South Pointe Rehabilitation and Care Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the facility was a clean and sanitary homelike environment during 4 of 4 observations made for a clean and sanitary homelike environment. The administrator identified 212 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain safe hot water temperatures accessible to residents for 10 (#24, 27, 29, 33, 72, 90, 96, 130, 124, and #130) of 10 sampled residents hand sinks water temperature measured. The administrator identified 46 residents resided on hall 100 (locked unit) and 56 residents resided on hall 200.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. ensure medications were secure for 1 (Hall 400) of 1 medication/treatment carts observed. b. ensure stored medications were monitored at proper temperatures and other appropriate controls to preserve their integrity on 4 (hall 100, 200, 400, and 600) of 4 medication storage rooms observed. The DON identified 209 residents receive nutrition from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify the resident and/or resident representative of the risk and benefits of a psychotropic medication for 1 (#4) of 5 sampled residents reviewed for notifications. The DON identified 156 residents were prescribed psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained free from abuse by failing to protect a resident (#213) from staff's use of physical intervention during meal service. The administrator identified 212 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident representative of discharge to another facility for 1(#223) of 1 sampled residents reviewed for discharge. The administrator identified 212 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the narcotic controlled substance card count was correctly reconciled for 1 (Hall 200) of 8 medication carts observed. The administrator identified 212 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were educated and offered the opportunity to create an advance directive for 5 (#46, 55, 77, 94, and #175) of 35 sampled residents reviewed for advance directives. The DON identified 177 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were coded to reflect the status for 3 (#105, 126, and #175) of 35 sampled residents reviewed for resident assessments. The DON identified 177 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide in between meal snacks for 1 (Hall 3) of 1 halls reported during resident council meeting. The administrator reported 174 residents were provided meals from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to serve the noon day meal in a manner that minimized the risk of infection/cross contamination for 174 or 174 residents who ate meals prepared from the kitchen. The adminstrator identified 174 residents who ate meals from the facility kitchen. On 04/22/25 at 12:15 p.m., cook #1 was observed to plate food from the steam table to be served to residents. With gloved hands, the cook touched the counter, shelving, and utensils other kitchen staff had touched as well. [NAME] #1 was observed to use their gloved hands to hold plated food in position by placing their gloved fingers on the plate and pushing the food together to one side of the plate. The cook then used their gloved hands to place a roll on the residents' plates. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure pneumococcal vaccines were offered to residents for 3 (#105, 123, and #133) of five sampled residents reviewed for vaccines. The DON identified 177 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to act upon grievances presented during residents council meetings or provide rationale as to why concerns could not be provided from the facility. The DON identified 177 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had access to their personal funds during non banking hours for 2 (#27 and #39) of 3 sampled residents reviewed for personal funds. The BOM identified 103 residents in the facility trust account.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received quarterly statements for 2 (#27 and #39) of 3 sampled residents reviewed for personal funds. The BOM identified 103 residents in the facility trust account.

Inspectors wroteBased on record review and interview, the facility failed to perform a background check for 1 (contract laborer #1) of 1 contracted employee. The DON identified 176 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse for 1 (#79) of 4 sampled residents to the Oklahoma State Department Health for alleged abuse within 2 hours after the allegation was made. The DON identified 177 residents resided in the facilty.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure physician ordered abdominal girth measurement amounts were completed for 1 (#21) of 1 sampled resident reviewed for non pressure skin conditions. The DON identified one residents with orders to measure abdominal girth resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a PRN order for an anti-psychotic drug was limited to 14 days for 1 (#92) of 5 sampled residents reviewed for unnecessary medications. The DON identified 177 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure labs were obtained as ordered for: a. 1 (#24) of 1 sampled resident reviewed for dialysis; and b. 1 (#92) of 5 sampled residents reviewed for unnecessary medications. The DON identified 177 residents resided in the facility and three residents received dialysis services.

Inspectors wroteBased on record review and interview, the facility failed to: a. notify the physician of missing labs for 1 (#24) of 1 residents reviewed for dialysis. b. develop a lab policy. The DON identified 177 residents resided in the facility.

Inspectors wroteOn 02/27/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident #12 from mental and physical abuse. On 02/25/25 at 3:02 p.m., Resident #12 was interviewed and stated on 01/23/25 at 6:00 p.m. a person came to door 2 (hall 200) pounding on the door. Resident #12 stated CMA #1 let this person in and they immediately staring cussing and making a move to hit CMA #1. Resident #12 stated they took off down towards them and asked the unknown person what they were doing. Resident #12 stated the person took two swings at them and on the second swing hit them on the face. Resident #12 stated it hurt like the [NAME]. Resident #12 stated ever since then, I don't feel safe. Resident #12 stated, It could happen again. [...]

