Mitchell Care & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were educated and offered the opportunity to create an advance directive for 4 (#16, 17, 56, and #58) of 5 sampled residents reviewed for advance directives. The administrator identified 57 residents who resided in the facility. Findings: 1. Resident #16 was admitted to the facility on [DATE]. A review of Resident #16's electronic health records showed no advance directive information had been provided. 2. Resident #17 was admitted to the facility on [DATE]. A review of Resident #17's electronic health records showed no advance directive information had been provided. 3. Resident #56 was admitted to the facility on [DATE]. A review of Resident #56's electronic heath record showed no advanced directive information had been provided. 4. Resident #58 was admitted to the facility on [DATE]. A review of Resident #58's electronic health records showed no advanced directive information had been provided. On 03/25/25 at 3:17 p.m., 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 significant change assessment was completed within 14 days of electing the hospice benefit for 1 (#60) of 1 sampled resident who was reviewed for hospice services. The administrator identified 57 residents resided in the facility. Findings: Resident #60 had diagnosis which included senile degeneration of the brain. A physician's order, dated 01/16/25, showed Resident #60 was admitted to hospice. Resident #60's quarterly assessment, dated 02/05/25, did not show hospice while a resident. A significant change assessment was not located in the residents electronic health record. On 03/25/25 at 9:43 a.m., the ADON stated Resident #60 was admitted to hospice services on 01/16/25. On 03/25/25 at 9:44 a.m., the ADON stated a significant change assessment had not been completed for Resident #60 after they were admitted to hospice. They stated the assessment should have been completed after the resident admitted to hospice care.

Based on record review and interview, the facility failed to update a care plan for 1 (#60) of 1 sampled resident for hospice services. The administrator identified 57 residents resided in the facility. Findings: A facility policy titled Comprehensive Person-Centered Care Plan, dated 10/23/19, read in part, Upon a Change in Condition, the Comprehensive Person-Centered Care Plan or Baseline Care Plan will be updated. Resident #60 had diagnosis which included senile degeneration of the brain. A physician's order, dated 01/16/25, showed Resident #60 was admitted to hospice. There was no documentation in Resident #60's care plan to reflect they had been admitted to hospice care. On 03/26/25 at 9:47 a.m., the ADON stated Resident #60's care plan had not been updated to reflect them being admitted to hospice.

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained for 1 (#16) of 13 residents sampled for infection control during the administration of medications. The administrator identified 57 residents resided in the facility. Findings: On 03/26/25 at 1:02 p.m., CMA #1 was observed popping Resident #16's gabapentin (an anticonvulsant) from the blister pack into their bare hand. On 03/26/25 at 1:04 p.m., Resident #16 was observed dropping their tramadol (an opioid analgesic) tablet on their shirt while attempting to take both medications. CMA #1 was observed to immediately pick up the tablet from the resident's shirt with their bare hands and returned it to the medication cup. On 03/26/25 at 1:05 p.m., Resident #16 took both of their medications as administered. An undated facility policy titled Emergency Pharmacy Services, read in part, Does not handle pills with bare hands. Resident #16 had diagnosis which included chronic pain syndrome. A physician's order, dated 10/29/24, showed gabapentin capsule 300 mg, give one capsule 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 observation, record review, and interview, the facility failed to ensure electrical outlets on both the East and [NAME] side hallways, nurses' stations, and living room areas had protective plates covering them. The administrator identified 60 residents resided in the facility. Findings: A Safe Homelike Environment policy, dated 04/28/2022, read in parts, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment .'Environment' refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas .6. a. The maintenance Director will perform periodic rounds to ensure functioning lights .9. General Considerations: f. Report any environmental concerns to the Administrator. 1. Res #1 had diagnoses which included Alzheimer's disease and cognitive communication deficit. A significant change in status assessment, dated 05/15/24, documented the resident's cognition was severely…

