Every finding on record at Heavener Nursing & Rehab

Based on record review and interview, the facility failed to ensure a resident did not physically abuse another resident for 1 (#11) of 5 sampled residents reviewed for abuse. The DON identified 69 residents resided in the facility. Findings: An undated Abuse Policy and Procedure, read in part, We will endeavor to protect our occupants from maltreatment, which means any exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of property. A nurse progress note, dated 12/22/25, showed Resident #11 tried to take a plate of food from another unnamed resident. The unnamed resident refused to release the tray. The note showed Resident #11 grabbed the unnamed resident's arm and clawed them. The altercation resulted in a skin tear to unnamed resident's right forearm with moderate bleeding. The note showed the two residents then tried to hit each other but were separated by CNAs and nurse. The note showed Resident #11 had been up all night wandering around taking things that were not theirs. A quarterly assessment, dated 04/27/26, showed Resident #11 was admitted on [DATE] and had a brief interview for mental status score of 1 indicating severe cognitive impairment. The assessment showed Resident #11 was diagnosed with Alzheimer's dementia. On 06/09/26 at 12:28 p.m., the DON stated Resident #11 had not hurt other residents, but Resident #11 was combative towards staff when they were trying to provide care. The DON stated Resident #11's medications had changed about two months ago during their last geriatric psychiatric hospitalization, and they had been pleasant since their return. On 06/10/26 at 12:54 p.m., LPN #1 stated At 1:30 p.m. every day, [Resident #11] would decide they were done with us. LPN #1 stated Resident #11 would then start to become more combative towards staff trying to provide care. LPN #1 stated Resident #11 had been to geriatric psychiatric facilities at least twice and had tried three different psychotropic medications. LPN #1 stated the hospital had prescribed lower potency drugs initially and then prescribed higher potency medications when the resident returned to the hospital. LPN #1 stated since Resident #11 came back from the hospital the second time, the medications had helped Resident #11 allow staff to provide care. On 06/11/26 at 2:36 p.m., the DON was provided the progress note written on 12/22/25. The DON stated they had not known about the incident, but it should have been reported.

Based on observation and interview, the facility failed to ensure infection control was maintained during finger stick blood sugar checks and insulin injections for 7 (#12, 13, 14, 15, 16, 17, and #18) of 7 sampled residents observed for infection control. The regional consultant identified 19 residents required finger stick blood sugar checks. Findings: On 06/10/26 at 12:02 p.m., LPN #1 was observed obtaining Resident #12's FSBS. LPN #1 lanced Resident #12's finger and obtained a blood sample using a glucometer. LPN #1 was not observed to have cleaned the glucometer after the procedure. On 06/10/26 at 12:04 p.m., LPN #1 was observed obtaining Resident #13's FSBS. LPN #1 lanced Resident #13's finger and obtained a blood sample using a glucometer. LPN #1 was not observed to have cleaned the glucometer after the procedure. On 06/10/26 at 12:08 p.m., LPN #1 was observed administering an insulin injection to Resident #13. LPN #1 was not observed to have worn gloves during the insulin injection. On 06/10/26 at 12:10 p.m., LPN #1 was observed obtaining Resident #14's FSBS. LPN #1 lanced Resident #14's finger and obtained a blood sample using a glucometer. LPN #1 was not observed to have cleaned the glucometer after the procedure. On 06/10/26 at 12:13 p.m., LPN #1 was observed administering an insulin injection to Resident #14. LPN #1 was not observed to have worn gloves during the insulin injection. On 06/10/26 at 12:15 p.m., LPN #1 was observed obtaining Resident #15's FSBS. LPN #1 lanced Resident #15's finger and obtained a blood sample using a glucometer. LPN #1 was not observed to have cleaned the glucometer after the procedure. LPN #1 was not observed to wash or sanitize their hands after the procedure. On 06/10/26 at 12:21 p.m., LPN #1 was observed obtaining Resident #16's FSBS. LPN #1 lanced Resident #16's finger and obtained a blood sample using a glucometer. LPN #1 was not observed to have cleaned the glucometer after the procedure. LPN #1 was not observed to wash or sanitize their hands after the procedure. On 06/10/26 at 12:28 p.m., LPN #1 was observed obtaining Resident #17's FSBS. LPN #1 lanced Resident #17's finger and obtained a blood sample using a glucometer. LPN #1 was not observed to have cleaned the glucometer after the procedure. On 06/10/26 at 12:34 p.m., LPN #1 was observed obtaining Resident #18's FSBS. LPN #1 lanced Resident #18's finger and obtained a blood sample using a glucometer. LPN #1 was not observed to have cleaned the glucometer after the procedure and before placing the glucometer back into the medication cart. LPN #1 was not observed to wash or sanitize their hands after the procedure. On 06/10/26 at 12:39 p.m., LPN #1 stated the process to obtain a FSBS was to sanitize the skin and poke the side of the finger. LPN #1 stated they had two glucometers they would alternate use of to allow for sanitization, but one of the glucometers had been misplaced.On 06/11/26 at 2:35 p.m., the DON stated the glucometer should have been cleaned between each resident.

