a State incident report form completed for this incident of abuse.
There were no interventions in place to address Resident #12 not feeling safe after
this incident.
On 02/27/25 at 6:22 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.
On 02/27/25 at 6:26 p.m., the DON was notified of the IJ situation.
On 02/28/25 at 11:04 a.m., an acceptable plan of removal was approved by the Oklahoma Stated Department of Health. The plan of removal, read in part,
South Pointe IJ Abatement Plan for Removal 02/28/25 at 3:45 p.m.
The preparation of the following plan of correction for this deficiency does not constitute and should not be interpreted as admission nor an agreement by the facility of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction prepared for these deficiencies was executed solely because provisions of State and Federal law require it.
1) Immediate Fix
2) Potential Residents Affected
3) System Changes
4) Monitoring/QAPI
5) DOC
1. a. Trauma informed questionnaire completed for Resident #12 on 2/27/25 by
Social Services. Resident #12 stated that [they] had no previous trauma. [Their] intervention to feel safe is journaling which [they] has been provided with a notebook for journaling. Resident #12 has agreed to meeting with social services 5Xs a week and speaking to a psychology service on 2/27/25.
b. Social Services educated on psychosocial health regarding abuse incidents by the DON on 2/27/25. Any residents who do not feel safe will have follow up completed by social services regarding obtaining a referral to psychology services and report findings to DON/LNHA.
c. All door codes changed by the Maintenance Director on 2/27/25. Signage was placed on 2/28/25 by the Maintenance Director stating 'After 5pm, please go to Unit 400 door and ring doorbell for assistance.'
d. Facility staff were educated on the new process on 2/28/25 by Department Heads. Staff will be educated prior to working their next shift.
e. Resident safe surveys completed by department heads on 2/27/25.
f. Social Services to follow up with resident#12 5Xs a week for one month to ensure no signs of fearfulness.
Date of Compliance: 2/28/25 at 10:10am.
The IJ was lifted, effective 02/28/25 at 3:45 p.m., when all components of the plan of removal had been verified as complete. The deficient practice remained at an isolated level with the potential for more than minimal harm.
Based on record review and interview, the facility failed to protect a resident from mental and physical abuse for 1 (#12) of 3 residents sampled for abuse.
ADON #1 identified 182 residents resided in the facility.
Findings:
The Abuse Prevention Policy, dated 10/21/22, read in part, The facility is committed to protecting the facility from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents . Abuse: Willful infliction of injury .with resulting physical harm, pain, mental anguish or emotional distress.
Resident #12 had diagnoses which included anxiety disorder and chronic embolism and thrombosis of other specified veins.
Resident #12's annual assessment dated [DATE], showed their cognition was intact with a BIMS score of 15.
An Incident Note, dated 01/23/25, showed at around 6:30 p.m., during shift, LPN #2 witnessed a confrontation between the Resident #12 and a med-delivery person while observing from the nursing station. The note showed the resident had seen and heard the med-delivery person verbally abuse a staff member by yelling and calling the staff member the B word several times. The note showed the resident then tried to tell the med-delivery person not to speak to the staff member in that manner. The note showed LPN #2 then saw the med-delivery person dip their hand towards the resident's face. The note showed LPN #2 then called 911. The note showed the DON and resident's family member were notified of the incident. The note showed the officer came shortly after and took their statement.
On 02/25/25 at 3:02 p.m., Resident #12 stated on 01/23/25 at 6:00 p.m. a person came to door 2 (hall 200) pounding on the door. Resident #12 stated CMA #1 let the person in and they immediately staring cussing and making a move to hit CMA #1. Resident #12 stated they took off down towards them and asked the unknown person what they were doing. Resident #12 stated the person took two swings at them and on the second swing hit them on the face. Resident #12 stated it hurt like the [NAME]. Resident #12 stated ever since then, I don't feel safe. Resident #12 stated, It could happen again. Resident #12 stated they did not know who the person was, but they were delivering medications for a company and the administrator and DON would know who they were. Resident #12 stated the cops were called and charges were pressed. Resident #12 stated they needed security at the doors.
On 02/27/25 at 8:52 a.m., CMA #1 stated the med-delivery person was banging on the door. CMA #1 stated they walked by the door and opened it and the med-delivery person stated, Yeah, [expletive], you saw me the first time. CMA #1 stated they told the med-delivery person they had to make a stop first. CMA #1 stated the med-delivery person stated, You heard what the [expletive] I said, and the med-delivery person bucked at them. CMA #1 stated when the med-delivery person bucked at them, Resident #12 came up to them and told the med-delivery person to leave them alone. CMA #1 stated the med-delivery person then swung and hit Resident #12 in the eye. CMA #1 stated they thought the med-delivery person swung two more times. CMA #1 stated Resident #12 and the med-delivery person continued to argue and they told LPN #2 to call the police.
On 02/27/25 at 11:49 a.m., the DON stated they had not been notified at the time of the incident. The DON stated they were unaware of Resident #12 not feeling safe.
On 02/27/25 at 11:52 a.m., the DON stated they did not know what else they could have done to make Resident #12 feel safe.
On 02/27/24 at 11:54 a.m., the DON stated everyone should come through one door, but that was not the way anymore.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/25/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure safety and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/25/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure safety and supervision for Resident #4 who smoked.
On 02/24/25 at 5:40 p.m., Resident #7 was observed in the outside courtyard smoking area without staff present. Resident #7 was observed to remove a cigarette, lit it with a match, and began to smoke. Resident #7 stated they had only been at the facility for a week. Resident #7 stated they smoked whenever they wanted to and kept their own cigarettes and matches.
A Smoking Policy, dated 11/06/24, read in part, The facility shall maintain safety for residents who request to Smoke, as well as for those who do not. Residents requesting to smoke during their stay may be permitted with staff assistance of handling, igniting, and extinguishing (as needed) of smoker materials and may only smoke in designated areas .For Safety concerns, Residents will be Supervised during Smoking.
Resident #4's Smoking Safety Evaluation, dated 01/13/25, read in part, Supervision will be required for all Residents during designated smoking times. This evaluation showed admission as the description of the assessment.
A significant change resident assessment, dated 01/15/25, showed Resident #4's cognition was intact with a BIMS score of 14 and they required substantial/maximum assistance for personal hygiene, shower/bathe self, lower body dressing, and toilet hygiene.
A State incident report form, dated 02/14/25, showed at approximately 5:05 p.m., the charge nurse was making rounds and smelled cigarette smoke in the hallway (Hall 200) and began opening doors to investigate. The report showed the charge nurse opened Resident #4's door and observed a Kerlix wound dressing to the resident's leg on fire. The report showed the nurse observed a lit cigarette and lighter on the vanity and the room was filled with smoke. The report showed third degree burns were noted to the resident's right posterior lower extremity. The report showed the skin was charred and fascia exposed. The report showed the resident was sent to the emergency room for an evaluation and treatment.
An incident note, dated 02/14/25 at 5:10 p.m., showed LPN #1 entered Resident #4's room and observed flames of fire burning on the bandage wrapped around the entire right foot. The note showed the flame was observed to affect the resident's pants as well. The note showed LPN #1 used a bed pad and extinguished the fire. The note showed upon examination the resident had suffered burns to the right lower leg on the posterior aspect. The note showed LPN #1 was asked to send a picture of the affected area to the DON. The note showed it was then rated as a third degree burn and LPN #1 was instructed to send Resident #4 to the emergency room.
A wound progress note, dated 02/21/25, showed Resident #4 had a full thickness burn of the right calf which measured length 9 cm, width 22 cm, depth 0.2 cm.
There was no Smoking Safety Evaluation located in Resident #7's clinical record.
On 02/25/25 at 2:24 p.m., the DON stated smoking evaluations were to be completed on admission. They stated all residents who smoked were to be supervised for safety.
On 02/25/25 at 2:48 p.m., the DON stated Resident #7 admitted to the facility on [DATE] and there was not a smoking assessment in the computer. They stated they were not sure if the resident smoked.
On 02/25/25 at 3:03 p.m., the social services supervisor stated they did not complete a smoking assessment for Resident #7. They stated they were not aware the resident was a smoker.
On 02/25/25 at 3:29 p.m., the social service assistant stated they had a mess up. They stated Resident #7 did not smoke until they admitted to the facility. They stated they completed an assessment today and went over the policy for smoking.
On 02/25/25 at 5:27 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation.
On 02/25/25 at 5:30 p.m., the DON was notified of the IJ situation.
On 02/26/25 at 10:41 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,
South Pointe IJ Abatement Plan for Removal 2.25.25
The preparation of the following plan of correction for this deficiency does not constitute and should not be interpreted as admission nor an agreement by the facility of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction prepared for these deficiencies was executed solely because provisions of State and Federal law require it.
1) Immediate Fix
2) Potential Residents Affected
3) System Changes
4) Monitoring/QAPI
5) DOC
1. a. Resident #4 had a smoking safety evaluation completed on 2/14/25 by the DON. Resident #4 was educated on the smoking policy/procedures/smoking times on 2/14/25. Ad hoc QAPI was completed on 2/14/25 by the DON.
b. Resident #7 had a smoking safety evaluation completed on 2/25/25 by Social Services. Resident #7 was educated on smoking policy/procedures/smoking times by Social Services on 2/25/25.
c. Resident rooms will be searched on 2/25/25 by Social Services and Unit Managers to ensure no residents have lighters, matches, cigarettes, or vape. Any items found will be added to the smoking cart.
d. All residents will have a smoking assessment completed on 2/25/25 by the DON, Unit Managers, and Social Services. Residents that smoke will receive education on smoking policy and smoking times on 2/25/25.
2. Residents who smoke have the potential to be affected.
3. Staff will be educated on 2/25/25 by the DON/LNHA on smoking policy/procedures including rounding between smoking times. No residents will be permitted to smoke without supervision. No staff will work until education is conducted. All new employees will be educated on smoking policies and procedures prior to working.
4. Rounding between smoking times will be completed randomly x 90 days to ensure compliance. Monitored findings will be brought to the monthly QAPI for review.
5. DOC: 2/25/25 at 9:42 PM.
The IJ was lifted, effective 02/25/25 at 9:42 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained at an isolated level with the potential for more than minimal harm.
Based on observation, record review, and interview, the facility failed to ensure:
a. safety and supervision for a resident who smoked for 2 (#4 and #7); and
b. smoking assessments were completed on admission and quarterly for 2 (#1 and #7) of 3 sampled residents reviewed for smoking.
ADON #1 identified 182 residents resided in the facility. The DON identified 39 residents who smoked resided in the facility.
Findings:
1. On 02/24/25 at 5:45 p.m., Resident #4 was observed being assisted to a lying position in bed by CMA #1. Resident #4 was observed to have a dressing in place to their right lower leg. CMA #1 was unable to identify the reason for the resident's dressing. Resident #4's room was observed to have the odor of burned flesh present. Resident #4 was unable to answer questions by the surveyor appropriately.
A Smoking Policy, dated 11/06/24, read in part, The facility shall maintain safety for residents who request to Smoke, as well as for those who do not. Residents requesting to smoke during their stay may be permitted with staff assistance of handling, igniting, and extinguishing (as needed) of smoker materials and may only smoke in designated areas .For Safety concerns, Residents will be Supervised during Smoking.
Resident #4 had diagnoses which included unspecified lack of coordination, muscle weakness, and muscle wasting and atrophy of the left shoulder.
Resident #4's Smoking Safety Evaluation, dated 01/13/25, read in part, Supervision will be required for all Residents during designated smoking times. This evaluation showed admission as the description of the assessment.
A significant change resident assessment, dated 01/15/25, showed Resident #4's cognition was intact with a BIMS score of 14 and they required substantial/maximum assistance for personal hygiene, shower/bathe self, lower body dressing, and toilet hygiene.
A State incident report form, dated 02/14/25, showed at approximately 5:05 p.m., the charge nurse was making rounds and smelled cigarette smoke in the hallway (Hall 200) and began opening doors to investigate. The report showed the charge nurse opened Resident #4's door and observed a Kerlix wound dressing to the resident's leg on fire. The report showed the nurse observed a lit cigarette and lighter on the vanity and the room was filled with smoke. The report showed third degree burns were noted to the resident's right posterior lower extremity. The report showed the skin was charred and fascia exposed. The report showed the resident was sent to the ER for an evaluation and treatment.
An incident note, dated 02/14/25 at 5:10 p.m., showed LPN #1 entered Resident #4's room and observed flames of fire burning on the bandage wrapped around the entire right foot. The note showed the flame was observed to affect the resident's pants as well. The note showed LPN #1 used a bed pad and extinguished the fire. The note showed upon examination the resident had suffered burns to the right lower leg on the posterior aspect. The note showed LPN #1 was asked to send a picture of the affected area to the DON. The note showed it was then rated as a third degree burn and LPN #1 was instructed to send Resident #4 to the emergency room.
Resident #4's care plan, revised 02/17/25, showed the resident was at risk for adverse reactions due to smoking cigarettes. The care plan showed Resident #4 was a supervised smoker secondary to smoking in their room. The care plan showed Resident #4's smoking materials and lighters would be locked up with staff and the resident would attend the supervised smoking times to smoke.
A wound progress note, dated 02/21/25, showed Resident #4 had a full thickness burn of the right calf which measured length 9 cm, width 22 cm, depth 0.2 cm.
On 02/25/25 at 8:38 a.m., Resident #13 stated the facility should have been enforcing smoking rules before Resident #4 burnt their foot. Resident #13 stated they sat right on their bed and saw what happened.
On 02/25/25 at 8:55 a.m. Resident #13 stated Resident #4 was in their room smoking. Resident #13 removed a notebook from their room and stated it was 02/14/25 and the ambulance came and took Resident #4 who had burnt their foot.
On 02/25/25 at 9:10 a.m., Resident #4 stated they had been at the facility about a year. When asked to explain the dressing to their right lower leg, the resident replied, It's kind of a long story. Resident #4 stated, It's fear I'm gonna lose my leg. Resident #4 stated, All of a sudden it starts aching. Resident #4 stated, I smoke outdoors I don't smoke inside. Resident #4 started closing their eyes.
