Baptist Village Of Owasso

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the form CMS - 10055 was provided to residents with accurate information for 3 (#81, 82, and #103) of 3 sampled residents reviewed for beneficiary notices. LPN #2 stated 44 residents had discharged from skilled services between 01/01/25 and 06/23/25. Findings: 1. An undated face sheet for Res #81 showed the resident was admitted to the facility on [DATE]. A form CMS-10055, dated 12/31/24, showed Res #81 was informed the last day of their skilled services would be 12/31/24. This was the date of their admission to the facility and the form did not provide the cost of the skilled services listed. 2. An undated face sheet for Res #82 showed the resident was admitted to the facility on [DATE]. A form CMS-10055, dated 03/25/25, showed Res #81 was informed the last day of their skilled service would be 03/25/25. This was the date of their admission to the facility and the form did not provide the cost of the skilled services listed. 3. An undated face…

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 was not prescribed psychotropic medications for dementia for 1 (#69) of 5 sampled residents reviewed for unnecessary medications. The pharmacist stated 45 residents at the facility were prescribed antidepressant medications (antidepressants are psychotropic medications). Findings: A facility policy titled Baptist Village Communities Psychotropic Medication Policy and Procedure, dated 02/20/24, read in part, The indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. A physician's order for Res #69, dated 05/15/25, showed the resident had been prescribed sertraline (psychotropic medication approved for the treatment of depression) 25 mg once daily for dementia. A medication administration record, dated 06/01/25 through 06/30/25, showed Res #69 had been administered one sertraline 25 mg tablet each day starting on 06/01/25 and ending on 06/25/25 for a total of 25…

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 discharge assessments were completed for 1 (#72) of 5 sampled residents reviewed for assessments. The administrator reported the facility census was 74. Findings: A discharge note, dated 02/22/25, showed Res #72 was discharged on 02/22/25. A face sheet, dated 06/25/25, showed Res #72 was admitted on [DATE]. The face sheet also showed the resident had diagnoses which included sepsis and anemia. A review of Res #72's health record did not show a discharge MDS had been completed. On 06/25/25 at 2:49 p.m., MDS coordinator #1 stated a discharge MDS had not been completed upon Res #72's discharge. They also stated they were unsure why the discharge MDS was not completed.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was updated after a resident had a fall that resulted in an injury for 1 (#69) of 18 sampled residents whose care plans were reviewed. The DON reported that 74 residents at the facility had care plans. Findings: A facility policy titled Comprehensive Care Plan Policy and Procedure, dated 02/20/24, read in part, The comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). It will be updated quarterly, annually, with significant change, or as needed/identifies as preference changes occur or health need warrants. Res #69's care plan, dated 09/17/24, was reviewed. The care plan had a problem of falls, with past falls listed as 10/17/24, 10/27/24, 11/10/24, 12/08/24, 12/19/24, and 01/17/25. There were no falls, goals for fall prevention, or correlated interventions after 01/17/25. An admission MDS assessment, dated 04/01/25, showed Res #69 had a diagnosis of dementia and a BIMS score of 5 which indicated the resident's…

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 EBP were in place during catheter care for 1 (#73) of 2 sampled residents reviewed for indwelling urinary catheters. The DON reported 6 residents in the facility with indwelling urinary catheters. Findings: On 06/27/25 at 10:55 a.m., CNA #2 was observed providing catheter care to Res #73. The CNA was not observed to be wearing a gown. A sign was observed on the resident's door that showed the resident was on EBP. A facility policy titled Baptist Village Communities Policy and Procedure for Personal Protective Equipment Use to Prevent Spread of Multidrug-resistant Organisms, dated 02/20/24, read in part, For EBP, team members will employ targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. An admission assessment, dated 05/27/25, showed Res #73 had a BIMS score (a test for cognitive function) of 12, which was indicative of moderate cognitive…

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 residents did not receive an antipsychotic medication, unless for a specific diagnosis condition for three (#37, 55, and #43) of five residents reviewed for unnecessary medications. The Administrator reported 79 residents resided in the facility. Findings: 1. Resident #37 admitted to the facility with diagnoses which included dementia, depression, and cognitive communication deficit. A physician's order, dated 02/05/24, documented Risperdal 0.25 mg tablet Hour Of Sleep for unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident's electronic health record was reviewed and contained no documentation the resident had a diagnoses of psychotic disturbance/mood disorder. 2. Resident #55 admitted to the facility with diagnoses which included dementia, altered mental status, anxiety, and cognitive communication deficit. A physician order, dated 3/27/24, documented Quetiapine 25mg tablet 1/2 tablet every evening for unspecified dementia.…