Based on record review and interview, the facility failed to report an allegation of physical abuse for 1 (#11) of 1 sampled resident reviewed for abuse. The DON identified 69 residents resided in the facility. An undated Abuse Policy and Procedure, read in part, All allegations of resident maltreatment, including neglect, physical abuse .shall be promptly reported to Administrator and investigated by Facility management. Administrator will immediately report the allegation to the Oklahoma State Department of Health and the Local Police. An Acknowledgement of Resident Rights Training which includes Abuse, Neglect, Misappropriation of Property and Burnout, signed by RN #1 on 08/23/25, read in part, I understand the definition of abuse .I also understand when and to whom I am to report any violation of resident rights and what my participation is expected to be during any investigation of an allegation of such. Two actions to be taken immediately are stopping the abuse and reporting it to my supervisor/administrator immediately upon finding, I understand that any violation of resident rights can result in a variety of disciplinary actions up to termination of employment. A nurse progress note signed by RN #1, dated 12/22/25, showed Resident #11 tried to take a plate of food from another unnamed resident. The unnamed resident refused to release the tray and Resident #11 grabbed the unnamed resident's arm and clawed them. The note showed the altercation resulted in a skin tear to the unnamed resident's right forearm with moderate bleeding. The two residents then tried to hit each other but were separated by CNAs and a nurse. The note showed Resident #11 had been up all night wandering around taking things that were not theirs. A quarterly assessment, dated 04/27/26, showed Resident #11 was admitted on [DATE] and had a brief interview for mental status score of 1 indicating severe cognitive impairment. The assessment showed Resident #11 had a diagnosis of Alzheimer's dementia. On 06/09/26 at 12:28 p.m., the DON stated Resident #11 had not hurt other residents, but Resident #11 was combative towards staff when they were trying to provide care. The DON stated Resident #11's medications had changed about two months ago during their last geriatric psychiatric hospitalization, and they had been pleasant since their return. On 06/11/26 at 2:36 p.m., the DON was provided the progress note written on 12/22/25. The DON stated they had not known about the incident, but it should have been reported.

Based on record review and interview, the facility failed to ensure residents were allowed to have visitors of their choice for 1 (#1) of 3 sampled who were reviewed for visitation. The administrator identified 71 residents resided in the facility. Resident #1's face sheet, dated 01/22/25, showed the resident had diagnoses which included depression and hypertension. A quarterly MDS, dated [DATE], showed the residents cognition was moderately impaired with a BIMS score of 11. An undated policy titled, Visitation, read in part, 2. The facility provides 24-hour access to all individuals visiting with the consent of the resident. On 05/21/25 at 8:20 a.m., Resident #1 stated their grandson would not allow the resident's daughter to visit them in their room. Resident #1 stated they had discussed this with the social services director but nothing was done about it. Resident #1 stated they would like to have their daughter visit in their room for privacy, but their grandson had told the staff they wanted a witness to their visits. The resident stated there was constant arguing between the daughter and the resident's grandson. On 05/21/25 at 8:39 a.m., the housekeeping supervisor looked into the resident's file and stated the Resident #1's grandson does not have power of attorney and the resident was their own person. On 05/21/25 at 8:45 a.m., the housekeeping supervisor called the social services director who stated the resident's grandson does not have power of attorney. On 05/21/25 at 10:02 a.m., LPN #1 stated the grandson did not want the Resident #1's daughter to visit because the resident was always upset after the visits and the grandson wanted witnesses to the visits. They were following the grandson's instructions to only allow visits in the lobby or outside. LPN #1 looked in the resident's record and stated the resident did not have a power of attorney listed. On 05/22/25 at 10:25 a.m., the administrator stated they were not aware the resident's grandson was restricting visitation.

Based on record review and interview, the facility failed to ensure a comprehensive assessment was completed within fourteen days after admission for 2 (#58 and #70) of 2 sampled residents reviewed for assessments. The regional director of operations identified four residents who had been admitted to the facility in the last 30 days. Findings: 1. Res #58 was admitted on [DATE] with diagnoses which included type II diabetes mellitus and bipolar disorder. The clinical record contained no comprehensive admission assessment. 2. Res #70 was admitted on [DATE] with diagnoses which included Parkinson's disease and protein-calorie malnutrition. The clinical record contained no comprehensive admission assessment. On 04/03/25 at 1:20 p.m. the MDS coordinator stated they were behind in completing comprehensive admission assessments. They stated a comprehensive admission assessment for Res #58 and Res #70 had not been completed since admission. The MDS coordinator stated the comprehensive admission assessment for Res #58 and Res #70 should have been completed within 14 days of admission.