On 02/25/25 at 9:14 a.m., CMA #2 entered Resident #4's room and assisted the resident to a lying position. Resident #4 closed their eyes and did not continue the interview.
On 02/25/25 at 1:00 p.m., CNA #4 stated the facility really did not have a smoking policy before Resident #4 burnt their leg. CNA #4 stated, It was supervised smoking, but they weren't following protocol. CNA #4 stated residents were going out by themselves and had their own cigarettes. CNA #4 stated now staff were supervising all residents when they smoked and the cigarettes and lighters were kept in the Hall 200 medication room in a lock box.
On 02/25/25 at 1:10 p.m., CNA #5 stated the facility just started enforcing the smoking policy after Resident #4 caught themselves on fire. They stated now staff supervised residents on scheduled smoke breaks every two hours. CNA #5 stated before the policy was enforced, residents kept their own cigarettes and lighters and went out on their own.
On 02/25/25 at 1:28 p.m., LPN #3 stated residents were not allowed to have cigarettes or lighters on their person or in their room. They stated residents were taken out by staff every two hours for supervised smoke breaks. They stated no residents could safely smoke by themselves. LPN #3 stated this process took place after Resident #4 burnt their leg. LPN #3 stated Resident #4 was smoking in their room due to the cold weather and dropped their cigarette on their bandage.
On 02/25/25 at 2:10 p.m., LPN #1 stated the facility had scheduled times to smoke and residents were not allowed to have lighters or cigarettes in their rooms. LPN #1 stated staff had a locked box with smoking supplies. They stated no residents smoked without supervision. LPN #1 stated the day of the incident, they were walking by Resident #4's room and smelt burning. LPN #1 stated they started opening resident rooms, and the second door they opened was Resident #4's room. LPN #1 stated they saw a flame on the resident's leg. LPN #1 stated they immediately called for help, and used a bed pad to get the flame out. LPN #1 stated Resident #4 had a package of cigarettes and a cigarette and lighter on the bed. LPN #1 stated they saw ashes on the bed and smoke spots. LPN #1 stated the flame affected the right foot dressing and they had to peel it off. LPN #1 reported they called the administrator and physician and sent the resident to the hospital.
On 02/25/25 at 2:24 p.m., the DON stated the facility had supervised and unsupervised smokers before the incident with Resident #4. The DON stated after the 02/14/25 incident, staff collected all smoking materials and explained to residents and staff the new supervised smoking schedule. The DON stated right now everyone was supervised and staff had to light cigarettes for them. The DON stated smoking evaluations were to be completed on admission. They stated all residents who smoked were to be supervised for safety. The DON stated they received a call immediately when the incident with Resident #4 happened. They stated staff reported seeing flames on Resident #4's leg and used bed pads to extinguish the fire. They stated Resident #4 admitted to smoking in their room and they were sent to the emergency room for an evaluation.
On 02/25/25 at 2:40 p.m., the DON stated a smoking schedule was put in place the night it happened. They stated the same policy was in effect when the incident occurred and residents should have been supervised during smoking. The DON stated now all cigarettes were on a count sheet and staff had to sign them out. They stated smoking supplies were locked in the Hall 200 medication room.
2. On 02/24/25 at 5:02 p.m., a facility smoke break was observed. CNA #1 stated resident cigarettes had their names on them and they along with the lighters were kept locked up in the medication room. CNA #2 was observed filling out a binder during the smoke break. CNA #2 stated they documented the resident name, date, cigarette time, and how many cigarettes were given in the log book. CNA #3 was observed lighting cigarettes for residents during the smoke break. There were eleven smokers observed during this supervised smoke break.
On 02/24/25 at 5:40 p.m., Resident #7 was observed in the outside courtyard smoking area without staff present. Resident #7 was observed to remove a cigarette, lit it with a match, and began to smoke. Resident #7 stated they had only been at the facility for a week. Resident #7 stated they smoked whenever they wanted to and kept their own cigarettes and matches.
Resident #7 had diagnoses which included nontraumatic subarachnoid hemorrhage and acute respiratory failure with hypoxia.
Resident #7's admission record showed the resident admitted to the facility on [DATE].
There was no Smoking Safety Evaluation located in Resident #7's clinical record.
On 02/24/25 at 5:15 p.m., Resident #7 stated the facility staff took all lighters and cigarettes from residents after Resident #4 caught themselves on fire. They stated smoke breaks were now supervised by staff.
On 02/25/25 at 2:24 p.m., the DON stated smoking evaluations were to be completed on admission. They stated all residents who smoked were to be supervised for safety.
On 02/25/25 at 2:48 p.m., the DON stated Resident #7 admitted to the facility on [DATE] and there was not a smoking assessment in the computer. They stated they were not sure if the resident smoked.
On 02/25/25 at 3:03 p.m., the social services supervisor stated they did not complete a smoking assessment for Resident #7. They stated they were not aware the resident was a smoker.
On 02/25/25 at 3:29 p.m., the social service assistant stated they had a mess up. They stated Resident #7 did not smoke until they admitted to the facility. They stated they completed an assessment today and went over the policy for smoking.
3. Resident #1 had diagnoses which included paraplegia and anxiety disorder.
Resident #1 had a Smoking Safety Evaluation completed on 07/23/24.
An annual resident assessment, dated 01/08/25, showed yes for current tobacco use. There was no Smoking Safety Assessment completed in conjunction with this annual resident assessment.
On 02/26/25 at 9:10 a.m., the DON reviewed Resident #1's smoking evaluations. They stated they were completed on 02/13/24, 07/23/24, and 02/25/24. The DON stated Resident #1's MDS assessments were completed on 02/13/24, 05/08/24, 07/31/24, 10/23/24, and 01/08/25. The DON stated they could not explain the reason a smoking evaluation/assessment was not completed for Resident #1 between 07/23/24 and 02/25/25. The DON stated, There should have been one with every quarterly and annual.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to report an allegation of abuse to the OSDH for 1 (#12) of 3 residents sampled for abuse.
ADON #1 identified 182 residents resided in the fac...
Read full inspector narrative →
Based on record review and interview, the facility failed to report an allegation of abuse to the OSDH for 1 (#12) of 3 residents sampled for abuse.
ADON #1 identified 182 residents resided in the facility.
Findings:
The Abuse Prevention Policy, dated 10/21/22, read in part, The facility is committed to protecting the facility from abuse by anyone including, but not necessarily limited to: facility staff, other residents, and staff from other agencies providing services to our residents . Abuse: Willful infliction of injury .with resulting physical harm, pain, mental anguish or emotional distress.
Resident #12 had diagnoses which included anxiety disorder and chronic embolism and thrombosis of other specified veins.
Resident #12's annual assessment, dated 01/23/25, documented Resident #12's cognition was intact with a BIMS score of 15.
An Incident Note, dated 01/23/25, showed at around 6:30 p.m., during shift, LPN #2 witnessed a confrontation between the Resident #12 and a med-delivery person while observing from the nursing station. The note showed the resident had seen and heard the med-delivery person verbally abuse a staff member by yelling and calling the staff member the B word several times. The note showed the resident then tried to tell the med-delivery person not to speak to the staff member in that manner. The note showed LPN #2 then saw the med-delivery person dip their hand towards the resident's face. The note showed LPN #2 then called 911. The note showed the DON and resident's family member were notified of the incident. The note showed the officer came shortly after and took their statement.
There was no documentation an incident report was sent to the OSDH.
On 02/27/25 at 11:48 a.m., the DON stated there was no report sent to the OSDH for the incident.
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 F0657
(Tag F0657)
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 care plan was updated for 1 (#12) of 14 sampled residents ...
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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 care plan was updated for 1 (#12) of 14 sampled residents whose care plans were reviewed.
ADON #1 identified 182 residents resided in the facility.
Findings:
A Comprehensive Person Centered Care Plan policy, dated 01/2019, read in part, Each resident will have a person centered care plan to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care.
Resident #12 had diagnoses which included anxiety disorder and chronic embolism and thrombosis of other specified veins.
Resident #12's annual assessment dated [DATE], showed Resident #12's cognition was intact.
An Incident Note, dated 01/23/25, showed at around 6:30 p.m., during shift, LPN #2 witnessed a confrontation between the Resident #12 and a med-delivery person while observing from the nursing station. The note showed the resident had seen and heard the med-delivery person verbally abuse a staff member by yelling and calling the staff member the B word several times. The note showed the resident then tried to tell the med-delivery person not to speak to the staff member in that manner. The note showed LPN #2 then saw the med-delivery person dip their hand towards the resident's face. The note showed LPN #2 then called 911. The note showed the DON and resident's family member were notified of the incident. The note showed the officer came shortly after and took their statement.
The care plan did not address any physical altercations toward Resident #12. The care plan had no interventions on how to assist Resident #12 in feeling safe after the altercation.
On 02/27/25 at 11:30 a.m., MDS coordinator #1 stated the process for updating the care plan was for a change in events, something like a fall and behaviors.
On 02/27/25 at 11:34 a.m., MDS coordinator #1 stated the care plan should have been updated with this altercation and it was not.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to:
a. provide an adequate supply of towels for bathing on resident hall...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to:
a. provide an adequate supply of towels for bathing on resident halls or in the laundry room;
b. ensure shower beds were clean and in good repair for two of two shower beds;
c. ensure a shower hose was not missing in the shower room located next to room [ROOM NUMBER]; and
d. ensure broken tiles on the floor and wall of a shower located in the shower room on Hall 300 were repaired.
ADON #1 identified 182 residents resided in the facility. The DON identified the facility had two shower beds and seven shower rooms.
Findings:
1. On 02/24/25 at 4:29 p.m., a confidential interview was held with a resident. The resident stated, Sometimes we don't have towels.
On 02/25/25 at 9:40 a.m., Resident #3 stated, For a few months we don't have towels.
On 02/27/25 at 9:12 a.m., CNA #6 stated they were limited on supplies. They stated they run out of towels a lot. CNA #6 opened room [ROOM NUMBER] with a total of 11 towels observed available for use. They stated, This is all for the 200 residents.
On 02/27/25 at 10:15 a.m., CNA #7 was asked to show where the towels used for bathing were. CNA #7 stated there were No towels. They stated they had to go to the closet on station three for towels.
On 02/27/25 at 10:27 a.m., LPN #6 was asked to show where they kept their towels for bathing. LPN #6 opened the door by room [ROOM NUMBER] and stated, No towels in there. LPN #6 also looked in the shower room and was unable to locate any towels.
On 02/27/25 at 10:30 a.m., the LPN #4 opened the shower room on Hall 600 and stated there were no towels.
On 02/27/25 at 10:43 a.m., CNA #8 opened the room labeled whirlpool room on Hall 100 and stated there were no towels.
On 02/27/25 at 2:40 p.m., the laundry room was observed. Laundry #1 was asked to show all bath towels in the room. They pointed to a stack of 11 towels available for use. They stated, Normally they order a lot of them. They stated, This is what I have right now.
On 02/27/25 at 4:30 p.m., the DON was provided the opportunity to locate all bath towels in the facility. They went to the storage room on Hall 200 and stated here is one towel.
On 02/27/25 at 4:35 p.m., the DON observed two linen carts on Hall 200 and stated there were no towels. They observed the linen cart on Hall 300 and stated, None.
On 02/27/25 at 4:36 p.m., the DON observed the storage room on the back of Hall 300 and stated, I don't see any towels. CNA #9 who was standing in the room stated, Usually we have to go to laundry and get towels.
On 02/27/25 at 4:37 p.m., the DON observed the linen closet on Hall 600 and stated, No towels.
On 02/27/25 at 4:40 p.m., the DON observed the linen cart in the Hall 400 shower room and stated, I don't see any towels. The DON observed one dirty towel in a sack.
On 02/27/25 at 4:41 p.m., the DON located two towels in the Hall 500 shower room. The DON stated, So we're up to four. They stated, There's not enough.
On 02/27/25 at 4:45 p.m., the DON walked into the laundry room and located two bath towels. The DON stated, We don't have near enough.
2. On 02/24/25 at 4:29 p.m., a confidential interview was held with a resident. They stated sometimes the shower chairs aren't clean.
On 02/24/25 at 5:15 p.m., Resident #1 stated they had to go use the shower on Hall 400 because it was the cleanest. They stated once they had observed the shower bed with a bunch of cuticle wooden sticks under it.
On 02/25/25 at 9:40 a.m., Resident #3 stated a shower chair was broken, they complained, and the facility fixed it. Resident #3 stated they took a shower yesterday and observed another broken shower chair. They stated the shower was not clean and it smelled bad.
On 02/27/25 at 9:22 a.m., the shower room by room [ROOM NUMBER] was observed to have a shower bed with a blue cushion on top of it. The blue cushion was observed to have a white substance smeared on it. The cushion was lifted and a metal nut along with large amounts of brown and white debris was observed scattered throughout the shower bed. The shower bed was observed to be dry. CNA #6 stated, This is usually the state of it. The white undercarriage used for draining was observed to be disconnected on one half of the bed with the hose unattached. CNA #6 stated it was broken and won't stay up to drain. CNA #6 stated they told the nurse, the nurse put it into the electronic maintenance system, but it has not been fixed.
On 02/27/25 at 10:15 a.m., CNA #7 stated when something needed repaired, they would put it into the computer for maintenance to fix. The shower bed in the shower room next to room [ROOM NUMBER] was observed to have a blue pad on top of it. The blue pad was lifted up and a pen, rubber band, plastic razor head cover, and lots of yellow, blue, and white debris was observed on the shower bed. CNA #7 stated, They're supposed to clean it. They stated, After each use. The white undercarriage of the shower bed was observed to be held up on one side with a black trash bag. CNA #7 stated, We told them we needed a new one. CNA #7 stated it was weeks ago. CNA #7 stated they did not know who put the trash bag there to hold it up.
On 02/27/25 at 9:26 a.m., CNA #6 stated staff were supposed to clean the shower beds after each use. They stated they were supposed to use a chemical and spray them down. CNA #6 stated the shower bed was not clean.
On 02/27/25 at 2:02 p.m., the DON stated shower chairs/beds were supposed to be cleaned after every shower.
