Accel at Crystal Park

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were available for administration per physician orders for 2 (#5 and #11) of 6 sampled residents reviewed for medication administration. The administrator identified 53 residents resided in the facility. Findings1. A physician order for Resident #11, dated 04/02/26, showed Xalatan 0.005% solution (a medicated eye drop for glaucoma) one drop into both eyes nightly at bedtime, with a start date of 04/02/26. A physician order for Resident #11, dated 04/02/26, showed Modafinil (a medication to promote wakefulness) 200 mg one time a day, with a start date of 04/03/26. A medication administration record for Resident #11, dated 04/02/26 through 04/12/26, showed the following:Modafinil 200 mg tablet was held or missed from 04/03/26 through 04/11/26. Documentation showed the medication was not available. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to perform hand hygiene and wear a gown during wound care per enhanced barrier precautions for 1 (#1) of 3 sampled residents reviewed for wound care and infection control. The DON identified 19 residents with wounds and 21 residents with enhanced barrier precautions.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge plan was completed, reviewed with resident, and a copy was provided to the resident and/or family for 2 (#5 and #11) of 3 sampled residents reviewed for discharges. The DON identified 188 residents had been discharged in the past 90 days.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for 1 (#1) of 1 sampled resident reviewed for PEG tube medication administration. The DON identified two residents with PEG tubes.

Inspectors wroteOn [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure physicians orders were followed for medication administration and colostomy care in order to receive timely intervention to prevent a new stoma from becoming necrotic. On [DATE] at 1:59 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 3:04 p.m., the administrator and corporate nurse consultant were notified of the IJ situation and the IJ template was provided. On [DATE] at 8:37 a.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part,PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY.Summary of Details which lead to outcomesFailed to ensure timely intervention for a necrotic stoma for Resident #7. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure baseline care plans were completed for 2 (#4 and #5) of 9 sampled residents whose baseline care plans were reviewed. The DON identified 52 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to:a. ensure a hospital's discharge orders were transcribed and administer as ordered for 1 (#7); andb. administer medications as ordered for 1 (#4) of 5 sampled residents reviewed for medications as ordered. The DON identified 52 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had a care plan for the use of a PICC line for 1 (#5) of 9 sampled residents whose care plans were reviewed. The DON identified 52 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to administer IV medication as ordered for 1 (#5) of 2 sampled residents reviewed for IV therapy. The travelling DON identified seven residents received IV therapy in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to handle intravenous tubing to prevent cross contamination and follow EBP protocol during IV medication infusion for 1 (#5) of 2 sampled residents reviewed for IV therapy. The travelling DON identified 21 residents on EBP in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the abuse policy was implemented and abusive behavior was reported to the abuse coordinator in a timely manner within 2 hours of occurrence to prevent further risk to other residents for one (#21) of one resident sampled for abuse. The administrator identified 56 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure toileting was provided in a timely manner for one (#142) of three sampled residents reviewed for timely ADLs. The DON identified 46 residents who needed assistance with ADLs resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the admission weight and weekly weights were obtained for a resident on dialysis for one (#21) of one sampled resident reviewed for dialysis. The DON identified three dialysis residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a discharge hospital order for a fluid restriction was followed upon admission for one (#241) of three sampled residents reviewed for fluid restrictions. The administrator identified three residents on fluid restrictions resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was administered as ordered and a resident was supervised during the administration of a nebulizer treatment for one (#243) of one sampled resident reviewed for respiratory care. The DON identified 20 residents who received continuous oxygen therapy in the facility.

