Betty Ann Nursing Center

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of abuse was reported to the health department within the required 2-hour timeframe for 1 (#1) of 4 sampled residents reviewed for abuse. The DON reported the facility census was 53.

Inspectors wroteOn 05/08/25, an Immediate Jeopardy (IJ) was determined to exist related to the facility's failure to protect residents from abuse. The failure resulted in nine physical assaults by Res #2 on eight other residents between 01/03/25 and 05/01/25. On 05/08/25 at 5:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 05/08/25 at 6:04 p.m., the administrator and DON were notified of the IJ situation and provided the IJ template. On 05/09/25 at 9:06 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal, read in part, 1. Resident # [2] is currently in inpatient psychiatric facility, [name withheld]. [NAME] Nursing Center is working with [name withheld] to find alternate placement for resident other than this facility. [...]

Inspectors wroteBased on record review and interview, the facility failed to revise a resident's care plan for 1 (#2) of 9 sampled residents whose care plans were reviewed. The DON identified 49 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for one (#1) of five sampled residents reviewed for abuse and neglect. The DON reported the census was 51.

Inspectors wroteBased on observation and interview, the facility failed to ensure survey results were posted and accessible for residents and visitors. The DON identified 47 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure baseline care plans were completed for one (#150) and failed to ensure residents and/or resident representatives were provided a summary of the baseline care plan for one (#29) of 14 sampled residents whose care plans were reviewed. The DON identified 47 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure holding temperatures were obtained for one (noon meal) of one meal observed for meal service. The DON identified 47 residents who received nourishment from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed foods were a smooth consistency for one (noon meal) of one meal observed for pureed foods. The DON identified two residents who received pureed diets.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. foods were covered and dated in the refrigerator for one of three refrigerators observed in the kitchen; b. infection control was maintained during meal service for one (the noon meal) of one meal observed during meal service; c. infection control was maintained when meals were delivered to residents who ate in their rooms for one of two meals observed during dining; and d. the ice machine was maintained in a sanitary manner for one of one ice machines observed. The DON identified 47 residents who received nourishment from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control protocols for enhanced barrier precautions were maintained during medication administration and wound care. The DON identified nine residents who were on enhanced barrier precautions.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident mobility was included in the resident assessment and the plan of care for one (#29) of one sampled residents who was reviewed for mobility and positioning. The DON identified seven residents with limited range of motion.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed for one (#29) of 23 sampled residents who were reviewed for comprehensive care plans. The administrator identified 47 residents who resided at the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the care plan was revised and updated for one (#14) of 12 sampled residents whose care plans were reviewed. The administrator identified 47 residents who resided at the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure interventions were in place to prevent reduction in range of motion/mobility for one (#29) of one sampled residents who were reviewed for range of motion/mobility. The DON identified seven residents who had limited range of motion.

Inspectors wroteBased on record review and interview, the facility failed to ensure supplements were offered/documented for one (#29) of one sampled residents who was reviewed for nutrition. The dietary manager identified 14 residents who was ordered supplements in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for one (#36) of five sampled residents who were reviewed for unnecessary medications. The DON identified 47 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure hot foods were served at palatable temperatures for one (#29) of one sampled resident who was reviewed for food. The DON identified 47 residents who received nourishment from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure code status orders were accurately documented for two (#23 and #51) of three residents sampled for advance directives. The Resident Census and Conditions of Residents form, dated [DATE], documented 51 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of vital signs out of parameter per physician orders for two (#41 and #46) of five residents sampled for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/24/23, documented 51 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the physical environment of the facility was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 51 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to update care plans for changes in treatment for two (#23 and #27) of 13 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 07/24/23, documented 51 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. change a resident's catheter as ordered by the physician, b. obtain an order to change a resident's catheter, catheter bag, and tubing, and c. provide catheter care every shift for one (#39) of one sampled resident reviewed for catheters. The Resident Census and Conditions of Residents report, dated 07/24/23, documented five residents who had internal or external catheters.

Inspectors wrote3. The Catheter Care, Urinary policy, revised 09/2014, read in parts, .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor . Res #39 had diagnoses which included urinary retention. A physician order, dated 04/11/23, documented to change Foley catheter 16 Fr/10 cc bulb one time a day every 30 days. On 07/24/23 at 12:16 p.m., Res #39 was observed in their wheelchair in the dining room. Their catheter bag below their wheelchair and was resting on the floor. On 07/24/23 at 12:47 p.m., Res #39 was observed propelling themselves in their wheelchair down the hall from the dining room to their room. Their catheter bag below their wheelchair was dragging the floor. On 07/25/23 at 9:19 a.m., Res #39 was in their bed. Their catheter bag was observed resting on the floor on the side of their bed. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure transfers were performed safely for one (#46) of three residents sampled for accidents. Findings 1. Res #46 had diagnoses which included cerebral palsy and physical debility. A quarterly MDS, dated [DATE], documented the resident was totally dependent on two staff for transfers. On 07/24/23 at 11:53 a.m., Res #46 was observed during a transfer from their bed to their wheelchair. The resident was observed being transferred via a full body lift. The staff were observed lifting the resident from the bed and moving the lift to rest above the resident's wheelchair. CNA #2 was observed tilting the empty wheelchair onto its back wheels and moving it under the lift. CNA #1 was observed lowering the resident into the wheelchair with the front wheels held off of the ground. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were administered according to physician orders for one (#16) of four residents sampled for medication pass. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 51 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medication error rate below five percent. A total of 41 opportunities were observed with 16 errors. Total medication error rate was 39.02%. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 51 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to obtain labs as ordered by the physician for one (#39) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 51 residents resided in the facility.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure the surety bond was at an amount to cover the total amount of monies in the trust account for 53 of 53 residents who were identified as having a personal funds account with the facility.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to maintain a clean ice machine. The facility identified 53 residents who obtained ice from the ice machine.

Inspectors wroteBased on interview and record review, it was determined the facility failed to provide care and services according to the resident's plan of care for one (#39) of ten residents sampled for care provision. The facility failed to notify a resident's physician of results of low finger stick blood sugars (FSBS). The facility identified 12 residents who had orders for FSBS.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to implement an infection control program to prevent potential infections for eight (#8, #27, #36, #48, #50, #53, #54, and #106) of 22 residents reviewed for infection control. The facility failed to: a. provide treatment of a pressure ulcer in a manner to prevent infection for resident (#36), b. failed to perform hand hygiene in a manner to prevent cross contamination during the medication pass for seven (#8, #27, #48, #50, #53, #54, and #106). The facility identified 53 residents resided in the facility.

Inspectors wroteBased on observation and interview, it was determined the facility failed to ensure call lights in resident rooms and bathrooms were functional for six (#2, #18, #25, #32, #42, and #51) of the 24 residents whose call lights were checked. This had the potential to affect all 53 residents who resided in the facility.