Aspen Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Broken Arrow, Oklahoma.
- Location
- 1251 West Houston, Broken Arrow, Oklahoma 74012
- CMS Provider Number
- 375351
- Inspections on file
- 22
- Latest survey
- July 8, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Aspen Health And Rehab during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical conditions filed grievances about peer interactions and unsupervised children. After submitting complaints, the resident was told by staff to consider whether the facility was the right place for them and was cautioned about complaining too much. The resident reported feeling threatened and silenced, and staff interviews confirmed that inappropriate comments were made regarding the resident's right to voice grievances.
Unsupervised children brought to the facility by staff were observed making excessive noise, playing with equipment, accessing resident snacks, and entering resident rooms and common areas without supervision. Multiple residents and staff reported that the children’s presence disrupted the environment and created discomfort, with some residents feeling responsible for supervising the children.
Staff failed to follow a resident's written plan of care by transferring the individual manually without a mechanical lift, despite documented requirements for mechanical lift use and two-person assistance due to impaired mobility and left side weakness. The transfer was performed by a CNA and an LPN, resulting in the resident experiencing knee pain and a temporary decrease in therapy participation.
Multiple residents reported being physically mistreated, neglected, and spoken to harshly by CNAs, including being thrown onto a bed, denied timely toileting assistance, and left in soiled linens. Residents also described staff ignoring call lights and handling them roughly during care, with some residents afraid to report these incidents. Staff interviews and grievance logs confirmed these patterns of abuse and neglect.
The facility did not discontinue a muscle relaxant as ordered for one resident and failed to obtain daily weights as ordered for another resident with edema. Additionally, a blood pressure medication that was ordered to be discontinued was not removed from the administration record and was sent home with the resident upon discharge. These deficiencies were linked to missed documentation reviews and lack of awareness among nursing staff.
The facility did not complete laboratory tests as ordered by physicians for two residents, one with COPD and another with CHF, despite established processes for monitoring and implementing lab orders. The DON and medical records staff confirmed the labs were not completed and could not explain the failure.
A resident with dementia reported an allegation of sexual abuse to the ADON, who promptly informed the administrator and DON. Despite facility policy requiring immediate reporting of abuse allegations to the State Agency within two hours, the report was not submitted until the next day. The administrator stated they were unaware of the two-hour reporting requirement.
A resident with sleep apnea, who had a physician's order to use a BiPap at bedtime and confirmed nightly use, was not accurately assessed for non-invasive mechanical ventilator use in their quarterly MDS assessment. The MDS coordinator later confirmed the assessment was inaccurate.
The facility did not secure protected health information for six residents, as sensitive details were found handwritten on sheets of paper in a wall bin outside the social services office. The information included names, room numbers, diagnoses, and other personal details. The administrator acknowledged that these records were not secured.
A resident with paralytic syndrome affecting the right side had no interventions developed for a contracture in their right hand. Despite being cognitively intact and participating in a restorative program, the resident's care plan lacked specific measures for their limited range of motion. The DON confirmed that no interventions had been implemented since admission, and charge nurses were expected to report changes during weekly assessments.
The facility failed to consistently monitor and document side effects for residents on psychotropic medications, as required by their care plans. A resident with depression did not have a timely dosage adjustment, and several residents with psychiatric disorders had incomplete side effect monitoring records. The DON acknowledged these deficiencies but could not explain the lapses.
A facility failed to assess the continued need for an indwelling urinary catheter for a resident admitted with a catheter due to a femur fracture. The resident indicated they could use a urinal, and an LPN found no diagnosis justifying the catheter's use. The DON confirmed the absence of a required diagnosis, affecting one of four residents reviewed for catheter use.
The facility failed to document the temperature of the second-floor medication room and refrigerator consistently, with only a few entries recorded in June 2024. Additionally, treatment and medication carts were found unlocked when unattended, contrary to facility policy. Staff interviews revealed confusion about responsibilities for temperature documentation and cart security, with the DON confirming the lead CMA's role in these tasks.
