Accel At Crystal Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 315 Sw 80th Street, Oklahoma City, Oklahoma 73139
- CMS Provider Number
- 375570
- Inspections on file
- 36
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Accel At Crystal Park during CMS and state inspections, most recent first.
A resident with a new colostomy and complex medical history did not receive prescribed bowel medications or daily assessments of their stoma, leading to a necrotic and odorous stoma that was not promptly addressed. Nursing staff failed to document vital signs, pain, and bowel sounds during the resident's decline, and communication with the physician was delayed. Another resident also lacked required daily skilled assessments, indicating a broader issue with compliance to care protocols.
Two residents, one recently re-admitted after major orthopedic surgery and another admitted with multiple chronic conditions, did not have baseline care plans completed within 48 hours of admission or re-admission. The DON confirmed the absence of these care plans and indicated that nurses were responsible for their completion.
The facility did not fully transcribe and administer hospital discharge medication orders for a resident with multiple diagnoses, omitting key medications at admission. Additionally, another resident did not receive prescribed pain medication as ordered, with several doses held without proper documentation or communication, despite reports of significant pain.
A resident with a PICC line did not have this device included in their care plan, despite documentation of central IV access and a relevant surgical diagnosis. Staff confirmed the PICC line had been present since admission and acknowledged that such devices should be addressed in the care plan, but this was not completed.
A resident receiving IV meropenem for a vascular condition was administered the medication without a specified infusion rate in the physician's order or MAR. An LPN started the infusion at a standard rate without consulting the physician, despite facility policy requiring verification of the infusion rate. The medication bag listed a different rate, which was not initially followed, and the DON confirmed the order was incomplete.
A resident receiving IV antibiotics via a PICC line was observed with uncapped IV tubing hanging near the floor, no date labeling, and improper use of personal protective equipment by an LPN who did not wear a gown as required under Enhanced Barrier Precautions. The LPN was unfamiliar with EBP protocols and did not replace the end cap after discarding it, contrary to facility policy. The DON confirmed these actions did not meet infection control standards.
A resident with end-stage renal disease and legal blindness reported feeling intimidated and verbally abused by a CNA, but the incident was not reported to the Abuse Coordinator within the required two-hour timeframe. The resident's family member also expressed concerns about the staff's behavior. The administrator only learned of the incident the next day through clinical notes, highlighting a failure to follow the facility's abuse policy.
A resident with acute respiratory failure received a nebulizer treatment without staff supervision, contrary to facility policy. The oxygen concentrator was set at 3.5 liters per minute instead of the ordered 2 liters. The LPN admitted to managing multiple treatments simultaneously and not staying with the resident, and could not provide documentation for the oxygen discrepancy. The DON confirmed the resident was not assessed to self-administer the treatment.
A facility failed to document post-dialysis care for a resident with end-stage renal disease. The facility's policy required nurses to complete post-dialysis sections of communication forms, including vital signs and assessments. However, forms for two dates lacked this documentation. The resident confirmed that staff did not take their vital signs or assess them before or after dialysis. An LPN and the DON acknowledged the missing documentation.
A medication error occurred when a resident with hypothyroidism received their prescribed levothyroxine dose at 9:10 a.m. instead of the ordered 5:00 a.m. The error was identified when a CMA, after being informed by an outgoing nurse that all medications had been given, noticed the levothyroxine was missed and administered it late. An LPN confirmed the error, and the DON notified the resident's physician.
A resident with a scheduled toileting program was not assisted in a timely manner despite activating the call light. The resident expressed the need to urinate, but staff, including the DON, failed to promptly address the call light and inquire about the resident's needs, resulting in a delay in care.
A facility failed to obtain admission and weekly weights for a dialysis resident, as required by their weight monitoring policy and physician orders. The resident, who has end-stage renal disease, had only one weight recorded despite orders for weekly monitoring. Interviews with staff confirmed the deficiency, with an LPN acknowledging the lack of documentation in the EHR.
A facility failed to implement a fluid restriction for a resident with chronic kidney disease and pulmonary edema, as specified in the hospital's discharge orders. The resident's fluid restriction status was unclear to staff, and no fluid restriction orders were present in the resident's records. A water pitcher with 700 ml of fluids was observed at the bedside, and staff confirmed the oversight in entering the hospital orders upon admission.
