Seminole Pioneer Nursing Home

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was dated for one (#52) of one resident sampled for oxygen. The administrator identified 50 residents resided in the facility. Findings: Res #52 admitted to the facility with diagnoses which included COPD. On 11/04/24 at 1:58 p.m., Resident #52's oxygen tubing was observed with no date. On 11/05/24 at 12:05 p.m., the DON reported the tubing was supposed to be changed weekly and dated.

Based on observation and interview, the facility failed to ensure census information was posted with the daily staffing roster. The administrator identified 50 residents resided in the facility. Findings: On 11/05/24 at 9:14 a.m., the staffing roster was observed posted next to the nurses station. The census was not included in the posted information. On 11/05/14 at 9:16 a.m., the administrator stated they were unaware the census had to be posted.

Based on record review, and interview, the facility failed to ensure residents were free of significant medication errors for one (#49) of five sampled residents reviewed for unnecessary medications. The administrator identified 50 residents resided in the facility. Findings: Res #49 had diagnoses which included mood disorders. A physician's order, dated 10/21/24, documented to administer Zyprexa (an antipsychotic) 5 mg at bedtime for mood disorder. An October 2024 MAR documented blanks for the PM doses of Zyprexa on 10/22/24 and 10/30/24. A behavior monitoring tracker for October 2024 documented Res #49 had behaviors on 10/22/24 and 10/30/24. On 11/05/24 at 9:22 a.m., CMA #1 stated the blanks on the MAR meant the medication was not given. On 11/05/24 at 9:24 a.m., the DON stated there was no way to prove the medications were administered if the administration record was blank. They were made aware of the resident's behaviors on the days the medication was not given. They shrugged and had no additional comment regarding the behaviors.

Based on observation and interview, the facility failed to ensure the physical environment was maintained in good repair. The administrator identified 41 residents who resided in the facility. Findings: On 03/04/24 at 1:30 p.m., the following observations were made: a. a white five-gallon plastic bucket seated directly beneath the fire alarm control panel box in the front lobby. The bucket had approximately one inch of brown-tinged water with dark sediment in the bottom. A clear plastic light cover had been partially opened directly above the bucket. The plaster ceiling above the light cover had brown watermark stains and patches of black residue directly beside the lighting and wiring, and b. the dining room ceiling had three large areas without plaster exposing the sheetrock above. The areas had brown watermark stains. On 03/04/24 at 2:00 p.m., the maintenance supervisor stated the facility had several roof leaks over the last couple of months. They stated a roofing crew had patched the leaks in the dining area a few weeks ago but the area above the fire alarm control panel box…

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 were bathed as scheduled for three (#3, 5, and #7) of three residents, and provided assistance with dressing for two (#5 and #7) of three sampled residents reviewed for assistance with ADLs. The administrator identified 41 residents who resided in the facility. Findings: A Shower List, dated 03/01/24, read in part, . Residents are to be cleaned and free from odors at all times. Showers are based on need as well as the schedule. If a resident needs or desires a shower, it is to be done . 1. Res #3 was admitted with diagnoses which included dementia, anxiety, and tremor. A facility shower list documented Res #3 was to receive staff assisted showers on Tuesday, Thursday, and Saturday weekly. A care plan, dated 07/15/23, documented the resident needed assistance with ADLs and required staff intervention to remain clean, neat, and free of body odors. The care plan documented an intervention to provide/assist with bath or shower two to three times weekly or more often as desired by the resident.…

