ROSE MANOR NURSING CENTER
LOCATED: 1610 NORTH BRYAN AVENUE, SHAWNEE, OK 74804

ROSE MANOR NURSING CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT

LEVEL OF HARM –IMMEDIATE JEOPARDY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the failure of the facility to assess and monitor resident #3 following a change in condition related to level of consciousness.

At 9:14 a.m., a confidential family interview was conducted for resident #3. The family member was asked to describe the events surrounding their family members stay at the facility.

 He/She stated the family member was admitted to the facility because they required around the clock nursing care at home which was expensive.

He/She stated the hospice provider whom the facility staff told them they had to use stated they would not cover the [MEDICATION NAME]/ [MEDICATION NAME] which his/her family member was on at home. They stated the hospice provider they had at home did cover the patches.

They stated they had taken their loved one to their primary care physician and obtained a hard script for the [MEDICATION NAME] pills. They stated when their loved one was admitted to the facility they had two [MEDICATION NAME]/ [MEDICATION NAME] on which had been placed the day prior to admission.

He/She stated the admitting nurse was aware the resident had two [MEDICATION NAME] in place on admission.

He/She stated the admitting nurse stated they would confirm the physician’s orders [REDACTED].

He/She stated the only reason the medication was changed from [MEDICATION NAME] to the [MEDICATION NAME] pills was because the hospice would not cover the patches and it would have cost over $600 per month.

He/She stated they believed that was what killed their loved one. They stated when they arrived at the facility the next morning, their loved one was lying on their back in bed choking on vomit and out of it. They stated when they asked what was wrong with their loved one the staff stated it could have been a result of transitioning to the nursing home.

He/She stated they asked the nurse, did you take those patches off? He/She stated the nurse never answered them.

He/She stated then the nurse said they had removed the patches. The family asked when. The staff stated to the family they had just removed the patches and they were in the nurses’ pocket.

He/She stated they had told the nurse the resident was overdosed. He/She stated they were never able to have a conversation with the named resident again. They stated when the resident came into the facility she could verbalize her needs and even sign her own checks.

He/She stated it all changed when the facility overdosed the resident. He/She stated, they pushed her over the edge.

At 12:35 p.m., the DON stated she reviewed the notes. She stated the monitoring was in the progress note/nurse notes. She was asked to review the note on [DATE] at 2:18 p.m. which documented the resident had a decrease in level of consciousness, was slow to respond, would continue to monitor due to change in medication and would pass on to oncoming nurse. She was asked to review the late note on [DATE] at 2:20 p.m. which documented the physician was notified of the [MEDICATION NAME] not being removed when the [MEDICATION NAME] was started, would continue to monitor. She was asked to review the next note which was completed at 10:56 p.m. She was asked if any monitoring related to the over sedation occurred between these notes.

She stated no. The next note was in eight hours. She stated the staff probably charted every shift.

Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.