A facility failed to administer a prescribed topical pain medication to a resident with a diagnosis of pain. The physician's order required Voltaren arthritis pain 1% topical gel to be applied every 12 hours to the resident's right knee. However, the MAR indicated the medication was not given on multiple occasions, marked with an 'x' and noted as 'due to special parameters,' without explanation. Interviews with the resident, a family member, and staff confirmed the medication was not administered, and the DON acknowledged the issue.
The facility failed to implement infection control measures, including enhanced barrier precautions and proper hand hygiene, during wound and incontinent care. Staff did not change gloves or sanitize hands between tasks, leading to potential cross-contamination. The facility's policies were not consistently followed, as observed in the care of multiple residents with pressure ulcers and other conditions.
A resident with acute respiratory failure and other conditions experienced significant drops in oxygen saturation levels, but the facility failed to notify the physician as required. Despite interventions to stabilize the resident, documentation showed no evidence of physician notification, which was confirmed by the DON and family member.
The facility failed to protect two residents from the misappropriation of their controlled medications. One resident with a fracture and low back pain and another with hip and back pain were affected when their prescribed pain medications were found missing. The DON discovered the issue when the medications were not available despite being received from the pharmacy. An LPN was suspended pending investigation, and the facility determined that 60 tablets of each medication were missing.
A facility failed to obtain physician-ordered vital signs for a resident with acute respiratory failure and other conditions. The order required vital signs every two shifts, but records showed missing entries for several nights, indicating they were not taken. The DON confirmed the oversight, noting the presence of new nurses and the resident's short stay.
A resident with a sacral pressure ulcer did not receive wound care as ordered by the physician. The LPN applied a xeroform and foam bordered dressings instead of following the prescribed regimen of cleansing with normal saline, packing with mesalt, and using a nonbordered dressing. The LPN admitted to not following the orders, citing their own knowledge from nursing school. The DON stated that staff should perform an initial skin assessment and follow wound care orders upon a resident's admission.
A resident with acute respiratory failure experienced inadequate oxygen therapy management when staff increased oxygen flow to 10 LPM without a physician's order, contrary to the prescribed 3 LPM. Family members expressed concerns about the facility's response to the resident's breathing difficulties, and the DON acknowledged the need for staff to contact the physician when oxygen saturation dropped.
A facility failed to provide showers in a timely manner for a resident with a fracture and muscle atrophy, as per the care plan and physician orders. The resident was supposed to receive baths twice a week, but documentation showed only two instances of bathing during a two-week stay. Interviews with staff revealed missing documentation and a lapse in following established procedures for shower assignments.
A dirty bedside commode was found in the hallway, contrary to infection control protocols, as confirmed by two CNAs. The administrator acknowledged the oversight, noting it should have been stored in the dirty utility closet. Other unattended items were also observed in the hallway.
The facility failed to investigate abuse allegations for two residents. One resident with severe quadriplegia reported feeling unsafe and had their call light moved away by staff, while another resident with bacterial pneumonia reported feeling unsafe depending on the staff. The Administrator admitted to not addressing these issues in a timely manner.
The facility failed to provide adequate staff to ensure timely administration of medications for two residents. One resident with chronic pain received oxycodone-acetaminophen late multiple times, while another resident received gabapentin and a Lidocaine patch late on several occasions. Staff interviews indicated that the heavy workload and insufficient staffing contributed to the delays.
The facility failed to ensure timely administration of medications for two residents. One resident with chronic pain received oxycodone-acetaminophen late multiple times, while another resident with pain received gabapentin and a Lidocaine patch late on several occasions. Staff interviews confirmed frequent delays in medication administration, and the DON acknowledged the issue.
A resident with depression requested their entire medical record but did not receive it in a timely manner. Despite completing the necessary paperwork, the request took significantly longer than the typical three to four days, and the records were not released because the resident was no longer in the facility and there was uncertainty about payment.
The facility failed to resolve a resident's grievance regarding not receiving pain medication during the night as per their grievance policy. The resident reported the issue, but there was no documentation of resolution, and the Administrator confirmed the absence of an official timeframe for resolving grievances.