Based on record review and interview, the facilty failed to ensure a quarterly assessment was completed for 5 (#23, 27, 40, 41, and #46) of 13 residents sampled for MDS assessments. The regional director of operations identified 65 residents resided in the facility. Findings: 1. Res #23 had an annual assessment dated [DATE]. A quarterly assessment with a reference date of 01/19/25 was not completed. 2. Res #27 had an annual assessment dated [DATE]. A quarterly assessment with an assessment reference date of 01/06/25 was not completed. 3. Res #40 had a discharge-return anticipated assessment dated [DATE] and an entry assessment dated [DATE]. A quarterly assessment with an assessment reference date of 12/11/24 was not completed. 4. Res #41 had a significant change assessment dated [DATE]. A quarterly assessment with a reference date of 02/26/25 was not completed. 5. Res #46 had a quarterly assessment dated [DATE]. A quarterly assessment with a reference date of 01/08/25 was not completed. On 04/03/25 at 1:05 p.m., the MDS coordinator stated they were behind on completing many of the residents' assessments. They stated the quarterly assessments should have been completed within three months of the last assessment.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed: a. upon admission to the facility for 2 (#58 and #70) of 2 residents sampled for new admissions; b. for bed rail use for 2 (#13 and #41) of 2 residents sampled for accidents; and c. for hospice services for 1 (#46) of 1 resident sampled for hospice services. The regional director of operations identified 65 residents resided in the facility. They identified four residents who were admitted in the last thirty days. Findings: 1. Res #58 was admitted on [DATE] with diagnoses which included type II diabetes mellitus and bipolar disorder. The clinical record contained no comprehensive care plan. 2. Res #70 was admitted on [DATE] with diagnoses which included Parkinson's disease and protein-calorie malnutrition. The clinical record contained no comprehensive care plan. On 04/03/25 at 1:29 p.m. the MDS coordinator stated they were behind in developing care plans. They stated a comprehensive care plan for Res #58 and Res #70 had not been completed since admission. The MDS coordinator stated the comprehensive care plans should have been completed within 21 days of admission. They stated Res #58's care plan should have been completed by 03/24/25 and Res #70's care plan should have been completed by 03/25/25. 43023 3. On 04/01/25 at 9:18 a.m., Res #13 was observed resting in bed with their eyes closed. Half rails were observed in use on both sides of the bed. Res #13 admitted to the facility with diagnoses which included cerebral infarction, diabetes mellitus, and unspecified dementia. A care plan, dated 01/2025, showed no documentation of bed rails. On 04/03/25 at 11:50 a.m., the MDS coordinator stated the bed rails should have been care planned. 4. On 04/01/25 09:27 a.m., Res #41 was observed resting in bed with their eyes closed. Half rails were observed on both sides of the bed. Res #41 admitted to the facilty with diagnoses which included metabolic encephalopathy and chronic kidney disease. A care plan, dated 02/2025, showed no documentation of bed rails. On 04/03/25 at 11:50 a.m., the MDS coordinator stated the bed rails should have been care planned. 5. Res #46 admitted to the facility with diagnoses which included dementia, anxiety, and depressive disorders. A physician's order, dated 02/06/25, showed to admit to hospice. A care plan, dated 01/2025, did not that show hospice was implemented on the care plan. On 04/03/25 at 11:49 a.m., the MDS coordinator stated the care plan should have been developed to implement hospice.

Based on observation, record review, and interview, the facility failed to ensure a resident who entered the facility with an indwelling urinary catheter had a physician order and was assessed for the use for 1 (#7) of 1 sampled resident reviewed for the use of an indwelling urinary catheter. The DON identified 11 residents with indwelling urinary catheters. Findings: On 03/31/25 at 1:10 p.m., the resident was lying in a low bed and had a indwelling urinary catheter hanging from their bedside. Resident #7 had diagnoses which included urinary tract infection and diabetes mellitus. A 5 day assessment, dated 02/13/25, showed the resident was cognitively intact and had a BIMS score 12. The assessment showed the resident was always continent of bladder. A treatment administration record/medication administration record for April 2025 did not show catheter care for the resident. There was no current physician order for an indwelling catheter when Resident #7 returned from the hospital on 03/21/25. On 03/31/25 at 1:14 p.m., the resident stated they had the indwelling urinary catheter when they returned from the hospital. The resident stated they were not sure why they had the indwelling urinary catheter. On 04/02/25 at 8:54 a.m., LPN/charge nurse #1 stated the resident returned from the hospital on 03/21/25 with the indwelling urinary catheter. The LPN reviewed the resident's clinical record and stated they could not find a physician order, physician care orders, or a diagnosis for the need of the indwelling urinary catheter. On 04/02/25 at 9:09 a.m., the DON reviewed the resident's clinical record and stated they could not find physician care orders or a diagnosis of the need of an indwelling urinary catheter. The DON stated they were not aware the resident had an indwelling urinary catheter. The DON stated per the facility policy if a resident returned to the facility with a catheter and did not have an order for the catheter, the catheter would be removed within 24 hours.

Based on record review and interview, the facility failed to provide all monthly medication regimen reviews from January 2024 through February 2025 for 5 (#20, 23, 37, 41, and #49) of 5 sampled residents reviewed for unnecessary medications. The DON identified 65 residents resided in the facility. Findings: A policy titled Monthly Medication Regimen Reviews, revised May 2024, read in part, The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medications. Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated .Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. 1. Res #49 was admitted with diagnoses which included dementia and bipolar disorder. A quarterly assessment, dated 11/30/24, showed Res #49 was cognitively intact with a BIMS score of 14 and had no depression or behaviors. The assessment showed Res #49 received antipsychotic, antidepressant, anticoagulant, hypoglycemic, and opioid medications. On 04/01/25 at 1:00 p.m., Res #49's monthly medication regimen reports for January 2024 through February 2025 were requested for review. On 04/02/25 at 2:00 p.m., the corporate regional director of operations provided Res #49's medication regimen review reports for the months of September 2024, October 2024, November 2024, December 2024, and January 2025. On 04/03/25 at 11:04 a.m., the corporate regional director of operations stated they were unable to locate Res #49's medication regimen review reports for the months of January 2024 through August 2024, and February 2025. They stated the reviews should have been completed monthly per policy and kept in the medical record. 43023 2. Res #20 admitted to the facility with diagnoses which included anxiety disorder and major depressive disorder. A care plan, dated 01/2025, showed the resident used antidepressant, antianxiety, and antipsychotic medications, and was at risk for side effects. On 04/02/25 at 2:00 p.m., the corporate regional director of operations provided monthly medication regimen reviews for the months of April 2024, September 2024, October 2024, and November 2024. 3. Res #23 admitted to the facility with diagnoses which included anxiety, depressive disorders, diabetes mellitus. A care plan, dated 01/2025, showed the resident used anxiety, antidepressant, and antipsychotic medication, and was at risk for side effects. On 04/02/25 at 2:00 p.m., the corporate regional director of operations provided monthly medication regimen reviews for the months of November 2024 and February 2025. They provided three medication regimen reviews with no date of when the pharmacy made the recommendations. 4. Res # 37 admitted to the facility with diagnoses which included anxiety and depression. A care plan, dated 02/2025, showed the resident was at risk for side effects due to antipsychotic and antianxiety drug use. On 04/02/25 at 2:00 p.m., the corporate regional director of operations provided monthly medication regimen reviews for the months of April 2024, June 2024, and September 2024. They provided five medication reviews with no date of when the pharmacy made the recommendations. 5. Res #41 admitted to the facility with diagnoses which included bipolar disorder and depression. A care plan, dated 02/2025, showed the resident was at risk for side effects related to antipsychotic, antianxiety, and antidepressant drug use. The corporate regional director of operations provided monthly medication regimen reviews for the months of April 2024, June 2024, July 2024, September 2024, and October 2024. They provided one medication review with no date of when the pharmacy made the recommendation. On 04/03/25 at 10:00 a.m., the corporate regional director of operations stated they were unable to locate all of the monthly medication regimen reviews for Residents #20, 23, 37, and #41. They stated the reviews should have been completed monthly per policy and kept in the medical record.

Based on observation, record review, and interview, the facility failed to label and date food items in the walk in refrigerator. The dietary manager identified 65 residents who ate meals prepared by the kitchen. Findings: On 03/31/25 at 10:44 a.m., a kitchen observation was made. The walk in refrigerator had a container with scrambled eggs and two sausage links that were not labeled or dated. There was a container of meat in six plastic bags, with one open to air, that were not labeled or dated. There was a large container not labeled or dated the DM identified as vanilla pudding. A policy titled Food Receiving and Storage, revised October 2024, read in part All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). On 03/31/25 at 10:50 a.m., the DM stated items in the refrigerator should be labeled and dated.

Based on observation, record review, and interview, the facility failed to maintain an infection control program for EBPs for 3 (#7, 12, and #70) of 3 sampled residents reviewed for infection control practices. The DON identified 11 residents with indwelling urinary catheters, six residents with wounds, and one resident with a PEG tube. Findings: A policy titled Enhanced Barrier Precautions, dated August 2022, read in part, Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator .and h. wound care (any skin opening requiring a dressing). 1. On 04/01/25 at 2:20 p.m., LPN #1 was observed gathering supplies to complete wound care for Resident #7. Upon approaching the resident's room there was no signage posted or PPE available at the door. LPN #1 used gloves for the procedure. LPN #1 did not use EBPs and wear a gown during the wound care. Resident #7 had diagnoses which included cirrhosis of liver, diabetes mellitus, and depressive disorders. An admission assessment, dated 01/06/25, showed the resident was cognitively intact and had a BIMS score of 15. The assessment showed the resident did not have pressure ulcers. A physician order, dated 03/29/25, showed an order for wound care to the coccyx. The order was to clean the wound with normal saline, pat dry, apply collagen, and cover with a dressing every day and as needed. On 04/01/25 at 2:21 p.m., LPN #1 stated they were not aware of additional precautions or PPE required for the resident's wound care. On 04/02/25 at 3:10 p.m., the IP stated EBPs were not being utilized in the facility. The IP stated they were unsure if staff had been educated regarding the use of EBPs. The IP stated signage and PPE should be posted at the door and available to staff and visitors. 2. On 04/02/25 at 2:10 p.m., LPN #2 was observed gathering supplies to complete wound care for Resident #12. The resident's door did not have signage posted for the use of PPE. LPN #2 donned a pair of gloves for the procedure. LPN #2 did not use EBPs and wear a gown for the wound care. Resident #12 had diagnoses which included metabolic encephalopathy, urinary tract infection, and hypertension. A physician order, dated 03/28/25, showed staff were to secure the biliary drainage tube to the resident's abdomen with a large tegaderm to prevent accidental tugging with each split gauze change every day. On 04/02/25 at 2:12 p.m., LPN #2 stated they had heard of EBPs, but was not sure of the requirements. 46582 3. On 04/02/25 at 7:38 a.m., ACMA #1 was observed administering medications to Resident #70 through their PEG tube. ACMA #1 was observed to have worn gloves during the administration of the medications. ACMA #1 was not observed to have worn a personal protective gown during the administration. No PPE was observed outside or near Resident #70's room. Resident #70 was admitted with diagnoses which included protein-calorie malnutrition and gastroesophageal reflux disease. A physician order, dated 03/04/25, showed to administer medications through the PEG tube. 04/02/25 07:45 a.m., ACMA #1 was asked if any additional PPE should have been worn during the administration of medication through Resident #70's PEG tube. ACMA #1 stated they only needed to wear gloves because the resident was not in any kind of isolation. On 04/02/25 at 3:10 p.m., the IP stated EBPs were not being utilized in the facility per policy. They stated all residents with wounds, catheters, PEG tubes, and other indwelling devices should have EBPs in place. The IP stated ACMA #1 should have worn a gown and gloves during the administration of medications through Resident #70's PEG tube. On 04/03/25 at 8:00 a.m., ACMA #1 stated they had never heard of EBPs. They stated the facilty had not educated them on the need to wear a personal protective gown during the care of residents with a PEG tube.

