Barnsdall Nursing Home

Based on observation, interview, and record review, it was determined the facility failed to ensure medication labels were written to reflect a current physician order for two (#13, and #14) of five residents whose medication labels were observed. The facility identified 25 residents who received medications. Findings: A facility policy titled, Medication Management, dated April 2018, documented, .In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use . 1. Resident #13 was admitted to the facility with diagnoses which included diarrhea. A physician order, dated May 2021, documented, .HM Fiber 28.3% administer 1 tbsp q am in liquid of choice .diarrhea, unspecified . On 05/04/21 at 8:00 a.m., during observation of medication administration, the medication label was observed to read, administer one tsp (teaspoon) po (by mouth) daily. Prior to administration of…

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 and interview, it was determined the facility failed to: ~Ensure hospice records were accessible for two (#7 and #21) of two sampled residents whose records were reviewed for hospice services. The facility identified four residents who received hospice services. Findings: 1. On 05/04/21 hospice records were requested for resident #7 and resident #21. The charge nurse stated the records were not in the facility and he would have to call hospice. At 12:35 p.m., the charge nurse stated hospice was going to bring the resident records back to the facility as soon as possible. The charge nurse was asked how hospice care was coordinated with the facility. He stated, through word of mouth and through the nurses. He was asked how staff knew what services they were to provide for the resident as opposed to what hospice was going to provide. He stated, We are all responsible for resident care no matter what. He was asked who was responsible to ensure hospice records remained in the facility. He stated, I guess I am. He was asked what the facility policy was regarding…

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, interview, and record review, it was determined the facility failed to ensure equipment was properly stored and the room locked for one of 12 resident rooms on the west hall. The facility identified 15 residents who resided on the west hall. Findings: An undated facility policy titled, Space and Equipment, documented, .areas will have space for storing and utilizing mobility devices, assistive technology, physical therapy or adaptive equipment . On 05/03/21 at 11:25 a.m., an unlocked and unoccupied resident room on the west hall was observed to contain the following: ~Five beds; ~One floor buffing machine; ~Three wheelchairs (one lying on top of a bed); ~Four walkers (two lying on top of a bed); ~One commode sitting on top of a bed; ~One chair sitting on top of a bed; ~One night stand sitting on top of a bed; ~Lamp and lamp shade sitting on top of a bed; and ~Pictures lying on top of a bed. At approximately 11:30 a.m., LPN (licensed practical nurse) #2 was asked how many residents wandered in the facility. He stated three. At 12:00 p.m., maintenance was asked…

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 interview and record review, it was determined the facility failed to respond to suggestions/concerns brought forth from the resident council group. This had the potential to affect all 33 residents who resided in the facility. Findings: On 02/11/19 at 1:30 p.m., a group meeting was held with ten alert and oriented residents. The group was asked if the facility acted upon grievances, concerns, and/or recommendations of the resident council group. They collectively stated no. They stated they never knew if the issue had been addressed by the facility. On 02/12/19 at 4:09 p.m., the social services director was asked how the facility addressed grievances, suggestions, and/or recommendations voiced during the resident council group meetings. She stated she shared the meeting notes with the DON (Director of Nursing) and administrator. She stated the concerns were discussed during QA (Quality Assurance) meetings. She was asked where it was documented the grievance, concern, and/or recommendation from the resident council group had been addressed by the facility. She stated on 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 observation and interview, it was determined the facility failed to ensure a statement was posted and available with contact information regarding a resident's right to file a complaint with the state survey agency and the state Ombudsman contact information. This had the potential to affect all 33 residents who resided in the facility. Findings: An undated policy titled, Policy of Posting Ombudsman and State Contact Information, documented, .It is the policy of Barnsdall Nursing Home that information to contact the local Ombudsman and the State Department of Health be located on the bulletin board located outside of the dining room . On 02/11/19 at 10:20 a.m., the bulletin board across from the dining room was observed to have a medication cart that obstructed it's view which did not allow the Ombudsman information to be seen. The contact information for filing a complaint with the state agency was also obstructed. On 02/11/19 at 1:30 p.m., a group meeting was held with ten alert and oriented residents. The group was asked if they knew how to contact the state agency with…

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, interview, and record review, it was determined the facility failed to ensure resident bathrooms had hot water for eight (rooms 102, 104, 105, 107, 106, 108, 110, and 112) of 12 rooms observed for homelike environment on the west hall. The facility identified six resident bathrooms on the west hall. Findings: An undated policy titled, Temperature Checks, documented, .If the water temperatures are above or below state recommended parameters the maintenance director will adjust the temperature accordingly . On 02/10/19 at 4:00 p.m., the following hot water temperatures were obtained from the residents' bathroom sinks: ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 69.9 degrees F (Fahrenheit); ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 88.7 degrees F; ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 79.2 degrees F; and ~ room [ROOM NUMBER] and room [ROOM NUMBER] - 76.9 degrees F. On 02/10/19 at 4:08 p.m., resident #26 was asked how long it took for the water to get warm in her bathroom sink.…