Inspectors wroteOn 02/25/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure safety and supervision for Resident #4 who smoked. On 02/24/25 at 5:40 p.m., Resident #7 was observed in the outside courtyard smoking area without staff present. Resident #7 was observed to remove a cigarette, lit it with a match, and began to smoke. Resident #7 stated they had only been at the facility for a week. Resident #7 stated they smoked whenever they wanted to and kept their own cigarettes and matches. A Smoking Policy, dated 11/06/24, read in part, The facility shall maintain safety for residents who request to Smoke, as well as for those who do not. [...]

Inspectors wroteBased on observation and interview, the facility failed to: a. provide an adequate supply of towels for bathing on resident halls or in the laundry room; b. ensure shower beds were clean and in good repair for two of two shower beds; c. ensure a shower hose was not missing in the shower room located next to room [ROOM NUMBER]; and d. ensure broken tiles on the floor and wall of a shower located in the shower room on Hall 300 were repaired. ADON #1 identified 182 residents resided in the facility. The DON identified the facility had two shower beds and seven shower rooms.

Inspectors wroteBased on observation and interview, the facility failed to ensure handrails were firmly secure to the wall in 2 (Hall 100 and Hall 200) of 7 shower rooms observed. ADON #1 identified 182 residents resided in the facility. The DON identified seven shower rooms in the facility.

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse to the OSDH for 1 (#12) of 3 residents sampled for abuse. ADON #1 identified 182 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan was updated for 1 (#12) of 14 sampled residents whose care plans were reviewed. ADON #1 identified 182 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were free of neglect for one (#3) of four sampled residents reviewed for neglect. Resident #3 took a water pitcher from the medication cart and proceed down the hall. Resident #2 blocked Resident #3 from leaving down the hall and ended up grabbing Resident #3 on the shoulders and base of the neck forcefully pushing them to the ground. Resident #3 sustained a fractured hip requiring surgery. CNA #1 was present and did not intervene to protect Resident #3 from Resident #2. The DON identifed 13 residents who resided on hall 600 memory care unit.

Inspectors wroteBased on record review and interview, the facility failed report an allegation of abuse to OSDH for two (#11 and #12) of seven sampled residents reviewed for abuse. The Administrator identified 170 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to: a. protect resident from abuse for four (#3, 5, 8, and #9 ), and b. conduct a thorough investigation for allegations of abuse for five (#3, 5, 7, 8, and #9) of five sampled residents reviewed for abuse. The Administrator identified 170 residents resided in the facilty.

Inspectors wroteBased on record review and interview, the facility failed to ensure medication and treatments were administered as ordered for one (#6) of three sampled residents who were reviewed for medication administration. The Administrator identified 170 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents have access to the grievance procedure and failed to post information regarding the name of the grievance official. The DON identified 176 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the menu was followed and adequate portion sizes were offered to residents for one of one meal service observed. The DON identified 173 residents received services from the kitchen in the facility.

Inspectors wroteBased on record review and interview, the facility failed to implement their abuse policy by immediately reporting abuse for two (#1 and #2) of three residents reviewed for abuse. The DON reported 171 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated for two (#1 and #2) of three residents reviewed for abuse investigations. The DON reported 171 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure ADL care was provided according to the plan of care for three (# 1, 7, #8) of four sampled residents reviewed for ADL care. The Assistant Administrator identified 183 residents resided in the facility. A Turning and Repositioning policy, dated 07/21/22, read in part, .The Facility will aid with Turning & Repositioning residents to prevent skin breakdown. Nursing employees will Turn & Reposition residents as reflected in their plan of care . A Incontinent Care policy, dated 07/21/22, read in part, .The Facility will Provide Incontinent Care as Directed in the Plan of Care . 1. Resident #7 had diagnoses which included need for assistance with personal care. Resident #7 care plan dated 07/11/24 documented the resident had self care performance deficit and required staff participation. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the ice machine was clean and free from debris for one of one ice machine observed in the kitchen. The Assistant Administrator identified 183 residents resided in the facility.