The facility failed to ensure care plan fall interventions were in place for a resident with a femur fracture. The resident's call light was observed out of reach on multiple occasions, and staff confirmed it was not accessible, contrary to the care plan's requirements.
Failure to Follow Physician Orders and Perform Timely Colostomy Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that physician orders were followed for medication administration and colostomy care, resulting in a resident not receiving timely intervention for a new stoma that became necrotic. The resident, who had a history of volvulus, heart failure, and chronic kidney disease, was admitted with a pink, patent, and protruding ostomy. Physician orders included medications such as Colace and polyethylene glycol for bowel management, as well as daily colostomy care and assessments. However, documentation revealed that the resident did not receive the ordered Colace, and there was no evidence that daily assessments of the colostomy site, stoma, and bowel sounds were performed as required. The resident experienced ongoing pain, nausea, and changes in condition, including a black, necrotic, and odorous stoma, which was not promptly addressed. Nursing notes indicated that the resident's condition deteriorated, with symptoms such as slurred speech, bleeding from the stoma, and abdominal distention. Despite these changes, there was a lack of comprehensive assessment and documentation, including vital signs, pain assessment, and bowel sound evaluation at critical times. Communication with the physician was delayed, and the facility did not demonstrate a sense of urgency in responding to the resident's declining condition. Further review showed that other residents also experienced lapses in daily skilled assessments, as required by facility policy. For example, another resident with multiple diagnoses did not have daily skilled notes or assessments completed for several days. Interviews with staff confirmed that assessments were expected but not consistently performed or documented. These failures contributed to the deficient practice of not providing appropriate treatment and care according to physician orders and resident needs.
Removal Plan
- Audit of current residents inhouse was performed to ensure stoma is patent and healthy appearing
- Stoma site will be evaluated daily with care on the treatment record
- DON/designee will provide education to all clinical staff on completion of colostomy care, evaluation, and documentation on the treatment record
- The Administrator/designee will be responsible for the implementation of the New Process
- The New Process/system will be started and no licensed staff will be able to return to work until they complete the above stated education
Failure to Complete Baseline Care Plans Upon Admission or Re-admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed for two of nine sampled residents upon admission or re-admission. For one resident who was re-admitted following major orthopedic surgery, there was no documentation of a baseline care plan being completed at the time of re-admission, as confirmed by the Director of Nursing (DON) who was unable to locate the required documentation. Another resident, admitted with diagnoses including diabetes, hypertension, and gait and mobility abnormalities, also did not have a baseline care plan completed upon admission. The DON confirmed that this resident did not have a baseline care plan and stated that nurses were responsible for completing these plans at the time of admission.
Failure to Transcribe and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that hospital discharge medication orders were fully transcribed and administered as ordered for one resident, and failed to administer medications as ordered for another resident. In the first case, a resident admitted with diagnoses including volvulus, heart failure, and chronic kidney disease had a hospital discharge summary listing several medications, including Lasix and Colace. Upon review, it was found that while most medications were ordered by the facility, Lasix and Colace were not ordered at admission as required. The Director of Nursing (DON) confirmed that these medications should have been ordered and that the facility's process involves initialing orders and having them checked by the DON or assistant DON. In the second case, a resident with diabetes, hypertension, and mobility issues had a physician's order for Lortab to be given every six hours for pain. The medication administration record (MAR) showed that several doses were held, some without documented reasons, even when the resident reported significant pain. Staff interviews revealed that medications were sometimes held due to unavailability or other undocumented reasons, and there was no evidence of communication with the pharmacy or physician regarding the missed doses. The DON stated that staff should notify the physician if medications are held for reasons not specified in the orders.
Failure to Develop Care Plan for PICC Line Use
Penalty
Summary
The facility failed to ensure that a resident with a peripherally inserted central catheter (PICC) line had an appropriate care plan in place to address the use and management of the PICC line. Observation on 10/07/25 confirmed the presence of a PICC line in the resident's right arm. The resident's 5-day PPS scheduled assessment documented central IV access and a diagnosis of major orthopedic surgery, but the care plan revised on 09/08/25 did not include any documentation regarding the PICC line. Interviews with the RN and MDS coordinator confirmed that the resident had a PICC line since admission and that all PICC lines should be included in the care plan, but this was not done for this resident.
