Muskogee Nursing Center

Based on record review and interview, the facility failed to ensure accurate staffing information for the PBJ reports was provided to CMS for the fourth quarter of 2024. A facility document titled All Residents, dated 01/06/25, documented 38 residents resided at the facility. Findings: A CMS PBJ Staffing Data Report dated 07/01/24 through 09/30/24, documented the facility had not provided the required RN coverage or licensed nurse coverage for the quarter of 2024. A review of the facility daily staffing reports for the fourth quarter of 2024 revealed the facility had been adequately staffed for RN coverage, licensed nurse coverage, and weekend staffing. On 01/08/25 at 10:14 a.m., the administrator stated the information submitted was not accurate and the person who had entered the data had erroneously submitted incorrect information at another one of their facilities on another occasion. On 01/08/25 at 10:32 a.m., the administrator stated they had not been aware the wrong information had been submitted. They stated the employee who had entered the data had recently been let go…

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 SNF ABN forms included the required information for two (#43 and #48) of three sampled resident reviewed for skilled services beneficiary review. The DON identified 10 residents that had discharged from part A skilled services in the previous six months to the survey. Findings: 1. A SNF ABN form for Resident #43, dated 09/20/24, was reviewed and found not to have the reasons for non-coverage and estimated cost of those services documented on the form. 2. A SNF ABN form for Resident #48, dated 12/23/24, was reviewed and found not to have the reasons for non-coverage and estimated cost of those services documented on the form. On 01/08/25 at 9:59 a.m., the infection preventionist stated they had been tasked with creating the SNF ABN forms and presenting them to the residents. They stated they were unaware the section about the reason for potential non-payment and estimated cost were required to be included on the form. They stated they understood now the information was needed for the resident and 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 record review and interview, the facility failed to ensure licensed nurses were competent to perform tasks of their position by conducting a skills check and documenting the results for each licensed nurse. A facility employee list provided by the DON documented eight licensed nurses worked at the facility. Findings: A review of LPN #1's employee file did not reveal a skills review. On 01/08/25 at 8:56 a.m. the DON stated they had looked at LPN #1's records and did not find a skills check. They stated the former DON had stopped performing skill checks at some point and they would be restarting that process. They stated it was their expectation each licensed nurse would possess the skills to perform their duties. They stated their was no facility policy or procedures regarding skills checks. On 01/08/25 at 9:01 a.m., the administrator stated none of their current licensed nurses had a skills check in their file because the previous DON had not done them. On 01/08/25 at 9:06 a.m., the assistant administrator stated the nurses last skills check had occurred in 2021.

Based on observation and interview, the facility failed to: a. implement an enhanced barrier precaution policy to prevent the spread of multidrug-resistant organisms; and b. ensure a licensed practical nurse performed hand hygiene during tracheostomy care for one (#36) of one sampled resident reviewed for tracheostomy care. The administrator reported the census in the facility was 38 and one resident had a tracheostomy. Findings: 1. On 01/06/25 at 8:45 a.m., a tour of the facility was conducted. No signage was noted indicating enhanced barrier precautions were in place to protect at risk residents. On 01/07/25 at 12:42 p.m., CNA #1 stated the facility did not use EBP. On 01/07/25 at 12:45 p.m., CNA #2 stated they were not familiar with EBP. On 01/08/25 at 09:41 a.m., LPN #1 stated the facility was in the process of implementing enhanced barrier precautions. On 01/08/25 at 10:35 a.m., the infection preventionist stated they are currently not using EBP. b. A facility Trach policy, dated 11/05/24, read in part, Cleaning A Non Disposable Inner Cannula 1. Prepare supplies before cleaning…

