Choctaw Residential Center

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to protect residents from abuse for two (2) of (2) residents reviewed for abuse (Resident # 1 and Resident # 3). Specifically, the facility failed to prevent resident-to-resident inappropriate sexual contact, when (2) incidents occurred when one resident touched another resident inappropriately.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure residents received the necessary behavioral health care and services, specifically, the facility failed to proactively assess and implement effective behavioral interventions to address inappropriate sexual behaviors for two (2) of five (5) sampled residents reviewed for behavioral concerns. Resident #1 and Resident #3.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to resolve a resident grievance in a timely manner related to missing clothing, activities, and noisy environment for four (4) of seven (7) residents that attended resident council. Residents #27, #76, #100, and #309 Findings Include: Review of the facility policy titled Grievance/Complaint Policy unrevised, revealed, It is a policy of this facility that a resident/responsible party/legal representative has the right to voice grievances as follows: . All grievances should be directed/reported to the departmental supervisor and departmental director. Review of the facility policy titled Resident Personal Belongings unrevised, revealed under, Policy: [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for nail care, oral hygiene, and hand rolls for one (1) of 25 sampled residents. Resident #74 Findings Include: Review of the facility policy titled Comprehensive Care Plans unrevised, revealed under, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Review of Resident #74's Care Plan Report revealed under, Focus: [...]

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review, the facility failed to provide a safe, clean homelike environment for Residents #6, #11, and #60. This was for one (1) of four (4) hallways.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure licensed nursing staff followed professional standards of practice for medication administration. This resulted in the administration of discontinued and incorrectly scheduled medications, and failure to administer prescribed medications. This deficient practice was identified for four (4) of 37 medication administration observation opportunities (Resident #39, Resident #90) CROSS REFERENCE F759

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident dependent on staff for Activities of Daily Living (ADLs) received oral care and nail care for one (1) of 25 sampled residents. Resident #74 Findings Include: Review of the facility policy titled Activities of Daily Living Policy with a revision date of 7/2014, revealed under, Policy Statement: Based on previous evaluations and current date, the nursing staff, in conjunction with Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify the level of care a resident requires for ADLs. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to provide activities that met the interest of the residents for three (3) of 25 sampled residents. Resident #6, #9, and #41 Findings Include: Review of the facility policy titled Activities revealed under, Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure hand rolls were applied for a resident with finger contractures for one (1) of 25 sampled residents. Resident #74 Findings Include: Review of the facility policy titled Prevention of Decline in Range of Motion unrevised, revealed under, Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. [...]

Inspectors wroteBased on staff interviews, record reviews, and facility policy review, the facility failed to obtain a stop date for as-needed (PRN) psychotropic medications for two (2) of six (6) residents reviewed who were receiving psychotropic medications (Resident #43 and Resident #259). Findings Include: Review of the facility policy titled, Use of Psychotropic Medications, last revised in March 2025, revealed the following under Policy Explanation and Compliance Guidelines: Section 16: Psychotropic medications used on a PRN basis must be limited to no more than 14 days unless the provider determines it is appropriate to extend the order. The medical record must indicate a specific duration. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review and facility policy review, the facility failed to maintain a medication error rate less than 5% as evidence by the administration of discontinued and incorrectly scheduled medications and failure to administer prescribed medications. This deficient practice was identified in four (4) of 37 medication administration observation opportunities. The medication error rate was 10.81%. This affected Resident #39 and Resident #90.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure a medication cart was locked and secured for one (1) of four (4) survey days. Findings Include: Review of the facility policy titled Medication Storage unrevised, revealed, Policy Explanation and Compliance Guidelines . c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. An observation on 3/03/25 at 12:45 PM revealed the medication cart located on C hall was unlocked and unattended without a nurse in view. An observation and interview with Licensed Practical Nurse (LPN) #1 on 3/03/25 at 12:49 PM confirmed she walked away from the medication cart and left it unlocked. She explained that she got called away and forgot to lock it. [...]

Inspectors wroteBased on staff and resident interview, record review and facility policy review the facility failed to assist a resident with his right to vote for one (1) of five (5) residents reviewed for voting rights. Resident #31 Findings Include: Review of the facility policy titled, Resident Rights with no revision date revealed that each resident had, . A. The right to civil and religious liberties . Review of the facility policy titled, Voting Policy revealed It is a policy of this facility that all residents reserve the right to vote in local, State and Federal elections .If a resident desires to go to the local precinct to vote, transportation arrangements will be made if .and Social Services will be responsible for arranging voting by absentee ballot for any resident who so desires. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to notify the Physician or the Nurse Practitioner (NP) of changes in condition for medication administration for a resident for one (1) of nine (9) residents reviewed. Resident #63.

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review, the facility failed to provide a follow up to grievances voiced by residents related to laundry services for two (2) of seven (7) residents reviewed during investigations (Resident #37 and Resident #150) and for grievance reported during resident council for one (1) of six (6) residents in attendance, (Resident #93).

Inspectors wroteBased on record review, staff interviews and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessments for a Preadmission Screening Resident Review (PASRR) for Resident #23 and restraint use for Resident #63 for two (2) of 24 sampled residents.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review the facility failed to implement a care plan for fluid restriction for Resident #25, Activity of Daily Living (ADL) care for Resident # 86 and splint application for Resident #91, for three (3) of 27 care plans reviewed.

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review the facility failed to provide incontinent care every two hours and as needed for a resident dependent on staff for Activities of Daily Living (ADL) for one (1) of 98 residents reviewed.

Inspectors wroteBased on observation, staff interview, record review, and facility policy the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion as evidenced by staff not applying a hand splint as ordered for one (1) of 41 residents with limited range of motion.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy the facility failed to follow a physician order for a resident who was prescribed fluid restriction for one (1) of nine (9) residents on fluid restriction.

Inspectors wroteBased on staff interview and record review, the facility failed to provide a written notification of transfer to the hospital and/or to the resident and/or the Resident Representative (RR) for three (3) of (3) residents reviewed for hospitalization. Resident # 4, Resident # 33 and Resident # 45.

Inspectors wroteBased on observation, staff and resident interviews, record review and review of the facility policy, the facility failed to provide the necessary services to maintain good grooming and personal hygiene as evidenced by failure to provide nail care and washing of hair for two (2) of nineteen (19) residents observed for Activities of Daily Living (ADL) care. Resident # 76 and # 28.

Inspectors wroteBased on observations, staff interviews, record reviews and facility policy review, the facility failed to prevent the possible spread of infection for three (3) of 12 residents observed during medication pass and Percutaneous Endoscopic Gastrostomy (PEG) site care, Resident #43, Resident #19 and Resident #78. FACILITY Findings Include: A review of facility's policy,Infection Control Standard Precautions,dated April 2006, revealed that single use items should be properly discarded. On 04/12/21 02:15PM in an observation and interview with LPN, #1 doing Percutaneous Endoscopic Gastrostomy (PEG) tube care on Resident # 43. Resident # 43 was under observation due to leaving the facility with family. LPN #1 stated resident would be under observation until 4/18/21. [...]