Ambassador Manor Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 1340 East 61st Street, Tulsa, Oklahoma 74136
- CMS Provider Number
- 375168
- Inspections on file
- 33
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Ambassador Manor Nursing Center during CMS and state inspections, most recent first.
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.
A resident with diabetes and other complex medical conditions had an order for daily insulin glargine that was correctly reflected on the MAR but not on the TAR. Over several days, a CMA documented the insulin order on the MAR and in progress notes and reported it to the nurse, but did not notify anyone else and believed the resident did not receive the medication. An LPN stated they only used the TAR when administering medications and did not review the MAR, resulting in the ordered insulin not being given because it was placed on the MAR instead of the TAR, leading to multiple missed doses.
A resident with a history of alcohol abuse, cannabis use, stimulant dependence, and other psychoactive substance abuse, and who was cognitively intact, was found in possession of suspected illicit drug paraphernalia after housekeeping observed a small glass pipe with residue and notified the administrator. The administrator met with the resident, revoked self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and disposed of the pipe, while nursing documentation noted continued illicit substance use and reports of providing substances to other residents. Despite a facility policy requiring prompt physician notification and documentation when changes may require physician intervention, the physician/medical director was not notified and there was no documentation of any physician notification related to the incident.
A resident with a history of substance abuse and intact cognition was found in possession of suspected drug paraphernalia after staff observed them handling a small glass pipe with residue. The administrator obtained the item from the resident and disposed of it in the trash, and nursing documentation noted ongoing illicit substance use and reports that the resident provided substances to others despite prior education and revocation of self sign-out privileges. Although facility policy and state law require reporting suspected crimes and drug paraphernalia to law enforcement and the state health department, the DON and administrator acknowledged that no reports were made to either authority.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
The facility did not maintain complete and accurate clinical records for two residents receiving wound care and one resident receiving insulin, as required by physician orders. Documentation was missing for several wound care treatments and insulin administrations, with staff and the DON confirming that these treatments were either not documented or the records could not be found.
A resident with severe cognitive impairment, unhealed pressure ulcers, and on hospice care was observed in a room with multiple flies, with both the resident and an LPN noting the persistent fly problem. Facility policy identified mechanical controls for fly abatement, but an exterminator's report found gaps around exterior doors, and the maintenance supervisor noted that doors were often left open, allowing flies to enter.
A resident with moderate cognitive impairment and a history of anxiety and depression had a medication card containing several doses of alprazolam, along with the corresponding narcotic sheet, go missing from the medication cart. The missing medication was reported by a CMA to the DON, who was unable to determine the cause of the loss, resulting in a failure to safeguard the resident's property.
A resident with moderate cognitive impairment and a history of anxiety and depression was prescribed alprazolam as needed. When a CMA discovered that several doses of this medication and the corresponding narcotic sheet were missing, the incident was reported internally to the DON but not to law enforcement or the state health department, contrary to facility policy and state regulations.
A resident with anxiety and moderate cognitive impairment had several doses of alprazolam and the related narcotic sheet go missing from the medication cart. The CMA reported the incident to the DON, who did not obtain written staff statements or document interviews, and was unable to determine the fate of the missing medication, resulting in a failure to thoroughly investigate the allegation.
A medication cart was found unlocked and unattended outside the DON's office. A CMA later locked the cart and confirmed that facility policy requires carts to be locked when not attended.
A facility failed to properly label an enteral feeding bag for a resident with a gastrostomy. The feeding bag was observed to be dated two days prior without necessary information like the resident's name, formula type, and time of change. An RN admitted that bags were sometimes refilled instead of changed, and the DON confirmed the requirement for a 24-hour change and proper labeling.
The facility did not ensure dishes were air-dried before use. A CNA was observed preparing room trays with wet plate covers, and the dishwasher staff admitted to stacking dishes immediately after washing. The dietary manager confirmed that dishes should be air-dried before stacking.
A resident with dementia and a history of traumatic brain injury was involved in an incident where they hit an RN, who then slapped the resident. This action violated the facility's policy on resident abuse, which ensures residents' rights to be free from physical abuse.
A facility failed to provide daily nephrostomy care as ordered for a resident with urinary tract issues and anxiety. An LPN confirmed that dressings had not been changed for two days, contrary to physician orders. The DON acknowledged that care should be provided daily.