The facility was found to have garbage containers in the kitchen without lids, as observed during a survey. A large garbage can without a lid was seen next to a food preparation table, filled with food waste, and three other uncovered containers were noted beside a refrigerator. A staff member confirmed that the garbage cans should be covered, and the DM admitted there was no policy but agreed that lids should be used.
Resident Discouraged from Filing Grievances Without Fear of Reprisal
Penalty
Summary
The facility failed to ensure that a resident was able to file grievances without fear of reprisal. A resident with intact cognition and multiple medical diagnoses, including hypertension, renal insufficiency, and diabetes, submitted grievances regarding issues with another resident and concerns about unsupervised children in the facility. Documentation showed that after submitting these grievances, the resident was approached by the social services director (SSD) and activities director (AD), who questioned the resident about their satisfaction with living at the facility and suggested that if they were unhappy, they might consider whether the facility was the right place for them. During this conversation, the resident became visibly upset and expressed feeling silenced, stating they would "just shut [their] mouth and not say a word ever again." Further evidence from a video recording and interviews confirmed that the resident was told to be careful about how much they complained about matters not in their control, and that repeated complaints could result in consideration of alternative placement. The resident reported feeling threatened and stated that the interaction had taken away their joy of being around people. Staff interviews revealed conflicting perspectives, with the SSD acknowledging that telling a resident to be careful about complaining would be inappropriate, while the AD stated that residents could submit as many grievances as they wished. The facility's grievance policy was described as allowing residents to submit grievances without limitation, but the actions taken in this case did not align with that policy.
Unsupervised Children Cause Excessive Noise and Disruption
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by allowing unsupervised children to be present in resident areas, resulting in excessive noise and disruption. Observations included children playing loudly in the billiard room, slamming billiard balls, and wearing staff communication headsets. Children were also seen accessing resident snacks from the snack cart and entering elevators and hallways without supervision. Multiple residents reported that children entered their rooms without permission, played on therapy equipment, and created disturbances in common areas. One resident described a child lying on their bed without consent, and another expressed discomfort with having to supervise children who were not their responsibility. Staff confirmed that the children, who were brought to the facility by employees, were often unsupervised and did not remain in designated areas. The administrator acknowledged that children were informed of expected behavior but maintained that their presence was therapeutic for residents. Despite this, both residents and staff reported that the children’s activities led to excessive noise and a lack of supervision, negatively impacting the environment and comfort of the residents.
Failure to Follow Resident Transfer Plan of Care
Penalty
Summary
Facility staff failed to follow the written plan of care for a resident who was documented as requiring transfer with a mechanical lift and two-person assistance due to confusion, left side weakness, and impaired mobility following a stroke. The resident's care plan and comprehensive assessment indicated substantial to maximal assistance was needed for transfers, and the use of a mechanical lift was specified in the closet care plan. Despite these documented requirements, staff transferred the resident manually without the mechanical lift. The incident occurred when a CNA and an LPN entered the resident's room to transfer the resident from a wheelchair to a bed. The LPN instructed the resident to place their hands around the nurse's neck and attempted to lift the resident out of the wheelchair, but was unable to clear the wheelchair armrest. Multiple attempts were made, during which the resident's feet became caught in the wheelchair foot pedals, and the resident was ultimately lifted over the armrest and onto the bed without proper support. The family member present reported the transfer was performed in a rough manner, resulting in the resident's head and legs being left dangling off the bed before being quickly repositioned by the nurse. Following the transfer, the resident complained of left knee pain and was unable to participate in physical therapy at their previous level for several days. An x-ray showed no acute fracture or dislocation, but moderate osteoarthritic changes were noted. The therapist confirmed the resident's knee pain limited therapy participation temporarily, though the resident returned to baseline function within a week. The facility's investigation, including review of camera footage, substantiated that the staff did not follow the resident's plan of care, as the mechanical lift was not used during the transfer.
