Choctaw Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record reviews, and facility policy review, the facility failed to follow up on grievances from Resident council meetings related to missing silverware and condiments for four (4) of six (6) residents in the Resident Council Meeting. Resident #4, Resident #10, Resident #11, and Resident #35. Findings include: Record review of facility policy titled, Resident and Family Grievances, undated, revealed, It is the policy of this facility to support each resident's and family member's right to voice grievance without discrimination, reprisal or fear of discrimination or reprisal . Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance . An interview on 04/17/24 at 1:45 PM, at the Resident Council meeting, revealed Resident #4 (Resident Council President), Resident #10, Resident #11, and Resident #35, had concerns that they were at times still missing silverware and condiments on their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and facility policy review, the facility failed to notify the physician when a resident receiving enteral nutrition by a percutaneous endoscopic gastrostomy (PEG) tube developed drainage around insertion site for one (1) of two (2) residents observed with tube feedings. Resident #103 Findings include: Record review of facility policy titled, Care and Treatment of Feeding Tubes, undated, revealed, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible Policy Explanation and Compliance Guidelines .6. b. Examination of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection and notify MD when need arises .The facility will notify and involve the physician or designated practitioner of any complications and in evaluating and managing care to address the complications and risk factors.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plans for two (2) of the nineteen resident care plans reviewed. Resident #18 and Resident #36 Findings include: Review of the facility policy titled, Comprehensive Care Plans undated revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Resident #18 Record review of Resident #18's care plan revealed, Problem/onset: 06/20/2018 Activities of Daily Living (ADL). I require assistance with ADL care .Approaches .Provide nail care weekly and as needed (PRN). During an observation on 4/16/24 at 9:05 AM, and again at 1:55 PM with interview, revealed Resident #18's fingernails on both hands were approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to provide Activities of Daily Living (ADL) care for two (2) of 56 residents observed during the initial tour related to nail care. Resident #18 and Resident #36. Findings include: Review of the facility policy Activities of Daily Living (ADL's), undated, revealed .Care and services will be provided for the following activities of daily living: 1 .Bathing, dressing, grooming and oral care. 3 A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming and personal . hygiene. Resident #18 An observation on 4/16/24 at 9:05 AM, and again at 1:55 PM, revealed Resident #18 fingernails on both hands were approximately three-fourth (¾) inches long and jagged with a brown substance under each nail. Resident #18 stated, I guess they need to cut them. During an observation and interview on 04/16/24 at 3:18 PM, the Director of Nurses (DON) confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident with a catheter had a catheter securing device for one (1) of six (6) catheters in the facility. Resident #28. Findings Include: Review of the facility policy titled Appropriate Use of Indwelling Catheters undated, revealed .Policy Explanation and Compliance Guidelines: . 7. Indwelling urinary catheters (urethral and suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible An observation during catheter care on 4/17/2024 at 10:15 AM, revealed Resident #28 did not have a catheter securement device, and the catheter was pulled tight with tension from the bedside drainage bag that was attached to the lower bed. An observation and interview on 4/17/2024 at 10:31 AM, with Certified Nurse Aide (CNA) #1 confirmed Resident #28 did not have a catheter securing device. An interview with the Infection Preventionist (IP) on 4/17/2024 at 11:06 AM, revealed Resident #28 should have a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident receiving enteral feedings via percutaneous endoscopic gastrostomy (PEG) tube received appropriate care and services to prevent possible complications for one (1) of two (2) residents observed with tube feedings. Resident #103 Findings include: Record review of facility policy titled, Care and Treatment of Feeding Tubes, undated, revealed, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: .6. b. Examination of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection and notify MD when need arises .10. The facility will notify and involve the physician or designated practitioner of any complications and in evaluating and managing care to address the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review and facility policy review, the facility failed to submit accurate information into the Payroll Based Journal system as required by the Centers for Medicare and Medicaid Services (CMS) which was discovered through a CMS audit of period between January 1, 2023 through March 31, 2023. Due to the audit findings, the facility was lowered to a one star on the five-star staffing rating system for the quarter of October 1, 2023 through December 31, 2023 for one (1) of four (4) quarters reviewed. Based on the facility's implementation of corrective actions completed on 06/14/23, the State Agency (SA) determined this