Failure to Administer IV Medication as Ordered Due to Missing Infusion Rate
Penalty
Summary
A deficiency occurred when a resident with a history of atherosclerosis of the right leg with ulceration was ordered to receive intravenous meropenem every eight hours. The physician's order and the medication administration record did not specify the rate of infusion for the antibiotic. During observation, an LPN initiated the infusion at a rate of 125ml/hr, based on routine practice rather than a specific order. The medication bag itself indicated a rate of 100ml/hr, but the LPN did not initially follow this rate and did not contact the physician to clarify the appropriate infusion rate prior to administration. The facility's policy required nurses to verify that the medication label matched the prescriber's order, including the infusion rate, and to contact the physician if the rate was not specified. Both the LPN and the DON acknowledged that the rate should have been confirmed with the physician before administration. The DON also confirmed that the order lacked the required infusion rate and emphasized the importance of this information for safe medication administration.
Failure to Follow Infection Control Protocols During IV Therapy
Penalty
Summary
The facility failed to properly handle intravenous (IV) tubing and follow evidence-based protocols during IV medication administration for a resident with a peripherally inserted central catheter (PICC) line. Observations revealed that the IV tubing was left without an end cap and was hanging 2 to 3 inches above the floor, connected to a new bag of meropenem, with no date labeled on the tubing. Two empty medication bags and a syringe cap were found in the trash, and the tubing was not dated as required by facility policy. During the administration of the IV medication, the LPN did not wear a gown as required under Enhanced Barrier Precautions (EBP) and was unsure about the frequency of IV tubing changes or the meaning of EBP. The LPN also admitted to discarding the original end cap and not replacing it, leaving the tubing uncapped. The resident involved had a diagnosis of major orthopedic surgery and a physician's order for meropenem IV infusions related to atherosclerosis with ulceration. The facility's policies required that intermittent administration sets used more than once in 24 hours be capped with a sterile end cap, labeled with date and time, and changed every 24 hours. The Director of Nursing confirmed that the observed practices did not align with facility policy, as the tubing should have been capped, dated, and the staff should have worn both gown and gloves for EBP. The LPN's lack of knowledge regarding EBP and proper IV tubing handling contributed to the deficiency.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement its abuse policy and report an incident of alleged abuse in a timely manner, as required by their policy. The incident involved a resident with end-stage renal disease and legal blindness, who reported feeling intimidated and verbally abused by a CNA. The resident's family member also expressed concerns about the staff's behavior, which they perceived as abusive. The facility's policy mandates that any suspected abuse be reported to the Abuse Coordinator within two hours, but this was not done. The incident began when the resident requested pain medication, and there was a delay in receiving it. The resident reported that the CNA became rude and made derogatory comments about their eyes and family. The situation escalated when the resident's family member called the facility, upset about the alleged intimidation and verbal abuse. The family member reported the incident to the charge nurse, who did not immediately report it to the Abuse Coordinator as required by the facility's policy. The administrator was only made aware of the incident the following morning after reading the clinical notes, rather than being informed directly by the staff. The charge nurse involved did not perceive the incident as abuse but rather a misunderstanding, and allowed the CNA to continue working with other residents. This failure to report the incident promptly and follow the facility's abuse policy resulted in a deficiency being cited by the surveyors.
Failure in Supervision and Administration of Respiratory Care
Penalty
Summary
The facility failed to ensure proper administration and supervision of respiratory care for a resident, specifically in the administration of oxygen and nebulizer treatments. The resident, who had a diagnosis of acute respiratory failure, was observed receiving a nebulizer treatment without staff supervision, contrary to the facility's policy which requires staff to remain with the resident unless they are assessed and authorized to self-administer. The resident was unsure of the time the treatment was administered and had to turn off the nebulizer themselves, indicating a lack of supervision. Additionally, the oxygen concentrator was set at 3.5 liters per minute, which was not in accordance with the physician's order of 2 liters per minute. The LPN responsible for the resident's care admitted to administering multiple nebulizer treatments simultaneously and not being able to stay with the resident during the treatment. The LPN also acknowledged that the resident's oxygen was set higher than the ordered amount and could not provide documentation to support any communication with the provider regarding this discrepancy. The DON confirmed that staff were expected to follow physician orders and remain with residents during nebulizer treatments, and that the resident had not been assessed to self-administer the treatment.