Based on record review and interview, the facility failed to ensure a significant change resident assessment was completed when a resident was placed on hospice services for 1 (#46) of 2 sampled residents reviewed for hospice services. The MDS coordinator identified 16 hospice residents resided in the facility. Findings: Res #46 admitted to the facility with diagnoses of unspecified dementia, anxiety, and depressive disorders. A physician's order, dated 02/06/25, showed admit to hospice. There was no documentation a significant change resident assessment was completed when Resident #46 began hospice services. On 04/03/25 at 11:49 a.m., the MDS coordinator reported a significant change should have been completed.

Based on observation and interview, the facility failed to ensure the ice machine in the lobby remained locked. The DON reported 61 residents resided in the facility. Findings: On 12/11/23 09:20 a.m., the ice Machine is located in the lobby and observed to be unlocked. On 12/13/23 9:21 a.m., the ice machine which is in the dining room was observed to be unlocked. On 9:23 a.m., the regional director stated the ice machine should be locked and they get a tag for that every year.

Based on interview and record review, the facility failed to ensure assessments were encoded and transmitted to CMS in the required time frame for three (#7, 47 and, #50) of 18 residents whose assessments were reviewed. The Long-Term Care Facility Application for Medicare and Medicaid form documented 61 residents resided in the facility. Findings: 1. Res #7's quarterly assessment, dated 11/09/23, documented transmitted. The final validation report documented the assessment was transmitted 12/11/23. 2. Res #47's quarterly assessment, dated 11/06/23, documented transmitted. The final validation report documented the assessment was transmitted 12/11/23. 3. Res #50's annual assessment, dated 11/09/23, documented transmitted. The final validation report documented the assessment was transmitted 12/11/23. On 12/13/23 at 9:20 a.m., the MDS coordinator stated the assessments were transmitted late for the named residents. The MDS coordinator stated they input the information into the system but then it sometimes takes a while to get them transmitted. The MDS coordinator stated she had been working the floor some also.

Based on record review, observation, and interview, the facility failed to obtain a physician order for oxygen needs for one (#50) and failed to provide oxygen as ordered by the physician order for one (#3) of three sampled residents for respiratory therapy. Findings: Res #50 was admitted to the facility with diagnoses of COPD, bipolar disorder, and anxiety disorder. On 12/12/23 at 10:17 a.m., the resident was observed resting in bed with eyes closed. The resident was observed wearing oxygen on at 2 liters per minute via nasal canula. On 12/13/23 at 8:50 a.m., the resident's record was reviewed and did not document a physician's order for oxygen. LPN #1 was asked to review the resident's physician orders and she reported the resident did not have and order for oxygen therapy. On 12/13/23 at 10:13 a.m., the corporate nurse reported the resident should have had an order for oxygen. Res #3 was admitted to the facility with diagnoses of hypoxia, congestive heart failure, bipolar disorder, and Alzheimer's disease. A physician's order, dated 07/15/22, documented oxygen @ 4LPM via nasal canula. On 12/11/23 at 11:47 a.m., resident #3 was observed sitting up in geri chair in the dining room. The resident was observed with oxygen on at 1 1/2 liters per minute via nasal canula. On 12/12/23 at 11:40 a.m., the resident was observed sitting u in a geri chair without oxygen. On 12/13/23 at 7:29 a.m., the resident was observed up in a geri chair at the table in the dining room. The resident was observed without oxygen at this time. On 12/14/23 at 8:00 a.m., LPN #1 reported the resident should have had his oxygen.