citation to be Past Non Compliance (PNC) prior to the SA's entrance on 4/15/24. Findings include: Record review of facility policy titled, Payroll Based Journal, undated, revealed, Policy: It is the policy of this facility to electronically submit timely to CMS (Centers for Medicare and Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and facility policy review, the facility failed to discard soiled linen in a safe and sanitary manner to prevent the possibility of the spread of infection for one (1) of three (3) care observations. Resident #28 Findings Include: Record review of the facility policy titled Handling Soiled Linen undated, revealed Policy: It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection . Policy Explanation and Compliance Guidelines: 1. Linen can become contaminated with pathogens from contact with intact skin, body substances, or from environmental contaminants . 3. Linen should not be allowed to touch the . floor and should be handled as little as possible . 4. Used or soiled linen shall be collected at the bedside and placed in a linen bag or designated linen receptacle . An observation during catheter care for Resident #28, on 4/17/2024 at 10:15 AM, with Certified Nurse Aide (CNA) #1, revealed after completing the necessary care, she discarded two (2) soiled bath…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide treatment and services to prevent and heal pressure ulcers for two (2) of four (4) facility acquired pressure ulcers. Resident #2 and Resident #40 Findings include: Review of the facility policy titled Pressure Injury Prevention and Management revealed this facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure/injury, prevent infection and the development of additional pressure ulcers/ injuries. Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interviews, record review, and facility policy review, the facility failed to thoroughly investigate and report the results of an allegation of abuse for one (1) of six (6) grievances reviewed. Resident #1. Findings include: Record review of facility policy titled, Abuse/Neglect Reporting, dated 12/20, revealed, .5. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator . On [DATE] at 8:45 AM, in a phone interview with complaint Resident #1's Resident Representative (RR), revealed he filed the complaint because the resident had told him that a black worker hit her in the head, and he feels that was what caused her death. He stated he did not report this when she told him, but he did tell the nurse after the resident passed away. He stated the death certificate had the resident's cause of death as Congestive Heart Failure. On [DATE] at 9:15 AM, in an interview with the facility Administrator, revealed Complaint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility policy review, the facility failed to follow the comprehensive care plan for two (2) of 16 care plans reviewed. Resident #2 and Resident #40 Findings include: A review of the facility's Comprehensive Care Plans policy revealed, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #2 A record review of Resident #2's comprehensive care plan, Problem/Need: Problem onset dated 1/8/23 Problem: I have a stage 3 pressure ulcer to my sacrum .Approaches: Clean stage 3 to sacrum with Dakin's, apply Silvercel to wound bed, cover with silicone border dressing daily, and PRN (as needed) for soilage/drainage. An interview and observation on 01/09/23 at 2:15 PM revealed, Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and facility policy review, the facility failed to notify the Responsible Party (RP) and the Ombudsman in writing, regarding residents transfer to the hospital, Resident #2, Resident #34, and Resident #63; for three (3) of three (3) residents reviewed for hospitalization. Findings Include: Resident #2 Review of the facility's Bed Hold Policy, not dated, revealed, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed, in writing, of the bed-hold and return policy. Review of Nurses notes, dated 8/22/19, revealed Resident #2 was transferred to the local hospital at 7:45 AM, due to hypoglycemia, with a blood sugar of 28. On 8/22/19 at 12:30 PM, the facility called and notified the RP that Resident #2 would be placed on bed hold due to hospitalization. There was no evidence that written notification of the transfer was provided to the RP. There is no evidence to indicate the Ombudsman was notified of Resident #2's transfer to the hospital. On 10/02/19 at 10:35 AM, during an interview, the Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and facility policy review the facility failed to provide written notice, to the Responsible Party (RP) and Ombudsman, of a bed hold upon transfer to hospital; Resident #2, Resident #34, and Resident #63; for three (3) of three (3) residents reviewed for hospitalization. Findings Include: Review of the facility's Bed Hold Policy, undated, revealed Prior to transfers and therapeutic leaves, residents or resident representatives will be informed, in writing, of the bed-hold and return policy. Resident #2 Review of a Nurse's note, dated 8/22/19 revealed Resident #2 was transferred to the local hospital at 7:45 AM, and admitted , due to hypoglycemia. There was no evidence that written notification of the bed hold was provided to the RP. Resident #63 Record review revealed Resident #63 was transferred to the hospital on 9/13/19, and admitted . Record review revealed documentation in the nurse's note, dated 9/13/19, concerning the resident's condition, Physician notification and Responsible Party (RP) notification by phone. Record review revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.