Broken Bow Health And Rehab

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Broken Bow Health and Rehab

700 West Jones Broken Bow, OK 74728

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Broken Bow Health and Rehab

700 West Jones Broken Bow, OK 74728

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Broken Bow Health and Rehab

700 West Jones Broken Bow, OK 74728

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865

Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet