Fort Gibson Care & Rehab Center

In the surveyor’s words

From the most serious findings on record at Fort Gibson Care & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 15, 2025

  Based on observation, record review, and interview, the facility failed to update and implement individualized fall interventions in the care plan for a resident who fell and sustained a head injury for one (#47) of one sampled resident reviewed for falls. The DON identified 17 residents who had fallen in the past three months. Findings: A policy titled FALL MANAGEMENT, read in parts, To provide an environment that remains as free of accident hazards as possible. The Facility will complete a Morse Fall Scale Evaluation on Residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further Falls and/or reduce injuries .Identified risk factors should be addressed in the Resident's Care-Plan… […]

• No harm, potential for more than minimal, patternF688Jan 15, 2025

  Based on observation, record review, and interview, the facility failed to ensure a resident received restorative services to maintain or improve their ability to carry out activities of daily living for one (#26) of one sampled resident reviewed for activities of daily living. The DON identified nine residents who were currently receiving restorative services. Findings: A document titled Policy and Procedure Range of Motion, read in parts, To exercise the resident's joints and muscles as required and/or clinically indicated .Verify exercise to be completed with physician's orders or treatment plan. Unless otherwise specified, repeat each exercise (3) times. There was no policy regarding restorative services provided. […]

• No harm, potential for more than minimal, patternF812Jan 15, 2025

  Based on observation, record review, and interview, the facility failed to ensure: a. the ovens were clean; b. foods were labeled and dated in the refrigerator; and c. the ice scoop was maintained in a sanitary manner. The administrator identified 51 residents resided in the facility. Findings: A policy titled Ice Machine, read in parts, The ice machine, scoop, and storage container will be maintained in a clean and sanitary condition .The scoop and storage container will be cleaned once per day. A policy titled Refrigeration, read in part, Foods shall be stored in an organized manner and shall be maintained in their original containers unless they are considered a leftover. […]

• No harm, potential for more than minimal, patternF880Jan 15, 2025

  Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions were utilized during resident care for one (#32) of one sampled resident observed during care. The administrator identified 11 residents that required enhanced barrier precautions. Findings: An Enhanced Barrier Precautions (EBP) policy, last reviewed on 05/15/24, read in part, enhanced barrier precautions refer to the use of gowns and gloves during high-contact resident care provides opportunities for transfer of multidrug resistant organisms to hands or clothing. […]

• No harm, potential for more than minimal, patternF812Sep 20, 2023

  Based on observation and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The Resident Census and Conditions of Residents form documented 45 residents resided at the facility. Findings: On 09/14/23 at 12:21 p.m., an initial tour of the kitchen and food storage areas was conducted. On 09/14/23 at 12:30 p.m., the ice machine in the kitchen was wiped from the ice drop with a clean white paper towel. The paper towel was observed with a black substance on it. At that time the DM observed the black substance. The DM stated the ice machine had been cleaned on 07/18/23. The DM stated the maintenance man and the DM cleaned the ice machine. On 09/14/23 at 12:37 a.m., a hand sanitizer dispenser was observed on the wall inside the kitchen door. […]