Failure to Document Post-Dialysis Care
Penalty
Summary
The facility failed to ensure that dialysis communication forms were consistently filled out for a resident with end-stage renal disease who required dialysis services. The facility's Dialysis-Hemodialysis policy required community nurses to complete specific sections of the communication form post-dialysis, including vital signs and an assessment of the resident. However, for two separate dates, the forms for a resident were missing documentation in the post-dialysis section. The resident confirmed that staff did not take their vital signs or assess them before or after returning from dialysis. An LPN acknowledged the absence of documentation, and the DON verified the missing forms and confirmed the resident's statement.
Medication Administration Error Leads to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 7.14% error rate during a medication administration observation. The deficiency involved Resident #142, who had a diagnosis of hypothyroidism and was prescribed levothyroxine 200 mcg and 25 mcg tablets to be taken together at 5:00 a.m. On the date of observation, the medication was administered at 9:10 a.m., which was not in accordance with the physician's orders. The facility's Medication Administration policy requires medications to be administered as prescribed and within 60 minutes of the scheduled time, except for specific meal-related orders. The error occurred when CMA #1 prepared and administered the medication at 9:01 a.m., after being informed by an outgoing agency nurse that all medications due had been given. However, upon observation, the CMA noticed the levothyroxine had not been administered and proceeded to give it to the resident. LPN #2 confirmed that the medication was not administered according to the physician's orders and acknowledged the error. The Director of Nursing (DON) was informed of the incident and notified the resident's physician and nurse practitioner, but no new orders were received.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance to Resident #142, who had a care plan in place to reduce incontinent episodes through a scheduled toileting program. On the morning of January 14, 2025, Resident #142 expressed the need to urinate to CMA #1, who activated the call light and left the room. Despite the call light being on and beeping, it was not addressed promptly by the staff. Observations noted that both CMA #1 and LPN #2 were present in the hallway, and the wellness director passed by the room without responding to the call light. The Director of Nursing (DON) eventually entered the room, turned off the call light, but did not inquire about the resident's needs. The resident later confirmed they were still waiting to use the urinal. The DON acknowledged the oversight and arranged for CNA #4 to assist the resident. The delay in responding to the call light and addressing the resident's toileting needs resulted in the resident's needs not being met in a timely manner, as confirmed by the DON.
Failure to Obtain Weekly Weights for Dialysis Resident
Penalty
Summary
The facility failed to ensure that admission and weekly weights were obtained for a resident on dialysis, identified as Resident #21. The facility's weight monitoring policy, reviewed in May 2023, requires newly admitted residents to be weighed upon admission and weekly for four weeks, then monthly unless otherwise indicated by a physician's order. Resident #21, who was admitted with end-stage renal disease and dependence on dialysis, had a physician order dated December 28, 2024, specifying weekly weights every Wednesday on day shift for 28 days on admission, then weekly for four weeks, and monthly if stable. However, the resident's weight record showed only one weight recorded on January 1, 2025. Interviews with the resident, a CNA, and an LPN revealed that the weekly weights were not conducted as ordered, with the LPN acknowledging that only one weight was documented in the electronic health record (EHR).
Failure to Implement Fluid Restriction for Resident
Penalty
Summary
The facility failed to follow a discharge hospital order for a fluid restriction for one resident with chronic kidney disease and pulmonary edema. The hospital's After Visit Summary specified a fluid restriction of no more than 2000 milliliters in a 24-hour period, but the resident had no fluid restriction orders upon admission to the facility. The resident reported that staff were unsure about their fluid restriction status, and a water pitcher with 700 ml of clear fluids was observed at the bedside. A CNA stated that they would be informed by nurses if a resident was on a fluid restriction, but there was confusion about the resident's status. An LPN confirmed that there was no order for a fluid restriction in the resident's records. The ADON acknowledged that the resident should have been on a fluid restriction and identified an oversight in entering the hospital orders upon admission.
