Broken Bow Health And Rehab
Broken Bow Health and Rehab in Broken Bow, OK — inspection on August 26, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on record review and interview, the facility failed to ensure a care plan was updated for 1 (#1) of 3 sampled residents reviewed for care plan.The DON reported 61 residents resided in the facility.Findings:A facility policy titled Care Plan, Comprehensive Person-Centered, dated December 2016, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .13.
Assessments of resident are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 14.
The Interdisciplinary Team must review and update the care plan: a.
When there has been a significant change in the resident's condition;A physician consultation note for Resident #1, dated 03/24/25, read in part, Principal Diagnosis: Breast Cancer.A care plan for Resident #1, dated 05/27/25, showed no interventions or diagnosis for cancer was updated on the most recent care plan.On 08/21/25 at 10:51 a.m., the ADON reviewed Resident #1's most recent care plan, dated 05/27/25.
They stated Resident #1 had no cancer diagnosis or interventions.On 08/21/25 at 11:16 a.m., the DON stated according to policy Resident #1's care plan should have been updated with interventions and a cancer diagnosis.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Broken Bow Health and Rehab
700 West Jones Broken Bow, OK 74728
SUMMARY STATEMENT OF DEFICIENCIES
read in part, 2.
The facility shall contract with a licensed consultant pharmacist to help obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements.A medication order sheet, dated 04/2025, read in part, date received: 04/28/25 Anastrozole 1 mg rx# 1563586, amount received 30, received by CMA #1.A nursing note, dated 04/30/25, showed, read in part, concerning Resident #1 oncology apt they called and spoke with the POA and they said cancel appointment due to not receiving the medication oncologist was supposed to put Resident #1 on the first time they seen the doctor .The nurse said the oncologist had sent the script to pharmacy back then.A medication order sheet, dated 04/2025, showed, read in part, date received: 04/28/25 Anastrozole 1 mg rx# 1563586, amount received 30, received by CMA #1.A MAR, dated 05/01/25 through 05/31/25, showed the cancer medication was administered daily from 05/26/25 through 05/31/25. Resident #1 did not receive 77 doses of the cancer medication.A fax document, dated 05/20/25, read in part, Anastrozole 1 mg tablet, 1mg orally daily .To be done: 03/24/25. with LPN #1 signature on 05/26/25.On 08/21/25 at 10:50 a.m., the ADON stated the physicians order was written on 03/24/25 for Resident #1.
They did not administer the medication for Resident #1 until 05/26/25. On 08/21/25 at 10:51 a.m., the DON stated Resident #1's cancer medication was not administered in March 2025 and April 2025. Resident #1 went 2 months without the cancer medication.On 08/21/25 at 10:01 a.m., the social services personnel stated they scanned the physician orders into their system for Resident #1 on 04/28/25.On 08/21/25 at 10:20 a.m., CMA #1 stated Resident #1's medication was received on 04/28/25 on the medication order and reorder form.
The nurses were supposed to put the orders in the system.
They did not put the medication in the system until 05/26/25, so they did not know to administer the medication to Resident #1.On 08/21/25 at 10:23 a.m., the DON stated without the administration of the medication the cancer could spread.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Broken Bow Health and Rehab
700 West Jones Broken Bow, OK 74728
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, record review, and interview, the facility failed to ensure 3 (#1, #2 and #3) of 3 sampled treatment carts were locked.The DON reported 61 residents resided in the facility.Findings:On 08/19/25 at 2:26 p.m., treatment cart #1 was observed to be on the left side of the nurse's station unlocked and unsupervised.On 08/19/25 at 2:27 p.m., treatment cart #2 was observed to be on the right side of the nurse's station unlocked and unsupervised.On 08/19/25 at 2:28 p.m., treatment cart #3 (wound care cart) was observed to be at the front entrance by the ADON office unlocked.A facility policy titled Security of Medication Cart, revised 04/2007, read in part, 1.
The nurse must secure the medication cart during pass to prevent unauthorized entry .4.
Medication carts must be securely locked at all times when out of the nurse's view .5.
When the medication cart is not being used, it must be locked and parked.On 08/19/25 at 2:25 p.m.
LPN #2 was observed walking away from the unlocked treatment cart.
They walked into a medication supply closet and closed the door.
There were no other staff observed in the area.On 08/19/25 at 2:29 p.m., the ADON was asked about treatment carts being unlocked.
They stated, According to policy, all the carts are to be locked and supervised.On 08/19/25 at 3:21 p.m., LPN #2 stated they went to go get medication cups out of the medication room.
The treatments carts were supposed to be locked and supervised.On 08/26/25 at 12:31 p.m., the DON stated they had no wanderers in the facility.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Broken Bow Health and Rehab
700 West Jones Broken Bow, OK 74728
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review and interview, the facility failed to ensure a resident who missed 77 cancer medications was included quality assurance and program improvement for 1 (#1) of 3 sampled residents reviewed for medication administration.The DON reported 61 residents resided in the facility.Findings:A facility policy titled Quality Assurance and Performance Improvement, revised 02/2020, read in part, This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed .
Coordination 2.
The QAPI coordinator assists other committees, individuals, departments, and/or services in developing quality indicators, monitoring tools, assessments methodologies and documentation, and in making adjustments to plan.On 08/19/25 at 11:19 a.m., the ADON stated how could they QAPI for the cancer medication we did not know about.On 08/26/25 at 11:40 a.m., the DON stated our last QAPI meetings were 06/10/25 and 08/08/25 and Resident #1's cancer diagnosis or interventions were not included in the meetings.
Facility ID: