Grand Lake Villa

Based on record review and interview, the facility failed to ensure facility staff had been trained in the Quality Assurance and Performance Improvement program for 103 of 103 employees of the facility.The assistant director of nursing identified 103 employees worked in the facility.Findings:An undated Quality Assurance / Assessment and Performance Improvement Plan, read in part, All staff, including contracted staff, are educated on the principles of QAPI. QAPI is included in the orientation of new employees and in the annual education that all staff are required to attend.An undated Inservice Schedule, was reviewed. The schedule did not included training on the subject of QAPI.On 04/28/26 at 11:43 a.m., the DON stated the facility had not conducted any training with all their staff on QAPI. The DON stated they had reviewed their records and found no documentation of the facility staff being trained in QAPI. The DON stated they had looked at their annual training list and did not find QAPI listed as one of the subjects.

Based on record review and interview, the facility failed to ensure residents understood binding arbitration agreements before signing them for 2 (#55 and #56) of 2 sampled residents reviewed for binding arbitration agreements.The DON identified 65 residents resided in the facility.Findings:1. An Arbitration of Disputes document in the assessment agreement, dated 09/29/25, read in part, Any and all claims, controversies, disputes, disagreements or demands of any kind .arising out of or in any relating to the Agreement, including the interpretation of this Agreement, or the Residents stay at, or the care of services provided by, the Facility shall be resolved exclusively by binding arbitration. The document showed Res #56's name printed in the resident representative's section of the signature page of the admission agreement. The SSD signed in the facility's representative area of the signature page.An admission assessment, dated 10/05/25, showed Res #56 had a BIMS score of 15 (a BIMS score of 15 indicated the resident's cognition was intact and was able to make decisions of daily…

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 ensure binding arbitration agreements did not pre-determine the arbitrator for arbitration proceedings for 2 (#55 and #56) of 2 sampled residents binding arbitration agreements reviewed for binding arbitration agreements.The DON identified 65 residents resided in the facility.Findings:1.An Arbitration of Disputes document in the assessment agreement, dated 09/29/25, read in part, The parties' intend that the Arbitration Services shall be Judicial Arbitration and Mediation Services, Inc (JAMS) or its successor. If JAMS is unable or unwilling to service as the Arbitration Service, the parties' intent [sic] that the National Arbitration Forum ('NAF') or its successor shall serve as the Arbitration Service. The document showed Res #56's name printed in the resident representative's section of the signature page of the admission agreement. The SSD signed in the facility's representative area of the signature page.2.An Arbitration of Disputes document in the assessment agreement, dated 04/08/26, read in part, The parties' intend…

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 include the estimated cost of services on a SNF ABN form CMS-10055 for 1 (#69) of 3 sampled residents reviewed for beneficiary notices.The DON identified 29 residents had been discharged from skilled services within the last six months. Findings:A document titled Form Instruction Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 (2018), dated 2018, read in part, Estimated Cost Section. In this section, the SNF enters the estimated cost of the corresponding care that may not be covered by Medicare. The SNF should enter an estimated total cost or a daily, per item, or per service cost estimate.A CMS-10055 form for Res #69, dated 03/25/26, showed the resident's representative had indicated on the form they wanted to continue the skilled services mentioned on the form and they may be responsible for the costs if Medicare denied the claim. The form showed physical therapy, occupational therapy, daily skilled nursing care, and speech therapy as the services that may not be covered by…

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 report an alleged incident of sexual abuse to the OSDH within the required two-hour time frame for 1 (#48) of 1 sampled resident reviewed for abuse.The DON identified 65 residents resided in the facility.Findings:An abuse policy titled Abuse - Neglect - Misappropriation - Mistreatment Policy, dated 02/16/24, read in part, The facility will send a report to all reporting agencies as required by OSDH guidelines. The facility will send a report to the ODSH on form 283 within 2 hours of being notified of any allegation.A health status note authored by RN #1, dated 03/11/26 at 7:53 p.m., showed LPN #3 had found Res #17 touching Res #48 inappropriately through Res #48's clothing. The note showed RN #1 had separated the two residents, RN #1 had asked Res #48 if they were ok with the other resident touching them, and Res #48 had replied, No. The note showed the DON had been contacted about the incident.An initial incident report, dated 04/22/26, showed an incident of alleged abuse had occurred on 03/11/26 and was reported 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 ensure a quarterly assessment accurately reflected a resident's fall history for 1 (#2) of 17 sampled residents reviewed for MDS assessment accuracy.The DON identified 65 residents resided in the facility.Findings:A quarterly assessment, dated 01/08/26, showed Res #2 had not had any falls. A health status note, dated 01/19/26 at 7:51 p.m., showed Res #2 had been found lying on the floor. The note showed no injuries were found on the resident.An incident note, dated 02/22/26 at 1:58 p.m., showed Res #2 had been found on the floor of their room. The note showed no injuries were found on the resident.An incident note, dated 03/05/26, showed Res #2 had been found on the floor of their room. The note showed no injuries were found to the resident.An incident note, dated 03/24/26, showed Res #2 was found on the floor of the locked unit's television room and the resident had a small hematoma on their head.A health status note, dated 04/09/26, showed Res #2 had been found lying on the floor after they were hit by a door someone had…

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 ensure APS was notified of an allegation of abuse for 1 (#3) of 3 sampled residents reviewed for abuse. The DON reported the facility census was 59. Findings: An admission record, dated 05/12/22, showed Res #1 had diagnoses which included Alzheimer's disease and anxiety. A facility document titled Abuse-Neglect-Misappropriation-Mistreatment Policy, dated 02/16/24, read in part, The facility will send a report to all reporting agencies as required by OSDH guidelines .The facility will send copies of the report to the OSDH/Adult Protective Services at the same time the report is sent to the OSDH. A quarterly assessment, dated 05/15/25, showed Res #3 had a brief interview for mental status score (a test for cognitive function) of 3, which was indicative of severe cognitive impairment. The assessment also showed Res #3 was dependent on staff for care. A nurse's note, dated 06/09/25 at 8:28 a.m., showed an allegation of abuse was reported to facility staff involving Res #3. The note also showed the OSDH, police department,…

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 ensure an alleged incident of physical and verbal abuse was reported to the facility administrator and Oklahoma State Department of Health within two hours of the allegation for one (#1) of four sampled resident reviewed for abuse. A facility census report, dated 07/08/24, documented 56 residents resided in the facility. Findings: An Abuse Investigating and Reporting policy, dated 2017, read in part, An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR (sic) resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND (sic) has not resulted in serious bodily injury. An ODH 283 form (incident report form) documented an allegation of physical and verbal abuse occurred on 06/08/24. The form documented the allegation was reported to the DON on 06/10/24. A facility…

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 the ice machine in a sanitary manner for one of one ice machines observed. The DON identified 63 residents who received nourishment from the kitchen. Findings: On 05/02/23 at 10:40 a.m., the maintenance supervisor was asked who was responsible for cleaning the ice machine. The maintenance supervisor stated the machine was leased and the leasing company performed all cleanings. The maintenance supervisor stated the machine was last cleaned in March 2023. The ice machine was observed with the maintenance supervisor. They removed the panel covering the mechanical components used to make the ice. An opaque tube, which appeared to run from the water reservoir, located at the base of the machine, to the top of the evaporator, was observed to have a shadowy, transitioning to a solid black, substance caked to the interior of the tube. The maintenance supervisor was asked what the substance was in the interior of the tube. The maintenance supervisor stated it was nasty and they would contact the supplier to clean the machine.

Based on record review and interview, the facility failed to ensure assessments were accurate for one (#2) of one resident who was reviewed for hospice services. The Resident Census and Conditions of Residents report, dated 05/02/23, documented 12 residents received hospice services. Findings: Resident #2 had diagnoses which included congestive heart failure. A Physician's Order, dated 08/30/22, documented to admit the resident to hospice services. A Hospice Certification of Terminal Illness form, dated 09/01/22 through 11/29/22, read in part, .Verbal Certification .Medical Director .I certify that this patient is terminally ill with a life expectancy of six months or less if the disease follows its normal course . The Certification was electronically signed by the physician. The significant change assessment, dated 09/09/22, documented the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. A Hospice Certification of Terminal Illness form, dated 11/30/22 through 02/27/23, read in part, .Verbal Certification .Medical…

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 ensure care plans were reviewed and revised for one (#36) of 15 residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 05/02/23, documented 60 residents resided at the facility. Findings: Resident #36 had diagnoses which included congestive heart failure. A Physician's Order, dated 02/15/23, documented to administer lorazepam 0.5 mg every eight hours as needed for anxiety. This order was discontinued on 03/04/23. Review of the Care Plan, dated 02/23/23, did not reveal a problem, goal, or interventions for anxiety. A Physician's Order, dated 03/04/23, documented to administer lorazepam 0.5 mg every eight hours as needed for anxiety. On 05/05/23 at 3:15 p.m., the MDS/Care Plan nurse was asked why the care plan for Resident #36 had not been revised to include a care plan for anxiety. They stated they must have overlooked it.

Based on record review and interview, the facility failed to ensure as needed psychotropic medications were not ordered past 14 days without a documented physician's clinical rationale for two (#24 and #36) of five residents reviewed for unnecessary medications. The DON identified 12 residents who received as needed psychotropic medications. Findings: An Antipsychotic Medication Use policy, dated December 2016, read in part, .The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order . 1. Resident #36 had diagnoses which included congestive heart failure. A physician's order, dated 02/15/23, documented to administer one tablet of lorazepam 0.5 mg every eight hours as needed for anxiety. A physician's order, dated 03/04/23, documented to administer one tablet of lorazepam 0.5 mg every eight hours as needed for anxiety for 60 days. Review of the April 2023 medication administration records revealed the resident had the order for…

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.