Elmbrook of Hugo

Inspectors wroteOn 04/17/25, a past noncompliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #35 was not verbally abused. On 04/17/25 at 1:30 p.m. the OSDH was notified and verified the existence of the past noncompliance IJ related to the facility's failure to ensure residents were not verbally abused. On 05/06/25 at 12:48 p.m. the administrator was notified of the immediate jeopardy situation. The administrator was provided the IJ template. Documentation showed the facility completed staff in-service regarding abuse on 03/03/25. Employee #1 was suspended, then terminated on 03/04/25. A quality assurance meeting was held on 03/05/25 regarding abuse. Based on observation, record review, and interview, the facility failed to ensure a resident was not verbally abused for 1 (#35) of 3 sampled residents reviewed for abuse. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure assessments were accurate for indwelling catheters for 1 (#24) of 13 sampled residents reviewed for resident assessments. The ADON identified 52 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan was implemented for 1 (#33) of 1 resident sampled for smoking. The ADON reported five residents in the facility smoked.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow the plan of care for 1 (#18) of 1 sampled residents reviewed for respiratory care . The ADON reported 52 residents resided in the facility.

Inspectors wroteA past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective [DATE] related to the facility's failure to ensure cardio-pulmonary resuscitation was provided according to standards of care for Res #1 who was a full code status and implement all components of the facility's CPR policy On [DATE] at 4:20 p.m., the Oklahoma State Department of Health was notified and verified the existence of the past noncompliance IJ related to the facility's failure to implement their CPR policy and provide CPR to Res #1 who was a full code. The past noncompliance IJ was removed effective [DATE] after the facility put measure in place to prevent recurrence. On [DATE] staff were in-serviced on CPR status, DNR code status policy and procedures were reviewed, code status identification policy and procedures were included in all new hire packets, with in-person training upon hire. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a resident's change in condition for one (#1) of four sampled residents who were reviewed for neglect. The administrator identified 55 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was offered the choice to formulate an advanced directive for one (#1) of four sampled residents whose advance directive acknowledgements were reviewed. The administrator identified 55 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to: a. follow physician's orders for a resident with oxygen, b. obtain orders for a CPAP, and c. ensure a CPAP was in working order for one (#1) of four sampled residents who were reviewed for neglect. The administrator identified 55 residents who resided in the facility.

Inspectors wroteBased on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The DON identified 59 resident residing in the facility who receive meals from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents with limited range of motion received restorative services and /or assistance to prevent further decrease in range of motion for one (#37) of one sampled resident reviewed for mobility. The Long-Term Care Facility Application for Medicare and Medicaid form documented 60 residents resided in the facility. The DON reported eight residents had contractures.

Inspectors wroteBased on observation, record review and interview, it was determined the facility failed to ensure the code status was identified and correct for two (#18 and #19) of three resident whose code status was reviewed. The administrator identified 60 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide a CMS 10123 NOMNC form to a resident who received skilled services and afterwards went home for one (#261) of three residents sampled for beneficiary protection notification review. The administrator identified 60 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and investigation, the facility failed to ensure MDS assessments accurately reflect the residents' status for two (#11 and #37) of 15 residents whose assessments were reviewed. The facility failed to accurately assess for: a. gradual dose reduction for Res #11. b. ROM for Res #37. The Long-Term Care Facility Application for Medicare and Medicaid form documented 60 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a PASARR level I was completed correctly and the OHCA was notified of residents with serious mental illnesses for two (#42 and #47) of two residents reviewed for PASARR. The administrator identified 60 resident's resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to document a recapitulation of stay on the discharge summary for two (#59 and #60) of two sampled residents whose closed records were reviewed. The Long-Term Care Application for Medicare and Medicaid form documented a census of 61 residents.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure the kitchen properly labeled and stored food, cleaned/sanitized dishes and surfaces in a proper manner for 46 residents who received meals from the kitchen: The Resident Census and Conditions of Residents, dated 07/12/22, documented 46 residents received meals from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans included care of residents with gastric tubes and UTI's for one (#25) of three residents reviewed for gastric tubes and one (#23) of two residents reviewed for UTI's. The Resident Census and Conditions of Residents report, dated 07/12/22, documented three residents with gastric tubes. The DON identified one resident with a UTI.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure outdated medications were not available for administration to residents. The Resident Census and Conditions of Residents, dated 07/12/22, documented 49 residents resided in the facility.