Failure to Administer Topical Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a topical pain medication was administered as ordered for a resident diagnosed with pain. The physician's order specified the application of Voltaren arthritis pain 1% topical gel every 12 hours to the resident's right knee. However, the Medication Administration Record (MAR) for January 2025 documented that the medication was not administered on several occasions, marked with an 'x' and noted as 'due to special parameters,' without any explanation provided for these parameters. During interviews, the resident stated they had not received any topical medication for their knee, and a family member confirmed they had never seen staff apply any pain cream. An LPN and the Director of Nursing (DON) reviewed the MAR and confirmed the medication was not administered, with the DON indicating that the 'x' meant the medication was not given and that the 'due to parameters' could be related to vital signs. The LPN also admitted to not administering the topical pain gel during the resident's current stay.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to implement its infection prevention and control program effectively, as evidenced by multiple deficiencies observed during wound care and incontinent care. Specifically, the facility did not adhere to its enhanced barrier precautions policy for a resident with a pressure ulcer. The staff did not use gowns and gloves as required for direct patient care, and there was no use of normal saline to clean the resident's wound, contrary to the physician's orders. Additionally, the facility did not ensure proper hand hygiene and glove use during incontinent care for several residents. Staff members were observed not changing gloves or washing/sanitizing their hands when transitioning from dirty to clean tasks. This was noted during the care of multiple residents, where staff continued to perform tasks and handle items without changing gloves or sanitizing hands, leading to potential cross-contamination. The facility's policies on hand hygiene and perineal care were not followed, as staff failed to wash or sanitize their hands after providing care to one resident and before assisting another. This was observed in several instances, including when staff moved between residents and handled personal items and equipment without proper hand hygiene. The Director of Nursing and other staff members acknowledged the expected procedures, but these were not consistently practiced, resulting in the identified deficiencies.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician when a resident experienced a change in condition, specifically regarding oxygen saturation levels. The resident, who had diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase, was admitted for a skilled stay related to orthopedic aftercare for cervical stenosis. On one occasion, the resident removed their oxygen, leading to a significant drop in oxygen saturation to 76%, prompting a family member to request hospital transfer. The staff responded by increasing the oxygen flow, stabilizing the resident's condition, but did not notify the physician of the incident. Further documentation revealed another instance where the resident's oxygen saturation was recorded at 86%, yet again, there was no evidence of physician notification. Interviews with the family member and the Director of Nursing (DON) confirmed these events, with the DON acknowledging that staff should have contacted the physician when the resident's oxygen levels dropped. The facility's policy required documentation of physician notification in such cases, which was not adhered to, leading to the deficiency.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, affecting two residents who were reviewed for this issue. Resident #8, with diagnoses including an unspecified fracture of the shaft of the left fibula and low back pain, had a physician's order for hydrocodone 10 mg - acetaminophen 325 mg to be administered every four hours as needed for pain. Resident #9, with diagnoses including low back pain and pain in both hips, had a physician's order for acetaminophen 300 mg - codeine 30 mg to be administered every six hours as needed for low back pain. Both residents were affected by the misappropriation of their prescribed pain medications. The incident was identified when the Director of Nursing (DON) discovered that the pain medications for these residents were not available, despite having been received from the pharmacy. An investigation revealed that the medications were missing, and LPN #1, who was the receiving staff member, was suspended pending further investigation. The facility determined that 60 tablets of hydrocodone 10 mg - acetaminophen 325 mg and 60 tablets of acetaminophen 300 mg - codeine 30 mg were missing. The medications had to be reordered, and the facility conducted a search and staff interviews to address the issue.
Failure to Obtain Physician-Ordered Vital Signs
Penalty
Summary
The facility failed to ensure that physician-ordered vital signs were obtained for a resident who was being monitored for a change in condition. The resident had diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase. A physician order dated June 24, 2024, required vital signs to be checked every two shifts, including systolic and diastolic blood pressure, pulse, respirations, temperature, and O2 saturation. However, the medication administration record for June 2024 showed blanks for the night shift vital signs on the 26th, 28th, and 30th, indicating that these vital signs were not obtained. The Director of Nursing (DON) confirmed that the absence of recorded vital signs meant they were not taken and noted that the facility had several new nurses and the resident was not at the facility for long.