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 and interview, the facility failed to ensure staff followed infection control guidelines to prevent the potential spread of communicable disease in the shower rooms. The administrator identified 41 residents who resided in the facility. Findings: An Environmental Services Cleaning guideline, dated 2020, read in part, .It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, and tasks being performed in the area .The purpose is to provide standard operation procedures for a clean, safe, and sanitary environment for the residents .Surfaces such as sinks, tubs, shower floors and all other surfaces will be cleaned daily using an EPA approved hospital grade disinfectant - detergent solution .These surfaces will also be cleaned as needed when spills or soiling occur . On 03/04/24 at 11:15 a.m., a tour of three shower rooms 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 record review and interview, the facility failed to ensure an nurse had a valid nursing license. The Resident Census and Conditions of Residents form, dated 10/24/23, documented 44 residents resided in the facility. Findings: An Oklahoma Board of Nursing Verification Report, dated 10/24/23, documented LPN #1's license had lapsed as of 06/30/23. An hours report for July 2023, documented LPN #1 worked 21 shifts without a license from 07/01/23 through 07/31/23. A hours report for August 2023, documented LPN #1 worked 23 shifts without a license from 08/01/23 through 08/31/23. A hours report for September 2023, documented LPN #1 worked 18 shifts without a license from 09/01/23 through 09/30/23. An Employee Details Report for October 2023, documented LPN #1 worked as a LPN without a license on 10/02/23, 10/03/23, and 10/04/23. A typed statement from the administrator documented LPN #1 was discovered to not have a valid license on 10/04/23 and was removed from the floor and providing patient care. The statement documented LPN #1 had not been performing nursing duties since…

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 ensure the kitchen was kept clean and maintained to promote food safety and sanitation. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 45 residents resided in the facility. Findings: On 08/10/23 8:51 a.m., a follow-up tour of the kitchen was conducted. The following observations were made: a. an accumulation of lint and a black substance was on the heat/air return vent, b. a thick accumulation of dirt, debris, and a brown and black residue was surrounding the floors by the base boards in the kitchen and both dining rooms, c. an accumulation of black and brown residue was on the wall beside the kitchen refrigerator, d. an an accumulation of white residue was on the sink in the dining room, e. floor tiles were worn down to the concrete in the kitchen, f. no wastebasket at the handwashing sink, g. an accumulation of dust, debris, and hair was on the counters where the pans were kept, h. an accumulation of dust and debris was underneath the dishwasher, i. the caulking surrounding the counter…

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, interview, and record review, the facility failed to ensure care plans were updated to prevent falls for two (#12 and #98) and failed to update care plan related to wounds for one (#14) of 24 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 08/08/23, documented 45 residents resided in the facility. Findings: 1. Res #14 had diagnoses which included non-pressure wounds to right axilla, left groin, and right groin. A care plan, revised 03/22/23, documented the resident was currently receiving treatment for wounds to right axilla and right groin. A physician's order, dated 07/07/23, documented to clean left groin with dermal wound cleanser, pat dry, apply Puracil or equivalent to wound bed, cover with Duoderm every other day Monday, Wednesday, Friday. On 8/9/23 at 1:52 p.m., LPN #1 was asked how many and the location of the wounds for Res #14. LPN #1 stated, right axilla, right groin, left perineal crease. On 8/09/23 3:33 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 observation, record review, and interview, the facility failed to ensure a physician order was obtained for a urinary catheter for one (#15) of one sampled resident reviewed for urinary catheter placement. The Resident Census and Conditions of Residents report, dated 08/08/23, documented one residents with a urinary catheter resided in the facility. Findings: Res #15 had diagnoses which included urinary retention and chronic kidney failure. A quarterly MDS assessment, dated 06/05/23, documented Res #15's cognition was intact, had an indwelling urinary catheter, and required extensive to total assistance with ADLs. A care plan, updated 06/17/23, documented Res #15 has the potential for complications related to indwelling urinary catheter. On 08/09/23 at 11:41 a.m., observed Res #15 to have a urinary catheter bag attached to the side of their bed. On 08/10/23 at 12:21 p.m. the DON was asked if Res #15 had a physician's order for urinary catheter placement or catheter care. The DON reviewed Res #15's physician orders and stated there were no orders for urinary catheter…

