University Park Skilled Nursing and Therapy Memory

In the surveyor’s words

From the most serious findings on record at University Park Skilled Nursing and Therapy Memory, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 24, 2021

  On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to ensure safe transfers with the mechanical lift and/or transfer residents with the mechanical lift as per the resident's assessment and care plan. Resident #4 was admitted to the facility on [DATE] and was assessed to be dependent on two staff members for transfers. The resident's care plan documented the resident was to be transferred with a mechanical lift using two staff members. On [DATE], the resident was transferred by one staff member with a mechanical lift. The lift sling came off of the lift, resulting in the resident falling. The resident sustained [REDACTED]. […]

• Immediate jeopardy, isolatedF684Feb 24, 2021

  On 02/23/21, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to assess and monitor a resident with a significant change in condition. Resident #3 was admitted to the facility on [DATE] and was assessed to require extensive assistance of two staff members for transfers. The resident's care plan documented the resident was to be transferred with a mechanical lift. On 12/04/20 and 12/05/20, the resident exhibited signs and symptoms of excruciating pain. Staff did not assess for the cause of the pain. The staff did not monitor for ongoing pain symptoms. On 12/05/20, the resident was sent to the hospital and found to have bilateral femur fractures. At 3:59 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. […]

• Actual harm, patternF600Feb 24, 2021

  Based on interview and record review, it was determined the facility failed to ensure residents were free from neglect when it failed to: ~ ensure its policies and procedures related to mechanical lifts and transfers were implemented for two (#3 and #4) of four sampled residents who were reviewed for transfers; and ~ assess, monitor, and notify the physician of the new on-set of excruciating pain for one (#3) of four sampled residents who were reviewed for pain. Resident #4 was transferred by one staff member instead of two utilizing a mechanical lift. While being transferred the sling came off the lift. The resident fell to the floor and sustained a scalp laceration and fractures to the right clavicle, scapula, and ribs. […]

• No harm, potential for more than minimal, widespreadF812Nov 30, 2023

  Based on observation, record review, and interview, the facility failed to ensure food and dishes were stored properly. The administrator identified all residents received services from the kitchen. Findings: A Food Storage policy, dated 04/20/09, read in part, .Storage: Area .floor should be .regularly cleaned .Shelving should be .cleaned .Any opened products should be placed in zip lock bags . On 11/27/23 at 12:28 p.m., a tour of the kitchen was conducted. The following observations were made: a. a blue bag of shredded cheese and a gallon bag of sliced cheese were not sealed or dated in the walk in refrigerator, b. several beans were observed on bottom shelf in dry storage not in a container/bag, c. a container of all purpose mix with the lid not secured in the dry storage, d. […]

• No harm, potential for more than minimal, widespreadF802Apr 13, 2021

  Based on observation, interview, and record review, it was determined the facility failed to provide competent and skilled dietary staff to meet the residents needs. This had the potential to affect 73 of 73 residents who received meals prepared in the kitchen. Findings: On 04/05/21 at 9:52 a.m., an initial tour of the kitchen was conducted. The over all condition of the kitchen was unsanitary. The stove had layers of cooked food and grease on it. The floors were covered with dirt and debris. At 9:57 a.m., the sugar bin was observed open, the counter tops had food and liquid from thawing orange and apple juice setting on the counter. The garbage cans had food and a black substance on the inside of the lids. The inside of the microwave was observed to be covered with food. […]