McAlester Nursing & Rehab

Based on observation, record review, and interview, the facility failed to ensure the shower curtain was kept clean and ceiling tiles were in good repair for 1 (east hall shower room) of 2 shower rooms observed.The administrator identified 25 residents used the east hall shower room. Findings:On 05/19/26 at 12:39 p.m., the east hall shower room was observed to have a grey and white shower curtain hanging with spots of black discoloration (too numerous to count) and two ceiling tiles with brown rings and water damage.A Laundry and Bedding, Soiled policy, revised 11/2010, read in part, shower linen ie curtains .shall be laundered as needed.A Bathrooms_Showers policy, revised 02/2021, read in part, showers . are cleaned and disinfected daily, shower linen is to be laundered monthly or when residue is noticed in accordance with our established procedures. On 05/19/26 at 12:45 p.m., maintenance #1 stated the black discoloration on the shower curtain looked like mold or mildew.On 05/19/26 at 12:47 p.m., maintenance #1 pointed at the damaged ceiling tiles and stated, Those are water leaks,…

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 ensure a resident was free from sexual abuse for 1 (#2) of 4 sampled residents reviewed for abuse. The DON identified 43 residents resided in the facility.Findings:1. On 05/18/26 at 12:25 p.m., Resident #2 was observed sitting in a wheelchair in a common area. The resident was clean and dressed for the day. Resident #2 did not verbally respond when spoken to, just smiled. Resident #2 did not have any visible bruises or wounds noted. Staff approached Resident #2 and spoke in a calm pleasant manner. Resident #2 smiled at the staff and did not appear fearful.An undated admission report showed Resident #2 had diagnoses which included frontotemporal neurocognitive disorder, focal traumatic brain injury, cognitive social or emotional deficit, and speech and language deficit.A quarterly assessment for Resident #2, dated 02/24/26, showed the resident had a BIMS of 3 (which indicated they were severely impaired in cognition) and did not have behaviors. 2. An undated admission record showed Resident #1 had diagnoses…

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 Resident Assessments were accurately coded for two (#39 and #50) of 13 sampled residents reviewed for accurate assessments. The Administrator identified 43 residents resided in the facility. Findings: 1. Resident #39 had diagnoses which included hepatic encephalopathy, metabolic encephalopathy, and cirrhosis of the liver. Resident #39's physical therapy treatment notes documented they received services on 06/26/24, 06/27/24, and 07/01/24. A Quarterly Resident Assessment, dated 07/01/24, documented Resident #39 did not receive physical therapy services. On 07/30/24 at 3:22 p.m., MDS Coordinator #1 stated they would code a resident received therapy services in section O of the Resident Assessment. They stated therapy brought them a log to identify what residents had received therapy services. They stated no therapy services were coded on Resident #39's assessment. MDS Coordinator #1 reviewed Resident #39's physical therapy records and stated the 06/26, 06/27, and 07/01/24 physical therapy services should have been…

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 care plan was updated related to an unstageable pressure ulcer for one (#152) of 12 sampled residents reviewed for care plans. The Administrator identified 43 residents resided in the facility. Findings: Resident #152 had diagnosis which included unstageable pressure ulcer. A nursing note, dated 07/18/24, documented Resident #152 had readmitted to the facility with a 5.0 cm in length by 3.0 cm in width by 0.1 cm in depth moisture associated wound to their right buttock. A Physician's order, dated 07/26/24, documented, clarification order clean unstageable area on buttock with wound wash, pat dry, apply hydrogel and collagen. cover area with foam dressing every day and PRN x 14 days then re-evaluate. There was no documentation of Resident #152's unstageable pressure ulcer in the care plan. On 07/31/24 at 9:39 a.m., MDS Coordinator #1 stated they had not updated the care plan since Resident #152 had returned from the hospital.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure accurate documentation of blood pressure for one (#6) of five sampled residents observed for medication pass. The administrator identified 43 residents resided in the facility. Findings: A Nursing Care Policies and Procedures, for blood pressures, revised 05/18/01, documented, A blood pressure measurement is taken to accurately determine the blood pressure to assist in diagnosis and to show progress and change in a resident's condition. Resident #6 admitted on [DATE], with diagnoses which included essential hypertension and tachycardia. A Physician's order, dated 06/08/24, documented metoprolol tartrate give 25 mg twice daily, hold if SBP is less than 110. On 07/31/24 at 10:08 a.m., LPN #1 obtained Resident #6's blood pressure with a wrist cuff. the blood pressure reading was 101/52 with a pulse of 101. On 07/31/24 at 10:09 a.m., LPN #1 stated, I always round up so it is 102/52. On 07/31/24 at 10:10 a.m., LPN #1 documented 102/52…

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 ensure information on how to file a formal complaint with the State agency was visible to the residents. The Administrator identified 43 residents resided in the facility. Findings: On 07/30/24 at 10:05 a.m., a meeting with the Resident Council Group was held. They stated they had not been informed of their right and given information on how to formally complain to the State about the care they were receiving. On 07/30/24 at 10:39 a.m., the Long Term Care Facility Complaint Procedure form was observed on a brown board next to the dining room. Only the top part of the form was visible. A plastic sleeve that contained survey results was observed covering the bottom half of the form. There was no contact information, mailing address, e-mail address, or telephone number for filing a formal complaint to the State viewable. On 07/30/24 at 11:02 a.m., Social Services stated they went over resident rights and how to file a grievance during Resident Council meetings. They stated as far as with the State agency, they…

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 ensure residents had access to the most recent survey results conducted by State surveyors. The Administrator identified 43 residents resided in the facility. Findings: A complaint investigation was conducted at the facility on 12/11/23. On 07/30/24 at 10:05 a.m., a meeting with the Resident Council Group was held. They stated they did not know how to access the results of the State inspections. They stated the facility had not informed them. On 07/30/24 at 10:39 a.m., there were State survey results observed in a clear plastic sleeve on a brown board next to the dining room. There was no sign indicating these were the State survey results. The survey results located inside were dated 06/28/23. On 07/30/24 at 10:52 a.m., the survey results for the 12/11/23 complaint survey conducted at the facility were not observed in the clear plastic sleeve. On 07/30/24 at 10:57 a.m., Social Services stated survey results were usually posted up by one of the west doors. Social Services stated they honestly didn't share…

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 record review and interview, the facility failed to ensure a resident's code status was updated in the care plan for one (#38) of 12 sampled residents reviewed for code status. The Administrator identified 43 residents resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, revised December 2016, documented assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions changed and when a resident had been readmitted to the facility from a hospital stay. Resident #38 admitted on [DATE] with diagnoses which include myocardial infarction and atherosclerotic heart disease of the native coronary artery without angina pectoris. A Care Plan, dated 05/03/24, documented Resident #38 had chosen a full code and staff were to follow full code protocol. A Physician's order, dated 06/27/24, documented Resident #38's code status as DNR. Resident #38's chart had an orange sticker on the front and the side that documented…

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 ensure medications were not left at a resident's bedside for one (#39) of 16 residents observed for bedside medications. The Administrator identified 43 residents resided in the facility. The DON identified no residents with orders to self-administer medications. Findings: A Medication Storage in the Facility policy, revised 08/14, read in part, .Medications and biologicals are stored safely, securely, and properly .Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications .permitted to access medications . Resident #39 had diagnoses which included hepatic encephalopathy, metabolic encephalopathy, and cirrhosis of the liver. Resident #39's July 2024 Physician Order's did not contain an order to self-administer medications. On 07/28/24 at 9:37 a.m., Resident #39 stated they noticed a white pill they hadn't been taking during medication pass. They stated the staff was going to go and see what the medication was. Resident #39 stated the staff reported it was oxxybutynin,…

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 ensure meat products were thawed in a manner to prevent cross-contamination for one of two kitchen observations. The Administrator identified 43 residents resided in the facility. The DON identified one resident who received nothing by mouth. Findings: A Food Receiving and Storage policy, revised 10/17, read in part, Foods shall be received and stored in a manner that complies with safe food handling practices .Uncooked and raw animal products and fish will be stored separately in drip-proof containers . On 07/28/24 at 9:00 a.m., there was a grey container observed on the bottom shelf of the walk in cooler. There was one clear wrapped container of meat labeled ground beef that was dated 07/11/24. In the same container, there were two partially frozen hams with a use by date of 10/29/24. There was a red liquid substance noted at the bottom of the container the meats were stored in. On 07/28/24 at 9:10 a.m., the Dietary Manager stated the meats were supposed to be separated. They stated both items required…