Failure to Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered for a resident with a sacral pressure ulcer. The resident was admitted with a physician's order to cleanse the wound with normal saline, pat dry, pack with mesalt, cover with a nonbordered dressing, and secure with tape, to be changed daily and as needed. However, during an observation, it was noted that the wound was not cleaned with normal saline, was not packed with mesalt, and a nonbordered dressing was not used. Instead, an LPN applied a xeroform and two foam bordered dressings over the resident's coccyx, which did not align with the physician's orders. The LPN involved admitted to not following the physician's orders, stating they used their own knowledge from nursing school to decide on the wound care. The LPN also mentioned that the resident's dressing had come off earlier in the shift and that they attempted to get an order for wound care. The Director of Nursing (DON) stated that when a resident is admitted with a wound, staff are expected to perform an initial skin assessment and follow any existing wound care orders. If no orders are present, staff should contact the provider to obtain them. The failure to adhere to the prescribed wound care regimen resulted in a deficiency in the care provided to the resident.
Inadequate Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure oxygen therapy was consistent with professional standards of practice for a resident who had diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase. A physician order indicated the resident was to receive three liters per minute (LPM) of oxygen via nasal cannula. However, a nurse note documented an incident where the resident removed their oxygen, leading to a significant drop in oxygen saturation to 76%. In response, staff increased the oxygen flow to 10 LPM without obtaining a physician's order, which was not in accordance with the prescribed treatment plan. Family members reported concerns about the resident's breathing difficulties and the facility's response. They noted instances where the resident's oxygen saturation dropped significantly, and they had to intervene by increasing the oxygen flow themselves. The Director of Nursing (DON) acknowledged the situation and stated that staff should have contacted the physician when the resident's oxygen saturation dropped. The DON also reviewed the nurse note and could not explain the charting of 'hyperventilate,' indicating a lack of clarity and adherence to proper procedures in managing the resident's oxygen therapy.
Failure to Provide Timely Showers According to Care Plan
Penalty
Summary
The facility failed to provide showers in a timely manner and according to the plan of care for a resident with diagnoses including a fracture of the lower end of the left femur and muscle atrophy. The facility's Bathing policy, revised in January 2023, required staff to provide bathing services within standard practice guidelines and document the procedure. A Self-Care Deficit care plan initiated in January 2024 indicated the resident would assist with bathing and hygiene daily over the next 90 days. A physician order from January 2024 specified the resident was to receive baths on Tuesdays and Fridays. However, during a two-week stay, documentation showed that a bath or shower was only offered on two occasions. Interviews with facility staff revealed that showers should be given twice a week, but documentation to support this was missing. The Assistant Director of Nursing (ADON) confirmed the lack of documentation, and the Director of Nursing (DON) stated that shower assignments are listed on daily assignment sheets, which were not located for the relevant time frame. The regional nurse mentioned that orders for baths should be entered at admission and checked the next business day, indicating a lapse in following the established procedures.
Improper Storage of Dirty Bedside Commode
Penalty
Summary
The facility failed to ensure proper storage of a dirty bedside commode, leading to a potential risk of cross-contamination among residents. On May 21, 2024, a dirty bedside commode with a yellow-orange substance was observed in the hallway outside a resident's room. This was contrary to the statements of two CNAs who confirmed that bedside commodes should be sterilized between uses and never stored in the hallway. Additionally, other items such as an IV pole with a blue baseball cap, a red cane, and wheelchair footrest attachments were also left unattended in the hallway. The administrator acknowledged that the commode should have been taken to the dirty utility closet for proper handling, indicating a lapse in staff adherence to infection control protocols.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were investigated for two residents. Resident #5, who had severe quadriplegia, reported feeling unsafe and disrespected by night staff. A grievance was filed by the resident's family, stating that staff had moved the call light away from the resident, who had limited use of their extremities. Despite these reports, there was no documentation that the allegations had been investigated. The Social Services Director (SSD) confirmed that the grievance was reported to the Administrator, who acknowledged the issue but had not addressed it in a timely manner. Resident #6, diagnosed with bacterial pneumonia, also reported feeling unsafe depending on the staff. This concern was documented in a Safe Survey, but again, there was no documentation that the allegation had been investigated. The SSD confirmed that the Safe Surveys were given to the Administrator, who admitted to not catching the issues sooner and failing to investigate the allegations promptly. The Administrator acknowledged that the failure to investigate these allegations was a problem and confirmed that the allegations had not been reported and investigated in a timely manner.
