Oklahoma Memory Care Institute

Inspectors wroteBased on record review and interview, the facility failed to maintain an abuse free environment for 3 (#2, 3, and #4) of 5 sampled residents reviewed for abuse. The administrator identified 38 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to perform a background check for 1 (PCW #1) of 1 personal care worker contracted by a family to care for an individual resident. The DON identified one resident whose family contracted a private sitter.

Inspectors wroteA past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 01/30/25 related to the facility's failure to supervise and prevent a resident from elopement. The facility failed to prevent Resident #1 from eloping from the facility which had the potential to result in serious injury or harm. On 02/11/24, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent accident hazards related to elopement. The past noncompliance IJ was removed effective 01/31/25 after the facility put measures in place to prevent recurrence. [...]

Inspectors wroteBased on record review and interview, the facility failed to report injuries of unknown origin to required agencies for one (#1) of three sampled residents who were reviewed for injuries of unknown origin. The DON identified 47 residents resided at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were treated with dignity by being called their preferred name for three (#18, 20, and #24) and failed to ensure dignity with dining for nine (#5, 10, 12, 15, 18, 26, 33, 34, and #44) of eight sampled residents who were reviewed for dignity. The DON identified eight residents who were dependent on staff for meals who ate in the dining room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were transferred safely with a mechanical lift for two (#21 and #18) of two sampled residents reviewed for mechanical transfers. The DON identified four residents who utilized a mechanical lift.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin was dated when opened for one (treatment cart #1) of two medication carts observed for medication storage. The DON identified four medication carts in the facility and five residents who were ordered insulin.

Inspectors wroteBased on record review and interview, the facility failed to ensure documentation was maintained that staff were educated and offered the COVID-19 vaccine for two of two employees reviewed for the COVID-19 vaccination. The COVID-19 Vaccination policy, dated 06/27/23, read in part, .The facility will maintain documentation related to staff COVID-19 vaccination and includes at a minimum: a. Education to the staff regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. The offering of the COVID-19 vaccine or information on obtaining the COVID-19 vaccine; c. The COVID-19 vaccine status of staff . On 10/31/24 at 3:03 p.m., the infection preventionist stated they did not have any documentation related to staff education of the COVID-19 vaccination for CNA #2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurate for one (#9) of one sampled residents reviewed for accuracy of assessments. The administrator identified 48 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were monitored during nebulizer treatments for one (#20) of one sampled residents reviewed for respiratory care. The DON identified one resident who had orders for nebulizer treatments. An undated Nebulizer Therapy policy, read in part, .Observe resident during the procedure for any change in condition . Resident #20 had diagnoses which included chronic obstructive pulmonary disease. A physician order, dated 10/06/24, documented the resident was ordered ipratropium-albuterol (broncodilator) 0.5-2.5 (3mg/3ml) inhale every six hours. On 10/28/24 at 8:47 a.m., CNA #2 was observed to turn off the nebulizer machine and remove the nebulizer mask from Resident #20. On 10/29/24 at 11:42 a.m., LPN #1 was observed to prepare and administer ipratropium-albuterol via nebulizer to Resident #20. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was accurately assessed for the safe use of bed rails for one (#98) of three sampled residents reviewed for bed rails. The DON identified four residents who had bed rails applied to their beds.

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control was maintained during dining for two (morning and noon meal) of two meals observed. The DON identified eight residents who were dependent on staff for meals. On 10/28/24 at 8:27 a.m., the DON was observed to assist four residents with the morning meal. The DON was observed to pick up a biscuit with jelly with their bare hands and place it to a resident's mouth without sanitizing their hands. On 10/28/24 at 12:12 p.m., the ADON was observed to assist four residents with the noon meal. The ADON was observed to assist a resident with a drink by touching the straw then continue to assist other residents with their meal without sanitizing their hands. On 10/28/24 at 12:18 p.m., the DON was observed to pick up a dinner roll and hand it to a resident they were assisting without sanitizing their hands. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ongoing monitoring and supervision of bed rails for one (#98) of one resident sampled for bed rails. The DON identified four residents who had bed rails.

Inspectors wroteBased on record review and interview, the facility failed to provide financial quarterly statements for four (#2, 3, 4, and #5) of four sampled residents who had monies deposited in the facility's resident trust. The trust account balance statement, dated 10/15/24, documented 10 residents with funds deposited in the facility trust.

Inspectors wroteBased on record review and interview, the facility failed to provide toenail care for one (#1) of five sampled residents whose clinical records were reviewed for foot care. The facility's resident list report, dated 10/14/24, documented 46 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide a NOMNC and ABN notice for two (#23 and #15) of three sampled residents reviewed for Beneficiary Notices. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete a significant change assessment for two (#2 and #5) of four sampled residents reviewed for a significant change of status. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to complete smoking risk assessments to ensure the continued safety during smoking for one (#22) of one sampled resident reviewed for smoking. The Resident Census and Conditions of Residents report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure side effects were monitored for the use of anxiety medications for one (#2) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions report, dated 09/19/23, documented 17 residents received anxiety medications and 38 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to obtain lab (Hemoglobin A1c) for one (#15) of one sampled resident reviewed for laboratory services. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain the kitchen to promote food safety and sanitation. The Resident Census and Condition of Residents report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure trash cans in the kitchen were covered. The Resident Census and Condition of Residents report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to submit accurate data for 24 hour licensed skilled nursing to CMS for three of three months reviewed. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff sanitized a blood pressure cuff between two (#24 and #17) of five sampled residents reviewed during medication observation. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure privacy during the provision of toileting for one (#27) of three sampled residents reviewed for ADL care. The Resident Census and Conditions of Residents report, dated 09/19/23, documented 38 residents resided in the facility. Findings Resident #27 had diagnoses to include Alzheimer's disease, and seizures. A Quarterly Assessment, dated 07/26/23, documented Resident #27 had clear speech, usually understood, usually understands, and required extensive assistance for transfers, walking, and toileting. A Care Plan, dated 04/22/22, was provided by the facility and did not address ADLs or the extent of assistance required by staff. On 09/22/23 at 1:45 p.m. Resident #27 was observed to be in full view from the hallway, to be seated on the toilet, undressed from the waist down. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a written notice of transfer for one (#38) of one resident reviewed for hospitalization. The Resident Census and Conditions of Residents report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a copy of the bed hold policy was provided for one (#38) of one resident reviewed for a discharge to the hospital. The Resident Census and Condition of Residents report, documented 38 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to post daily staffing information in a prominent place which was readily accessible to residents and visitors. The Resident Census and Conditions report, dated 09/19/23, documented 38 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure Do Not Resuscitate (DNR) forms were complete for one (#10) and ensure the code status was accurate for one (#73) of two sampled residents who were reviewed for advanced directives. The facility identified twelve residents who had a DNR on file.

Inspectors wroteBased on observation, record review. and interview, the facility failed to attempt alternatives, assess for risks, and obtain informed consent for the use of bedrails for two (#72 and #121) of two residents reviewed for bed rails. The DON identified two residents with bed rails.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medication was available for one (#74) of ten residents who were observed during medication pass. The DON identified 26 residents who received medications.