Southern Hills Healthcare and Rehabilitation

Inspectors wroteBased on record review and interviews, the facility failed to refer 1 (#70) of 1 resident with a new diagnosis of bipolar disorder for a level II PASARR.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#33) of 2 total residents reviewed for anticoagulant medications. The facility failed to develop a care plan for Resident #33's cerebral infarction and anticoagulant therapy.

Inspectors wroteBased on record review and interview, the facility failed to transmit an assessment within 14 days after completion for 1 (#56) of 1 resident reviewed for resident assessments.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received supervision during incontinent care for 1 (#2) of 3 (#1, #2, #3) residents reviewed for falls. The deficient practice resulted in an immediate jeopardy for Resident #2 on 04/26/2025 at approximately 5:00 a.m. when Resident #2 fell out on the left side of the bed during incontinent care when S4CNA (Certified Nursing Assistant) failed to ensure the resident was secured and safe in the bed to prevent her from falling before she turned away to retrieve an adult brief from the over bed table leaving Resident #2 unsupervised causing Resident #2's fall resulting in a fractured right femur. Resident #2 was transferred to a local ER (Emergency Room) on 04/26/2025. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from another resident for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. Resident #36 was subject to unwanted sexual contact by Resident #2. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's unlit dining room. S5RN (Registered Nurse) asked Resident #36, who was cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. S5 RN asked Resident #36 if she wanted that to happen and Resident #36 replied, No. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure an alleged violation of sexual abuse was reported immediately to the facility's administrator, to the appropriate state agency within 2 hours after the allegations were made and to local law enforcement for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. Resident #36 was subject to unwanted sexual contact by Resident #2. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's unlit dining room. S5 RN (Registered Nurse) asked Resident #36, who is cognitively impaired, Were you (Resident #36) being touched by Resident #2? and Resident #36 replied, Well yeah, just down here as she pointed to S5 RN's breast. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #36) of 2 (Resident #2 and Resident #36) residents reviewed for abuse. The facility failed to have an effective system in place to: 1. protect Resident #36 from sexual abuse by Resident #2 and ensure all residents were free from abuse; 2. report abuse to the appropriate state agency and law enforcement. The deficient practice resulted in an Immediate Jeopardy on 09/08/2024 at 9:00 p.m. when S4 CNA (Certified Nursing Assistant) observed Resident #2 touching Resident #36's breast in the facility's glassed-in, unlit dining room. [...]

Inspectors wroteBased on record review and interview the facility failed to notify the resident's representative and physician after an incident of sexual abuse for 1 (#36) of 2 (#2 and #36) residents reviewed for abuse.

Inspectors wroteBased on record reviews, observations, and interviews the facility failed to develop and implement a comprehensive person-centered care plan for 2 (#22, #326) out of 18 sampled residents reviewed. The facility failed to ensure a physician's order was in place for Resident #22's wander guard alarm device and for the maintenance/monitoring and/or discontinuation of Resident #326's PICC (Peripherally Inserted Central Catheter) line.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure correct use and maintenance of bed rails by ensuring 3 (#13, #50, #51) out of 3 residents reviewed for bed rails were assessed for the risk of entrapment from bed rails and 1 (#51) out of 3 residents nurse data collection and screening for bed rails was completed correctly.

Inspectors wroteBased on review of personnel records and an interview the facility failed to ensure an annual performance review was completed for 1 (S11) of 5 (S11, S12, S13, S14, & S15) CNAs (Certified Nurse Assistant) at least once every 12 months.

Inspectors wroteBased on record reviews, observation, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for 1 (#326) of 1 (#326) resident reviewed for antibiotic use.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan had been revised for 1 (Resident #2) of 18 sampled residents. The facility failed to update Resident #2's care plan to include increased monitoring/supervision after an incident of resident to resident abuse. Findings Resident #2 was admitted to the facility on [DATE] with diagnoses, which included in part bipolar disorder, major depressive disorder-single episode severe with psychotic features, anxiety disorder, intellectual disabilities and delusional disorders. Review of Resident #2's most recent quarterly MDS (Minimum data Set) assessment dated [DATE] revealed in part, Resident #2 had a BIMS (Brief Interview of Mental Status) score of 09 out of 15 indicating moderate cognitive impairment. Resident #2 used antipsychotic medication on a routine basis. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that a resident with a urinary catheter received appropriate care and services to prevent urinary tract infections by having the urinary catheter tubing on the floor for 1 (#70) of 1 (#70) resident reviewed for urinary catheters.

Inspectors wroteBased on record review, observations, and interview, the facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding not infusing at the ordered rate ordered for 1 (#18) out of 1 (#18) residents reviewed for tube feedings. Findings Review of Resident #18's medical diagnoses revealed the following, but not limited to moderate protein calorie malnutrition, dysphagia, atrial fibrillation, and Parkinson's disease. Review of Resident #18's MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #18 received 51% or more of total calories through feeding tube and 501cc (cubic centimeters)/day or more of average fluid intake per day through feeding tube. [...]

Inspectors wroteBased on record review and an interview, the facility failed to ensure the required members were present for quarterly Quality Assessment and Assurance (QAA) meetings reviewed since last annual survey.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge assessment was completed for 1 (#65) of 3 (#12, #45, #65) residents reviewed for resident assessment.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident MDS (minimum data set) assessments were transmitted within the required timeframe for 1 (#12) of 3 (#12, #45, #65) residents reviewed for resident assessment.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an effective pest control program by having evidence of insects in 5 rooms (R-B, R-C, R-D, R-F, R-G) of 59 resident rooms and 4 hallways (Hall A, Hall E, Hall H, Hall I) of 5 hallways observed for insects/pests. This had the potential to affect any of the 76 residents currently residing in the facility.