Chickasha Nursing Center, Inc

Inspectors wroteBased on observation, record review, and interview, the facility failed to:a. implement their abuse policy to protect a resident,b. report within two hours,c. immediately investigate, andd. conduct assessments when an allegation of sexual abuse was received for 1 (#19) of 3 sampled residents reviewed for abuse. On 06/03/26, an IJ situation was determined to exist related to the facility's failure to implement their abuse policy to protect a resident, report within two hours, immediately investigate, and conduct a resident assessment when an allegation of sexual abuse was received. On 06/02/26 at 9:00 a.m., an incident report, dated 06/01/26, was faxed to the OSDH for a sexual abuse allegation. The incident report showed CNA #1 reported an allegation of sexual abuse for CNA #2 toward Resident #19. [...]

Inspectors wroteBased on record review and interview, the facility failed to report and investigate a reasonable suspicion of illegal drug use by an employee providing care for residents while on shift. On 06/04/26, an IJ situation was determined to exist related to the facility's failure to report and investigate reasonable suspicion of a crime, resulting in employees suspected of using or being under the influence of illegal drugs being allowed to continue to provide care to residents. On 03/30/26 around 2:00 a.m., RN #1 found a purse was found in an employee restroom that contained suspected illegal drugs and drug paraphernalia. RN #1 locked the suspected illegal substance in the DON's office, questioned CNA #3 and CNA #4 about the purse belonging to one of them, watched the two CNAs for any sign of being under the influence of an illegal drug, and allowed both CNAs to continue working their shift. [...]

Inspectors wroteBased on record review and interview, the facility failed to have an administrator to ensure: a. a facility assessment was updated annually, b. a PBJ report was sent quarterly, c. criminal activity was investigated and reported to the OSDH, and other required entities. d. in-service training was done monthly, and e. QAPI meetings were conducted quarterly. The DON identified 25 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to have a licensed administrator. The DON identified 25 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a facility assessment had been completed annually. The DON identified 25 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the required PBJ staffing data was submitted to CMS within the mandated timeframe. The DON identified 25 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to maintain an effective training program for 4 (CNA #2, CNA #3, administrator, and DON) of 5 new and existing staff whose records were reviewed for training requirements. The DON identified 25 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to include QAPI program mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program. The DON identified 25 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the quality assurance committee met at least quarterly. The DON identified 25 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure quarterly assessments were completed not less than once every three months for 1 (#8) of 12 sampled residents whose assessments were reviewed. The DON identified 25 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed for oxygen use for 1 (#26) of 3 sampled residents reviewed for oxygen use. The ADON identified one resident with routine oxygen and 11 residents whose oxygen was used as needed.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain clean and sanitary equipment during 3 of 3 dining observations. The dietary manager identified 25 residents utilized the ice machine daily.

Inspectors wroteBased on record review and interview, the facility failed to submit PBJ data to CMS for the second quarter of the fiscal year for 2024. The DON identified 29 residents resided in the facility. Findings The PBJ Staffing Data Report documented the facility failed to submit data for the second quarter of 2024 (January 1 - March 31). On 09/05/24 at 2:13 p.m., the DOO stated they were unable to submit staffing data to CMS due to technical issues.

Inspectors wroteBased on record review and interview, the facility failed to: a. have a current contract with a dialysis provider, b. ensure ongoing communication with the dialysis provider, and c. conduct routine assessments before and after dialysis treatments for one (#14) of one sampled resident reviewed for dialysis. The DON identified one resident who received dialysis services.

Inspectors wroteBased on record review and interview, the facility failed to perform annual nurse aide competency reviews for two (CNA #3 and CNA #4) of two sampled employee files reviewed for annual competencies. The DON identified 29 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen and dining room were kept clean and maintained in good repair. The DON identifed 29 residents received services from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to clean the mechanical lift before or after each resident use and have a water management program to prevent Legionella. The DON identified 29 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for one (#7) of 14 sampled residents reviewed for care plans. The DON identified 29 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had a physician order for O2 therapy for one (#8) of one sampled resident reviewed for respiratory care. The DON identified 16 residents who had orders for O2.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assess and monitor a resident for the use of bed rails for one (#4) of one sampled resident reviewed for bed rails. The DON identified 11 residents who had bed rails.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered the choice to formulate advance directives for 11 (#4, 8, 13, 14, 16, 17, 21, 25, 27, 30 and #134) of 11 sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 29 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who were discharged from Part A skilled services, with benefit days remaining, were issued ABN and/or NOMNC notices for three (#4, 14, and #135) of three residents reviewed for beneficiary notices. The Beneficiary Notice worksheet identified 15 residents who were discharged from Part A skilled services with benefit days remaining in the previous six months.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing information was posted on a daily basis in a prominent place readily accessible to residents and visitors. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 29 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident medications were administered according to physician ordered parameters and per best standard practices for three (#6, 21, and #30) of five sampled residents reviewed for unnecessary medications. The DON identified four residents who received digoxin and five residents who received sliding scale insulin.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen and dining area was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 29 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate coding of MDS assessments for anticoagulant use for two (#3 and #14) of two sampled residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents report, dated 08/08/23, documented 29 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to update the care plan related to significant weight loss for one (#2) of one resident whose care plan was reviewed. The Resident Census and Conditions of Residents documented three residents with unplanned significant weight loss/gain.