Inspectors wrote2. Resident #11 had diagnoses which included other abnormalities of gait and mobility and unspecified osteoarthritis. Resident #11's care plan, dated 11/20/23, documented resident had a fall with minor injury on 11/20/23 while transferring out of the wheelchair. The intervention documented was to place anti roll back bars to the wheelchair. A Quarterly Assessment, dated 12/20/23, documented Resident #11 required substantial/maximal assistance with sit to stand. On 01/12/24 at 1:50 p.m., LPN #6 stated Resident #11 was to have anti lock on their chair, however there had been a change in Resident #11's chair and Resident #11 was in a borrowed chair at this time. On 1/12/24 at 1:52 p.m. LPN #6 stated the anti lock was not on Resident #11's chair. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure SNF ABN and NOMNCs were provided timely for two (#113 and #236) of three sampled residents reviewed for SNF Beneficiary notices. A Beneficiary Notice form, documented 13 residents had been discharged from skilled services in the past six months.

Inspectors wroteBased on observation and interview, the facility failed to ensure sufficient staffing was in place to conduct destruction of medications. The DON identified 181 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the census was documented on the daily staffing sheets and it was posted in a prominent place which was readily accessible to residents and visitors. The DON identified 181 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician responded to a GDR for four (#52, 54, 85, and #162) of five sampled residents reviewed for unnecessary medications. The DON identified 181 residents resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to: a. Ensure medications were secured for one of five medication/treatment carts observed for medication storage; b. Have a system in place for an accurate account of discontinued medications awaiting destruction; c. Ensure expired medications were removed from stock; and d. Ensure medication room clean from debris. The DON identified 181 residents resided in the facility. The DON identified no residents resided on Hall 500.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure there was sufficient dietary staff to serve the residents in a timely manner for two of two meal services observed. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the menu was followed for one of two meal services observed. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a therapeutic diet was served as ordered for two (#130 and #59) of two sampled residents reviewed for diets. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were served in a timely manner for two of two meal services observed. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were covered for one of two meal services observed. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff donned PPE while performing COVID-19 testing on residents. The DON identifed 181 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure pneumococcal vaccine was offered to two (#113 and #79) and ensure influenza vaccine was offered to one (#79) of five sampled residents reviewed for vaccines. The DON identified 181 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure call devices were in working order for one of six halls sampled for call devices. The DON identified 181 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure a pest free environment. The DON identified 181 residents resided in the facility. She identified two residents received nutrition and hydration solely through a feeding tube.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure call devices were within reach for one (#162) of 40 sampled residents reviewed for accommodation of needs. The DON identified 181 residents resided in the facility.

Inspectors wroteBased on observations, record review, and interview, the facility failed to maintain a comfortable room temperature and a clean bathroom for two (#114 and #93) of 40 sampled residents. The DON identified 181 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to follow their abuse policy to ensure an injury of unknown origin was investigated and reported the to OSDH for one (#88) of two residents reviewed for abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure a significant change had been completed after a resident had been admitted to hospice for one (#156) of 35 residents reviewed for assessments. The DON identified 181 residents resided in the facility. She identified five residents were on hospice.

Inspectors wroteBased on record review and interview, the facility failed to ensure an MDS assessment was accurate for one (#156) of 35 sampled residents reviewed for assessments. The DON identified 181 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan had been revised for a resident who had been admitted to hospice for one (#156) of 35 residents reviewed for care plans. The DON identified five residents were receiving hospice services and 181 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed ensure fall interventions were maintained when DME was replaced by hospice for one (#156) of one sampled resident reviewed for hospice. The DON identified five residents were receiving hospice services.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident who required peg tube feedings: A. had been administered feedings as ordered by the physician, and B. had their peg tube feeding bag labeled and dated for one (#35) of one sampled resident reviewed for peg tube feeding. The DON identified five residents received peg tube feedings.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was ongoing communication with the dialysis center and ongoing assessment of a resident before and after dialysis for one (#35) of one sampled resident reviewed for dialysis services. The DON identified five residents received dialysis.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered for one (#484) of six sampled residents reviewed for medications. The DON identified 181 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to: a. ensure cooked items were stored,covered and labeled with dates in the walk-in, b. ensure food items were not stored on the floor, c. ensure raw meats were not stored with or above uncooked food items, and d. clean a food processor container and blade using standardized cleaning practices between uses. The Resident Census and Condition of Residents report, dated 01/14/23, documented 174 residents resided in the facility. The Administrator identified two residents who did not receive nutrition from the kitchen.