Bartlesville Health and Rehabilitation Community

Inspectors wroteOn [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure CPR was administered in accordance with the AHA standards of practice, which states the primary goal is to ensure a firm, hard surface to maximize compression depth and the facility policy for resident #6. CPR was administered in Resident #6's bed without a back board and was ineffective. On [DATE] at 5:15 p.m., the OSDH was notified and verified the existence of the IJ related to the facility's failure to implement their CPR policy and provide effective CPR to Resident #6. On [DATE] at 6:00 p.m., the administrator, DON, and ADON were notified of the IJ situation and the IJ template was provided. On [DATE] at 2:38 p.m., an acceptable plan of removal was approved by the OSDH. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure pre and post dialysis patient assessments were filled out completely and routinely by staff for one (#45) of one sampled resident reviewed for dialysis care. The DON identified one resident at the facility received dialysis services.

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary staff wore hair nets and beard guards while preparing food for the residents. The administrator identified 74 residents routinely ate meals provided by the facility kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. a licensed practical nurse cleaned their hands during wound care and catheter care for one (#16) of two sampled residents reviewed for wound care and catheter care; and b. failed to maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. A resident matrix provided by the administrator documented seven residents had indwelling catheters. The DON stated 71 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's representative was notified of a fall for one (#57) of one resident reviewed for notification of changes. The DON reported the facility census was 71.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical director and/or their representative participated in care plan development for one (#45) of 18 sampled residents whose care plans were reviewed. A Facility Listing Report, dated 12/02/24, documented 71 residents resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to monitor a resident after a fall for one (#57) of one resident reviewed for falls. The DON reported the facility census was 71.

Inspectors wroteBased on record review and interview, the facility failed to ensure an antianxiety medication was not prescribed on an as needed basis without a 14-day limit or a physician's explanation why it should be used beyond 14 days for one (#69) of five residents reviewed for unnecessary medications. The ADON reported 29 residents at the facility were prescribed psychotropic medications.

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse policy for screening potential employees for the prevention of abuse for three (CNA #1, CNA #7, and LPN #3) of five sampled personnel files reviewed. The administrator identified 64 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated for two (#1 and #2) of three sampled residents reviewed for abuse. The administrator identified 64 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse was reported to OSDH no later than two hours after the allegation was made for one (#1) of three sampled residents reviewed for abuse. The administrator identified 64 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. implement interventions to prevent the reoccurrence of falls; b. complete incident reports and neurological checks according to policy and procedure; and c. revise the care plan with new interventions to prevent falls for one (#23) of two sampled residents reviewed for accident hazards. Resident #23 experienced 15 falls between 08/18/22 and 07/27/23. On 09/06/22, Res #23 fell and sustained a traumatic subdural hemorrhage, laceration on the left side of their face, and left sided fifth and seventh rib fractures, resulting in the resident being admitted to the hospital ICU. On 06/12/23, the resident fell and sustained a left fractured shoulder. The Resident Census and Conditions of Residents form, dated 08/22/23, documented 60 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility. The CDM identified all residents received services from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' code status was accurate for two (#41 and #43) of two sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure AAT was maintained below 81 degrees F. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure care plans were reviewed and revised after falls for one (#23) of 24 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 08/22/23, documented 60 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician order for a blood pressure medication was accurately transcribed for one (#12) of five sampled residents reviewed for medications. The DON identified seven residents who had physician orders for BP medications with parameters.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were being monitored for side effects for the use of an anticoagulant and/or diuretic for two (#4 and #55) of five sampled residents reviewed for medications. The DON identified 19 residents who had physician orders for an anticoagulant and 28 residents who had physician orders for a diuretic.

Inspectors wroteBased on record review and interview, the facility failed to ensure behaviors and/or side effects were monitored for the use of psychotropic medications for four (#4, 12, 17, and #55) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 40 residents received psychoactive medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure labs were collected as ordered by the physician for two (#4 and #12) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain an informed consent prior to installation for one (#18) of one sampled resident reviewed for side rails. The ADON identified three residents had grab bars and 17 residents had side rails.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to resident representatives for two (#34 and #44) of three residents who had transferred to acute care facilities. The Director of Nursing identified 19 resident who had been transferred to acute care facilities in the past one year.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold policy to resident representatives for two (#34 and #44) of three residents reviewed who had transferred to acute care facilities. The Director of Nursing identified 19 resident who had been transferred to acute care facilities in the past one year.

Inspectors wroteBased on interview and record reviews the facility failed to prevent the use of unnecessary antipsychotic medications for one (#15) of five residents reviewed for the use on unnecessary medications. The Director of Nursing identified 14 residents who were prescribed antipsychotic medications.

Inspectors wroteBased on interview and record reviews the facility failed to document if residents received education on the COVID-19 vaccines and their decision to accept or decline vaccine administration for three (#6, 12, and #54) of five residents reviewed for infection control. The Director of Nursing identified five unvaccinated residents at the facility.