Inspectors wroteBased 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 identified three residents in the facility received dialysis services.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a topical pain medication was administered as ordered for one (#85) of five sampled residents reviewed for unnecessary medications. The administrator identified 56 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a medication error of less than five percent for one (#142) of four residents observed during medication administration. The medication error rate was 7.14% The administrator identified 56 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. the enhanced barrier precautions policy was implemented for a resident with a pressure ulcer for one (#6) of one sampled resident observed during wound care; b. wound care was provided in a manner that prevented cross contamination for one (#6) of one sampled resident observed during wound care; c. incontinent care was provided in a manner that prevented cross contamination for three (#1, 5, and #6) of three sampled residents observed during incontinent care; and d. staff members washed/sanitized their hands after providing care to a resident and before assisting another resident for four (#1, 4, 5, and #6) of four residents observed receiving assistance from staff. The DON identified seven residents with enhanced barrier precautions and eight residents with pressure ulcers resided in the facility. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician was notified when a resident experienced a change in condition for one (#2) of three sampled residents reviewed for change in condition. LPN #2 identified 53 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure controlled medications were not misappropriated for two (#8 and #9) of three sampled residents who were reviewed for misappropriation. The LPN #2 identified 53 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician ordered vital signs were obtained for one (#2) of three sampled residents reviewed for a change in condition. The DON identified all 53 residents in the facility had physician ordered vital signs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pressure ulcer treatment was provided as ordered for one (#6) of one sampled resident observed during wound care. The DON identifed eight residents with pressure ulcers resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure oxygen therapy was consistent with professional standards of practice for one (#2) of three sampled residents reviewed for oxygen therapy. The DON identified 18 residents with orders for oxygen therapy resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide showers in a timely manner and according to the plan of care for one (#1) of four sampled residents reviewed for assistance provided with showers. The administrator identified 53 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure a dirty bedside commode was stored in a manner to prevent cross contamination to facility residents. The administrator identified 53 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure allegations of abuse were investigated for two (#5 and #6) of three sample residents reviewed for abuse. The DON identified 46 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide adequate staff to ensure medications were administered timely for two (#2 and #5) of two sampled resident reviewed for staffing. The DON identified 46 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered timely for two (#2 and #5) of three sampled residents reviewed for medications. The DON identified 46 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had the right to view or receive copies of their clinical record for one (#1) of three residents reviewed. The DON reported 46 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resolution of grievances for one (#5) of three sampled residents reviewed for grievances. The DON identified 46 residents resided at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care plan fall interventions were in place for one (#3) of three sampled residents reviewed for falls. The DON identified 46 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident assessment was accurate for one (#55) of 15 sampled residents whose assessments were reviewed for accuracy. The DON identified 42 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was ongoing communication with the dialysis center and ongoing assessment of a resident after dialysis for one (#115) of one sampled resident reviewed for dialysis. The DON identified 42 residents resided in the facility.

Inspectors wroteBased on observation and interview, and facility failed to ensure medications were secured for one of two medication carts observed during medication pass. The DON identified two medication carts and two treatment carts were utilized in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain infection control for one of one ice chest observed. The DON identified 42 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered timely and as ordered for one (#2) of three sampled residents reviewed for timely medication administration. The Resident Census and Conditions of Residents report, dated 08/24/23, documented 49 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure used insulin needles were disposed of properly for two (#9 and #45) of two sampled residents observed during insulin administration. RN #2 identified nine residents received insulin injections.

Inspectors wrote2. Resident #45 had diagnosis which included acute and chronic respiratory failure. A physician's order, dated 10/06/22, documented, administer Wixela Inhub 500 mcg-50 mcg for inhalation twice a day. On 10/26/22 at 7:40 a.m., RN #3 was observed to administer Trelegy Elllipta 100-62.5-25 inhaler to Resident #45. On 10/26/22 at 11:05 a.m., RN #3 was asked how staff ensured medications were administered as ordered by the physician. RN #3 stated they looked at the name and medication and compared to the EHR. RN #3 was asked what inhaler was administered to Resident #45 this morning. RN #3 stated, Treledy. RN #3 was asked if the resident had a physician's order for Trelegy. RN #3 was observed to look at EHR. RN #3 stated the resident didn't. RN #3 was asked if the correct inhaler was administered to Resident #45. RN #3 stated, No. 3. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a medication administration observation error rate was less than five percent. There were three errors out of 32 opportunities observed during a medication pass which made the medication error rate 9.38%. The Resident Census and Conditions of Residents report, dated 10/25/22, documented 45 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff cleaned reusable blood pressure cuff and pulse ox monitor between residents for three (#158, #157 and #52) of three residents observed for vital signs. The Resident Census and Conditions report, dated 10/25/22, documented 45 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure call lights were kept within reach for one (#45) of 16 sampled residents reviewed for accommodation of needs. The Resident Census and Conditions of Residents report, dated 10/25/22, documented 45 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to assess, intervene and consult the physician for a resident with tachycardia (heart rate over 100 beats/minute), bradycardia (slow heart rate below 60 beats/minute) and an elevated blood pressure for one (#119) of three sampled residents reviewed for vital signs. The Resident Census and Condition report, dated 10/25/22, documented 45 residents resided in the facility.