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 interview and record review, it was determined the facility failed to ensure residents received their baths for two (#2 and #3) of three sampled residents who were reviewed for ADL (Activities of Daily Living) care. The facility identified 30 residents who required assistance from staff for bathing. Findings: An untitled policy, dated 06/03/16, documented, .It is the responsibility of the dayshift charge nurse to oversee that all baths are given in a timely manner and to report to [sic] DON [Director of Nursing] or ADON [Assistant Director of Nursing] if a resident continues to refuse the baths or bath is omitted so that an alternate plan of care may be implemented . 1. Resident #2 had diagnoses which included osteoarthritis and pain. A quarterly assessment, dated 01/18/19, documented the resident was cognitively intact for daily decision making and required physical assistance for transfers with bathing. A care plan, updated 01/29/19, documented the resident required assistance from one staff member for bathing. On 02/10/19 at 2:58 p.m., resident #2 was asked if she…

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, interview, and record review, it was determined the facility failed to ensure hot water was kept at a safe temperature for two (South and West) of two halls in which residents resided. This had the potential to affect seven residents who resided on the South hall and seven residents who resided on the [NAME] hall who utilized hot water in their bathrooms. Findings: An undated policy titled, Barnsdall Nursing Home Policy on Water Temperature Checks, documented, .If the water temperatures are above or below state recommended parameters the maintenance director will adjust the temperature accordingly . On 02/10/19 from 3:53 p.m. to 4:11 p.m., hot water temperatures were obtained in the following bathrooms: ~room [ROOM NUMBER]/103 at 127.5 degrees Fahrenheit (F); ~room [ROOM NUMBER]/111 at 125.2 degrees F; and ~room [ROOM NUMBER]/115 at 136.4 degrees F. Three months of the facility's weekly water temperature logs were reviewed. No unsafe hot water temperatures were documented in the temperature…

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 interview and record review, it was determined the facility failed to ensure a rationale was provided for continuance of a medication and/or dosage reduction for a consultant pharmacist recommendation for two (#8 and #22) of five sampled residents whose records were reviewed for unnecessary medications. Findings: A policy titled, Consultant Pharmacist Reports, dated April 2018, documented, .Recommendations are acted upon and documented by the facility staff and/or the prescriber .Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . 1. Resident #8 had diagnoses which included major depressive disorder, anxiety disorder, secondary Parkinsonism, and bipolar disorder. A pharmacist recommendation, dated 10/17/18, documented a request for reduction for the following medications; ~ Buspar 10 mg (milligram) three times daily for anxiety; ~ Wellbutrin XL 300 mg daily for depression; and ~ Hydroxyzine 25 mg three times daily for itching. On 11/01/18 the physician responded on the form by checking the disagree box. There was no rationale…

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, interview, and record review, it was determined the facility failed to provide a therapeutic diet of altered consistency of pureed for one (#9) of one sampled resident who received a pureed diet. The facility identified one residents who received a pureed diet. Findings: A policy titled, Therapeutic Diets, dated 10/17, documented, .a 'therapeutic diet' is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet . Resident #9 had diagnoses which included Alzheimer's disease. A care plan comment, dated 06/28/18, documented, Change diet back to pureed due to pocketing foods. A quarterly assessment, dated 01/10/19, documented she was severely impaired in cognitive skills for daily decision making, required assistance with eating, had swallowing difficulty with loss of liquids/solids from mouth, and held food in her mouth/cheeks. Current physician orders, dated February 2019, documented a diet order for puree/regular. On…

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, interview, and record review, it was determined the facility failed to: ~ have a functioning hand washing sink in the kitchen; ~ ensure a sanitary environment in the kitchen; ~ ensure kitchen staff followed appropriate glove use and handwashing during meal preparation and meal service; ~ ensure the dish washing machine operated per the manufacturer's specifications; ~ ensure there was adequate hot water in the kitchen for manual washing of dishes; The facility identified 33 residents who received nutrients from the kitchen. Findings: A policy titled, Sanitization, dated 10/08, documented, .All utensils, counter, shelves, and equipment shall be kept clean .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . Low-temperature dishwasher (Chemical Sanitization) Wash temperature 120 degrees F .Manual washing and sanitizing will employ a three-step process for washing, rinsing, and sanitizing .…