Based on observation, record review, and interview, the facility failed to ensure medications were administered according to physician's order for two (#3 and #12) of eight sampled residents reviewed for medication administration. The BOM identified 61 residents resided in the facility. Findings: An Administering Medications policy, dated December 2022, read in part, .Medication must be administered in accordance with the orders, including any required time frame . 1. Resident #12 had diagnoses which included colostomy status. A Physician's Orders, dated 03/23/23, documented Colace 100 mg was to be administered at bedtime. 2. Resident #3 had diagnoses which included gastro-esophageal reflux disease. A Physician's Orders, dated 07/22/22, documented Protonix every day at 11:00 a.m. On 12/13/23 at 7:40 a.m., CMA #3 was observed to administer Colace to Resident #12. On 12/13/23 at 8:00 a.m., CMA #2 was observed to administer Protonix to Resident #3. On 12/13/23 at 8:15 a.m., CMA #3 was asked what the process was for ensuring medications were administered as ordered. They stated they followed the MAR. CMA #3 was asked to when was the Colace administered. They were observed to look at the MAR and stated, My bad. I made a mistake. On 12/13/23 at 8:47 a.m., CMA #2 was asked what the process was for ensuring medications were administered as ordered. They stated they double checked the MAR and the medication card. CMA #2 was asked what time was the Protonix administered. They stated, Yeah, I gave it too early.

Based on record review and interview, the facility failed to ensure PRN psychotropic medications were limited for four (#34, 45, 50, and #39) of five sampled residents reviewed for unnecessary medications. The Regional Director identified 36 residents received psychotropic medications. Findings: An Antipsychotic Medication Use policy, dated December 2022, read in part, .The need to continue PRN orders for psychotic medications beyond 14 days requires that the practitioner document the rationale for the extended order . 1. Resident #45 had diagnoses which included anxiety. A Physician's Orders, dated 10/16/23, documented Ativan was to be administered every six hours as needed for anxiety. There was no documentation limiting the use of the medication. Resident #45's MAR, from November and December 2023, documented the resident received five doses beyond the 14 days limitation as documented in the facility's policy. There was no documentation the physician provided a rationale for extending the order. On 12/13/23 at 10:52 a.m., the ADON was asked if Resident #45 received PRN psychotropic medication. They were observed looking at the physician's orders and stated, I think [Resident #45] is. The ADON was asked to describe the policy regarding PRN psychotropic medications. They stated, I would have to pull it. The ADON was asked what the requires were regarding PRN psychotropic medications. They stated, I don't know it by heart. They stated the pharmacist had recommended putting a system into place limiting medications to 30 days but they haven't implemented anything. The ADON was asked if Resident #45's Ativan order had a limitation. They stated, No. 2. Resident #34 had diagnoses which included anxiety. A Physician's Orders, dated 11/12/23, documented Ativan was to be administered every eight hours as needed for anxiety. There was no documentation limiting the use of the medication. Resident #34's MAR, from November and December 2023, documented the resident received six doses beyond the 14 days limitation as documented in the facility policy. There was no documentation the physician provided a rationale for extending the order. On 12/14/23 at 9:07 a.m., the ADON was asked if Resident #34 had an order for a PRN psychotropic medication. They stated, Yes. The ADON was asked if there was a limitation to the order. They stated, Not on this order. 43023 3. Resident #50 had diagnosis of anxiety disorder. A physician's order, dated 10/31/23, documented Ativan 0.5mg tablet 1 po Q6 hours PRN anxiety. The order did not document a stop date 4. Resident #39 had a diagnosis which included anxiety disorder. A physician's order, dated 02/28/23, documented Ativan 1mg/0.5ml topical gel apply 1 syringe topically every 2 hours PRN anxiety/agitation. The order did not document a stop date. A physician's order, dated 09/05/22 documented Lorazepam 2mg/ml oral concent give 0.25 ML SL PRN Q2H. DX: Anxiety/Air Hunger. The order did not document a stop date. On 12/14/23 09:07 AM DON reported the PRN psychotropics should have had a stop date.

Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 28 opportunities were observed with two errors. The total medication error rate was 7.14%. The BOM identified 61 residents resided in the facility. Findings: 1. Resident #12 had diagnoses which included colostomy status. A Physician's Orders, dated 03/23/23, documented Colace 100 mg was to be administered at bedtime. 2. Resident #3 had diagnoses which included gastro-esophageal reflux disease. A Physician's Orders, dated 07/22/22, documented Protonix every day at 11:00 a.m. On 12/13/23 at 7:40 a.m., CMA #3 was observed to administer Colace to Resident #12. On 12/13/23 at 8:00 a.m., CMA #2 was observed to administer Protonix to Resident #3. On 12/13/23 at 8:15 a.m., CMA #3 was asked what the process was for ensuring medications were administered as ordered. They stated they followed the MAR. CMA #3 was asked to when was the Colace administered. They were observed to look at the MAR and stated, My bad. I made a mistake. On 12/13/23 at 8:47 a.m., CMA #2 was asked what the process was for ensuring medications were administered as ordered. They stated they double checked the MAR and the medication card. CMA #2 was asked what time was the Protonix administered. They stated, Yeah, I gave it too early. On 12/13/23 at 12:35 p.m., the ADON was asked how they ensured the medication error rate was less than 5%. They stated they complete inservices, the pharmacist monitors once a month, and have CMAs complete skills check offs. The ADON was notified of the observations and medication error rate of 7.14%.