Failure to Protect Residents from Abuse and Neglect by Staff
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving three residents. One resident, with a history of polyneuropathy, osteoarthritis, and physical debility, reported being physically mistreated by a CNA, who allegedly threw the resident onto the bed with enough force to move it and caused pain during care. The resident expressed fear of reporting the abuse due to concerns about retaliation. Additionally, the same resident reported that another CNA refused to assist with toileting, instructing the resident to use their brief instead, and failed to provide timely incontinence care, resulting in the resident being left in soiled linens until morning. Other residents also reported neglectful and abusive behaviors by staff. One resident stated that a CNA would turn off their call light and promise to return but never did, indicating a lack of timely response to care needs. Another resident described being handled roughly during bed mobility and having their call light thrown at them after care was provided. This resident also reported being told to urinate in their brief because staff did not have time to assist, and expressed reluctance to report these incidents out of fear of causing problems. The facility's grievance logs documented prior concerns about wait times, staff etiquette, and failure to provide timely incontinence care, but did not identify specific staff members involved. Assessments confirmed that the residents involved were cognitively intact and required varying levels of assistance with activities of daily living, including toileting and bed mobility. Staff interviews corroborated the residents' accounts, with one CNA admitting to neglectful behavior due to feeling rushed and another staff member acknowledging that the reported actions constituted abuse.
Failure to Implement Physician Orders and Obtain Daily Weights
Penalty
Summary
The facility failed to implement physician medication orders and obtain required daily weights for residents as directed. For one resident with chronic pain, a physician's order to discontinue cyclobenzaprine was documented in the progress notes, but the medication continued to be administered after the discontinuation order. The medication administration record did not reflect the discontinuation, and the error was not identified during daily audits by medical records staff or nursing leadership. Another resident with hypertension and generalized edema had a physician order for daily weights, but weights were not obtained on two consecutive days. Additionally, after a physician ordered the discontinuation of losartan due to low blood pressure, the medication remained on the administration record and was sent home with the resident upon discharge. The charge nurses were responsible for obtaining daily weights, but a recent staffing change contributed to the oversight. The nurses on the relevant unit were not aware they needed to review physician progress notes for new orders.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests ordered by physicians were completed for two of three sampled residents whose laboratory records were reviewed. One resident with chronic obstructive pulmonary disease had a physician's progress note instructing staff to obtain readmission labs, but the clinical record did not show that these labs were completed. Despite daily audits by medical records staff to ensure labs were ordered and implemented, no readmission labs were found for this resident. Another resident with congestive heart failure had physician orders for a CBC, CHEM 8, and A1c, but the clinical record did not show these labs were completed as ordered. The Director of Nursing and medical records staff confirmed that the labs had not been completed and were unable to provide a reason for the failure to implement the physician's orders.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with unspecified dementia to the Oklahoma State Department of Health within the required two-hour timeframe. According to facility policy, all alleged violations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. In this case, the resident reported to the ADON that an unidentified person had put their finger in her vagina during the evening shift. The ADON immediately notified the administrator and DON of the allegation. However, documentation showed that the initial report to the State Agency was not sent until the following day, well beyond the two-hour requirement. The administrator, who served as the abuse coordinator, stated they were unaware of the two-hour reporting requirement and believed they had 24 hours to report such allegations. This delay in reporting was confirmed by the fax cover sheet and interviews with facility staff.
Inaccurate Assessment of BiPap Use for Resident with Sleep Apnea
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for one of seven sampled residents. A resident with a diagnosis of sleep apnea was observed with a BiPap machine on their nightstand and had a physician's order to use the BiPap at bedtime. However, the resident's quarterly assessment did not indicate the use of a non-invasive mechanical ventilator, despite the resident confirming nightly use of the BiPap. Upon review, the MDS coordinator acknowledged that the assessment was inaccurate and should have reflected the resident's use of the device.
Failure to Secure Protected Health Information
Penalty
Summary
The facility failed to secure protected health information for six residents, as observed during an initial tour. The protected health information was found handwritten on six sheets of paper placed in a wall bin outside the social services office. Each sheet contained sensitive information, including the resident's name, room number, sex, diagnoses, insurance details, number of skilled nursing days available, hospital admission, therapy ordered, prior living environment, and discharge goals. The administrator confirmed that these records were not secured, affecting six residents out of the 113 identified in the facility.