The facility failed to ensure a prescribed medication was available for administration for a resident with sepsis and hypertension. The resident was prescribed bisacodyl 10 MG suppository daily, but the medication was not documented as given or held on one day and was held on another day before being administered. The DON stated that the pharmacy delivers medication twice a day and it should not take over 24 hours to receive medication.
The facility failed to ensure accurate resident records for a resident with nephrostomy care orders. The Treatment Administration Record (TAR) indicated care was provided on two specific dates, but an LPN found that the dressings had not been changed since an earlier date, contradicting the TAR entries.
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.
Missed Insulin Doses Due to Transcription and MAR/TAR Workflow Errors
Penalty
Summary
The deficiency involves a failure to accurately transcribe and administer an ordered insulin medication for one resident. The resident had multiple medical diagnoses, including diabetes mellitus due to an underlying condition with diabetic amyotrophy, acute kidney failure, COPD, and hyperkalemia. Clinical discharge instructions directed administration of insulin glargine 30 units subcutaneously every 24 hours, and the facility’s physician order and MAR reflected an active order for insulin glargine 30 units subcutaneously once daily starting the day after admission. The MAR entries for several consecutive days showed a chart code indicating documentation in nurses’ notes rather than actual administration of the insulin. Progress notes documented that a CMA repeatedly noted the insulin glargine order and reported it to the nurse each morning, stating they did not administer insulin and only informed the nurse when such medications appeared on the MAR. The CMA also stated they did not inform anyone else and did not think the resident received the medication. An LPN reported that they administered medications listed on the TAR and that CMAs administered medications on the MAR, and acknowledged they did not review the MAR when giving medications, which led to the insulin being missed because it was listed on the MAR instead of the TAR. The ADON confirmed that the insulin order had been placed on the MAR rather than the TAR and that the resident had missed doses of insulin as a result of this transcription and administration process failure.
Failure to Notify Physician of Resident’s Suspected Illicit Drug Paraphernalia
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of suspected illegal drug paraphernalia found in a resident’s possession, contrary to its own Notification of Change policy. The policy, dated 06/2025, required prompt notification of the resident, physician, and representative when there is an accident involving the resident that results in injury or has the potential for requiring physician intervention, with all notifications documented in the medical record. Resident #7 was admitted with diagnoses including alcohol abuse with withdrawal, cannabis use, other stimulant dependence, and other psychoactive substance abuse, and had a BIMS score of 15 indicating cognitive intactness. On 02/17/26, the care plan team and administrator met with the resident and in-serviced them regarding revocation of self sign-out privileges due to non-compliance with facility rules related to smoking devices and paraphernalia, which the resident acknowledged and signed as understanding. A subsequent nurse’s note dated 02/24/26 documented that on 02/17/26 the resident had received education about revocation of self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and that the resident continued to use illicit substances and was reported to provide substances to other residents despite prior education. There was no documentation that the physician was notified of the illicit paraphernalia found on 02/17/26. The resident later stated that a methamphetamine pipe had been found in their room in February, confiscated, and thrown in the trash. The HK supervisor reported that housekeeping observed the resident place a small glass pipe with residue in a box, notified the administrator, and then accompanied the administrator to the resident’s room, where the resident handed over the suspected drug paraphernalia, which was disposed of in the trash. The medical director confirmed they were not notified of the suspected drug paraphernalia, and the DON and administrator both stated that physician notification was not documented or completed.
Failure to Report Suspected Drug-Related Criminal Activity to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to notify law enforcement and the Oklahoma State Department of Health of suspected criminal activity involving drug paraphernalia. Facility policy on Resident Abuse, Neglect and Misappropriation of Property, revised 11/01/22, states that if there is a suspicion of a crime against a resident, the facility shall report the incident to the Department and law enforcement, and references Oklahoma statutes defining crime and prohibiting drug paraphernalia. Resident #7 was admitted with diagnoses including alcohol abuse with withdrawal, cannabis use, other stimulant dependence, and other psychoactive substance abuse, and had a BIMS score of 15, indicating cognitive intactness. A nurse’s note dated 02/17/26 documented that the care plan team and administrator met with the resident and in-serviced them regarding revocation of self sign-out privileges due to non-compliance with facility rules related to smoking devices and paraphernalia. A subsequent nurse’s note dated 02/24/26 documented that the resident had received education on 02/17/26 about revocation of self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and that the resident continued to use illicit substances and was reported to provide substances to other residents. There was no documentation that the suspected illegal activity or the paraphernalia found on 02/17/26 was reported to police or the state health department. In interviews, the resident stated that a methamphetamine pipe was found in their room and that staff confiscated and discarded it. The housekeeping supervisor reported seeing the resident place a small glass pipe with residue in a box, notifying the administrator, and accompanying the administrator when the resident surrendered the suspected paraphernalia, which was then thrown in the trash. The DON stated they followed the abuse policy but were not aware the suspected drug paraphernalia was a crime, acknowledged the incident should have been reported to the state health department, and confirmed it was not. The administrator also confirmed that neither police nor the state health department were notified of the incident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or the circumstances at the time of the deficiency are provided in the report.