Based on observation, and interview, the facility failed to ensure refrigerated medications were stored in a manner to maintain the integrity of the medications and failed to dispose of expired medications and supplies by the expiration dates. The Long-Term Care Facility Application for Medicare and Medicaid form documented 61 residents resided in the facility. Findings: A facility policy, dated April 2023, read in part, Storage of Medications .Discontinued, outdate, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately food and are labeled accordingly . On 12/13/23 at 10:23 a.m., the medication room was observed. A total of 47 prefilled heparin syringes were expired and 11 IV tubing's in packages were expired in the medication room. On 12/13/23 at 10:25 a.m., CMA #3 stated they look for expired medication once a month. CMA #3 stated the TB testing solution was kept in the ADON's office. On 12/13/23 at 10:30 a.m., CMA #3 stated the CMAs make sure there are not any expired medication and the nurses should make sure the heparin and IV tubing supplies were not expired. On 12/13/23 at 10:43 a.m., CMA #2 stated CMA #3 usually was the CMA to go through the medications to make sure they are not expired every month. On 12/13/23 at 10:57 a.m., There were two boxes of TB and 15 syringes of the flu vaccine contained in two boxes observed in the refrigerator with staff food. The ADON stated the food should not be in the refrigerator with the medications. On 12/13/23 at 11:24 a.m., the regional director stated the facility should not have anything expired in the medication store room and there should not be medication stored in the refrigerator with food items.

Based on record review and interview, the facility failed to ensure a resident assessment was accurate for one (#3) of 24 sampled residents whose assessments were reviewed for accuracy. The DON reported 61 residents resided in the facility. Findings: Res #3 was admitted to the facility with diagnoses of hypoxia, congestive heart failure, bipolar disorder, and Alzheimer's disease. A physician order, dated 07/15/22, documented oxygen at 4 liters per minute via nasal canula. A quarterly assessment, dated 08/24/23, contained no documentation the resident required oxygen therapy. On 12/13/23 at 1:12 p.m., the MDS coordinator reported the assessment should have documented oxygen therapy.

On 11/07/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the physician provided laboratory orders for routine monitoring for Res #63 who received Warfarin/Coumadin (an anticoagulant medication used as a blood thinner). On 11/07/22 at 4:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 11/07/22 at 4:45 p.m., the Regional Manager was notified of the IJ situation. On 11/08/22 at 11:30 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated 11/07/22, read in part: Plan of Removal Anticoagulant Therapy: Immediate Actions: 1. Review of facility records identified 3 residents on Coumadin therapy with identified resident #63 out to hospital. 2. Inservice started for Nursing staff regarding the following: a. Coumadin (Anticoagulant therapy Clinical Protocol P&P) b. Lab requirements for anticoagulant therapy to include routine draws of PT/INR c. Ensuring Physician [sic] orders are obtained for routine labs and monitor. d. Monitoring and follow up on labs. e. Readmission orders reconciled to catch new orders and orders to hold medication when critical labs are obtained. f. Ensuring MRR are completed with pharmacy monthly to be specific to Warfarin/Coumadin. e. Anticoagulant - PT/INR Flow sheets for monitoring. In-service completed on: 11/7/22 @ 6:55 p.m. 3. Baseline lab draws completed on all resident[sic] in facility receiving Coumadin/Warfarin therapy per PCP order. On 11/07/22 with results to be sent to PCP for further recommendation. Identified resident will have lab draw completed for baseline upon return to facility. 4. Careplans updated to reflect Coumadin (Anticoagulant therapy including labs, flow sheet and monitoring). Corrective Actions: 1. Anticoagulant therapy added to monthly at risk meeting for monitoring of labs and compliance with P&P of Anticoagulant therapy monthly. 2. ADON/DON to monitor Flow sheet weekly. 3. Staff will be in-serviced at hire and re-educated annually. The IJ was lifted, effective 11/08/22 at 2:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at an isolated level with a potential for harm to the resident. Based on record review and interview, the facility failed to ensure monitoring was provided for a resident (#63) on anticoagulant therapy. The RM identified three residents on anticoagulant therapy. Findings: Res #63 was admitted with diagnoses which included acute embolism and thrombosis to deep vein unspecified lower extremity. The Anticoagulant - Clinical Protocol revised, 11/18, read in parts, 1. The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; .periodically checking PT/INR .2. If Warfarin is used, staff should use a warfarin flow sheet .to follow trends in anticoagulant dosage and response in individuals on warfarin . A physician's order dated 03/03/22, read in part, Coumadin 5mg 1 PO QD . There were no physician's orders for lab to monitor Res #63's PT/INR (a blood test measuring the time it takes for blood to clot). This resulted in Res #63 going 236 days without monitoring of lab results. A nursing note dated, 10/16/22, read in parts, 12:00 p.m., .Resident sitting in floor .laceration to R top of scalp with blood .Dr. (name withheld) notified, new order to send to ER to eval and treat .7:45 p.m., Resident admitted to hospital with laceration to scalp with 37 staples. Dx of syncope and increased INR. A Hospital Medicine H&P dated, 10/16/22, read in parts, .Patient was found down on the floor with large posterior scalp laceration associated hematoma and bleeding .brought to the emergency room and has a scalp laceration repair [sic]. Patient is on Coumadin .INR was 2.8 (reference range: 0.9 - 1.2) .received 1 dose of Vitamin K in the emergency room the patient was referred to the hospitalist for observation . Hospital discharge instructions dated, 10/17/22, read in parts, HOLD Warfarin for 3 more days, then ok to restart. A Medication Administration Record (MAR) dated, October 2022, documented Warfarin was not held and was administered on 10/18/22, 10/19/22 and 10/20/22. On 11/07/22 at 11:00 a.m., the DON stated there should have been orders to monitor Res #63's PT/INR. On 11/07/22 at 11:02 a.m., LPN #2 was unable to locate orders to monitor Res #63's PT/INR. When asked if there should have been orders, LPN #2 stated I think so. On 11/07/22 at 12:15 p.m., Res, #63's physician stated lab tests should have been ordered at the time Warfarin was ordered. The physician's expectation would have been for nursing to call and request an order for lab monitoring. On 11/07/22 at 1:00 p.m., the Regional Manager reported they did not have flow sheets for residents taking Warfarin.

