Ballard Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ada, Oklahoma.
- Location
- 201 West 5th Street, Ada, Oklahoma 74820
- CMS Provider Number
- 375263
- Inspections on file
- 19
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Ballard Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering exited the facility through a back door after following a construction worker. Staff did not promptly notice or report the resident's absence, and the resident was found several blocks away before being returned. The facility's elopement policy was not followed, and staff acknowledged the incident was preventable.
The facility failed to maintain a clean and safe environment, with multiple areas observed to have black residue, strong urine odors, missing floor tiles, and peeling material on walls and ceilings. Despite staff claims of daily cleaning, significant lapses were noted, affecting the safety and comfort of residents.
The facility failed to conduct a thorough investigation into an abuse allegation involving a cognitively impaired resident. Despite suspending and terminating the employee involved, the facility did not document required interviews with the resident, witnesses, or other staff members, nor could they locate the witness statement.
The facility failed to ensure proper monitoring and communication for a resident requiring dialysis services. The resident reported that the facility did not send or receive communication forms to and from the dialysis center, and staff did not assess their dialysis port before or after treatments. The DON confirmed the lack of proper documentation and communication, highlighting the facility's failure to provide safe and appropriate dialysis care.
The facility failed to ensure medications were administered as ordered for a resident with heart failure, hypertension, and diabetes. Multiple instances were documented where medications were given outside the prescribed time frames, and blood pressure medication was administered despite not meeting the required heart rate parameter. The DON and a CMA confirmed the proper protocols were not followed.
The facility failed to maintain kitchen cleanliness and repair, affecting 51 residents, including two on feeding tubes. Observations included lint on vents, missing wall tiles, residue in machines, and improper storage of items on the floor. The DM confirmed these issues and stated that the kitchen was cleaned daily and maintenance concerns were logged.
The facility failed to follow infection control measures during fingerstick glucose monitoring for nine residents. An LPN did not perform hand hygiene before and after wearing gloves, did not disinfect glucometers between uses, and did not cleanse residents' fingertips prior to piercing the skin. The corporate nurse consultant and DON confirmed these deficiencies.
The facility failed to educate, offer, and screen two residents for eligibility to receive pneumococcal and influenza vaccinations, and did not document consent or declination in their medical records, as required by facility policies.
A resident with moderate cognitive impairment and a diagnosis of depression was found with a tablet on their over-the-bed table without a physician order to self-administer medications. An LPN confirmed the resident did not have such an order and identified the tablet as likely being the resident's trazodone.
The facility failed to ensure that call lights accommodated the needs of two residents with moderately impaired cognition and physical impairments, requiring them to rely on their roommates to activate the call lights.
The facility failed to ensure a resident's code status was accurately documented. A resident with multiple diagnoses had a signed DNR order on file, but a physician order documented CPR, and an LPN incorrectly identified the resident as a full code despite the resident's clear statement that they did not want CPR. The discrepancy was confirmed when the LPN was shown the signed DNR in the resident's EHR.
The facility failed to update the care plan for a resident admitted to hospice services. Despite a physician order and a significant change assessment indicating the need for hospice care, the care plan was not updated until an audit revealed the oversight months later. The resident had severe cognitive impairment and required assistance with most ADLs.
The facility failed to complete a discharge summary that included a recapitulation of the resident's stay for one of three sampled residents reviewed for discharge. The discharge summary did not document a diagnosis on discharge or a summary of the course of treatment. The corporate nurse consultant stated that the nurse should have filled out the recapitulation of stay portion of the discharge summary.
A resident with anxiety was prescribed buspirone but the facility failed to document monitoring for side effects from December to March, as confirmed by a corporate nurse consultant.