3. On 02/27/25 at 10:15 a.m., CNA #7 opened the shower room next to room [ROOM NUMBER]. One of the showers was observed to be missing the hose for the shower. CNA #7 was asked how long the shower hose had been missing and stated Its been a long while. CNA #7 stated when something needed repaired, they would put it into the computer for maintenance to fix.
4. On 02/27/25 at 10:24 a.m., LPN #6 opened the shower room by room [ROOM NUMBER]. The first shower was observed to have several missing tiles on the floor as well as two larger broken tiles where the floor meets the wall. LPN #6 stated, I think it's pretty fresh.
On 02/27/25 at 2:08 p.m., the maintenance supervisor stated if staff identified items which needed repaired, they would put it into the electronic system used for maintenance repairs. They stated there were no current repairs in the works.
On 02/27/25 at 2:15 p.m., the maintenance supervisor was shown the missing hose in the shower by room [ROOM NUMBER]. They stated, No one had reported it's missing. They observed the shower bed and stated they were not aware a trash bag was being used to hold up the undercarriage. They stated, It needs a new bottom tray.
On 02/27/25 at 2:35 p.m., the maintenance supervisor was shown the shower bed on Hall 200 and stated they had always seen the bed together. They stated no one reported to them it needed repaired. The maintenance supervisor was asked about the missing tiles in the shower by room [ROOM NUMBER]. They stated staff had reported the missing tiles to them today. They stated before today, they were not aware they were missing.
On 03/03/25 at 1:10 p.m., the administrator stated the facility did not have a policy on maintenance, shower beds clean and in good repair, or towels and they followed state and federal regulation.
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 F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure handrails were firmly secure to the wall in 2 (Hall 100 and Hall 200) of 7 shower rooms observed.
ADON #1 identified 182 residents res...
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Based on observation and interview, the facility failed to ensure handrails were firmly secure to the wall in 2 (Hall 100 and Hall 200) of 7 shower rooms observed.
ADON #1 identified 182 residents resided in the facility. The DON identified seven shower rooms in the facility.
Findings:
On 02/27/25 at 9:26 a.m., the first shower in shower room on Hall 200 was observed to have loose hand rails underneath both shower heads. Both hand rails wiggled easily and the metal coverings where they meet the wall were loose. CNA #6 stated it scared them to use. CNA #6 stated they reported it to the nurse who put it in the electronic maintenance notification system. They stated the issue was maintenance getting it fixed. The second shower had hand rails that wiggled significantly under each shower head. The metal coverings where the handrails meet the wall were observed loose. There was a third handrail on the back wall of this shower that was observed to be loose from the wall.
On 02/27/25 at 10:37 a.m., CNA #8 opened the shower room on Hall 100. The first shower was observed to have a handrail hanging off of the wall. CNA #8 stated they were not sure how long it had been like that, but they thought about two months. CNA #8 stated the staff did not use that side of the shower for that reason. The second shower in this room was observed with the handrail under the shower head loose from the wall with screws exposed. The metal plates where the handrail attaches to the wall was observed to be loose. CNA #8 stated, must be recent. They stated the last time they were in the shower, it was connected. CNA #8 stated when items needed repaired, they had a work order the nurse would sign and send to the maintenance area.
On 02/27/25 at 10:15 a.m., CNA #7 stated when something needed repaired, they would put it into the computer for maintenance to fix.
On 02/27/25 at 2:08 p.m., the maintenance supervisor stated if staff identified items which needed repaired, they would put it into the electronic system used for maintenance repairs. They stated there were no current repairs in the works.
On 02/27/25 at 2:32 p.m., the maintenance supervisor was shown the loose handrails in the Hall 100 shower room. They stated, No one said a word about it. They stated, That's dangerous.
On 02/27/25 at 2:35 p.m., the maintenance supervisor was shown the loose handrails in the Hall 200 shower room. They stated they were not aware of them being loose.
On 03/03/25 at 1:10 p.m., the administrator stated the facility did not have a policy on handrails and followed state and federal regulation.
Oct 2024
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Ed Roth
Based on observation, record review and interview, the facility failed to ensure residents were free of neglect for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Ed Roth
Based on observation, record review and interview, the facility failed to ensure residents were free of neglect for one (#3) of four sampled residents reviewed for neglect. Resident #3 took a water pitcher from the medication cart and proceed down the hall. Resident #2 blocked Resident #3 from leaving down the hall and ended up grabbing Resident #3 on the shoulders and base of the neck forcefully pushing them to the ground. Resident #3 sustained a fractured hip requiring surgery. CNA #1 was present and did not intervene to protect Resident #3 from Resident #2.
The DON identifed 13 residents who resided on hall 600 memory care unit.
Findings:
The Abuse Prevention policy, last revised 10/21/22, read in part, .Neglect: failure of an employee to provide reasonable or necessary services to maintain the physical and mental health of any consumer when that failure presents either imminent danger to the health, safety, or welfare of a consumer or substantial probability that death or serious injury would result. This would include, but is not limited to, failure to provide adequate supervision during an event in which one consumer causes serious injury to another consumer .
1. Resident #2 had diagnosis of dementia.
Resident #2's care plan, dated 07/10/24 , documented they had impaired cognition with dementia and had impaired process. The care plan documented the resident had difficulty making decisions, impaired decision making and long term memory loss.
Resident #2's quarterly MDS, dated [DATE], documented the resident had severe cognitive impairment.
2. Resident #3 had diagnoses which included dementia, depression, psychosis, and schizophrenia.
Resident #3's care plan, dated 02/19/24 , documented they had dementia and severe cognitive impairment.
Resident #3's quarterly MDS, dated [DATE], documented the resident had severe contrive impairment.
An incident progress note, dated 10/12/24 at 6:03 p.m., documented Resident #3 took a water pitcher and poured it on Resident #2. It documented Resident #2 pushed Resident #3 to the floor. It documented Resident #3 had a skin tear and started to yell when attempting to get off the floor. It documented Resident #3 was sent to the hospital for treatment.
An initial OSDH incident report, dated 10/12/24, documented Resident #3 had a water pitcher from the medication cart and tossed water on Resident #2. It documented Resident #2 pushed Resident #3 causing them to fall and sustain a skin tear to their left elbow and pain in their left hip and was sent to the hospital for evaluation. It documented the facility was reporting an allegation of abuse or mistreatment.
The emergency department to hospital admission record, dated 10/12/24, documented Resident #3 presented with a fall and was assaulted by another resident. The record also documented Resident #3 had a right hip intertrochanteric fracture and had surgery on 10/13/24.
On 10/25/24 at 10:23 a.m., the video footage of the incident between Resident #2 and Resident #3 was viewed with the DON. The video clip was dated 10/12/24 at 4:29 p.m. and was 42 seconds long. Resident #3 was observed at the medication cart taking a pitcher of water when CNA #1 approached them in attempts to get the water pitcher. Resident #3 kept turning away from CNA #1 as they attempted to get the pitcher. Resident #2 was observed coming up the hall towards Resident #3. Resident #3 walked down the hall towards Resident #2. Resident #2 stepped in front of Resident #3 and after several attempts to get by Resident #3 threw water from the pitcher on Resident #2. CNA #1 was observed in the video standing about five feet away and did not intervene to separate Resident #2 and Resident #3. CNA #1 was observed taking a few steps towards the resident and then backed away and did not intervene to protect each resident and separate them. Resident #2 grabbed Resident #3 on the shoulders and neck area pushing Resident #3 forcefully to the ground. LPN #1 was observed entering the video after Resident #3 was pushed to the floor and moved Resident #2 away from Resident #3 who was on the floor.
On 10/25/24 at 10:45 a.m., Resident #3's POA stated they had been notified Resident #3 was pushed down and had bloody elbows. They stated Resident #3 went to the hospital and had a fracture that required surgical repair. The POA stated they did not feel the residents were being watched like they should have been and they would have expected staff to intervene when any incident occurred like this.
On 10/25/24 at 11:26 a.m., the DON stated CNA #1 went towards Resident #2 and Resident #3, but backed away and looked like they were scared. The DON stated CNA #1 should have intervened and attempted to separate the two residents.
On 10/25/24 at 11:55 a.m., CNA #1 stated Resident #3 fell to the ground because Resident #2 pushed them to the floor. CNA #1 stated they were right there, but could not intervene and was not going to try and stop the residents because they were hit in the past by residents. CNA #1 stated they were afraid to intervene. CNA #1 stated they had only worked on the hall two other times and had been trained how to handle residents with dementia.
On 10/25/24 at 12:07 p.m., LPN #1 stated they were working at the time of the incident with Resident #2 and Resident #3. They stated CNA #1 was close to the residents and did not intervene and stop them. LPN #1 stated they counseled the CNA, who responded they were not going to get beat up and was scared. LPN #1 stated the CNA normally worked on another hall and that was the first shift they had worked together.
On 10/25/24 at 12:15 p.m., the DON was asked for a policy on dementia care. The DON stated they did not have one. They stated all they had was the abuse policy that had been provided. The DON stated LPN #1 never told them the aide was afraid to intervene.
On 10/25/24 at 12:30 p.m., the administrator stated they had copies of CNA #1's statement from the incident. They stated the nurses charted in the record and that was the nurses' statement. They stated Resident #2 stepped in front of Resident #3 and the aide was behind the residents. The administrator stated CNA #1 looked scared, but they did not ask why they looked scared. The administrator then stated the expectations would be for the aide to intervene and attempt to separate the two residents.
On 10/25/24 at 1:07 p.m., the DON was asked what the definition of neglect was. They stated, The willful intent to not take care of anybody. The DON was asked what the abuse policy indicated neglect was. They reviewed the policy and stated, Yes it was neglectful act on behalf of the aide. The DON added there was an altercation causing Resident #3 to fracture their hip and require surgery.
On 10/25/24 at 1:21 p.m., the administrator stated neglect was not taking care of someone. When asked what the policy indicated neglect was, the administrator stated they disagreed and would see about that.
Oct 2024
3 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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure medication and treatments were administered as ordered for one (#6) of three sampled residents who were reviewed for medication admi...
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Based on record review and interview, the facility failed to ensure medication and treatments were administered as ordered for one (#6) of three sampled residents who were reviewed for medication administration.
The Administrator identified 170 residents resided in the facility.
Findings:
Resident #6 had diagnosis which included DM type two and diabetic wound.
A physicians order dated 06/29/24 - 07/18/24, documented wound care to left ankle change once daily and as needed. Scheduled on day shift.
The TAR was blank on 07/18/24 day shift.
A physicians order dated 06/29/24 - 07/24/24, documented wound care to left heel change once daily and as needed. Scheduled on day shift.
The TAR was blank on 07/24/24 day shift.
A physicians order dated 07/19/24 - 07/25/24, documented wound care to left ankle once daily. Scheduled on day shift.
The TAR was blank on 07/25/24 day shift.
There was no other documentation located of the treatments completed for left ankle on 07/18/24 or 07/24/24, and the left heel for 07/25/24.
On 10/16/24 at 3:58 p.m., the DON stated if it was not documented then it was not given. They stated they did not see where the treatments had been done. The DON stated the wound care orders were not followed.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed report an allegation of abuse to OSDH for two (#11 and #12) of seven sampled residents reviewed for abuse.
The Administrator identified 170 r...
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Based on record review and interview, the facility failed report an allegation of abuse to OSDH for two (#11 and #12) of seven sampled residents reviewed for abuse.
The Administrator identified 170 residents resided in the facility.
Findings:
The Abuse Prevention policy, revised 10/21/22, read in part, The Administrator, or designee, shall report any allegations of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the Social Security Act to the Department of Health as required.
An OSDH Incident Report Form, dated 09/01/24, read in part, On 9.1.24 CNA [name withheld] reported to the DON that [resident name withheld] informed [them] that [they] did not want CNA [name withheld] to care for [them] anymore because [they] were rough with [them] and won't clean inside [their] labia. [resident] stated that the incident happened on 8.31.24. and [they] felt abused by this CNA. The charge nurse completed a head to toe assessment and pain eval, no new issues noted.
The investigation included 10 resident interviews. Two of those interviews had negative response.
1. Resident # 11 had diagnoses which included lymphedema.
An untitled form that documented, Re: [Resident #7] Incident 8-31-24 dated 09/06/24, read in part, 3. Do you feel that you have been abused by a staff member? yes. The document also read, 4. Are staff rough with you when they provide care? yes.
An undated Grievance Intake Form, documented No to the question of Is this person making a formal allegation of abuse or neglect? It documented resident # 11 did not feel safe there. It documented the reason they did not feel safe was because of their roommates company.
There was no documentation an incident report was filed to OSDH or notification to the local law enforcement.
2. Resident #12 had diagnoses which included hypertension.
An untitled form that documented, Re: [Resident #7] Incident 8-31-24 dated 09/06/24, read in part, 4. Are staff rough with you when they provide care? yes.
There was no documentation an incident report was filed to OSDH or notification to the local law enforcement.
On 10/14/24 at 3:28 p.m., the DON stated they did the initial investigation only and that the SSA did the follow up. They stated it should have been investigated further.
On 10/14/24 at 3:39 p.m., the Administrator stated the SSA should have followed up on a grievance form.
On 10/15/24 at 12:20 p.m., the SSA, DON, and Administrator were all present for interview. The SSA stated they followed up by doing a grievance on what the residents had said. When asked where the state reportable investigation was the SSA stated they did a grievance. The SSA stated that Resident #11 discharged that same day and was unable to gain contact information for them. The DON stated they were not involved with the resident interviews. No response from the Administrator.
The facility did not investigate the negative responses that resulted from interviews completed in conjunction with an abuse investigation.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to:
a. protect resident from abuse for four (#3, 5, 8, and #9 ), and
b. conduct a thorough investigation for allegations of abuse for five (#3...
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Based on record review and interview, the facility failed to:
a. protect resident from abuse for four (#3, 5, 8, and #9 ), and
b. conduct a thorough investigation for allegations of abuse for five (#3, 5, 7, 8, and #9) of five sampled residents reviewed for abuse.
The Administrator identified 170 residents resided in the facilty.
Findings:
The Abuse Prevention policy, revised 10/21/22, read in part, The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The policy also read, In addition to reporting to the State Agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency. The policy also read, Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. The policy also read, Findings will be reviewed by the Interdisciplinary Team during QAPI Meeting.
1. An OSDH Incident Report Form, incident dated 03/17/24, read in part, Residents Involved [Resident #3 and #5]., The form also read, At approximately 5:15 pm the charge nurse heard yelling coming from the room and immediately responded. As the nurse entered the room. [resident #3] was coming out and stated she hit me. Residents were separated. Head to toe assessment completed on both residents, no injury noted on either resident. [Resident #3] was moved to another room on the other side of the unit. Family APS, and physician have been notified. Investigation initiated.
There was an intervention for Resident #5 to have 1:1 weekly visits with the SSA. There was no documentation for this incident.
There was no documentation law enforcement had been notified and no QAPI for this incident.
2. An OSDH Incident Report Form, incident dated 05/28/24, read in part, Residents Involved [Resident #3 and #9]., The form also read, Residents [#5 and #3] were visiting in the social services office with the staff. [Resident #3] initiated a physical altercation with [Resident #5].
There was an intervention for Resident #3 to have 1:1 weekly visits with the SSA. There was no documentation for this incident.
There was no QAPI for this incident.
3. An OSDH Incident Report Form, incident dated 09/01/24, read in part, Resident Involved [Resident #7.], The form also read, CNA[name withheld] reported to the DON that [Resident #7] informed [them] that [they] did not want CNA [name withheld] to care for [them] anymore because [they] is rough with [them] and won't clean inside [their] labia. [Resident #7] stated that the incident happened on 08/31/2024 and [they] felt abused by this CNA. The charge nurse completed a head- to- toe assessment and pain eval, no issues noted.
There was no documentation law enforcement had been notified.
There was no QAPI for this incident.
4. An OSDH Incident Report Form, incident dated 09/12/24, read in part, Residents Involved [Resident #3 and #8]., The form also read, At 7:00 pm facility staff notified the Administrator and DON that [Resident #3] and [Resident #8] had a physical altercation in the smoking courtyard. Facilty surveillance system was accessed, it showed [Resident #3] roll up to [Resident #8] screaming at [them] and pointing [their] finger in [their] face. [Resident #3] then proceeds to grab the armrest of [Resident#8] wheelchair and forcefully pull [Resident #8] towards [them]. [Resident #8] then hits [Resident #3] in the face.
There was an intervention for Resident #3 to have weekly visits with SSA. There was no documentation for this incident.
There was no QAPI for this incident.
On 10/15/24 at 12:32 p.m., the SSA stated they did not have documentation and the DON stated there was no QAPI done for the incident 05/28/24.
On 10/15/24 at 12:43 p.m., the SSA stated they did not have documentation for the incident 09/12/24.
On 10/15/24 at 12:55 p.m., the SSA stated they did not have documentation. The DON stated there was no QAPI done for the incident 03/17/24.
On 10/15/24 at 2:21 p.m., the DON stated there was no law enforcement notification for incident 09/01/24.
On 10/15/24 at 2:27 p.m., the DON stated there was no law enforcement notification for incident 03/17/24.
On 10/16/24 at 10:59 a.m., the DON stated they did not have QAPI for any of the incidents listed.
Aug 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure the menu was followed and adequate portion sizes were offered to residents for one of one meal service observed.
The ...
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Based on observation, record review, and interview, the facility failed to ensure the menu was followed and adequate portion sizes were offered to residents for one of one meal service observed.
The DON identified 173 residents received services from the kitchen in the facility.
Findings:
The NUTRITIONAL SERVICES MENUS policy, revised 03/31/21, read in part, Menus shall be followed which have been reviewed and approved by a Registered Dietitian (RD) in compliance with the Federal and State Regulations and consistent with Standards of Practice on nutritional care.
A menu, dated 08/12/24, documented the following for regular/NAS lunch:
Meat sauce with spaghetti noodle - 8 oz ladle,
Italian vegetable blend - 1/2 cup (4 oz),
Garlic bread - one slice.
A menu, dated 08/12/24, documented the following for pureed lunch:
Meat sauce with spaghetti noodle - #8 scoop spaghetti (4 oz) and #8 scoop meat sauce (4 oz),
Italian vegetable blend - #10 scoop,
Garlic bread one slice - #20 scoop.
On 08/12/24 at 10:53 a.m., the CDM identified the above menu as scheduled to be served for lunch on 08/12/24.
On 08/12/24 at 11:50 a.m., Resident #1 stated sometimes they did not have enough food.
On 08/12/24 at 12:07 p.m., Dietary Aide #1 was observed to serve three regular diet plates with one tong of spaghetti, one spoodle of meat sauce, one vegetable blend, and one slice of garlic bread.
Resident #1's meal card documented regular diet, nectar thick fluids, puree, and double portions.
On 08/12/24 at 12:17 p.m., Dietary Aide #1 was observed to serve Resident #1's plate with one blue scoop pureed spaghetti, one blue scoop pureed meat sauce, and one blue scoop pureed vegetable blend.
There was no pureed garlic bread. The serving size was not listed on the three blue scoops used for serving.
On 08/12/24 at 12:19 p.m., Dietary Aide #1 stated Resident #1 does not get the garlic bread because they would choke. They stated they did not know what the serving size was for the blue scoops.
On 08/12/24 at 12:20 p.m., Dietary Aide #1 stated they could not tell if they served 8 oz of spaghetti and meat sauce for the three plates observed.
On 08/12/24 at 12:21 p.m., the CDM stated the spaghetti was served with a tong. The meat sauce and vegetable blend was served with a 2 oz ladle. They stated it should have been 4 oz each.
On 08/12/24 at 12:25 p.m., the CDM stated the serving size was not adequate for the three plates observed.
On 08/12/24 at 12:27 p.m., the CDM observed the blue scoops used to serve the puree diet. They were unable to determine the serving size for the blue scoops. They stated Resident #1 should have double portions and pureed garlic bread. They stated the menu was not followed and Resident #1 did not receive adequate portion size.
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure residents have access to the grievance procedure and failed to post information regarding the name of the grievance of...
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Based on observation, record review, and interview, the facility failed to ensure residents have access to the grievance procedure and failed to post information regarding the name of the grievance official.
The DON identified 176 residents resided in the facility.
Findings:
The GRIEVANCE/MISSING PROPERTY policy, revised 04/26/23, read in part, To provide an opportunity for Residents, Residents Representatives, and/or Families to present concerns or Grievances to the proper authorities at the Facility and receive responses to the issue(s) raised.
On 08/12/24 at 10:25 a.m., a tour of the facility was conducted. Ombudsman contact name, resident rights, and the facility's senior management concern procedure poster was observed on a wall near the main dining room entrance. There was no signage to indicate the person to contact to file a grievance or available forms in the resident units.
On 08/12/24 at 11:47 a.m., Resident #3 stated they did not know who the grievance official was or where to locate the information to file a grievance.
On 08/12/24 at 1:17 p.m., Resident #2 stated they informed nursing staff about their grievance. They were unsure who the grievance official was.
On 08/12/24 at 1:51 p.m., Resident #5 stated they did not know how to file a grievance or where to find the information to file a grievance.
On 08/12/24 at 2:17 p.m., the DON stated social service was responsible for grievances in the facility.
On 08/12/24 at 2:22 p.m., the Social Services Director stated all residents were educated on the facility's grievance process on admit.
On 08/12/24 at 2:28 p.m., the DON and the Social Services Director stated the grievance procedure and responsible official's information was not posted in the facility for resident access.
Jul 2024
2 deficiencies
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to implement their abuse policy by immediately reporting abuse for two (#1 and #2) of three residents reviewed for abuse.
The DON reported 17...
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Based on record review and interview, the facility failed to implement their abuse policy by immediately reporting abuse for two (#1 and #2) of three residents reviewed for abuse.
The DON reported 171 residents resided in the facility.
Findings:
A facility Abuse Prevention policy, dated 10/21/22, read The Administrator and Director of Nursing must be promptly notified of suspected abuse or incidents of abuse.
A State Incident Investigation Report, dated 05/17/24, documented the DON received a call reporting CNA #2 had been abusive to residents #1 and #2. The reports documented that LPN #1 was made aware of the issue and had not reported it to the DON or facility administration.
Res #1 admitted to the facility with diagnoses of dementia, psychosis, and other specified depressive episodes.
Res #2 admitted to the facility with diagnoses of cerebral infarction, insomnia, major depressive disorder, and anxiety.
On 07/16/24 at 1:00 p.m., the DON reported LPN #1 reported she had handled the allegation herself and did not report it to the DON. The DON reported LPN #1 was terminated for not following the facility's abuse policy and CNA #2 was terminated for sleeping on the job.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated for two (#1 and #2) of three residents reviewed for abuse investigations.
The DON ...
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Based on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated for two (#1 and #2) of three residents reviewed for abuse investigations.
The DON reported 171 residents resided in the facility.
Findings:
The facility policy Abuse Prevention, dated 10/21/22, read in part, . Any allegation of abuses, or neglect, misappropriation of property, or mistreatment shall be thoroughly investigated.
A report to the Oklahoma State Department of Health, dated 05/17/24, documented an allegation of abuse from CNA #1 who alleged CNA #2 was abusive to Residents #1 and #2. The report documented CNA #1 had reported the allegation to LPN #1 and nothing had been done.
A review of the investigation of the allegation contained interviews with the three staff members involved.
On 07/16/24 at 1:00 p.m., the DON reported they had only interviewed the three staff members directly involved. Reported they should have interviewed other staff that worked with the three staff members involved.
Apr 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure ADL care was provided according to the plan of care for three (# 1, 7, #8) of four sampled residents reviewed for ADL ...
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Based on observation, record review, and interview, the facility failed to ensure ADL care was provided according to the plan of care for three (# 1, 7, #8) of four sampled residents reviewed for ADL care.
The Assistant Administrator identified 183 residents resided in the facility.
A Turning and Repositioning policy, dated 07/21/22, read in part, .The Facility will aid with Turning & Repositioning residents to prevent skin breakdown. Nursing employees will Turn & Reposition residents as reflected in their plan of care .
A Incontinent Care policy, dated 07/21/22, read in part, .The Facility will Provide Incontinent Care as Directed in the Plan of Care .
1. Resident #7 had diagnoses which included need for assistance with personal care.
Resident #7 care plan dated 07/11/24 documented the resident had self care performance deficit and required staff participation.
Resident #7 ADL documentation of blanks as follows:
April 2024:
Bed mobility were eight out of 29 opportunities.
Personal hygiene were seven out of 19 opportunities.
Toilet use there were nine out of 31 opportunities.
Bowel and bladder elimination there were nine out of 31 opportunities.
On 04/19/24 at 3:20 p.m.,CNA #3 stated Resident #7 needed staff assist with all ADL's. They stated blanks on the documentation meant that it had not been done. They stated the blanks were as follows:
Bed mobility there were eight blanks.
Personal hygiene there were seven blanks.
Toilet use there were nine blanks.
Bowel and bladder elimination there were nine blanks.
CNA #3 stated the resident did not receive care per their plan of care and that if it was not charted then it was not done.
2. Resident #8 had diagnoses which included unspecified fracture of sacrum.
Resident #8 care plan dated 12/01/21 documented the resident had a self care performance deficit and required staff participation.
Resident #8 ADL documentation of blanks as follows:
February 2024:
Bed mobility were 29 out of 63 opportunities.
Personal hygiene were 19 out of 63 opportunities.
Toilet use were 27 out of 103 opportunities.
Bowel and bladder elimination were 28 out of 104 opportunities.
March 2024:
Bed mobility were 36 out of 98 opportunities.
Personal hygiene were 29 out of 62 opportunities.
Toilet use were 36 out of 98 opportunities.
Bowel and bladder elimination were 37 out of 98 opportunities.
April 2024:
Bed mobility were 23 out of 55 opportunities.
Personal hygiene were 20 out of 37 opportunities.
Toilet use were 21 out of 57 opportunities.
Bowel and bladder elimination were 22 out of 58 opportunities.
On 04/19/24 at 3:49 p.m. CNA #2 stated Resident #8 was dependent on staff. They stated blanks on the documentation meant not charted and not done.
CNA #2 stated the blanks were as follows:
February 2024:
Bed mobility were 29 blanks.
Personal hygiene were 19 blanks.
Toilet use were 27 blanks.
Bowel and bladder elimination were 28 blanks.
March 2024:
Bed mobility were 36 blanks.
Personal hygiene were 29 blanks.
Toilet use were 36 blanks.
Bowel and bladder elimination were 37 blanks.
April 2024:
Bed mobility were 23 blanks.
Personal hygiene were 20 blanks.
Toilet use were 21 blanks.
Bowel and bladder elimination were 22 blanks.
CNA #2 stated the resident did not receive care per their plan of care.
3. Resident #1 had diagnoses which included need for assistance with personal care.
Resident #1 ADL documentation of blanks as follows:
January 2024:
Check q 2 hours there were 15 out of 52 opportunities.
Bed mobility there were four out of 14 opportunities.
Personal hygiene there were three out of eight opportunities.
Toilet use there were four out of 14 opportunities.
December 2023:
Check q 2 hours there were 56 out of 372 opportunities.
Bed mobility there were 14 out of 124 opportunities.
Personal hygiene there were 11 out of 62 opportunities.
Toilet use there were 14 out of 96 opportunities.
On 04/19/24 at 4:00 p.m. CNA #2 stated Resident #1 was dependent with ADL's. They stated there were blanks on the documentation as follows:
January 2024:
Check q 2 hours there were 15 blanks.
Bed mobility there were four blanks.
Personal hygiene there were three blanks.
Toilet use there were four blanks.
December 2023:
Check q 2 hours there were 56 blanks.
Bed mobility there were 14 blanks.
Personal hygiene there were 11 blanks.
Toilet use there were 14 blanks.
CNA #2 stated Resident #1 did not receive care according to standards of practice.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure the ice machine was clean and free from debris for one of one ice machine observed in the kitchen.
The Assistant Admini...
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Based on observation, record review and interview, the facility failed to ensure the ice machine was clean and free from debris for one of one ice machine observed in the kitchen.
The Assistant Administrator identified 183 residents resided in the facility.
Findings:
A Work History Report documented preventative maintenance to the ice machine and bins and to check filters, clean coils, sanitize interior, delime was due on 03/31/24 and was completed on 03/04/24. It also documented it was due on 02/29/24 and had been done on 03/04/24 as well.
On 04/17/24 at 11:26 a.m., the ice machine was observed with the Dietary manager and Maintenance #1. There was black, brown and white slimmy residue and particles present at the right bottom corner of the machine on the other side of the coils above the ice bin. Maintenance #1 touched it with bare fingers and stated it was food. They stated it was to be cleaned every 30-40 days and had just been redone and was due at the end of the month.
On 04/18/24 at 3:57 p.m., the Area Director stated that if the water sits too long it can become stagnant, slimy, and mold. They stated they need to look into cleaning more often with the amount of ice used.
Jan 2024
25 deficiencies
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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #11 had diagnoses which included other abnormalities of gait and mobility and unspecified osteoarthritis.
Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #11 had diagnoses which included other abnormalities of gait and mobility and unspecified osteoarthritis.
Resident #11's care plan, dated 11/20/23, documented resident had a fall with minor injury on 11/20/23 while transferring out of the wheelchair. The intervention documented was to place anti roll back bars to the wheelchair.
A Quarterly Assessment, dated 12/20/23, documented Resident #11 required substantial/maximal assistance with sit to stand.
On 01/12/24 at 1:50 p.m., LPN #6 stated Resident #11 was to have anti lock on their chair, however there had been a change in Resident #11's chair and Resident #11 was in a borrowed chair at this time.
On 1/12/24 at 1:52 p.m. LPN #6 stated the anti lock was not on Resident #11's chair.
Based on observation, record review, and interview, the facility failed ensure interventions were in place, new intervention were implement after a fall, and staff were aware of fall interventions for two (#156 and #11) of four sampled residents reviewed for accident hazards.
Resident #156 had 16 falls over six months. The last fall resulted in Resident #156 sustaining a facial laceration, head contusion, and loosing a tooth.
The DON identified 181 residents resided in the facility.
Findings:
A Fall Management policy, dated 02/28/23, read in part .Prevention/Treatment .Investigate the Circumstances and Surroundings where the Fall Occurred .Implement Intervention to reduce further occurrences .Interdisciplinary Team .Review Post-Fall Residents within 24-72 Hours during Clinical Meeting .Evaluate Circumstances/Probable Cause for Fall .Revise/Modify Care Plan .Implement Interventions according to Treatment approach to minimize further Falls & reduce injury .
1. Resident #156 had diagnoses which included dementia, muscle weakness, difficulty with walking, and unsteadiness on feet.
Ten Fall Scale assessments, dated from June 2023 to November 2023, documented the resident was at high risk for falls.
A Quarterly Assessment, dated 10/11/23, documented Resident #156 sometimes understood others and sometimes made themselves understood. It documented Resident #156 had severe impaired cognition. It documented Resident #156 required substantial/maximal assistance with ADLs and mobility. It documented Resident #156 had two or more non injury falls, and two or more injury falls since prior assessment.
A Fall Incident Report, dated 07/03/23, documented the resident had a fall. It documented the intervention was to put a concave mattress in place.
A Fall Incident Report, dated 10/06/23, documented the resident had a fall. It documented the intervention was to drop the back seat of the wheelchair.
A Fall Investigation, dated 12/25/23, documented the resident was laying on the floor. It documented a laceration was observed to the center of the resident's forehead and a tooth was found on the floor. It documented the resident was transferred to the hospital.
A Progress Note, dated 12/25/23, documented the resident was sent to a local hospital and the resident received eight sutures, then returned to the facility.
An After Visit Summary, dated 12/25/23, documented the resident was diagnosed with a facial laceration and a head contusion.
On 01/08/24 at 8:47 a.m., Resident #156 was observed up in their wheelchair in the dining room. A closed laceration was observed in the middle of the resident's forehead. Purple and yellow bruising was observed around the laceration, and the bruising extended to the rest of the resident's forehead and down to their cheeks. The back of the resident's wheelchair seat was not observed to have been lowered.
On 01/08/24 at 10:49 a.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave.
On 01/09/24 at 9:24 a.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave.
On 01/10/24 at 10:14 a.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave.
On 01/10/24 at 1:06 p.m., the DON stated she was not aware the resident had a fall the last week of December.
On 01/10/24 at 2:23 p.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave. The wheelchair was observed in the room and the back of the seat was not observed to be lowered.
On 01/10/24 at 2:25 p.m., LPN #1 stated Resident #156 was a very high fall risk. They stated they try to keep the resident in sight and if they observe the resident wanting to get out of the wheelchair, they will assist the resident to lay down. LPN #1 stated they recalled Resident #156 had a fall on Christmas and had to get sutures to their forehead. LPN #1 was not sure what the intervention had been put in place regarding the fall.
On 01/10/24 at 2:27 p.m., LPN #1 observed the resident's room. They were able to identify some interventions in place. They did not identify the mattress should be concave nor the back of the wheelchair seat should be lowered.
On 01/11/24 at 10:36 a.m., the DON stated staff completed an incident report, unit managers completed room audits to ensure interventions were in place, interventions were put on the [NAME] for staff to see, and nurses communicated shift to shift. The DON stated some of Resident #156's current fall interventions in place were a concave mattress, and the back of the wheelchair lowered. The DON stated IDT completed risk meetings to review falls, interventions, and make changes if needed. The DON stated the last risk meeting regarding Resident #156 was 10/13/23. The DON stated the intervention for the fall that occurred on 12/25/23 was frequent checks. She stated she would probably change that because the resident had already been on hourly checks.
On 01/11/24 at 10:49 a.m., the DON observed Resident #156's room. She stated the mattress was not a concave mattress.
On 01/11/24 at 10:51 a.m., the DON observed Resident #156 in their wheelchair. She stated it didn't look like the back of the seat was lowered.
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 F0558
(Tag F0558)
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 call devices were within reach for one (#162) ...
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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 call devices were within reach for one (#162) of 40 sampled residents reviewed for accommodation of needs.
The DON identified 181 residents resided in the facility.
Findings:
A facility policy titled, Resident Call System, dated 10/20/22, read in part, .During rounds nursing & IDT team members will ensure resident call system is within reach of the resident .
Resident #162 had diagnoses which included bipolar disorder and cerebral infarction due to thrombosis of unspecified precerebral artery.
An annual MDS, dated [DATE], documented Resident #162 was cognitively impaired and required partial/moderate assistance with most of their ADLs.
On 01/08/24 at 8:37 a.m., Resident #162's call light was not in reach. The call light was observed on the floor at the foot of the bed.
On 01/08/24 at 8:39 a.m., CNA #4 stated the call light was not in reach of Resident #162.
On 01/11/24 at 2:45 p.m., the DON stated the facility policy for call lights in rooms was the residents were to have a call light within reach and it should be in working order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
2. Resident #93 had diagnoses which included type two diabetes mellitus.
An admission Assessment, dated 12/06/23, documented Resident #93's cognition was intact.
On 01/08/24 at 9:19 a.m., Resident #93...
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2. Resident #93 had diagnoses which included type two diabetes mellitus.
An admission Assessment, dated 12/06/23, documented Resident #93's cognition was intact.
On 01/08/24 at 9:19 a.m., Resident #93 stated their bathroom wasn't cleaned. The resident's bathroom was observed to have a piece of white paper and debris in the corner of the bathroom, behind the toilet, next to a plunger.
On 01/09/24 at 10:01 a.m., Housekeeper #1 was observed with the housekeeping cart outside Resident #93's room.
On 01/09/24 at 10:13 a.m., Housekeeper #1 was observed at a different resident's room. Resident #93's bathroom was observed with the paper and debris in the same place in the resident's bathroom.
On 01/10/24 at 10:16 a.m., Resident #93's bathroom was observed with the same paper and debris.
On 01/12/24 at 9:01 a.m., Resident #93's bathroom was observed with the same paper and debris.
On 01/12/24 at 9:03 a.m., Housekeeper #1 stated they cleaned the residents' bathrooms everyday by wiping down surfaces and mopping.
On 01/12/24 at 9:05 a.m., Housekeeper #1 was shown Resident #93's bathroom. They stated they missed things sometimes.
Based on observations, record review, and interview, the facility failed to maintain a comfortable room temperature and a clean bathroom for two (#114 and #93) of 40 sampled residents.
The DON identified 181 residents resided in the facility.
Findings:
1. A facility Test and log air temperatures form, undated, documented, .required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71 to 81 degrees Fahrenheit .consider the effective air temperature and the impact that .air movement in the building may be having on comfort .
On 01/09/24 at 8:43 a.m., Resident #114 stated their room was cold and there was not a heater in the room. Resident #114 stated the outside door was opened and closed all of the time, day and night, and it gets very cold. Resident #114's room was located near an outside door with frequent activity of staff going through the door during the interview. An ambient room temperature was obtained. The temperature was 65.5 Fahrenheit.
On 01/11/24 at 8:52 a.m., RN #2 was asked if Resident #114 ever complained their room was too cold. They stated, Yes, and we tell the maintenance people, and they adjust the temperature.
On 01/11/24 at 9:06 a.m., the maintenance assistance #1 was asked what the room temperatures were to be. They stated the thermostats are set at 72 and then adjusted according to temperatures. They were asked if any resident had reported their room to be too cold in the past few days. They stated there were complaints on a different hall and the temperature was corrected. They stated they were not aware of Resident #114 complaints of the room being too cold.
On 01/11/24 at 9:55 a.m., the administrator stated the room temperatures were checked with a temperature gun that was pointed at the vent or at the wall for room temperatures. They stated they had not been informed of a resident complaint of cold rooms. They were asked if a resident room should be 65 degrees at any time. They stated, No, it should be at 71 degrees or higher.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to follow their abuse policy to ensure an injury of unknown origin was investigated and reported the to OSDH for one (#88) of two residents re...
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Based on record review and interview, the facility failed to follow their abuse policy to ensure an injury of unknown origin was investigated and reported the to OSDH for one (#88) of two residents reviewed for abuse.
Findings:
A facility Abuse Prevention policy, dated 08/30/18, read in parts, .identify events, such as suspicious bruising .All violations .including injuries of unknown source . are reported immediately but not later than 2 hours after the allegation is made .
Resident #88 had diagnoses which included confusion, anxiety, depression and a delusional disorder.
A Nurse Note, dated 11/8/2023 at 8:13 p.m., read in parts, .CNA on duty informed this nurse this resident has bruises to [the resident's] left hip. immediately head to toe assessment was done. bruises noted. resident was asked what happened resident states 'I don't know .
A Skin Integrity care plan, read in parts, .11/8/23--bruise to left hip of unknown cause .
A Quarterly Assessment, dated 11/22/23, documented Resident #88 had severe cognitive impairment, hallucinations and delusions, and rejected care four to six days of the assessment.
On 01/16/24 at 1:04 p.m., the DON was asked to provide an IR for the event on 11/08/23. The DON stated the IR had not been signed by the administrator. The DON was asked if the event had been investigated as unknown origin bruise. The DON stated they were uncertain if it was investigated or reported due to the Administrator would have investigated this type of allegation. The DON was asked if the event should have been investigated and reported to OSDH. They stated it should have been but would need to have the Administrator clarify.
On 01/16/24 at 1:17 p.m., the Administrator was asked if they were aware of a bruise of unknown origin for Resident #88. They stated they did not remember hearing about a bruise on a hip of unknown origin. The Administrator was asked if they had signed the IR to indicate they had reviewed the report. They stated, I do not see I reviewed it. They were asked if the event had been investigated. They stated, It should have been. The Administrator was asked if the event had been reported to OSDH. They stated, It should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a significant change had been completed after a resident had been admitted to hospice for one (#156) of 35 residents reviewed for as...
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Based on record review and interview, the facility failed to ensure a significant change had been completed after a resident had been admitted to hospice for one (#156) of 35 residents reviewed for assessments.
The DON identified 181 residents resided in the facility. She identified five residents were on hospice.
Findings:
Resident #156 had diagnoses which included dementia.
A Patient Information Report, dated 11/30/23, documented Resident #156 was admitted to hospice.
On 01/08/24 at 8:45 a.m., LPN #1 identified Resident #156 was receiving hospice services.
There was no documentation a significant change assessment had been completed for Resident #156.
On 01/11/24 at 2:07 p.m., the MDS coordinator #1 stated a significant change assessment was completed within 14 days after a resident was admitted to hospice. They stated they were just notified Resident #156 had been admitted to hospice at the end of November 2023. They stated a significant change had not been completed.
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 an MDS assessment was accurate for one (#156) of 35 sampled residents reviewed for assessments.
The DON identified 181 residents res...
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Based on record review and interview, the facility failed to ensure an MDS assessment was accurate for one (#156) of 35 sampled residents reviewed for assessments.
The DON identified 181 residents resided in the facility.
Findings:
Resident #156 had diagnoses which included dementia.
A Fall Investigation, dated 12/25/23, documented Resident #156 was on the floor with a laceration to the center of their forehead.
A Quarterly Assessment, dated 01/03/24, documented the resident had two or more non injury falls. It did not document a fall with injury had occurred.
On 01/12/24 at 10:08 a.m., MDS Coordinator #1 stated if the resident had a fall since their last assessment, they would enter it on the MDS assessment. The MDS Coordinator #1 was asked to review the quarterly assessment from January 2024. They stated two or more non injury falls had been documented. They stated the injury fall had not been captured on the MDS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a care plan had been revised for a resident who had been admitted to hospice for one (#156) of 35 residents reviewed for care plans....
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Based on record review and interview, the facility failed to ensure a care plan had been revised for a resident who had been admitted to hospice for one (#156) of 35 residents reviewed for care plans.
The DON identified five residents were receiving hospice services and 181 residents resided in the facility.