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 records were complete and systematically organized for one (#44) of three sampled residents reviewed for closed records. The Resident Census and Conditions of Residents form, dated 08/08/23, documented 45 residents resided in the facility. Findings: Res #44 had diagnoses which included heart failure, HTN, DM, and depression. A discharge MDS, dated [DATE], documented the resident was discharged return not anticipated to an acute hospital. On 08/11/23 at 9:40 a.m., Res #44's progress notes from 05/17/23 to discharge were requested. On 08/11/23, at 2:04 p.m., the DON stated the resident's progress notes could not be located. They stated it could be due to the facilities filing system. They stated the facility did not have a medical records employee and the current system was to take the records, put a note on it, and place it in the medical records room to be filed later. They stated there was not currently anyone in the 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 record review and interview, the facility failed to explicitly inform the resident or his or her representative of their right not to sign an arbitration agreement and explicitly grant the resident or their representative the right to rescind an arbitration agreement within 30 calendar days of signing it. The administrator documented 25 residents had entered into binding arbitration agreements. Findings: A Dispute Resolution Provision, effective 10/01/2017, was reviewed for explicit language documenting the resident's right to not sign and the right to rescind the agreement within 30 days of signing. The document did not contain the explicit statements. On 08/11/23 at 12:58 p.m., the social services director was asked how the arbitration agreement was presented to residents. They stated it was part of the admission packet and they explained during admission how to file a complaint and who the chain of command for complaints was. They stated they were not aware the agreement was optional and that it was not a requirement of admission. On 08/11/23 at 1:03 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 that arbitration agreements provided for the selection of a venue that was convenient to both parties. The administrator documented 25 residents had entered into binding arbitration agreements. Findings: A Dispute Resolution Provision, effective 10/01/2017, documented in part, .Mediation shall be held in Oklahoma City, Oklahoma in accordance with the rules of procedure for mediation .Agreement or related to the provision of services at the Facility shall be settled solely by arbitration in Oklahoma City, Oklahoma . On 08/11/23 at 12:58 p.m., the social services director was asked about selection of venue for arbitration. They stated they were not aware of the requirement. On 08/11/23 at 1:03 p.m., the administrator was asked about the arbitration agreement. They stated they were unaware of the requirement and would have corrections made.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure accurate code status was documented for a resident with a DNR for one (#40) of 12 sampled residents whose code status was reviewed. The Resident Census and Conditions of Residents form, dated [DATE], documented 45 residents resided in the facility. Findings: Res #40 had diagnoses which included HTN, DM, pulmonary emphysema, and bipolar disorder. The resident's care plan, updated [DATE], documented Res #40 was a full code. On [DATE] at 1:00 p.m., Res #40's door was observed with a stop sign on the upper right hand side above their name. On [DATE] at 2:40 p.m., the resident's chart was observed with a sticker on the spine that documented the code status as DNR. The face sheet in the chart documented the resident's code status as full code. A record review did not document a signed DNR form. On [DATE] at 3:10 p.m., CNA #4 was asked how the staff know the code status of a resident. The CNA stated the code status is on the door. She…

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 conduct a thorough investigation into an allegation of abuse for one (#37) of three sampled residents reviewed for abuse. The Resident Census and Conditions of Residents form, dated 08/08/23, documented 45 residents resided in the facility. Findings: Res #37 had diagnoses which included Alzheimer's dementia, TBI, and Parkinson's disease. A quarterly MDS, dated [DATE], documented the resident was cognitively intact and independent with ADLs. An incident report form, dated 07/14/23, documented Res #37 reported a CNA for slamming down their food tray and making an obscene gesture at the resident. The report documented staff were interviewed and the allegation was unsubstantiated. On 08/08/23 at 12:27 p.m., Res #37 was observed in their room seated in a rocking chair. The resident stated he had an issue with a CNA recently in which they allegedly tossed the resident's food tray down and made a vulgar gesture at the resident. The resident…

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 physician response to a MRR for one (#32) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 08/08/23, documented 45 residents resided in the facility. Findings: Res #32 had diagnoses which included seizure, edema, HTN, and COPD. A MRR, dated 06/15/23, documented a request to collect labs including a CBC, CMP, TSH, and Depakote level. The resident's record did not document an order or lab results related to the MRR. On 08/10/23 at 3:55 p.m., the ADON stated they could not locate the physician response to the MRR.

