F0656

E

Failure to Develop and Implement Comprehensive Care Plans for ROM, Nutrition, and Lift Transfers

Oklahoma City, Oklahoma Survey Completed on 02-18-2026

Penalty

Fine: $50,116

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for multiple residents. For one resident with left-sided weakness, surveyors observed a contracted left hand closed into a fist and limited ability to raise the left arm above shoulder height, with no therapeutic devices in place. The resident reported having no use of the left hand and no therapies or devices to maintain or improve function. Staff, including CNAs and an LPN, confirmed the resident had left-hand contracture and weakness, was not on restorative services, had no therapeutic devices, and did not receive range of motion exercises. The DON acknowledged that the resident had not been admitted to therapy or the restorative program since admission, despite having limited range of motion and contracture, and the MDS coordinator confirmed the care plan did not address the upper extremity impairment or related interventions.

Another deficiency was identified for a resident with protein-calorie malnutrition and significant weight loss, whose care plan required staff to offer a meal replacement supplement when 50% or less of a meal was consumed. Weight records showed a decline from 170 pounds to 155 pounds over approximately two months, and a dietician’s note documented an 8.8% weight loss in one month and 15.3% in six months, with meal intake ranging from 25–50%. The dietician recommended health shakes three times daily with meals. The resident stated they were not receiving any meal supplements despite liking them, and a CNA confirmed the resident did not receive health shakes or additional supplements when eating 50% or less of meals. The DON stated the resident should have been receiving health shakes when 50% or less of meals were consumed.

A further deficiency was found for a resident dependent on staff for transfers and with severe cognitive impairment, who was observed being transferred with a mechanical lift by staff. The significant change in status assessment documented dependence for transfers, and multiple staff members, including CNAs and the resident, reported that a lift was used for transfers and had been in use since the CNA’s employment at the facility. Despite this, the resident’s care plan, revised earlier in the month, did not include the use of a mechanical lift for transfers. The MDS coordinator, responsible for completing care plans, stated that lift use should be documented on the care plan when used, and acknowledged that this resident’s care plan did not address the use of a lift for transfers.