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 resident MDS assessments were transmitted to CMS in the required time frame for three (#10, 24, and #37) of three residents sampled for MDS transmission. The Census and Conditions of Residents form, dated 06/28/23, documented a census of 43 residents. Findings: A CMS Submission Report, dated 06/27/23, documented an annual assessment for Res #10 with a target date of 04/16/23 was transmitted on 06/27/23, an annual assessment for Res #24 with a target date of 05/07/23 was transmitted on 06/27/23, and an annual assessment for Res #37 with a target date of 04/19/23 was transmitted on 06/27/23. On 06/27/23 at 3:30 p.m., the MDS coordinator reported the resident assessments were transmitted by the corporate office. The MDS coordinator reported the resident assessments for Res #10, #24, and #37 should have been transmitted within the 14 day required time frame.

Based on record review and interview, the facility failed to ensure insulin was held and blood sugars were obtained per physician's orders for one (#6) of one resident reviewed for diabetic care. The DON identified six residents with orders for insulin. Findings: Res #6 was admitted with diagnoses which included diabetes. A physician order, dated 01/14/22, documented to inject Novolog (Insulin to lower blood sugar) 10 U SQ TID at 0700, 1130 and 1630. Hold if FSBS below 110. A physician order, dated 11/08/22, documented to check FSBS AC (before meals) & HS (bedtime). The Finger Stick Blood Sugar and Injection log for April 2023 documented the following: On 04/01/23 at 4:00 p.m. - FSBS (blood sugar) was 90 and insulin was administered. On 04/09/23 at 4:00 p.m. - No FSBS reading was documented and insulin was administered. On 04/22/23 at 8:00 p.m. - No FSBS reading was documented On 04/23/23 at 4:00 p.m. & 8:00 p.m. - No FSBS reading was documented On 04/28/23 at 4:00 p.m. & 8:00 p.m. - No FSBS reading was documented On 04/29/23 at 6:00 a.m. - No FSBS reading was documented On 04/30/23…

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 ensure oxygen tubing and humidifier bottles were labeled per physician orders for three (#13, 26 and #28) of three sampled residents reviewed for oxygen therapy. The DON identified six residents on oxygen therapy. Findings: 1. Res #13 had diagnoses which included COPD and pulmonary hypertension. A physician order, dated 05/25/23, documented to change O2 concentrator humidifier bottle weekly on Sunday 10-6 shift and PRN and date bottle. A physician order, dated 05/25/23, documented to change O2 tubing weekly on Sunday 10-6 shift and PRN if contaminated and date O2 tubing. On 06/26/23 at 9:00 a.m., Res #13's oxygen was in use with tubing and humidifier bottle not labeled or dated. On 06/27/23 at 8:45 a.m., Res #13's oxygen was in use with tubing and humidifier bottle not labeled or dated. 2. Res #26 had diagnoses which included chronic lung disease. A hospice order, dated 05/27/23, documented to provide oxygen 3L via NC continuously. On 06/27/23 at 8:37, Res #26 was observed with oxygen at 3L per NC, there was…

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 ensure a care plan was developed for one (#13) of one resident sampled with a skin condition and one (#26) of one sampled resident with oxygen therapy. The DON identified one resident who had psoriasis (a skin condition) and six residents with oxygen therapy. Findings: 1. A physician order, dated 05/30/23, documented betamethasone (a steroid cream) 0.05% apply topically to affected areas twice daily as needed for psoriasis. A physician order, dated 05/30/23, documented Stelara (immunosuppressant drug) 90mg/ml inject one ml SQ every 12 weeks. On 06/26/23 at 12:45 p.m., Res #13 was observed to have large red areas on their torso, both arms, and legs. Res #13 was scratching and picking at the red areas. Res #13 reported they had psoriasis and stated, it has flared up and is bad. There was no care plan for Res #13's psoriasis. On 06/28/23 at 9:15 a.m., the MDS coordinator reported Res #13's psoriasis had been care planned and Res #13's skin had improved so the care plan was resolved. The MDS Coordinator also…

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.