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 dialysis communication forms were consistently filled out for one (#21) of one sampled resident reviewed for dialysis. The administrator reported three residents in the facility received dialysis services. Findings: A Nursing Home Dialysis Transfer Agreement, signed 01/21/14, read in part, Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all designated residents at the time of transfer to center. Resident #21 had diagnoses which included end stage renal disease. A physician's order, dated 11/03/21, documented Resident #21 was to receive dialysis every Tuesday, Thursday, and Saturday. Resident #21's 2024 TARs documented they had been transported to dialysis 13 times in November and 13 times in December. Out of 26 opportunities, the resident's health record contained five dialysis communication forms. On 01/08/25 at 9:41 a.m., LPN#1 stated the nurse on duty should ensure a dialysis communication form was sent with the resident to dialysis. They stated once 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 resident with a diagnosis of diabetes and received routine insulin had an HgbA1C lab collected as ordered by a physician for one (#22) of five sampled residents reviewed for unnecessary medications. The DON stated 23 residents at the facility have physician routine orders for HgbA1C tests. Findings: Resident #22 had diagnoses which included type two diabetes. A physician's order, dated 08/12/19, documented Resident #22 was to have HgbA1C labs drawn each January, April, July, and October. A review of the resident's EHR revealed no documentation the resident's HgbA1C had been collected since July 2024. On 01/07/25 at 9:45 a.m., the infection preventionist stated in October 2024 the facility's QA committee had identified through their quality assurance program the HgbA1C labs for Resident #22 had not been done. They were asked since the discovery, how many times had the resident's lab been checked. The infection preventionist stated they had not been checked since identified by the QA committee. They stated 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 lab work identified by the QA committee as not having been done was collected once the omission was identified for one (#22) of five sampled residents reviewed for unnecessary medications. A facility document titled All Residents, dated 01/06/25, documented 38 residents resided at the facility. Findings: An active physician's order, dated 08/12/19, documented Resident #22 was to have HgbA1C labs drawn each January, April, July, and October. A review of the resident's EHR revealed no documentation the resident's HgbA1C had been collected since July 2024. On 01/07/25 at 9:45 a.m., the infection preventionist stated in October 2024 the QA committee, through their quality assurance program, had identified the previous DON had not been monitoring labs and Resident #22 HgbA1c had not been collected since July 2024. The infection preventionist was asked how many times the resident's labs had been collected since October 2024. They stated the labs had not been collected. They were asked how effective the facility quality…

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 staff wore hair nets and beard guards while in the kitchen. The CDM identified 33 residents received services from the kitchen. She identified one resident who solely received nutrition and hydration through a peg tube. Findings: A Personnel Standards policy, undated, read in part, .The following standards have been adopted by the dietary department .Hair nets, covering all of the hair, must be worn at all times while on duty .Facial hair must be covered with a beard guard . On 11/14/23 at 11:22 a.m., [NAME] #1 was observed with very short hair on their head and the bottom half of their face. They were not observed to have a hair net or beard guard on. On 11/14/23 at 11:48 a.m., DA #1 was observed in the kitchen with longer facial hair observed from side burn to side burn, covering chin, and above top lip. They were not observed to wear a beard guard. On 11/14/23 at 12:00 p.m., [NAME] #1 and DA #1 were observed assisting with plating lunch and covering trays for delivery. Neither staff were observed…

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 update COVID-19 Policy and Procedures at least annually. The Administrator reported there were 34 residents residing in the facility. Findings: A COVID-19 Policy and Procedure, revised 12/23/20, stated in parts, .Staff will have their temperature checked 3 times per shift .Dietary staff to wear mask while in kitchen .Nurse's to wear N95 mask while completing breathing treatments .Facility will obtain and record temperatures on all residents qshift .Residents are to be encouraged to stay in their rooms .Residents are to wear face mask anytime they come out of their room . On 11/16/23 at 9:00 a.m., the Administrator stated the above practices documented in their current COVID-19 policy and procedures were no longer in effect and acknowledged the policy had not been updated at least annually.

Based on record review, observation, and interview, the facility failed to conduct routine pressure ulcer assessments, follow physician orders for pressure ulcer treatment, and update the care plan for one (#15) of two residents sampled for pressure ulcers. The Resident Census and Conditions of Residents form documented one resident with pressure ulcers. Findings: Res #15's significant change assessment, dated 08/13/22, documented the resident's cognition was moderately impaired, required extensive assistance with ADLs, and had no pressure ulcers. A nurse note, dated 09/06/22, documented the resident had a fluid filled blister to the left heel measuring 2.0 x 4.5 cm. The note documented an order to cleanse the area with wound wash, pat dry, and spray area with skin prep BID until resolved. A physician order, dated 10/05/22, documented to discontinue skin prep and apply Allevyn dressing to left heel and leave in place for seven days. The TAR documented the skin prep treatment was continued after the physician order documented to discontinue the treatment. The TAR did not document 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.