On 11/07/22, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the pharmacist conducted a MRR (Medication Regime Review) specific to Warfarin/Coumadin (a blood thinner) and lab monitoring from 03/03/22 to 10/26/22 for Res #63 who received Warfarin. On 11/07/22 at 4:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 11/07/22 at 4:45 p.m., the Regional Manager was notified of the IJ situation. On 11/08/22 at 11:30 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The facility's plan of removal, dated 11/07/22, read in part: Plan of Removal Anticoagulant Therapy: Immediate Actions: 1. Review of facility records identified 3 residents on Coumadin therapy with identified resident #63 out to hospital. 2. Inservice started for Nursing staff regarding the following: a. Coumadin (Anticoagulant therapy Clinical Protocol P&P) b. Lab requirements for anticoagulant therapy to include routine draws of PT/INR c. Ensuring Physician orders are obtained for routine labs and monitor. d. Monitoring and follow up on labs. e. Readmission orders reconciled to catch new orders and orders to hold medication when critical lab are obtained. f. Ensuring MRR are completed with pharmacy monthly to be specific to Warfarin/Coumadin. e. Anticoagulant - PT/INR Flow sheets for monitoring. In-service completed on: 11/7/22 @ 6:55 p.m. 3. Baseline lab draws completed on all resident in facility receiving Coumadin/Warfarin therapy per PCP order. On 11/07/22 with results to be sent to PCP for further recommendation. Identified resident will have lab draw completed for baseline upon return to facility. 4. Careplans updated to reflect Coumadin (Anticoagulant therapy including labs, flow sheet and monitoring). Corrective Actions: 1. Anticoagulant therapy added to monthly at risk meeting for monitoring of labs and compliance with P&P of Anticoagulant therapy monthly. 2. ADON/DON to monitor Flow sheet weekly. 3. Staff will be in-serviced at hire and re-educated annually. The IJ was lifted, effective 11/08/22 at 2:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at an isolated level with a potential for harm to the resident. Based on record review and interview, the facility failed to ensure the pharmacist conducted a MRR specific to Warfarin/Coumadin and lab monitoring from 03/03/22 to 10/26/22 for Res #63 who received Warfarin. The Regional Manager identified three residents on anticoagulant therapy. Findings: The Anticoagulant - Clinical Protocol revised, 11/18, read in parts, 1. The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; .periodically checking PT/INR .2. If Warfarin is used, staff should use a warfarin flow sheet .to follow trends in anticoagulant dosage and response in individuals on warfarin . Res #63 was admitted with diagnoses which included acute embolism and thrombosis to deep vein unspecified lower extremity. A physician's order dated 03/03/22, read in part, Coumadin 5mg 1 PO QD . There were no physician's orders for lab to monitor Res #63's PT/INR (a blood test measuring the time it takes for blood to clot). There were no physician's orders for lab to monitor Res #63's PT/INR (a blood test measuring the time it takes for blood to clot). This resulted in Res #63 going 236 days without lab work. There were no pharmacist recommendations to the physician between 03/03/22 through 10/26/22 requesting an order for laboratory monitoring for Res #63. A nursing note dated, 10/16/22, read in parts, 12:00 p.m., .Resident sitting in floor .laceration to R top of scalp with blood .Dr. (name withheld) notified, new order to send to ER to eval and treat .7:45 p.m., Resident admitted to hospital with laceration to scalp with 37 staples. Dx of syncope and increased INR. A Hospital Medicine H&P dated, 10/16/22, read in parts, .Patient was found down on the floor with large posterior scalp laceration associated hematoma and bleeding .brought to the emergency room and has a scalp laceration repair [sic]. Patient is on Coumadin .INR was 2.8 (reference range: 0.9 - 1.2) .received 1 dose of Vitamin K in the emergency room the patient was referred to the hospitalist for observation . On 11/07/22 at 11:00 a.m., the DON stated there were no pharmacy recommendations for Res #63 addressing laboratory monitoring. During a phone interview, on 11/07/22 at 12:15 p.m., Res, #63's physician stated they had not received a pharmacy recommendation requesting an order for laboratory monitoring. On 11/07/22 at 1:00 p.m., the Regional Manager reported there were no pharmacist recommendations to the physician between 03/03/22 through 10/26/22 requesting an order for laboratory monitoring for Res #63. On 11/07/22 at 1:52 p.m., the pharmacist reported they did not make a recommendation for lab monitoring of Res #63 until 10/27/22.