Failure to Provide Adequate Staffing for Timely Medication Administration
Penalty
Summary
The facility failed to provide adequate staff to ensure timely administration of medications for two residents. Resident #2, who had chronic pain, was prescribed oxycodone-acetaminophen to be taken every four hours. However, the medication was administered late multiple times between 12/08/23 and 12/22/23. Similarly, Resident #5, who also had pain, was prescribed gabapentin three times a day and a Lidocaine patch to be applied in the morning and removed in the evening. The resident received both medications late on several occasions between 12/01/23 and 12/27/23. Interviews with staff revealed that medications and treatments were often administered late due to a heavy workload and insufficient staffing.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure medications were administered timely for two residents reviewed for medications. Resident #2, who had a diagnosis of chronic pain, was prescribed oxycodone-acetaminophen 5 mg every four hours from 12/08/23 to 12/22/23 and 7.5 mg every four hours from 12/14/23 to 12/22/23. The medication administration record (MAR) showed that Resident #2 received the medication late multiple times. Similarly, Resident #5, who had a diagnosis of pain, was prescribed gabapentin three times a day and a Lidocaine patch to be placed in the morning and removed in the evening. The MAR indicated that Resident #5 received gabapentin and the Lidocaine patch late on several occasions. Interviews with staff confirmed that medications and treatments were often administered late, and the Director of Nursing (DON) acknowledged the delays after reviewing the administration times.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to ensure that residents had the right to view or receive copies of their clinical records. This deficiency was identified for one resident out of three reviewed. The resident, who had a diagnosis of depression, requested their entire medical record using the Oklahoma Standard Authorization To Use Or Share Protected Health Information form. Despite completing the necessary paperwork on 12/11/23, the resident did not receive their records in a timely manner. The Social Note dated 12/13/23 documented that the resident was informed they had to fill out the paperwork, which would then be submitted to corporate for processing before the records could be released. On 12/28/23, the medical records personnel confirmed that the resident's request was submitted on 12/11/23, but approval to release the records was not received until 12/26/23. The records had not been released because the resident was no longer in the facility, and there was uncertainty about the payment for the records. The medical records personnel stated that the timeframe for releasing records varied based on the size of the file and corporate processing times, typically taking three to four days. However, the resident's request took significantly longer, indicating a failure to comply with the policy and ensure timely access to medical records.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure the resolution of grievances for one of three sampled residents reviewed for grievances. The facility's grievance policy, dated 01/12/20, stated that residents would be informed of the findings of the investigation and the actions taken to correct any identified problems within three working days of filing the grievance. However, a grievance dated 12/21/23 documented that a resident reported not receiving pain medication during the night when requested and that the night shift ignored them. There was no documentation that the grievance had been resolved. The resident confirmed on 12/27/23 that they did not receive pain medication timely and had informed staff about their complaints. The Administrator stated that any staff could input a grievance in the EHR and that there was no official timeframe for resolving grievances, indicating a lack of adherence to the facility's grievance policy.
Failure to Ensure Call Light Accessibility for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure care plan fall interventions were in place for one of three sampled residents reviewed for falls. Resident #3, who had a diagnosis including a fracture of an unspecified part of the right femur, was observed with the call light out of reach on multiple occasions. On one occasion, the resident was observed looking for the call light and stated they did not know where it was. When asked, RN #3 also could not initially locate the call light and confirmed it was not within the resident's reach. The DON and other staff members acknowledged that ensuring call lights are within reach is a key measure to prevent falls, but this was not adhered to in the case of Resident #3.
Latest citations in Oklahoma
A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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