Based on observation, interview, and record review, the facility failed to ensure nursing staff followed the infection control guidelines to prevent the potential spread of communicable disease. The Resident Census and Conditions of Residents form dated 08/08/23, documented 45 residents resided in the facility. Findings: Resident #15 had diagnoses which included urinary retention and chronic kidney failure. A quarterly resident assessment, dated 06/05/23, documented res #15's cognition was intact, had an indwelling urinary catheter, and required extensive to total assistance with ADLs. On 08/10/23 at 10:48 a.m., LPN #1 was observed performing Res #15's catheter care. LPN #1 was observed to set up two wash basins, four wash cloths, and one towel. LPN #1 washed Res #15's genitalia with two separate wash cloths. LPN #1 did not change gloves between washing and rinsing Res #15's genitalia. On 08/10/23 at 10:55 a.m., the LPN was asked if she should have changed gloves between washing and rinsing during catheter care. The LPN stated, Normally, yes. On 08/10/23 at 11:21 a.m., the DON 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 record review, observation, and interview, the facility failed to ensure resident assessments accurately reflected the status of the residents for three (#2, 16, and #20) of 16 residents whose assessments were reviewed. The Resident Census and Conditions of Residents'' form documented 41 residents resided at the facility. Findings: 1. Res #2's physician order, dated 06/01/22, documented to reduce clozapine from 25mg in the a.m. and 25mg at 2:00 p.m. to 12.5mg in the a.m. and 25mg at 2:00 p.m. A pharmacist MRR, dated 07/12/22, documented a request to the physician to consider tapering one of the resident's psychoactive medications. The physician disagreed with the reduction at that time. An annual assessment, dated 07/23/22, documented the resident received an antipsychotic medication. The assessment documented a GDR for antipsychotic medication had not been attempted. The assessment documented a GDR was documented as clinically contraindicated by the physician on 11/17/21. On 08/16/22 at 5:21 p.m., the MDS coordinator stated she missed seeing the GDR and the last date a…

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, observation, and interview, the facility failed to revise the care plan interventions for falls for three (#16, 17, and #32) of five residents sampled for falls. The administrator identified 17 residents who fell in the last 6 months. Findings: 1. Res #32 had diagnoses of Parkinson's Disease, seizure disorder, major neurocognitive disorder, obsessive compulsive disorder, and major depressive disorder with psychotic signs and symptoms. Res #32's care plan, dated 10/05/21, documented the resident was at risk for falls and had a history of falls related to a diagnosis of seizures and routine antidepressant medication. The twelve interventions documented under this problem were dated 10/05/21. Incident reports, dated 01/13/22, 01/14/22, 01/18/22, and 02/07/22, documented Res #32 had fallen five times. No additional interventions addressing fall prevention were documented on the care plan. A quarterly MDS assessment, dated 07/01/22, documented the resident was independent with mobility, transfers, and locomotion with use of a walker. On 08/17/22 at 8:44 a.m., LPN…

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, observation, and interview, the facility failed to develop and implement interventions to prevent the recurrance of falls for three (#16, 17 and #32) of five residents reviewed for accidents. The administrator identified 17 residents who had fallen in the last 6 months. Findings: 1. Res #32 had diagnoses of Parkinson's Disease, seizure disorder, major neurocognitive disorder, and obsessive compulsive disorder. Res #32 care plan, dated 10/05/21, documented the resident was at risk for falls and had a history of falls related to a diagnosis of seizures and routine antidepressant medication. The twelve interventions documented under this problem were dated 10/05/21. An incident report, dated 01/13/22 at 9:45 p.m., read in part, .resident reports getting dizzy landing on buttocks . An incident report, dated 01/14/22 at 12:10 a.m., read in part, .resident in lobby, got off couch with walker and fell face down . An incident report, dated 01/18/22 at 9:55 p.m., read in part, .CNA reports resident fell to floor . An incident report, dated 01/18/22 at 11:00 p.m., read…

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, observation, and interview, the facility failed to ensure food was prepared, stored, and served in a sanitary manner. The Resident Census and Conditions of Residents form documented 41 residents resided in the facility on entry. Findings: On 05/03/22 between 9:24 a.m. and 10:15 a.m., an initial tour of the kitchen was conducted. The soap dispenser to hand washing sink was observed to not be in proper working order. A bottle of hand sanitizer was observed sitting beside the sink. Two large packages of frozen meat were observed floating in a large pan of water in the sink. The water was not observed to be running. The DM stated the meat had been placed in the pan to thaw for use by the 2-10 shift later in the day and she would put on to cook slowly. A refrigerator was observed to have a sandwich in a reclosable plastic bag without a label to identify the name, date, or time to dispose. A freezer was observed to have a broken inner plastic lining of the freezer lid. A large vat of frozen banana foster was observed to have been open to air with a large hole torn…

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.