Failure to Prevent Elopement of Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment and a known history of wandering. The resident, who had diagnoses including Alzheimer's, dementia, difficulty walking, muscle weakness, heart failure, anxiety, acute kidney failure, and repeated falls, was identified as an elopement risk on their care plan. Despite this, the resident was able to exit the facility through a back door, reportedly following a construction worker, and was not immediately noticed as missing by staff. Staff interviews revealed that the resident was not present at dinner, and it was only after searching and being notified by construction workers that the absence was recognized. The resident managed to get approximately three blocks away before being located and returned to the facility. The facility's elopement policy required prompt reporting and intervention when a resident was suspected of leaving or missing, but staff failed to follow these procedures. There was confusion among staff regarding the resident's whereabouts, and the incident was not reported in a timely manner. Additionally, it was noted that during certain facility activities, such as fire drills or door testing, doors became unlocked, potentially contributing to the resident's ability to leave undetected. The director of nursing and other staff acknowledged that the resident was at risk for harm and that the elopement was preventable.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure the physical environment was kept clean and maintained in good repair, affecting the safety and comfort of its residents. Observations revealed multiple areas with black residue, strong urine odors, missing floor tiles, and peeling material on walls and ceilings. Specifically, the women's visitor/staff restroom, several shower rooms, and resident restrooms were found to have black residue on the toilet bowls and floors. Additionally, the laundry room had an accumulation of lint and unfinished sheetrock near the window air unit. These conditions were confirmed by the housekeeping/laundry supervisor and the COO, administrator, and corporate nurse consultant. The facility's policy titled 'Homelike Environment' was not adhered to, as it mandates a clean, sanitary, and homelike setting. Despite staff claims of daily cleaning and reporting maintenance concerns, the observations indicated significant lapses in maintaining a clean and safe environment. The presence of gnats, missing floor drain covers, and unsealed sheetrock further highlighted the facility's failure to provide a safe and comfortable environment for its residents.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident diagnosed with nontraumatic intracerebral hemorrhage and dysphagia following cerebral infarction. The resident was severely cognitively impaired and required assistance with most ADLs. An incident was reported where a CMA observed the resident kissing a facility employee. The employee was suspended and later terminated after confessing to the allegation. However, there was no documentation of a comprehensive investigation as required by the facility's abuse policy, which mandates interviews with the resident, witnesses, other staff members, and a review of all events leading up to the incident. The administrator confirmed that while camera footage was reviewed and the appropriate agencies were notified, the facility did not document interviews with the resident, additional residents, or other staff members. Additionally, the witness statement from the CMA who observed the incident could not be located. This lack of thorough documentation and adherence to the facility's abuse investigation policy constitutes a deficiency in handling the abuse allegation properly.
Failure to Ensure Proper Dialysis Monitoring and Communication
Penalty
Summary
The facility failed to ensure proper monitoring and communication for a resident requiring dialysis services. The resident, diagnosed with end-stage renal disease, had physician orders to obtain weight before and after dialysis on specific days. However, the resident reported that the facility did not send or receive communication forms to and from the dialysis center. Additionally, the resident stated that staff did not assess their dialysis port before or after treatments, and the only people involved with their dialysis port were from the dialysis center. The Director of Nursing (DON) confirmed that communication forms were rarely returned and were not present in the resident's chart. The DON also admitted that the only assessment related to dialysis was obtaining the resident's weight before and after treatment. Further investigation revealed that there was no documentation in the resident's chart for an order to monitor or send the resident to dialysis. The DON acknowledged that there had never been an order for dialysis in the resident's chart, despite the resident's need for such treatment. The lack of proper documentation, communication, and assessment highlights the facility's failure to provide safe and appropriate dialysis care for the resident.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for one resident with diagnoses including heart failure, hypertension, and diabetes. The resident had specific physician orders for insulin aspart, metoprolol tartrate, insulin detemir, Lantus, and Humalog. The Medication Administration Records (MAR) for February and March 2024 documented multiple instances where medications were administered outside the prescribed time frames. Specifically, metoprolol was administered five times when the resident's heart rate was less than 65, contrary to the physician's order to hold the medication in such cases. Additionally, insulin aspart, insulin detemir, Lantus, and Humalog were frequently administered more than one hour after the scheduled times, with some medications being delayed up to 12 times in a month. On March 26, 2024, the Director of Nursing (DON) confirmed that medications should be administered no later than one hour before or after the scheduled time. A Certified Medication Aide (CMA) also stated that blood pressure medications should have been held if the heart rate parameter was not met and that the nurse should have been notified, with actions documented in the resident's chart. These failures indicate a lack of adherence to physician orders and proper medication administration protocols, leading to the identified deficiency.
Kitchen Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was kept clean and maintained in good repair, affecting 51 residents who received services from the kitchen, including two residents who relied solely on feeding tubes for nutrition and hydration. During a tour of the kitchen, several deficiencies were observed: lint on ceiling vents and surrounding areas, accumulation of lint on a floor fan, missing wall tiles behind the stove, holes and peeling material below the three-compartment sink, a baseboard tile pulling away from the wall near the back door, visible gaps and daylight under the back door, missing baseboards in the dish machine area, white residue on and in the dish machine, black residue inside the ice machine and on the floor under equipment, and improper storage of foam cups and multiple boxes of supplements and juice on the floor in the dry storage area. Additionally, the baseboard was missing in the employee storage area. The Dietary Manager (DM) confirmed these observations and stated that the kitchen was cleaned daily and maintenance concerns were recorded in a log. The DM also acknowledged that food and single-service items should be stored off the floor.
Infection Control Deficiency During Fingerstick Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper infection control measures during fingerstick glucose monitoring for nine residents. The observations revealed that the LPN did not perform hand hygiene before and after wearing gloves, did not disinfect the glucometers between uses, and did not cleanse the residents' fingertips prior to piercing the skin with a lancet. These actions were contrary to the facility's policy, which required hand hygiene, disinfection of equipment, and cleansing of the fingertip before the procedure. During the observation, the LPN was seen performing fingerstick glucose monitoring on multiple residents without adhering to the infection control protocols. The LPN did not perform hand hygiene after removing gloves and before donning new ones, and the glucometers were not disinfected between uses. Additionally, the LPN did not cleanse the residents' fingertips before obtaining blood samples, which is a critical step to prevent infection. The corporate nurse consultant and the Director of Nursing (DON) acknowledged the deficiencies in the LPN's practices. They confirmed that the LPN should have performed hand hygiene before and after each procedure, disinfected the glucometers between uses, and cleansed the residents' fingertips prior to piercing the skin. The DON stated that the use of two glucometers was intended to allow proper disinfection and drying time between residents, which was not followed by the LPN.