Failure to Develop Interventions for Limited Range of Motion
Penalty
Summary
The facility failed to develop interventions to address the limited range of motion for a resident diagnosed with paralytic syndrome affecting the right dominant side. The resident's care plan, revised in May 2024, noted hemiplegia/hemiparesis of the right side, but did not include specific interventions for the contracture of the right hand. Observations in June 2024 revealed the resident's right hand was closed with no splints or devices in place, and the resident reported an inability to fully open their hand. Interviews with the Director of Nursing (DON) and the MDS coordinator confirmed that no interventions had been implemented for the resident's contracture since admission. Although the resident participated in a restorative program for transfers in September 2023, no specific measures were taken to address the limited range of motion in the right hand. The DON acknowledged the lack of intervention and stated that charge nurses were expected to report any contractures or changes in range of motion during weekly skin assessments.
Inadequate Monitoring of Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of side effects for residents receiving psychotropic medications. Five residents were identified as not having their side effects monitored consistently, as required by their care plans. For instance, Resident #5, who was diagnosed with depression, had a pharmacy recommendation to decrease their Doxepin dosage, which was not implemented in a timely manner. Additionally, the resident's side effects were not documented consistently, with significant gaps in the monitoring records. Resident #27, diagnosed with major depressive disorder and schizoaffective disorder, also experienced inadequate monitoring of side effects for their antidepressant and antipsychotic medications. The documentation showed that side effects were recorded only a few times out of numerous opportunities, despite the care plan's requirement for every shift monitoring. Similar issues were observed with Resident #86, who had multiple psychiatric diagnoses, including bipolar disorder and anxiety, where side effects were documented only a handful of times out of many opportunities. The facility's Director of Nursing (DON) acknowledged the lapses in monitoring and documentation for these residents, as well as for Resident #39 and Resident #52, who also had incomplete side effect monitoring records. The DON was unable to provide explanations for these deficiencies, indicating a systemic issue in ensuring compliance with care plans and physician orders regarding psychotropic medication management.
Failure to Assess Continued Need for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to assess the continued need for an indwelling urinary catheter for a resident who was admitted with a catheter due to a displaced intertrochanteric fracture of the left femur. The resident, who had been using the catheter since hospitalization, indicated they could use a urinal if necessary. Upon review of the medical record, an LPN found no diagnosis justifying the use of the catheter, and the Director of Nursing confirmed there was no diagnosis requiring it. This oversight affected one of the four residents reviewed for catheter use, out of a total of 12 residents with indwelling urinary catheters in the facility.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and security of medication storage, as observed during a survey. The temperature of the second-floor medication room was only documented five times out of 30 opportunities in June 2024, and the temperature of the medication refrigerator was recorded six times out of 60 opportunities. This lack of documentation indicates a failure to adhere to the facility's policy, which requires daily temperature logging to ensure medications and biologicals are stored at appropriate temperatures. Additionally, the facility did not secure treatment and medication carts when unattended. An unlocked treatment cart was observed outside a resident's room, and staff interviews revealed confusion about responsibility for temperature documentation and cart security. A CMA and two LPNs acknowledged that carts should be locked when not in use, and the DON confirmed that the lead CMA was responsible for temperature documentation and ensuring carts were locked. This lack of adherence to security protocols further highlights the facility's failure to comply with its medication storage policy.
Improper Disposal of Garbage in Kitchen
Penalty
Summary
The facility failed to ensure that garbage containers in the food preparation area were covered with lids, as observed during a survey. On June 30, 2024, at 8:04 a.m., a tour of the kitchen revealed a large garbage can without a lid next to the metal food preparation table, filled with refuse including food waste from the breakfast meal. Additionally, three other large garbage containers without lids were observed beside a refrigerator. At 8:10 a.m., a staff member acknowledged that the garbage cans should be covered with lids. On July 1, 2024, at 9:30 a.m., the Dietary Manager (DM) admitted there was no policy regarding refuse containers but confirmed that garbage cans should always be covered with lids.
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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