Stroud Nursing & Rehab

Based on record review and interview, the facility to ensure OHCA was contacted for a resident that had a serious mental illness for one (#19) of four sampled residents reviewed for recommendations for evaluation and determination for PASARR level II assessments. The DON identified 35 residents with a serious mental health diagnosis. The facility's Behavioral Assessment, Intervention and Monitoring policy, dated 03/19, read in part, .If the level I screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability or related condition he or she will be referred to the state PASARR representative for the Level II (evaluation and determination) screening process . Res #19 was admitted to the facility with diagnosis which included stroke and hypertension. Resident #19's PASSAR level I , dated 05/27/12, had no diagnosis of a serious mental illness. A physician's note, dated 09/22/15, documented that Res #19 had a serious mental illness of schizophrenia. On 02/07/24 at 11:30 a.m., the ADON stated there was no documentation for Res #19 determination…

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 the PASARR for a resident with a serious mental health diagnosis was filled out correctly and referred to the OHCA for two (#12 and #42) of four sampled residents reviewed for PASARR evaluations. The DON identified 35 residents with a serious mental health diagnosis. 1. Res #12 was admitted to the facility with diagnoses of PTSD and major depressive disorder. A PASARR level I report, dated 12/20/22, documented the resident did not have a serious mental illness. On 02/07/24 at 11:30 a.m., the MDS coordinator stated the PASARR had not been filled out correctly and had not been reported to the OHCA. 2. Res #42 was admitted to the facility with diagnoses of depression, bipolar disorder, psychotic disorder, and schizophrenia. A PASARR level I report contained no documentation that OHCA was notified of the mental health diagnoses. On 02/07/24 at 11:30 a.m., the MDS coordinator reported OHCA was not notified.

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for Post Traumatic Stress Disorder (PTSD) for one (#12) of one sampled resident who was reviewed for PTSD. The Administrator reported 52 residents resided in the facility. Findings: Res #12 was admitted to the facility with diagnoses of PTSD and major depressive disorder. A care plan, dated 12/23/23, contained no documentation the resident had a diagnosis of PTSD and did not include goals or interventions for PTSD. On 02/07/24 at 11:30 a.m., the MDS coordinator reported a care plan should have been developed for PTSD.

Based on observation, record review, and interview, the facility failed to ensure pain medication was administered upon request for one (#51) of two sampled residents who were reviewed for pain management. The administrator reported 52 residents resided in the facility. Findings: The facility's Administering Pain Medication policy, revised 10/2022, read in part, .Pain management is a multidisciplinary care process that includes .Recognizing the presence of pain .Conduct an abbreviated pain assessment .Administer pain medications as ordered . Res #51 had diagnoses which included chronic pain. A Pain care plan intervention, dated 09/21/23, documented to anticipate Res #51's need for pain relief and respond immediately to any complaint of pain. An assessment, dated 12/15/23, documented Res #51's cognition was intact, had experienced pain, received scheduled pain medication, and had been offered or received as needed pain medication in the five day look back period. Current physician's orders, dated 02/08/24, documented to administer Gabapentin 300 mg one capsule three times a day for…

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 administer medication as ordered by the physician for one (#39) of seven residents reviewed for medication administration. The administrator reported 52 residents resided in the facility. Findings: The facility's Administering Medications policy, dated 04/2019, read in part, .Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . Res #39 had diagnoses which included cerebrovascular disease and pain. Physician's orders, dated 04/10/23, documented to apply Voltaren Gel 1 % two grams topically to the right shoulder and both knees four times a day for pain. A TAR, dated 01/01/24 through 01/30/24, documented Voltaren Gel was to be administered four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. The TAR documented the Voltaren Gel had not been signed out as administered on 01/26/24 at 4:00 p.m. or on 01/30/24 at 12:00 p.m. Current physician's orders, dated…

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 laboratory tests were obtained as ordered by the physician for one (#31) of five sampled residents reviewed for laboratory tests. The Resident Census and Conditions of Residents report, dated 01/06/23, documented 50 residents resided in the facility. Findings: The facility's Lab and Diagnostic Test Results policy, dated 11/2018, read in parts, .The physician will identify and order .lab testing based on the resident's diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests . Resident #31 had diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms, hyperlipidemia, heart failure, hypokalemia, and chronic obstructive pulmonary disease. A physician's orders, dated 07/06/22, documented to draw a CBC, CMP, Lipid profile, and a PSA (laboratory tests) every six months starting on 09/09/22. There was no laboratory results found in Resident #31's clinical record. On 01/18/23 at 2:34 p.m., the DON stated they could not find the laboratory results for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure emergency call systems were functioning and/or the call cords were long enough to be reached by the residents if they were lying on the floor in the shower in three of three shower rooms observed. The Resident Census and Conditions of Residents report, dated 01/06/23, documented three residents were independent with bathing and 50 residents resided in the facility. Findings: The facility's Answering the Call Light policy, dated 03/2021, read in parts, .Be sure the call light .is functioning at all times .Report all defective call lights to the nurse supervisor promptly . On 01/19/23 at 8:22 a.m., the emergency call cord in the shower room on Ocean View Drive was observed. The emergency call cord did not reach the shower floor. On 01/19/23 at 8:24 a.m., the shower room on [NAME] Blvd was observed. The emergency call cord was pulled, the light outside the shower room did not light up. On 01/19/23 at 8:26 a.m., the shower room on…