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 residents were free from abuse for two (#3 and #4) of four sampled residents reviewed for abuse. The DON identified 52 residents resided in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff .Mental Abuse: The use of verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame 1. Resident #3 had diagnoses which included major depressive disorder and morbid obesity. A 5-day resident assessment, dated 09/09/24, documented Resident #3's cognition was moderately impaired. It documented the resident made themselves understood and was able to understand others. On 11/05/24 at 2:35 p.m., Resident #3 was asked how they were treated by staff. They reported CNA #1 would talk mean to them and called them disgusting. Resident #3 stated it made them feel bad and they were glad CNA #1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report an allegation of abuse to the proper authorities for one (#2) of four sampled residents reviewed for abuse. The administrator reported there were 52 residents residing in the facility. Findings: An Abuse Prevention policy, revised 10/21/24, read in parts, The Administrator, or designee, shall report any allegations of abuse .to the Department of Health as required. Resident #2 had diagnoses that included muscle weakness, lack of coordination, and chronic respiratory failure. A MDS, dated [DATE], documented Resident #2 required one person assistance for hygiene and dressing, experienced shortness of breath with exertion, was oxygen dependent, and was currently using a wheelchair for mobility. A formal complaint submitted to the OSDH on 08/15/24 alleged that LPN #1 had been abusive towards Resident #2. The report documented Resident #2 had asked LPN #1 to get them a cup of coffee. It documented LPN #1 went and got a wheelchair, put it in 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 investigate an allegation of abuse for one (#2) of four sampled residents reviewed for abuse. The administrator reported there were 52 residents residing in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility will initiate at the time of any finding of potential abuse or neglect an investigation .and provide protection to any alleged victims to prevent harm during the continuance of the investigation. Resident #2 had diagnoses which included muscle weakness, lack of coordination, and chronic respiratory failure. A formal complaint submitted to the OSDH on 08/15/24 alleged that LPN #1 had been abusive towards Resident #2. The report documented Resident #2 had asked LPN #1 to get them a cup of coffee. It documented LPN #1 went and got a wheelchair, put it in the resident's doorway, and told the resident if they wanted a cup of coffee they would have to get it themselves. It documented LPN #1's response was considered abusive. On 11/05/24 at 2:35 p.m., LPN #1 reported they 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 complete nurse aide performance reviews at least yearly for 18 of 22 nurse aides employed by the facility. The administrator identified 22 full time nurse aides currently employed by the facility. Findings: An employee list documented 22 staff members currently working as certified nurse aides. On 07/22/24 at 3:17 p.m., the administrator provided documentation regarding a nurse aide skills performance checklist for four certified nurse aides currently working for the facility. On 07/22/24 at 4:00 p.m., the administrator stated only four of the 22 nurse aides currently working had a completed performance review. The administrator stated a previous employee had not completed the required task for all certified nurse aides.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide assistance with transportation to a scheduled physician appointment for one (#24) of one sampled resident reviewed for transportation. The administrator identified 60 residents who resided in the facility. Findings: A document titled [NAME] Manor Transportation Policy documented .[NAME] Manor will plan for transportation for all residents that reside at [NAME] Manor . Res #24 was admitted to the facility on [DATE] with diagnoses which included infection and inflammatory reaction due to internal joint prosthesis, chronic pain, and diabetes. A form titled Appointment NOV. 27---DEC. 2 documented the resident had an appointment scheduled on 11/27/23 at 1:00 p.m. On 11/27/23 at 11:21 a.m., the resident stated they had a doctor appointment scheduled for today, but couldn't make it. The resident stated they were informed there was no staff available for transportation. On 11/28/23 at 3:40 p.m., the social service staff stated the resident had a doctor…

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 the code status was identified and correct for one (#12) of one resident whose code status was reviewed. The administrator identified 60 residents who resided in the facility. Findings: Res #12 was admitted to the facilty on 06/05/17 with diagnoses which included dementia and diabetes. A form titled ''Oklahoma DNR'' was signed by the resident's POA on 06/06/17. The EHR documented the resident's code was full code. A physician order, dated 03/24/20, documented the resident's code status was a full code. On 11/30/23 at 9:29 a.m., the DON stated they miss-understood the new regulations regarding advanced directives and the DNR was revoked.

Based on record review and interview, the facility failed to complete correctly a PASARR level l evaluation for one (#11) of three residents reviewed for PASARR. The administrator identified 60 resident's resided in the facility. Findings: Res #11 was admitted to the facility with a diagnosis of major depressive disorder. The EHR documented the resident was diagnosed with schizoaffective disorder on 08/02/18. A PASSARR level l screen, dated 09/17/18, documented the resident did not have a diagnosis of a serious mental illness. A referral was not made to the state agency. On 11/29/23 at 10:35 a.m., the DON reviewed the PASARR level l and stated the form was not completed correctly. The DON stated a referral should have made to the state agency with the admitting diagnosis of major depressive disorder and with the new diagnosis of schizoaffective disorder.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility failed to ensure professional accepted standards of quality were met related to a mental health diagnoses given to one (#34) of five sampled residents reviewed for unnecessary medication and diagnoses. The administrator identified 60 residents who reside in the facility. Findings: Res #34 was admitted to the facility on [DATE] and had diagnoses which included anxiety, insomnia, dementia with behavioral disturbances, and delusional disorders. On 08/31/22, the physician ordered risperidone (an antipsychotic medication) 0.25 mg at bedtime. A quarterly assessment, dated 06/21/23, documented the resident had no diagnoses of schizophrenia. On 06/24/23, the physician documented, the resident had a new diagnoses of schizophrenia. An annual assessment, dated 09/11/23, documented the resident had a diagnoses of schizophrenia. On 11/30/23 at 8:55 a.m., the DON stated the physician just added the diagnoses of schizophrenia on 06/24/23 for the medication,…

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, record review, and interview, the facility failed to ensure the physician was notified and interventions in place for weight loss for one (#54) of one sampled resident reviewed for nutrition. The administrator identified 60 residents who resided in the facility. Findings: Res #54 was admitted on [DATE] and had diagnoses which included displaced avulsion fracture/chip fracture of right talus, osteoarthritis, depression, and malignant neoplasm of tongue. A admission assessment, dated 08/03/23, documented the resident was cognitively intact and required minimal assistance with ADLs. The assessment also documented the resident's weight was 181 pounds. The vital sign record, dated 10/18/23, documented a weight of 153.6 pounds. A dietary note, dated 10/23/23, documented a recommendation of health shakes twice a day between meals related to weight loss. A quarterly assessment, dated 11/03/23, documented the resident had a weight of 152 pounds and a weight loss of 5% or more in the last month or…

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.