Findings:
Resident #156 had diagnoses which included dementia.
A Patient Information Report, dated 11/30/23, documented Resident #156 was admitted to hospice.
On 01/08/24 at 8:45 a.m., LPN #1 identified Resident #156 was receiving hospice services.
There was no documentation Resident #156's care plan had been updated to address the resident was receiving hospice.
On 01/11/24 at 2:07 p.m., the MDS Coordinator #1 stated care plans were updated every day. They stated the care plan was updated when a resident was admitted to hospice. They stated Resident #156's care plan had not been updated to address hospice until today.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed ensure fall interventions were maintained when DME was replaced by hospice for one (#156) of one sampled resident reviewed for h...
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Based on observation, record review, and interview, the facility failed ensure fall interventions were maintained when DME was replaced by hospice for one (#156) of one sampled resident reviewed for hospice.
The DON identified five residents were receiving hospice services.
Findings:
Resident #156 had diagnoses had diagnoses which included dementia, muscle weakness, difficulty with walking, and unsteadiness on feet.
A Quarterly Assessment, dated 10/11/23, documented Resident #156 had severely impaired cognition. It documented Resident #156 required substantial/maximal assistance with ADLs and mobility.
A Fall Incident Report, dated 07/03/23, documented the resident had a fall. It documented the intervention was to put a concave mattress in place.
A Fall Incident Report, dated 10/06/23, documented the resident had a fall. It documented the intervention was to drop the back seat of the wheelchair.
A Patient Information Report, dated 11/30/23, documented Resident #156 was admitted to hospice.
On 01/08/24 at 8:45 a.m., LPN #1 identified Resident #156 was receiving hospice services.
On 01/08/24 at 8:47 a.m., Resident #156 was observed up in their wheelchair in the dining room. The back of the resident's wheelchair seat was not observed to have been lowered.
On 01/08/24 at 10:49 a.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave.
On 01/10/24 at 2:23 p.m., Resident #156 was observed laying in bed. The mattress was not observed to be concave. The wheelchair was observed in the room and the back of the seat was not observed to be lowered.
On 01/10/24 at 2:37 p.m., LPN #1 stated hospice had provided the resident's bed.
On 01/11/24 at 10:49 a.m., the DON observed Resident #156's room. She stated the mattress was not a concave mattress.
On 01/11/24 at 10:51 a.m., the DON observed Resident #156 in their wheelchair. She stated it didn't look like the back of the seat was lowered.
On 01/11/24 at 10:52 a.m., the DON asked LPN #1 when Resident #156's wheelchair had been changed. LPN #1 stated hospice had brought it.
On 01/16/24 at 12:52 p.m., the DON stated when the resident was receiving hospice services, hospice was notified of falls, and any changes in the residents condition. She stated if the resident required DME, hospice provided it. The DON was asked why fall interventions had not been maintained when DME was changed out by hospice. She stated they didn't know Resident #156 had been admitted to hospice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure a resident who required peg tube feedings:
A. had been administered feedings as ordered by the physician, and
B. had ...
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Based on observation, record review, and interview, the facility failed to ensure a resident who required peg tube feedings:
A. had been administered feedings as ordered by the physician, and
B. had their peg tube feeding bag labeled and dated for one (#35) of one sampled resident reviewed for peg tube feeding.
The DON identified five residents received peg tube feedings.
Findings:
Resident #35 had diagnoses which included dysphagia following unspecified cerebrovascular disease and dysphagia, oropharyngeal phase.
A Physician's order dated 12/02/23, documented Nepro at 60 cc/hr x 18 hours via peg off at 10:00 a.m. and on at 4:00 p.m.
On 01/10/24 at 10:00 a.m., peg tube feeding pump observed not running. The tube feeding bag was not labeled or dated.
On 01/10/24 at 10:10 a.m., LPN #5 was observed to enter Resident #35's room and set the tube feeding pump for 60 cc/hr and start the pump.
On 01/10/24 at 10:12 a.m., LPN #5 stated the bag was to be hung by the night shift. They stated the peg tube feeding bag was not labeled and the bag contained Nepro at 60 cc/hr.
On 01/10/24 at 10:19 a.m., LPN #5 was observed to place a label on the bag with the name of the peg tube feeding, the rate it was running, and their initials.
On 01/10/24 at 10:40 a.m., the peg tube feeding was observed to still be running at 60 cc/hr.
On 01/10/24 at 11:25 a.m., LPN #5 stated they had turned off the peg tube feeding at 10:30 a.m. They stated the order was to stop the peg tube feeding at 10:00 a.m.
On 01/10/24 at 11:26 a.m. LPN #5 stated they identified the contents of the bag by taking report this morning and seeing a piece of paper on it that documented Nepro. They stated they did not date the peg tube feeding bag because they did not hang it.
On 01/11/24 at 10:21 a.m. the DON stated the policy for peg tube feeding bags was to be labeled and dated. They stated if it was not dated or labeled, they would expect the entire system to be changed and Resident #35 had an order to stop the peg tube feeding at 10:00 a.m.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure there was ongoing communication with the dialysis center and ongoing assessment of a resident before and after dialysis for one (#35...
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Based on record review and interview, the facility failed to ensure there was ongoing communication with the dialysis center and ongoing assessment of a resident before and after dialysis for one (#35) of one sampled resident reviewed for dialysis services.
The DON identified five residents received dialysis.
Findings:
A facility policy, titled Dialysis Communication Transfer, revised 09/27/23, read in part, .A Dialysis Communication Transfer Form is completed each time a resident receives .outpatient dialysis. This ensures enhanced communication between the two facilities .Procedure .The top section of the Dialysis Communication Transfer Form is completed by the nurse responsible for sending the resident to the dialysis unit/facility .The bottom section of the form is completed by personnel responsible for the resident at the dialysis facility and returned to the nursing home with the resident .
Resident #35 had diagnoses which included end stage renal disease and dependence on renal dialysis.
Physician's orders, dated 12/02/23, documented to monitor dialysis site, obtain vital signs prior to sending to dialysis, and obtain vital signs upon returning from dialysis.
The October Dialysis Communication Transfer Forms were reviewed. Nine out of 13 reports had not been completed.
The November Dialysis Communication Transfer Forms were reviewed. Thirteen out of 30 reports had not been completed.
The December Dialysis Communication Transfer Forms were reviewed. Thirteen out of 31 reports had not been completed.
The January Dialysis Communication Transfer Forms were reviewed. Five out of 10 reports had not been completed.
On 01/11/24 at 10:26 a.m., the DON stated the policy for dialysis communication forms was the form should always go with residents to dialysis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#484) of six sampled residents reviewed for medications.
The DON identified 181 re...
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Based on record review and interview, the facility failed to ensure medications were administered as ordered for one (#484) of six sampled residents reviewed for medications.
The DON identified 181 residents resided in the facility.
Findings:
Resident #484 had diagnoses which included opioid dependence.
An Order Summary report, dated 01/05/24, documented Resident #484 was to receive Buprenorphine every morning.
An MAR, dated January 2024, documented blanks for Buprenorphine from 01/06/24 to 01/08/24.
On 01/09/24 at 9:09 a.m., Resident #484 stated they have been without the Buprenorphine for several days.
An admission Assessment, dated 01/12/24, documented the resident's cognition was intact.
On 01/17/24 at 10:23 a.m., the DON stated when a resident was admitted to the facility with orders for narcotics, the hospital faxed narcotic scripts to the pharmacy. The DON stated blanks on the MAR indicated the staff didn't give the medication or they didn't document. The DON reviewed Resident #484's MAR and stated it looked like Resident #484 didn't receive Buprenorphine for January 6th, 7th, and 8th. The DON stated if the hospital doesn't send the script to the pharmacy, staff would call the facility doctor and received orders.
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 F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure SNF ABN and NOMNCs were provided timely for two (#113 and #236) of three sampled residents reviewed for SNF Beneficiary notices.
A ...
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Based on record review and interview, the facility failed to ensure SNF ABN and NOMNCs were provided timely for two (#113 and #236) of three sampled residents reviewed for SNF Beneficiary notices.
A Beneficiary Notice form, documented 13 residents had been discharged from skilled services in the past six months.
Findings:
A Skilled Care policy, dated 04/25/19, read in part, .Anticipated last covered therapy day/Medicare end date/Date NOMNC and ABN will be issues .Must Provide[more than]2 Day Notice .
A NOMNC, dated 08/26/23, documented Resident #236's last covered day of a Medicare part A stay was 08/26/23. It documented verbal consent had been obtained on 08/26/23. A SNF ABN, dated, 08/26/23, was signed as verbal consent on 08/26/23.
A NOMNC, dated 12/04/23, documented Resident #113's last covered day of a Medicare part A stay was 12/04/23. The form was not signed by the resident. An undated SNF ABN notice for Resident #113, was not signed by the resident or dated.
On 01/11/24 at 8:34 a.m., the SSD was asked what the policy was for SNF ABNs. They stated they usually do them at the same time they do the NOMNC, three days prior to the last covered day. The SSD was asked what the policy was for providing the NOMNC. They stated to provide it at least two days prior to the last covered day.
On 01/11/24 at 8:45 a.m., the SSD stated Resident #113 and Resident #236 did not receive there NONMCs or SNF ABNs two days prior to the last covered day.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure sufficient staffing was in place to conduct destruction of medications.
The DON identified 181 residents resided in the facility.
Find...
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Based on observation and interview, the facility failed to ensure sufficient staffing was in place to conduct destruction of medications.
The DON identified 181 residents resided in the facility.
Findings:
On 01/10/24 at 4:00 p.m., a medication room was observed to be unlocked with multiple containers holding various loose medications in them.
On 1/10/24 at 4:15 p.m., the DON stated that destruction of medication requires two nurses and they have not had enough staff to conduct destruction of medications.
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 ensure the census was documented on the daily staffing sheets and it was posted in a prominent place which was readily accessible to resident...
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Based on observation and interview, the facility failed to ensure the census was documented on the daily staffing sheets and it was posted in a prominent place which was readily accessible to residents and visitors.
The DON identified 181 residents resided in the facility.
Findings:
On 01/09/23 at 9:09 a.m., a daily staffing sheet was observed on the nurses' station counter on hall 300. There was no census documented on the daily assignment sheet. LPN #3 was asked how residents in a wheel chair would be able to see the staffing sheet. LPN #3 stated the daily nurse staffing was normally kept on the counter for the staff and if residents had questions the staff would address them.
On 01/09/23 at 9:16 a.m., LPN #2 stated they had no idea about 2-10 or 10-6 shift postings and that the other shifts made the assignments. A blank white board was noted by the nurses station.
On 01/10/24 at 9:02 a.m., a daily staffing sheet was observed on the nurses station counter of hall 200. LPN #5 stated the census was not on the daily assignment sheets for hall 200, and the charge nurse was responsible for completing the assignment sheet.
On 01/10/24 at 1:51 p.m., staff coordinator stated the staffing was posted in a hallway near the front entrance. The glass cabinet was observed with the staffing coordinator. The glass case was observed and no daily staffing sheets were in the case. The staff coordinator stated the posted forms did not include the facility name, census, or total number of hours worked by the RN, LPN, or CNA staff. The staff coordinator denied there being a policy on what to include on the posted staffing sheet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure the physician responded to a GDR for four (#52, 54, 85, and #162) of five sampled residents reviewed for unnecessary medications.
T...
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Based on record review and interview, the facility failed to ensure the physician responded to a GDR for four (#52, 54, 85, and #162) of five sampled residents reviewed for unnecessary medications.
The DON identified 181 residents resided in the facility.
Findings:
A Monitoring of Anti-Psychotics policy, dated 2021, read in part, .The continued need for and the effectiveness the antipsychotic medication is reassessed monthly by the responsible physician .Gradual dose reduction is attempted with all residents who receive antipsychotic medications, unless clinically contraindicated. Contraindication to dose reductions must be documented in the resident's medical record by the responsible physician .
1. Resident #52 had diagnoses which included unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, depression, and dementia unspecified severity with mood disturbance.
A Medical Director Report, dated 10/19/23, documented a request for Vistaril to be discontinued. There was no documented response from the physician.
A Medical Director Report, dated 11/15/23, documented a request to either reduce or make changes to medications that could potentially contribute to falls. There was no documented response from the physician.
A Medical Director Report, dated 12/20/23, read in part, .physician response from November was not in medical record .
On 01/16/24 at 1:34 pm, LPN #3 stated they did not know why resident #52 was on all of the psychotropic medications. They stated they were on them when they came over from hall 400. They stated that the resident does not have any behaviors and that they were quiet and soft spoken.
On 01/17/24 at 8:30 am, the DON stated the facility was having trouble with the current physician responding to recommendations timely.
4. Resident #162 had diagnosis of bipolar disorder.
A physician's order, dated 02/08/23, documented olanzapine tablet 10 mg give 1 tablet by mouth two times a day.
Review of Medical Director Reports, for September, November, and December documented no physician responses.
On 01/17/24 at 1:01 p.m., the Corporate Administrator stated if the resident name was not highlighted the facility had not received a response from the physician.
3. Resident # 54 had diagnoses which included cognitive communication deficit, generalized anxiety disorder, and other recurrent depressive disorders.
A Medical Director Report, dated 12/19/23, read in part, .Psychiatry response from November was not in medical record. Please scan this into EMR when received and noted .
On 01/17/24 at 3:23 p.m., the DON stated they did not locate the psychiatry response. They stated it was not highlighted on the report so they did not receive it.
2. Resident #85 had diagnoses which included schizophrenia, insomnia, and major depressive disorder.
A Medical Director Report from a consulting pharmacist, dated 11/14/23, documented Resident #83 had a recent fall. It documented the resident was receiving the following medications that could contribute to or increase the risk of a fall:
a. Furosemide twice a day,
b. Guaifenesin twice a day,
c. Melatonin at bedtime,
d. Mirabegron every evening,
e. Norco every six hours
f. Quetiapine every evening,
g. Requip every evening,
h. Sertraline every day, and
i. Trazadone at bedtime. It requested the physician make any changes to the medications, document if the fall was unrelated to the medications, or document other changes.