Failure to Maintain Complete and Accurate Clinical Records for Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents regarding wound care and medication administration. For one resident with severe cognitive impairment and multiple ulcers, treatment sheets did not show documentation of daily dressing changes on several specified dates, despite physician orders requiring these treatments. The Director of Nursing (DON) confirmed that there was no documentation for the dressing changes on the missing dates and acknowledged that undocumented treatments are considered not done. The resident was unsure about the frequency or progression of their wound care, and the DON was unable to locate any records for the specified dates. Another resident, who was cognitively intact and had an ostomy and pressure ulcers, had physician orders for wound care to multiple sites. The treatment administration record lacked documentation for wound care on a specific date, and staff later admitted that the wound care was performed but not documented. Additionally, a third resident with diabetes and a high cognitive score had missing documentation for insulin administration on three occasions, even though the resident stated they received their insulin as ordered. The DON confirmed the absence of documentation for these medication administrations.
Failure to Control Flies in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program for the abatement of flies in one of four halls observed. During an observation of wound care, multiple flies were seen in a resident's room. The resident, who was severely impaired in daily decision making, had unhealed pressure ulcers, and was receiving hospice services, reported struggling with flies throughout the day. An LPN also commented on the severity of the fly problem in the room, and both the resident and staff were observed waving flies away during care. A review of the facility's pest control policy indicated that mechanical control measures such as window screens, screen doors, electric fans, and black light style traps were important for fly abatement. The exterminator's service report noted visible light around exterior doors, providing entry points for pests, and recommended replacing seals or door sweeps. The maintenance supervisor acknowledged the presence of flies in the facility and noted that exterior doors were often held open for extended periods, allowing insects to enter, but stated that no specific concentration of flies in any resident's room had been reported to them.
Failure to Protect Resident's Property: Missing Controlled Medication
Penalty
Summary
The facility failed to protect a resident's property from misappropriation when a medication card containing approximately six doses of alprazolam, prescribed for anxiety, and the corresponding narcotic sheet were discovered missing from the medication cart. The resident involved had diagnoses of anxiety disorder and major depressive disorder, with a BIMS score indicating moderate cognitive impairment. The missing medication was first noticed by a CMA, who was unable to locate the narcotic sheet at the nurse's desk and subsequently reported the incident to the DON. The DON confirmed being notified of the missing medications but was unable to determine what had happened to them. This incident demonstrates a failure to ensure the security of a resident's controlled medication and related documentation, as required by facility policy prohibiting misappropriation of property.
Failure to Report Suspected Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of property involving a resident's medication to local law enforcement and the Oklahoma State Department of Health (OSDH). According to facility policy, upon receiving an allegation of resident abuse, neglect, or misappropriation of property, the facility is required to begin an investigation and file reports with appropriate agencies if there is reasonable suspicion that a crime has occurred. Despite this, when a certified medication aide (CMA) discovered that a medication card containing approximately six doses of alprazolam and the corresponding narcotic sheet were missing from the medication cart, the incident was only reported internally to the Director of Nursing (DON) and not to external authorities. The resident involved had diagnoses including anxiety disorder and major depressive disorder, with a BIMS score indicating moderate cognitive impairment. The missing medication was an antianxiety drug prescribed as needed. The DON confirmed being notified of the missing medications but did not report the incident to OSDH or law enforcement, as required by facility policy and state regulations. This omission constituted a failure to follow mandated reporting procedures for suspected misappropriation of resident property.
