Burford Manor

Based observation, record review, and interview, the facility failed to protect a resident from physical and verbal abuse by a staff member for 1 (#3) of 3 residents sampled for abuse. The director of nursing reported 46 residents resided in the facility. Findings: A Preventing Resident Abuse policy, dated February 2014, read in part, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse.The facility's goal is to achieve and maintain an abuse-free environment.Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: .b. Allowing staff to express frustration with their job, or in working with difficult residents.f. Helping staff to deal appropriately with stress and emotions. An Oklahoma State Department of Health incident form 283, dated 03/04/25, showed the DON was notified by staff LPN #1 was becoming increasingly aggravated with Resident #3 due to the resident constantly trying to get up from…

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, record review, and interview, the facility failed to use enhanced barrier precautions for two (#13 and #25) of two sampled residents identified with the need for enhanced barrier precautions. Findings: The DON identified nine residents with the need for enhanced barrier precautions. A Multidrug-Resistant Organisms policy, read in part, .Appropriate precautions will be taken when caring for individuals known or suspected to have infection with a multi-drug resistant organism .Note: Infection means that the organism is present and is causing illness. Colonization means that the organism is present in or on the body but it is not causing illness . A Personal Protective Equipment policy, read in part, .Personal protective equipment appropriate to specific task requirements is available at all times .All tasks do not involve the same type or degree of risk, and therefore will not all require the same kind or extent of protection . 1. Resident #13 had diagnoses which included Alzheimer's, depression, and high blood pressure. Resident #13's plan of care, dated…

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, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary and safe environment for 47 of 47 residents who reside in the facility. Census: 47 Findings: On 07/16/24 at 8:40 a.m., maintenance was asked about the holes in the wood flooring located on the South Hall. They reported they could fill the holes with something, but it was the foundation. Maintenance was asked about the black areas that outline the base in the shower on the East/West Hall. They reported it was soap/grime around the base of shower. They reported they would caulk it every three months or so. They reported the North Hall shower was the same way and they were looking for contractors to replace that tile, because of the black/scum around the base of the shower. On 07/16/24 at 11:45 a.m., DON reported there were holes in the wood flooring on the South Hall and they were going to get that fixed. The East/West Hall observed with a black colored area at the base of the shower. They reported they were looking to hire a contractor to repair all 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 record review and interview, the facility failed to notify the resident's representative of a change of condition for one (#2) of three sampled residents reviewed for notifications related to changes of condition. The DON reported 47 residents resided in the facility. Findings: A Change in a Resident's Condition or Status policy, dated 09/01/23, read in part Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental conditions and/or status .Unless otherwise instructed by the resident, the nurse supervisor will notify the resident's family or representative when: The resident is involved in any accident or incident that results in an injury; There is a significant change in the resident's physical, mental or psychosocial status; and/or it is necessary to transfer the resident to a hospital/treatment center . Resident #2 had diagnoses which included Alzheimer's disease and dysphagia. A nurse's notes, dated 11/27/23, documented resident #2 had a laceration to side of head and was sent to 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 record review and interview, the facility failed to provide residents with beneficiary notices for three (#155, 156, and #157) of three sampled residents reviewed for beneficiary notices. The facility identified six residents discharged from Medicare covered part A stay with benefit days remaining in the previous six months. Findings: SNF Beneficiary Protection Notification Review forms, for resident #155, 156, and #157, documented the skilled nursing facility advanced beneficiary notice (SNF ABN, Form CMS-10055) form was not provided to residents and/or their representative. On 08/16/23 at 10:30 a.m., the BOM was interviewed regarding the facility policy for providing skilled residents with notice of Medicare non-coverage. The BOM reported she was not aware of a policy and was not familiar with any particular form used, but would check with the corporate office and other staff members. On 08/17/23 at 9:53 a.m., the BOM reviewed the SNF ABN Form (CMS-10055) and reported she had never used this form. She stated she did give the same information to the resident and/or 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.

Based on observation, record review, and interview, the facility failed to maintain a clean and sanitary kitchen floor and ice machine equipment. The facility failed to: a. maintain a floor which could be sanitized and cleaned appropriately, b. maintain the ice machine in a sanitary manner, and; c. ensure a covered container for trash was available. The Administrator reported all 52 residents were served foods and beverages from the kitchen. Findings: A kitchen Sanitization policy read in part, .the food service area shall be maintained in a clean and sanitary manner .ice machines and ice storage containers will be drained, cleaned and sanitized . kitchen and dining room surfaces .shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime [sic] . On 08/14/23 at 9:59 a.m., a tour of the kitchen was conducted. The kitchen floor was observed to be a concrete base with black and dark gray residue build-up in areas resulting in an uneven surface. A concentrated build-up of residue was observed under the hand sink, three compartment sink, and dishwasher…

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, the facility failed to provide supervision to prevent an elopement for one (#23) of two residents reviewed for elopement risk. The director of nurses reported three residents wandered throughout the facility and were at risk for elopement. Findings: Resident #23 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease, cognitive deficits, dementia, delirium, and mood disorder. An admission assessment, dated 10/03/21, documented the resident was severely impaired with cognition and exhibited wandering behaviors daily. A care plan, dated 10/09/21, documented the resident wandered and was at risk for elopement. The care plan documented the staff was to check the residents whereabouts every 30 minutes. The care plan documented for the staff to provide one on one as needed throughout the day. The care plan documented the resident would exit seek and go out unlocked doors. The care plan documented the resident would walk around…

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, the facility failed to provide sufficient staff to ensure call lights were answered in a timely manner. The administrator reported 47 residents lived in the facility. Findings: Resident council meeting minutes, dated November 2021, documented residents complained call lights were not being answered in a timely manner. On 11/29/21 at 10:13 a.m., resident #44 reported it took a long time for his call light to be answered. On 11/29/21 at 10:24 a.m., resident #14 reported it took too long for call light to be answered. On 11/29/21 at 10:50 a.m., resident #4 reported it took awhile for call light to be answered. On 11/30/21 at 10:14 a.m., resident #19's representative reported there was still not enough staff but it was getting better. The representative reported the resident was not checked for 3 to 5 hours at times unless she turned her call light on. On 12/02/21 at 9:15 a.m. CMA #1 reported there was not enough staff to meet the residents needs. On 12/02/21 at 9:20 a.m., CNA #2 reported there was not enough staff. On 12/02/21 at 9:25 a.m., CNA #3…

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 the facility failed to complete a comprehensive care plan for one (#38) of 19 residents reviewed. The administrator reported 47 residents lived in the facility. Findings: Resident #38 was admitted to the facility on [DATE] with diagnoses which included depression, Alzheimer's disease, congestive heart failure, and hypertension. An admission assessment, dated 11/03/21, documented the resident was moderately impaired with cognition, exhibited no depression or behaviors. The assessment documented the resident required extensive assistance with activities of daily living. The assessment documented the resident received an anti-psychotic, an anti-depressant, a diuretic, and an opioid for seven days of the look back period. The assessment documented the resident required oxygen therapy. The clinical record contained no comprehensive care plan. On 11/30/21 at 9:31 a.m., the resident was observed sitting up in her recliner. On 12/01/21 at 9:04 a.m., the minimum data set…

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.