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, interview, and record review, it was determined the facility failed to: ~ maintain infection control practices during administration of insulin for three (#08, #20, and #26) of six residents whose insulin administration was observed. The facility identified eight residents who received insulin injections; ~ maintain infection control practices when completing a fingerstick blood sugar for four (#11, #19, #20, #27) of four fingerstick blood sugar observed. The facility identified eleven residents who received fingerstick blood sugars; ~provide hot water for the hand wash sink located in the laundry room; ~provide a sanitizing agent for laundering facility linen and resident clothing; and, ~provide hot water for use in laundering facility linen and resident clothing. The facility identifed 32 residents who utilized laundry services. Findings: An undated policy titled, Guidelines for Laundry at Barnsdall Nursing Home, documented, .Hot Water Washing .Laundry should be washed with a detergent in water at least (160 F) [Fahrenheit] for 25 minutes . 1. On 02/11/19 at…

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, interview, and record review, it was determined the facility failed to ensure a resident was free from abuse for one (#7) of one sampled residents whose records were reviewed for abuse. The facility identified 33 residents who resided in the facility. Findings: An undated policy titled, Barnsdall Nursing Home Policy and Procedure Reporting and Investigating, documented, Purpose .Each resident has the right to be free from verbal .and mental abuse .Policy Statement .Residents will not be subjected to abuse by anyone, including but not limited to, facility staff .Definitions: Abuse: The willful inflection [sic] of .intimidation .or mental anguish to a resident . The facility's undated policy on prevention of resident abuse, documented, The Barnsdall Nursing Home will be pro-active in the prevention of any type of abuse .Licensed and supervisory staff are available each shift and responsible for intervening if any inappropriate behavior from staff . The facility's undated policy for protection of a resident during an investigation for an allegation of abuse,…

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, interview, and record review, it was determined the facility failed to ensure their abuse policies and procedures were implemented to ensure: ~ thorough investigations of allegations of abuse and intimidation were conducted; ~ residents were protected during an investigation of an allegation of abuse; and ~ allegations of intimidation and/or abuse were reported within the required timeframe to the OSDH (Oklahoma State Department of Health) for one (#7) of one allegation of abuse that were reviewed. The facility identified 33 residents who resided at the facility. Findings: An undated policy titled, Barnsdall Nursing Home Policy and Procedure Reporting and Investigating, documented, Purpose .Each resident has the right to be free from verbal .and mental abuse .Policy Statement .Residents will not be subjected to abuse by anyone, including but not limited to, facility staff .Definitions: Abuse: The willful inflection [sic] of .intimidation .or mental anguish to a resident . The facility's undated policy on prevention of resident abuse, documented, The Barnsdall…

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 and interviews, it was determined the facility failed to report allegations of abuse to the proper agencies for one (#7) of one sampled residents whose records were reviewed for an allegation of abuse. The facility identified 33 residents who resided at the facility. Findings: An undated policy titled, Barnsdall Nursing Home Policy and Procedure Reporting and Investigating, documented, Purpose .Each resident has the right to be free from verbal .and mental abuse .Policy Statement .Residents will not be subjected to abuse by anyone, including but not limited to, facility staff .Definitions: Abuse: The willful inflection [sic] of .intimidation .or mental anguish to a resident . The facility's undated policy for investigation and reporting, documented, .Barnsdall Nursing Home will complete a thorough investigation of an alleged incident .The facility administrator will provide proper notification of appropriate state and other regulatory agencies . A policy titled, Abuse P & P (policy and procedure), dated 12/04/17, documented, It is the policy of the Barnsdall…

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, interview, and record review, it was determined the facility failed to conduct a thorough investigation of an allegation abuse for one (#7) of one residents whose records were reviewed for abuse. The facility identified 33 residents who resided at the facility. Findings: An undated policy titled, Barnsdall Nursing Home Policy and Procedure Reporting and Investigating, documented, Purpose .Each resident has the right to be free from verbal .and mental abuse .Policy Statement .Residents will not be subjected to abuse by anyone, including but not limited to, facility staff .Definitions: Abuse: The willful inflection [sic] of .intimidation .or mental anguish to a resident . The facility's undated policy for protection of a resident during an investigation for an allegation of abuse, documented, .Barnsdall Nursing Home will provide on-going safety to all residents during the investigation .Staff member(s) alleged to be in a potential abuse/neglect situation is removed immediately from resident areas .Staff member(s) alleged to be in a potential abuse/neglect…

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 interview and record review, it was determined the facility failed to ensure RN (registered nurse) coverage for eight consecutive hours for one of 14 days of staffing schedules reviewed. This had the potential to affect all 33 residents who resided in the facility. Findings: Review of the facility employee time punch detail for 01/25/19 and 01/26/19 revealed the following: ~ 01/25/19 the RN worked from 2:03 p.m. and worked to 6:34 a.m. on 01/26/19; and ~ 01/26/19 the RN returned at 9:54 p.m and worked to 8:38 a.m. on 01/27/19. Which revealed the facility had 6.50 consecutive hours of RN coverage on 01/26/19. On 02/13/19 at 2:10 p.m., the administrator was asked why there was no RN coverage for eight consecutive hours on 01/26/19. He stated there was no reason, they just didn't. He was asked if they had a waiver for RN coverage. He stated no.