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 resident assessments for discharge were completed and submitted to CMS for two (#68 and #63) of 11 sampled residents who were reviewed for resident assessments. The administrator identified 79 residents who resided at the facility. Findings: 1. Resident #68 admitted with diagnoses which included acute and chronic respiratory failure, diabetes type II, and congestive heart failure. Review of the face sheet for Resident #68 revealed they had transferred to the hospital on [DATE] and expired at the hospital on [DATE]. On [DATE] at 11:42 a.m., a review of the assessment log for Resident #68 revealed a discharge assessment had not been completed/submitted. On [DATE] at 1:49 p.m., MDS Coordinator #1 stated Resident #68 had been sent to the hospital on [DATE] and expired on [DATE]. They stated the discharge assessment was missing from the log for Resident #68. MDS Coordinator #1 stated the assessment was missed because it was an unplanned discharge and…

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 coordination and certification of assessments for four (#23, 37, 42 and #73) of 11 sampled residents who were reviewed for assessments. The administrator identified 79 residents who resided at the facility. Findings: Review of the electronic clinical record, revealed Residents #23, 37, 42 and #73, were missing quarterly assessments, due to no signature from the RN. Resident #73 was missing a quarterly which required correction and to be opened by the RN. On 07/23/24 at 11:42 a.m., MDS Coordinator #1 stated the quarterly assessments required a signature from the RN before the assessments could be submitted. They stated Resident #74 had a rejected assessment for the mood miscalculation and required to be unlocked by the RN before the correction could be made. The MDS Coordinator stated they sent emails to the RN for signatures and when assessments required re-opening for correction.

Based on record review and interview, the facility failed to ensure assessments were accurate for one (#15) of one sampled resident reviewed for hospice services and four (#4, 6, 53, and #2) of four sampled residents whose assessments were reviewed for accuracy related to anticoagulant use. The Resident Census and Conditions of Residents report identified 15 residents who received hospice services. The consultant pharmacist identified 14 residents who received anticoagulant medications. Findings: 1. Resident #15 had diagnoses which included Parkinson's disease. A Written Certification, dated 05/05/23, documented the physician certified the resident was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. The significant change assessment, dated 05/08/23, documented the resident did not have an illness or condition that may lead to a life expectancy of six months or less. On 06/29/23 at 11:18 a.m., MDS coordinator #2 was asked where information was obtained to determine if a resident has an illness which may result in a life…

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 documented the need for residents with bed rails for three (#59, #53, and #2) of three sampled residents who were reviewed for bed rails. The administrator identified 65 residents who utilized bed rails. Findings: An undated document titled Bed Rail Policy, read in part, . 1. Resident Assessment . Before admission, prospective residents will be screened to help determine if care needs may necessitate specialized beds (e.g. bariatric equipment) or accessories (e.g. side rails) . Resident care plan will include the use of bed rails as evaluated . 1. Resident #59 had diagnoses which included muscle weakness. The Nursing admission Evaluation Comprehensive assessment, dated 12/20/22, documented the resident utilized bed rails for bed mobility or transfer. The Care Plan, updated 06/20/23, did not document a care plan regarding side rails. The quarterly assessment, dated 06/20/23, documented the resident was severely impaired in cognition for daily decision making and was totally dependent on staff for bed…

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 with bed rails were assessed for the use for three (#59, #53, and #2) of three sampled residents who were reviewed for bed rails. The administrator identified 65 residents who utilized bed rails. Findings: An undated document titled Bed Rail Policy, read in part, . 1. Resident Assessment .a. Before admission, prospective residents will be screened to help determine if care needs may necessitate specialized beds (e.g. bariatric equipment) or accessories (e.g. side rails). b. Upon admission, readmission or change of condition, residents will be screened to determine: 1) level of independence with bed mobility. 2) Bed comfort level 3) If the bed meets manufacturers recommendation and specifications pertaining to resident height and weight 4) Need for special equipment or accessories (e.g. side rails) c. Evaluate the resident to identify appropriate alternative prior to installing bed rails d. Evaluate the resident for risk of entrapment from bed rails prior to installation or use e. Bed rails…

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 residents with bed rails were regularly inspected for the use for three (#59, #53, and #2) of three sampled residents who were reviewed for bed rails. The administrator identified 65 residents who utilized bed rails. Findings: An undated document titled Bed Inspection Policy, read in part, . 2. Equipment Management and Environmental Services . b The environmental service department will conduct regular (prior to admission and quarterly thereafter) inspection of all bed frames, mattresses and bed rails as part of a regular environmental services program to identify areas of possible entrapment . 1. Resident #59 had diagnoses which included muscle weakness. The Nursing admission Evaluation Comprehensive assessment, dated 12/20/22, documented the resident utilized bed rails for bed mobility or transfer. The Care Plan, updated 06/20/23, did not document a care plan regarding side rails. The quarterly assessment, dated 06/20/23, documented the resident was severely impaired in cognition for daily decision making and 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.