There was no response from the physician.
A Medical Director Report from a consulting pharmacist, dated 12/19/23, documented the physician response from November was not in the medical record.
On 01/17/24 at 12:53 p.m., the corporate administrator stated their process for drug regimen reviews was the DON received the report from the pharmacist, sent it to the physician, received a response, and it would be uploaded to EHR. She looked in the EHR and was not able to locate the response.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to:
a. Ensure medications were secured for one of five me...
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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:
a. Ensure medications were secured for one of five medication/treatment carts observed for medication storage;
b. Have a system in place for an accurate account of discontinued medications awaiting destruction;
c. Ensure expired medications were removed from stock; and
d. Ensure medication room clean from debris.
The DON identified 181 residents resided in the facility. The DON identified no residents resided on Hall 500.
Findings:
A Medication storage in the facility policy, dated 2021, read in part, Medications and biologicals are stored safely, securely, and properly .The medications supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, one without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction .
a. On 01/08/24 at 8:30 a.m., a treatment cart on Hall 200 was observed to be unlocked. The cart contained resident medication cards.
On 01/08/24 at 8:31 a.m., LPN #5 stated their cart was left unlocked and their policy was to keep it locked.
b. On 01/10/24 at 3:46 p.m., room [ROOM NUMBER] was observed to be unlocked with three boxes of various medications located on the floor including:
1. 14 50 ml bags of IV Meropenem 1 g;
2. Two pens of Insulin Glargine. 142 ml in one and one with 250 ml;
3. 1/2 bottle of lactulose 10 mg/15 ml;
4. Five 100 ml bags of IV Ampicillin/Sulbactam 3 g;
5. Nine 50 ml bags of Cefazoline with dextrose 2 g
6. One 100 ml bag of Ertapenem 1 g;
7. Two pens of Flex touch insulin each with 250 ml;
8. Six 50 ml bags of IV Cefepime 2 g;
9. Four 100 ml bags of IV Metronidazole 500 mg;
10. 12 50 ml bags of Cefazolin 2 g;
11. Two 946 ml bottles of Lactulose 10 gm/15 ml;
12. 15 one ml syringes of Promethazine 25 mg/ml;
13. Two tablets of Alendronate 70 mg; and
14. Three bottles of Nitroglycerine 0.4 mg sublingual tablets.
During the observation of room [ROOM NUMBER], an unknown staff member was observed at the other end of the hall who stated they needed a private place to get sick.
On 01/10/24 at 4:00 p.m., a door labeled Med Room was observed unlocked on Hall 500. The room was full of various stacked boxes and containers of medications which included the following:
1. One clear plastic container with a blue lid with medication capsules and tablets too numerous to count;
2. One open grey container with medication tablets too numerous to count;
3. On grey rectangular container with two part lid with medication tablets and capsules too numerous to count;
4. Two open pink containers with medication capsules and tablets too numerous to count;
5. One clear plastic bag with medications capsules and tablets too numerous to count;
6. Three pen injectors of Bydureon Bcise 2 mg/0.85 ml; and
7. 12 100 ml bags of IV Cefepime 2 g, and
8. Multiple cards of prescription medications.
On 01/10/24 at 4:01 p.m., the DON stated meds are kept secured behind locked doors. They stated the policy and procedure for discontinued medications was to pull the medication from any stock and give to the unit manager, then secured behind locked door until destruction. The DON stated they were not aware of any medication in room [ROOM NUMBER]. They stated the last time they destroyed in there was 12/17/23 and there were no medications in there at that time.
On 01/10/23 at 4:04 p.m., the DON stated they were unaware why medications were in room [ROOM NUMBER] because normally they put the discontinued medications in the medication room on unit 500. The DON stated the medications should not have been in room [ROOM NUMBER] and did not know how they got there.
On 01/10/23 at 4:05 p.m., the DON stated they had punched out medications into the plastic container for destruction. They stated they did not have enough Drug Buster to destroy them, so they left them in the container.
On 01/10/23 at 4:06 p.m., The Regional Nurse Consultant stated the medications were over the counter medications, and non-controlled medications.
On 01/10/23 at 4:10 p.m., the DON was observed to pull blue tape out of the lock on the door to the unit 500 medication room. They stated they did not know who put the tape there. The DON stated they lost the key and had to break into the Med Room. The DON obtained a folded plastic sheet from the unlocked adjacent charting room and explained that was what they used to get into the room.
c. On 01/11/24 at 9:50 a.m., the nurse cart on unit 100 was observed with LPN #2. There was a bottle of antidiarrheal had an expiration date of 11/2023. A bottle of enema dated expiration 09/01/23. A bottle of stoma adhesive that expired 9/1/23. LPN #2 stated the policy and procedure for expired medications was they should not be in circulation period.
On 01/11/24 at 10:00 a.m., the unit 300 medication room was observed with LPN #2 and the unit manager for the unit. On the counter there were observations made of one box full of arginade extra with expiration date of March 2023, one glucogen emergency kit dated to use by 11/8/23 for an expired resident.
On 01/11/24 at 10:03 a.m., the unit manager for unit 300 and LPN #2 stated medications were checked for expiration before they were administered.
On 01/11/24 at 10:07 a.m., the unit manager for unit 300 stated the policy and procedure for expired medications was to get an order to discontinue and then to keep them boxed up and kept behind a locked door and destroyed. They stated they could not explain why they were in circulation other than they were missed.
d. On 01/11/24 at 10:10 a.m., there was observation of a three tier plastic cabinet in the corner of the medication room that had dust and debris on and around it. The unit manager stated maintenance is responsible for cleaning the medication rooms and stated it was not clean.
On 01/12/24 8:25 a.m., the DON stated they go through the carts once a week and remove expired meds immediately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure there was sufficient dietary staff to serve the residents in a timely manner for two of two meal services observed.
T...
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Based on observation, record review, and interview, the facility failed to ensure there was sufficient dietary staff to serve the residents in a timely manner for two of two meal services observed.
The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.
Findings:
A Mealtimes document, undated, documented breakfast was at 7:30 a.m. and lunch was at 11:30 a.m.
A Meal policy, dated 03/31/21, documented meal services were provided to residents on a regular schedule based on facility established times.
A Work Schedule, dated 01/08/24, documented one cook and one dietary aide was scheduled to work from 5:00 a.m. to 2:00 p.m. It documented one cook and two aides were scheduled to come into work at 2:00 p.m.
On 01/08/24 at 8:05 a.m., the CDM stated breakfast was served between 7:30 a.m. and 8:30 a.m. and lunch was served between 12:00 p.m. to 12:30 p.m.
On 01/08/24 at 9:37 a.m., Resident #83 stated breakfast was late again this morning.
On 01/08/24 at 9:40 a.m., Resident #484 stated they haven't received breakfast.
On 01/08/24 at 10:01 a.m., Resident #64 and #114 were seated in the hallway. Both residents stated they had not received breakfast. They were observed asking staff if they would be receiving breakfast.
On 01/08/24 at 10:31 a.m., Resident #62 received their breakfast tray.
On 01/08/24 at 10:35 a.m., LPN #2 stated breakfast was served at 8:00 a.m. They stated they thought some staff called in.
On 01/08/24 at 12:16 p.m., Resident #146 stated they didn't receive breakfast this morning.
On 01/08/24 12:26 p.m., LPN #1 stated lunch was usually at 12:00 p.m. They stated breakfast was late this morning.
On 01/08/24 at 12:37 p.m., Resident #114 stated they didn't receive breakfast today.
On 01/08/24 at 12:53 p.m., multiple residents were observed in the main dining room. No residents have a received a meal tray.
On 01/08/24 at 1:03 p.m., eight residents were observed in the dining room on hall 600. No residents have received a meal tray.
On 01/08/24 at 1:05 p.m., Resident #64 stated meals were always served late.
On 01/08/24 at 1:11 p.m., multiple residents were observed in the dining room on hall 100. No residents have received a meal tray.
On 01/08/24 at 1:26 p.m., the first tray was delivered to Resident #60 in the main dining room.
On 01/08/24 1:50 p.m., the first tray was delivered to a resident on hall 100.
On 01/08/24 at 2:00 p.m., CNA #6 stated hall 300 had not received meal cart.
On 01/08/24 at 2:05 p.m., lunch trays arrived to hall 600.
On 01/08/24 at 2:36 p.m., Resident #24 was served lunch.
On 01/08/24 at 2:39 p.m., the last lunch tray was served.
On 01/10/24 at 1:31 p.m., the CDM stated they had a system at their old job where staff would prep the day before. She stated, So we wouldn't be struggling like we are now. The CDM stated they have been trying to get staff to prep the day before because it was time consuming. She stated on 01/08/24 there was one cook and one aide, until the she arrived. The CDM stated six to seven staff were required in the morning to have sufficient staff for the meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure the menu was followed for one of two meal services observed.
The DON identified 181 residents resided in the facility....
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Based on observation, record review, and interview, the facility failed to ensure the menu was followed for one of two meal services observed.
The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.
Findings:
A Menu Substitutions Log, dated 01/08/24, documented roasted turkey and mixed vegetables will be served.
On 01/08/24 at 11:18 a.m., the CDM stated lunch was turkey, gravy, rice, mixed vegetables or roasted broccoli and cauliflower, and a roll.
On 01/08/24 at 2:27 p.m., DA #1 stated they were out of vegetables and turkey. They were observed to put hamburgers, rice and a roll on six meal trays.
On 01/10/24 at 1:31 p.m., the CDM stated they followed a weekly menu. They stated they didn't have enough turkey on 01/08/24 and served hamburgers when they ran out.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure a therapeutic diet was served as ordered for two (#130 and #59) of two sampled residents reviewed for diets.
The DON i...
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Based on observation, record review, and interview, the facility failed to ensure a therapeutic diet was served as ordered for two (#130 and #59) of two sampled residents reviewed for diets.
The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.
Findings:
1. Resident #130 had diagnoses which included dysphagia.
An Order Summary Report, dated 08/23/22, Resident #130 was to receive a ground meat with honey thicken liquids.
On 01/08/24 at 2:36 p.m., Resident #130 was observed to receive their lunch meal. A hamburger was observed on the tray.
On 01/08/24 at 2:43 p.m., CMA #1 was observed to bring medication and a cup of regular water to Resident #130. Resident #130 was observed to take their medication and drank the regular water.
On 01/08/24 at 2:45 p.m., CMA #1 stated they looked at the meal ticket so they knew what diet the resident was to receive. They stated Resident #130's ticket documented the resident was to receive ground meat and honey thicken liquids. They stated the hamburger was not ground meat. They stated the water was suppose to have been thickened.
On 01/10/24 at 1:31 p.m., the CDM stated staff followed meal tickets to ensure diets were followed.
2. Resident # 59 has diagnoses which included dysphagia.
A Physician Order, dated 03/15/22, documented Resident #59 was to be given a regular diet with a mechanical soft texture.
A dietary meal card, dated 01/08/24 lunch, documented Resident #59 had physician orders for a mechanical soft.
On 01/08/24 at 2:06 p.m., Resident #59 was observed to receive large chucks of turkey for lunch. A family member stated the resident didn't have teeth and couldn't eat regular food.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure meals were served in a timely manner for two of two meal services observed.
The DON identified 181 residents resided ...
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Based on observation, record review, and interview, the facility failed to ensure meals were served in a timely manner for two of two meal services observed.
The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.
Findings:
A Mealtimes document, undated, documented breakfast was at 7:30 a.m. and lunch was at 11:30 a.m.
A Meal policy, dated 03/31/21, documented meal services were provided to residents on a regular schedule based on facility established times.
On 01/08/24 at 8:05 a.m., the CDM stated breakfast was served between 7:30 a.m. and 8:30 a.m. and lunch was served between 12:00 p.m. to 12:30 p.m.
On 01/08/24 at 9:37 a.m., Resident #83 stated breakfast was late again this morning.
On 01/08/24 at 9:40 a.m., Resident #484 stated they haven't received breakfast.
On 01/08/24 at 10:01 a.m., Resident #64 and #114 were seated in the hallway. Both residents stated they had not received breakfast. They were observed asking staff if they would be receiving breakfast.
On 01/08/24 at 10:31 a.m., Resident #62 received their breakfast tray.
On 01/08/24 at 10:35 a.m., LPN #2 stated breakfast was served at 8:00 a.m. They stated they thought some staff called in.
On 01/08/24 at 12:16 p.m., Resident #146 stated they didn't receive breakfast this morning.
On 01/08/24 12:26 p.m., LPN #1 stated lunch was usually at 12:00 p.m. They stated breakfast was late this morning.
On 01/08/24 at 12:37 p.m., Resident #114 stated they didn't receive breakfast today.
On 01/08/24 at 12:53 p.m., multiple residents were observed in the main dining room. No residents have a received a meal tray.
On 01/08/24 at 1:03 p.m., eight residents were observed in the dining room on hall 600. No residents have received a meal tray.
On 01/08/24 at 1:05 p.m., Resident #64 stated meals were always served late.
On 01/08/24 at 1:11 p.m., multiple residents were observed in the dining room on hall 100. No residents have received a meal tray.
On 01/08/24 at 1:26 p.m., the first tray was delivered to Resident #60 in the main dining room.
On 01/08/24 1:50 p.m., the first tray was delivered to a resident on hall 100.
On 01/08/24 at 2:00 p.m., CNA #6 stated hall 300 had not received meal cart.
On 01/08/24 at 2:05 p.m., lunch trays arrived to hall 600.
On 01/08/24 at 2:36 p.m., Resident #24 was served lunch.
On 01/08/24 at 2:39 p.m., the last lunch tray was served.
On 01/10/24 at 1:31 p.m., the CDM stated they had a system at their old job where staff would prep the day before. She stated, So we wouldn't be struggling like we are now. The CDM stated they have been trying to get staff to prep the day before because it was time consuming.
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 and interview, the facility failed to ensure food items were covered for one of two meal services observed.
The DON identified 181 residents resided in the facility. She identifie...
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Based on observation and interview, the facility failed to ensure food items were covered for one of two meal services observed.
The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.