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 medications were administered as ordered for one (#55) of three sampled residents who were reviewed medication administration. The Resident Census and Conditions of Residents report, dated 03/07/23, documented 50 residents resided in the facility. Findings: The Admissions From Other Healthcare Facilities policy, dated 03/2017, read in parts, .Residents from other health care facilities may be admitted upon receipt of appropriate documentation .The following information will be provided to the facility prior to or upon the resident's admission .Physician orders for immediate care . The admission Assessment and Follow Up: Role of the Nurse policy, dated 09/2012, read in parts, .Conduct an admission assessment .including .Current medications .Reconcile the list of medications from the medication history, admitting orders .and the summary from the previous institution .Contact the Attending Physician to communicate and review findings of the initial…

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 properly label and store food in accordance with professional standards for food safety. The DON identified 50 residents that received meals from the kitchen. Findings: The facility's Food and Receiving Storage policy, dated October 2017, read in parts, .All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . On 1/10/23 at 10:56 a.m., during the brief initial tour of the kitchen, it was observed that multiple food items were found unlabeled and undated in the freezer. Food items that was observed in multiple bags included pizza crust, tilapia and biscuits. On 1/10/23 at 10:57 a.m., the Dietary Manager stated the unlabeled, undated food items stored in the freezer was pizza crust, tilapia, and biscuits. The Dietary Manager stated all food items stored in the freezer are supposed to be labeled and/or dated.

Based on record review and interview, the facility failed to ensure the pneumococcal vaccine was administered for one (#31) of five sampled residents reviewed for pneumococcal immunizations. The Resident Census and Conditions of Residents report, dated 01/06/23, documented 34 residents received the pneumococcal vaccine and 50 residents resided in the facility. Findings: The facility's Pneumococcal policy, dated 10/2019, read in part, .All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections . A pneumonia vaccination consent form, dated 03/09/22 , documented Resident #31's representative consented for Resident #31 to receive the pneumococcal immunization. There was no documentation the pneumococcal immunization was administered. On 01/18/23 at 4:13 p.m., the MDS coordinator stated Resident #31 had a signed consent in their chart to receive the pneumococcal vaccination. The MDS coordinator stated they would check with the IP. On 01/18/23 at 4:41 p.m., the IP stated Resident #31 had been screened and had a signed consent to receive 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 interview and record review, it was determined the facility failed to update and implement their abuse policy for two (#5 and #7) of two sampled residents who were reviewed for abuse. This had the potential to affect all 54 residents who resided in the facility. Findings: A policy titled, Policy and Procedure on Prohibition of Abuse, Neglect, Personal Degradation or Misappropriation, dated 08/08/19, documented, .All allegations of abuse, neglect or misappropriation will be reported to the Administrator, D.O.N., Charge Nurse, family members, Oklahoma State Department of Health, and the Nurse Aide Registry .Reporting and Responding: .If a resident makes a report to a staff member that indicates any type of psychological or physical abuse, then the department head shall perform an internal investigation to determine if any type of abuse actually occurred .The administrator may take written statements while the investigation is underway to determine if abuse has occurred .An incident report shall be signed by the employee or department head and shall be signed immediately 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 interview and record review, it was determined the facility failed to report to the appropriate authorities allegations of abuse in a timely manner for two (#5 and #7) of two sampled residents who were reviewed for abuse. This had the potential to affect all 54 residents who resided in the facility. Findings: A policy titled, Policy and Procedure on Prohibition of Abuse, Neglect, Personal Degradation or Misappropriation, dated 08/08/19, documented, .All allegations of abuse, neglect or misappropriation will be reported to the Administrator, D.O.N., Charge Nurse, family members, Oklahoma State Department of Health, and the Nurse Aide Registry .Reporting and Responding .The administrator .shall do an internal investigation .If the abuse is physical .If needed a report will be made per telephone or fax within twelve hours of incident and investigation and final report within five working days to the Oklahoma State Department of Health and Nurse Aide Registry .Upon report of any allegations or violations the Administrator or his/her designated representative will thoroughly…

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 interview and record review, it was determined the facility failed to complete a comprehensive care plan reflecting the status of the resident during the completion of the assessment and list the possible side effects to monitor when psychoactive medications were administered for four (#3, #8, #25 and #29) of fourteen sampled residents whose care plans were reviewed. The facility census and condition identified 35 residents who received psychoactive medications. Findings: 1. Resident #3 was admitted to the facility with diagnoses which included decreased vision related to glaucoma and age-related macular degeneration, insomnia, major depressive disorder, chronic pain syndrome, and arthritis. The resident's care plan, dated 03/10/21, documented, .Category Problem .I am currently on Remeron for Depression and Restoril for Insomnia . Category Approach .Administer Remeron and Restoril per orders for Depression and sleep .Staff will monitor me daily for any adverse reactions to Restoril and Remeron . The care plan had not documented what the possible adverse reactions were for…

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, interview, and record review, it was determined the facility failed to ensure oxygen tubing was changed in a timely manner to prevent cross contamination for one (#29) of two sampled residents whose oxygen tubing was observed. The facility reported 11 residents who received oxygen therapy. Findings: A facility policy titled, Policy & Procedures for Oxygen Tubing & Nebulizer Maintenance, dated 06/06/2017, documented, It is the policy of [name withheld] that oxygen tubing is changed weekly on Thursday and as needed for all residents using oxygen .All tubing is dated and initialed by the nurse changing the tubing. Resident #29 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease. A care plan, dated 04/06/21, had not documented oxygen as a focus area with measurable goals, or interventions. An admission assessment, dated 04/19/21, documented the resident's cognition was intact, utilized a cane or walker for mobility, and received oxygen therapy. A physician order, dated June 2021, documented, Oxygen via N/C (nasal…

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.