Failure to Thoroughly Investigate Missing Medication Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of a resident's property involving a resident with anxiety disorder and major depressive disorder, who had moderate cognitive impairment as indicated by a BIMS score of 11. The incident involved the disappearance of approximately six alprazolam tablets and the corresponding narcotic sheet from the medication cart, as reported by a CMA. The CMA searched for the missing narcotic sheet at the nurse's desk but was unable to locate it and subsequently reported the missing medication to the DON. Upon notification, the DON stated that an investigation was conducted; however, no written statements were obtained from staff members, and there were no notes documenting staff interviews. Additionally, the DON was unable to determine what happened to the missing medications. The lack of thorough documentation and follow-up in the investigation process led to the deficiency cited in the report.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart on the South hall, located outside the Director of Nursing's office, was observed to be unlocked and unattended at 3:05 p.m. This cart was one of two medication carts in the area. At 3:20 p.m., a certified medication aide (CMA) approached and locked the cart. The CMA confirmed that the cart should have been locked and stated that facility policy requires medication carts to be locked when unattended. The facility had 139 residents at the time of the observation.
Improper Labeling of Enteral Feeding Bag
Penalty
Summary
The facility failed to ensure proper labeling of an enteral tube feeding bag for a resident with a gastrostomy. The resident had a physician order for continuous feeding at a rate of 45 mL/hr. During an observation, the feeding bag was found to be dated two days prior and lacked additional required information such as the resident's name, formula type, and time of change. RN #2 acknowledged that the bag should be labeled with the date, time, and type of formula, and noted that sometimes bags were refilled instead of changed. The Director of Nursing confirmed that the tube feeding bag should be changed every 24 hours and properly labeled with the necessary details.
Failure to Air Dry Dishes
Penalty
Summary
The facility failed to ensure that dishes were properly air-dried before being used for meal service. During an observation, a CNA was seen preparing room trays with plate covers that had liquid running down the edges, indicating they were not dry. The CNA confirmed that the plate covers were not dry. Further interviews revealed that the dishwasher staff immediately stacked dishes on the rack after they came out of the dishwasher, without allowing them to air dry. The dietary manager acknowledged that dishes and plate covers should not be stacked immediately after washing but should be allowed to air dry.
Failure to Prevent Abuse of Resident
Penalty
Summary
The facility failed to prevent abuse for a resident who had diagnoses including dementia with behaviors and a history of traumatic brain injury. An incident occurred where the resident hit a registered nurse (RN), and the RN responded by slapping the resident. This incident was documented in an Incident Report Form. The facility's policy on resident abuse, neglect, and misappropriation of property states that residents have the right to be free from various forms of abuse, including physical abuse. The incident involving the RN and the resident constitutes a violation of this policy, as the RN's action of slapping the resident is considered physical abuse.
Failure to Provide Daily Nephrostomy Care
Penalty
Summary
The facility failed to ensure nephrostomy care was provided as ordered for a resident with diagnoses including acquired absence of other parts of the urinary tract and anxiety. A physician order dated 01/03/24 required the area around the left and right nephrostomy sites to be cleaned with normal saline, patted dry, and covered with a dry drainage sponge every day and as needed. On 02/05/25, an LPN was observed providing nephrostomy care and removed dressings dated 02/02/24, indicating that care had not been provided on 02/03/24 and 02/04/24. The LPN confirmed that the dressings had not been changed since 02/02/24. The Director of Nursing stated that nephrostomy care should be provided daily according to the physician order.
Failure to Ensure Timely Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure a prescribed medication was available for administration for one of three residents reviewed for medication administration. The resident had diagnoses including sepsis and hypertension and was prescribed bisacodyl 10 MG suppository daily. The physician order was dated 01/12/24. The Treatment Administration Record (TAR) for January 2024 did not document if the bisacodyl was given or held on 01/13/24 and indicated that the medication was held on 01/14/24. The medication was administered on 01/15/24. The Director of Nursing (DON) stated that the pharmacy delivers medication twice a day and that it should not take over 24 hours to receive medication from the pharmacy.
Inaccurate Resident Records for Nephrostomy Care
Penalty
Summary
The facility failed to ensure resident records were accurate for one of thirteen residents whose records were reviewed. Resident #1, who had diagnoses including acquired absence of other parts of the urinary tract and anxiety, had a physician order dated 01/03/24 for daily nephrostomy care. The Treatment Administration Record (TAR) for February 2024 documented that nephrostomy care was performed on 02/03/24 and 02/04/24. However, on 02/05/24, an LPN was observed providing nephrostomy care and found that the dressings on both nephrostomy sites were dated 02/02/24, indicating that care had not been provided on 02/03/24 and 02/04/24 as documented. The LPN confirmed that the dressings had not been changed since 02/02/24, contradicting the TAR entries.
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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