Findings:
On 01/08/24 at 10:32 a.m., bowls of hot cereal and a bowl of eggs on the hall trays on hall 200 cart was not observed to be covered.
On 01/08/24 at 10:35 a.m., CMA #3 was asked if the if the bowls of cereal and eggs were covered. They stated they weren't covered.
On 01/10/24 at 1:31 p.m., the CDM stated food was to be covered before it left the kitchen.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure staff donned PPE while performing COVID-19 testing on residents.
The DON identifed 181 residents resided in the facili...
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Based on observation, record review, and interview, the facility failed to ensure staff donned PPE while performing COVID-19 testing on residents.
The DON identifed 181 residents resided in the facility.
Findings:
A COVID-19 Testing policy, dated 09/02/20, documented staff were to maintain proper infection control by wearing full PPE during specimen collection.
On 01/08/24 at 10:28 a.m., RN #2 was observed performing COVID-19 testing on residents on hall 200. RN #2 was observed to wear a surgical mask and gloves. They were not observed to have on gown or goggles.
On 01/08/24 at 10:59 a.m., RN #2 stated they wore a mask and gloves for testing. They stated more PPE was worn if a resident was symptomatic or they worked on the COVID-19 hall.
On 01/17/24 at 2:04 p.m., DON reviewed the policy and stated gown, gloves, N95 mask, and face shield was to be worn when performing COVID-19 testing.
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 ensure pneumococcal vaccine was offered to two (#113 and #79) and ensure influenza vaccine was offered to one (#79) of five sampled residen...
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Based on record review and interview, the facility failed to ensure pneumococcal vaccine was offered to two (#113 and #79) and ensure influenza vaccine was offered to one (#79) of five sampled residents reviewed for vaccines.
The DON identified 181 residents resided in the facility.
Findings:
An Influenza Vaccine policy, dated 04/28/22, documented residents will be offered the influenza vaccine on an annual basis.
A Pneumococcal Vaccine policy, dated 04/28/22, documented residents will be offered the pneumococcal vaccine upon admission.
There was no documentation Resident #79 had received/refused the influenza or pneumococcal vaccine.
There was no documentation Resident #113 had received/refused the pneumococcal vaccine.
On 01/17/24 at 1:27 p.m., the Corporate Regional Nurse Consultant stated they would ask the IP if there was a binder with vaccine documentation.
No documentation was provided prior to exit.
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 F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure call devices were in working order for one of six halls sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure call devices were in working order for one of six halls sampled for call devices.
The DON identified 181 residents resided in the facility.
Findings:
A facility policy titled, Resident Call System, dated 10/20/22, read in part, .The facility call system relays calls directly to a centralized work area from the residents bedside, toilet, and bathing area. The call system is accessible to a resident lying on the floor as required by state/federal guidelines .Upon admission nursing will orientate resident to accessing the resident call system .During rounds nursing & IDT team members will ensure resident call system is within reach of the resident .In the even resident call system is down: call bells will be utilized until power is restored .Maintenance Director will complete routine resident call system inspections .
On 01/08/24 at 8:09 a.m., an observation was made of the call light cord hanging over the call system box in room [ROOM NUMBER].
On 01/08/24 at 8:15 a.m., an observation was made of no call light cord attached to the call system box in room [ROOM NUMBER].
On 01/08/24 at 8:19 a.m., observation was made of two call light cords tied together and hanging over the call system box in room [ROOM NUMBER]
On 01/08/24 at 8:32 a.m., CNA #3 stated the call light was not in working order for room [ROOM NUMBER].
On 01/08/24 at 8:39 a.m., an observation was made of no call light cord attached to the call system box in room [ROOM NUMBER].
On 01/08/24 at 8:46 a.m., CNA #3 stated they did not see a call cord attached to the call system box. They stated they did not know how long it had been missing.
On 01/08/24 at 8:48 a.m., an observation was made of no call light cord attached to the call system box in room [ROOM NUMBER].
On 01/08/24 at 8:52 a.m., RN #3 stated there was no working call light in room [ROOM NUMBER]. They stated they were going to ask CNA #5 about the call light. CNA #5 stated the call light was not working.
On 01/10/24 at 9:39 a.m. CNA #5 stated there had not been a call light placed in 110.
On 01/11/24 at 2:16 p.m., the maintenance assistant stated all the call lights on hall 100 had been down since the first of the week.
On 01/11/24 at 2:45 p.m., the DON stated the facility policy for call lights in rooms was the residents were to have a call light within reach and it should be in working order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure a pest free environment.
The DON identified 181 residents resided in the facility. She identified two residents received nutrition and...
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Based on observation and interview, the facility failed to ensure a pest free environment.
The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.
Findings:
On 01/08/24 at 8:00 a.m., the dish washing area in the kitchen was observed. Two food traps were observed full of left over food. Three live cockroaches were observed climbing on the walls, two live cockroaches were on the floor, and one dead cockroach on the floor under the sink.
On 01/08/24 at 8:25 a.m., the CDM stated they have been having pest problems. She stated they tell the administrator when they see them. She stated she thought they sprayed last week.
On 01/08/24 at 2:25 p.m., a live cockroach was observed crawling on the floor in the kitchen area where staff were preparing lunch trays.
On 01/10/24 at 10:27 a.m., Resident #6 was observed laying in bed sleeping. One large live cockroach was observed on the wall next to Resident #6.
On 01/10/24 at 10:29 a.m., Resident #6 was observed awake. They stated they have seen cockroaches in their room. They stated they lay there and watch them.
On 01/10/24 at 1:31 p.m., the CDM stated staff were to clean the food traps every night when they were done.
On 01/10/24 at 1:47 p.m., the CDM stated when the facility sprayed for pests, cockroaches run into the kitchen, and staff step on them.
On 01/17/24 at 9:25 a.m., the maintenance supervisor stated the pest control company comes out monthly and as needed. He stated they had an infestation approximately seven to eight months ago. He denied a current pest problem.
May 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician and family were notified for a change in condi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician and family were notified for a change in condition for one (#1) of three sampled residents reviewed for notification of changes.
The Resident Census and Conditions of Residents form, dated 05/01/23, documented 168 residents resided in the facility.
Findings:
A Notification Of A Change In A Resident's Condition policy, reviewed 04/28/21, read in parts, .The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations .Document in the Interdisciplinary Team (IDT) Notes .Resident Change in Condition .Physician/Physician Extender Notification .Notification of Resident Representative .
Resident #1 admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia and COPD.
An annual assessment, dated 04/04/23, documented Resident #1's cognition was intact and they required setup to extensive assistance with ADL's.
An admission Note, dated 04/09/23 at 10:48 p.m., documented, Resident confused and in and out of consciousness when I arrived to his room, aroused with sternal run [sic], he is asking if he is going to make it. He is purse lip breathing and VS 157/87, 77, 22, 97.9 91% on 3 liters NC. Call placed to [named] about sending resident to the ER. possible C02 to high causing the delusions. Permission to send him out. EMSA called and here to transport him to [hospital]. The incident did not document notification of physician or family representative.
On 05/02/23 at 3:35 p.m., the DON stated facility policy was to notify the physician and the family when sending someone out to the hospital or a change in condition. The DON stated the family representative had not been notified of the transfer.
On 05/02/23 at 3:47 p.m., LPN #1 was asked if they had notified the family representative of resident being sent to the hospital. They stated that night he was a full code and I didn't call the family, I just sent him out.
Feb 2023
1 deficiency
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility failed to:
a. ensure cooked items were stored,covered and labeled with dates in the walk-in,
b. ensure food items were not stored on th...
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Based on record review, observation, and interview, the facility failed to:
a. ensure cooked items were stored,covered and labeled with dates in the walk-in,
b. ensure food items were not stored on the floor,
c. ensure raw meats were not stored with or above uncooked food items, and
d. clean a food processor container and blade using standardized cleaning practices between uses.
The Resident Census and Condition of Residents report, dated 01/14/23, documented 174 residents resided in the facility. The Administrator identified two residents who did not receive nutrition from the kitchen.
Findings:
A Refrigeration policy, effective 03/31/21, read in parts, .All leftovers shall be labeled and dated with expiration date of no more than three days . Stock labeled with dates when received include month day and year. Raw foods, including raw meats, fish and egg shall be stored on the lower shelves of the refrigeration units. Cooked and ready-to-eat foods shall be stored above raw food and foods that are thawing. Foods, being thawed, other than those in single service containers, must be placed on a pan or container which enfolds the entire product. Items must be thawed separately it must be held in separate pans or containers, and dated when pulled. Cooked meats such as ham, lunch meat .must be thawed and pans/containers above storage of raw foods .Open leftover condiments such as salad dressing, ketchup, mustard, pickles, relishes shall be dated with 30-day expiration date .
A Warewashing policy, effective 03/31/21, read in parts, .Tableware and supplies shall be washed and sanitized according to food safety practices and regulatory guidelines .All tableware, utensils, preparation, and service supplies shall be washed and sanitized in the pot sink and/or through the use of a commercially approved dish machine .The pot sink shall be three (3) sink unit with a detergent in the first sink, a clear rinse water in the second, and a sanitizer in the third and final sink. Pots and pans washed in the pot sink may be sanitized in the dish machine .
On 02/14/23 at 9:16 a.m., [NAME] #1 was observed washing the food processor and a pan in a two compartment sink only using blue dawn dish soap. They rinsed the pan and food processor container and blade with warm water. No sanitizer was used.
On 02/14/23 at 9:24 a.m., there were left over cooked hamburger patties undated, undated cooked pasta with meat and red sauce, three cooked hams open and uncovered without dates, grape jelly with foreign contaminates covered in plastic without dates, pimento spread opened and undated, and cream of wheat leftovers covered in plastic with no dates or labels observed in the walk-in refrigerator.
On 02/14/23 at 9:24 a.m., uncooked roast beef was observed stored above uncooked raw onions in the walk-in refrigerator. Cheese wrapped in plastic was stored in the same container as thawing out roast beef, raw meat juices were observed leaking into the cheese.
On 02/14/23 at 09:24 a.m., three boxes of ground beef were observed stored on the floor in the walk-in refrigerator.
On 02/14/23 at 9:50 a.m., the ACDM was asked what the policy was for washing the food processor. They stated it would be washed and sanitized in the dishwasher. They were asked if dawn dish soap and luke warm water was acceptable. They stated,No.
On 02/14/23 at 10:10 a.m., [NAME] #1 was asked about the left overs in the walk-in and what were the policies for left overs and food storage. They stated the onions should not be stored under the meat. They were asked specifically about the jelly and foreign contaminants observed. They stated they were unsure when it was opened or put in the walk-in. They were asked what were the policies for food storage. They stated that the ground beef was placed on the floor when truck delivered the day prior. They stated the boxes were on the floor to open them. They stated food should never be stored on the floor. They were asked what the policies were for left overs and open food in the walk-in. They stated everything should be labeled and dated when opened or put in the walk-in. They were asked if pasta with red sauce, hamburger patties, cream of wheat, and jelly were labeled with dates in the walk-in. They stated, No. They were asked if the opened cooked hams were covered and labeled in the walk-in. They stated, No, I opened them yesterday.
On 02/14/23 at 10:15 a.m., the ACDM was asked about the ground beef on the walk-in floor and undated left overs. They stated, It should not be there. They stated the jelly was undated. They were asked, how do you know what was safe to serve. They stated, You can't tell.
On 02/14/23 at 10:37 a.m., the CDM was asked what was the policy for food storage in the walk-in. They stated all items should be wrapped, sealed, dated, and labeled. They were asked what about the leftover policy. They stated items could be held up to three days after they were cooled and labeled with dates. They were asked if left overs in the walk-in were labeled with dates. They replied, No. They were asked about policies regarding storing food on the floor. They stated, food should not be stored on the floor.
On 02/14/23 at 10:55 a.m., the CDM was asked what the policy was for washing dishes and food preparation equipment. They stated, Wash, rinse and sanitize in luke warm water. The CDM was asked what the sanitize water temperature should be. They stated, 98 F. The CDM stated they were told to not use sanitizer on food processor parts because it would contaminate the food. The CDM was asked about the raw meat stored over uncooked onions. They stated that the onions should not of been stored under the meat.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 42% turnover. Below Oklahoma's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), Special Focus Facility, 2 harm violation(s), $240,907 in fines, Payment denial on record. Review inspection reports carefully.
- • 57 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $240,907 in fines. Extremely high, among the most fined facilities in Oklahoma. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is South Pointe Rehabilitation And Care Center's CMS Rating?
CMS assigns South Pointe Rehabilitation and Care Center an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Oklahoma, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is South Pointe Rehabilitation And Care Center Staffed?
CMS rates South Pointe Rehabilitation and Care Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 42%, compared to the Oklahoma average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at South Pointe Rehabilitation And Care Center?
State health inspectors documented 57 deficiencies at South Pointe Rehabilitation and Care Center during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 53 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates South Pointe Rehabilitation And Care Center?
South Pointe Rehabilitation and Care Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MGM HEALTHCARE, a chain that manages multiple nursing homes. With 375 certified beds and approximately 173 residents (about 46% occupancy), it is a large facility located in Oklahoma City, Oklahoma.
How Does South Pointe Rehabilitation And Care Center Compare to Other Oklahoma Nursing Homes?
Compared to the 100 nursing homes in Oklahoma, South Pointe Rehabilitation and Care Center's overall rating (1 stars) is below the state average of 2.6, staff turnover (42%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting South Pointe Rehabilitation And Care Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is South Pointe Rehabilitation And Care Center Safe?
Based on CMS inspection data, South Pointe Rehabilitation and Care Center has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Oklahoma. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at South Pointe Rehabilitation And Care Center Stick Around?
South Pointe Rehabilitation and Care Center has a staff turnover rate of 42%, which is about average for Oklahoma nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was South Pointe Rehabilitation And Care Center Ever Fined?
South Pointe Rehabilitation and Care Center has been fined $240,907 across 3 penalty actions. This is 6.8x the Oklahoma average of $35,488. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is South Pointe Rehabilitation And Care Center on Any Federal Watch List?
South Pointe Rehabilitation and Care Center is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.