Failure to Educate, Offer, and Document Vaccinations
Penalty
Summary
The facility failed to educate, offer, and screen residents for eligibility to receive the pneumococcal and influenza vaccinations. Specifically, one resident was not screened for eligibility, nor provided with education regarding the risks, benefits, and side effects of the pneumococcal vaccine. Additionally, there was no documentation of consent or declination for this vaccination in the resident's medical record. Another resident was not screened for eligibility, nor provided with education regarding the risks, benefits, and side effects of the influenza vaccine. Similarly, there was no documentation of consent or declination for this vaccination in the resident's medical record. The facility's policies for pneumococcal and influenza vaccinations, revised in April 2012, require that residents be assessed for vaccination status within five working days of admission, provided with education, and that this education be documented in the medical record. The policies also state that vaccinations should be administered unless medically contraindicated, already given, or refused, with refusals documented in the medical record. The Director of Nursing confirmed that no documentation could be located for the two residents in question, indicating a failure to follow these policies.
Failure to Ensure Physician Order for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident had a physician order to self-administer medications. Resident #37, who had a diagnosis of depression and a physician order for trazodone HCL 100 mg at bedtime, was observed with a round white tablet in a clear medicine cup on their over-the-bed table. The resident, whose cognition was documented as moderately impaired, stated they did not know what the tablet was or how it got there. An LPN confirmed that the resident did not have a physician order to self-administer medications and identified the tablet as likely being the resident's trazodone. The LPN subsequently removed the medicine cup from the resident's room.
Failure to Accommodate Resident Needs with Call Lights
Penalty
Summary
The facility failed to ensure that call lights accommodated the needs of two residents, both of whom had moderately impaired cognition and physical impairments. Resident #10, who had rheumatoid arthritis and type 2 diabetes mellitus, was unable to use their call light because it required holding down a button to keep it activated. This resident had to rely on their roommate to activate the call light. Similarly, Resident #37, who had peripheral vascular disease and other unspecified symptoms, also had to hold down the button on their call light to keep it activated. This resident sometimes had to rely on their roommate to activate the call light as well. Interviews with CNAs and a corporate nurse consultant revealed that the facility used two types of call lights: one that stayed on when the button was pushed down and another older type that required holding the button down to keep it activated. Both CNAs confirmed that the residents in question were using the older type of call light, which they were unable to operate independently. The corporate nurse consultant was unaware of the existence of the older call lights and believed that only the newer type was in use. This lack of awareness and the presence of outdated call lights led to the deficiency in accommodating the residents' needs.
Failure to Ensure Accurate Code Status Documentation
Penalty
Summary
The facility failed to ensure a resident's code status was accurately documented. Resident #21, who had diagnoses including COPD, HTN, major depressive disorder, hyperlipidemia, osteoarthritis, PTSD, and chronic pain, had a signed DNR order on file. However, a physician order documented CPR, and an LPN incorrectly identified the resident as a full code despite the resident's clear statement that they had signed a DNR and did not want CPR. The discrepancy was confirmed when the LPN was shown the signed DNR in the resident's electronic health record (EHR).
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to update the care plan for a resident who was admitted to hospice services. The resident had diagnoses including Alzheimer's disease, dementia, and congestive heart failure. A physician order dated 10/31/23 documented the admission to hospice services due to congestive heart failure. A significant change assessment on 11/10/23 noted the resident was severely cognitively impaired and required partial to moderate assistance with most ADLs, and was receiving hospice services. However, the care plan, which was initiated on 03/24/24, did not include hospice services until an audit on 03/24/24 revealed the oversight. The MDS coordinator confirmed that the care plan should have been updated at the time of the hospice admission in October 2023 but was not.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of the resident's stay for one of three sampled residents reviewed for discharge. Resident #55 was discharged from the facility on 03/01/24. The discharge summary, dated 03/01/24, did not document a diagnosis on discharge or a summary of the course of treatment in the facility. On 03/26/24 at 1:32 p.m., the corporate nurse consultant stated that the nurse should have filled out the recapitulation of stay portion of the discharge summary.
Failure to Monitor Antianxiety Medication Side Effects
Penalty
Summary
The facility failed to ensure that an antianxiety medication was monitored for effectiveness and side effects for one of the five sampled residents reviewed for unnecessary medications. The resident had a diagnosis of anxiety and was prescribed buspirone 10 mg three times per day starting on December 7, 2023. A subsequent physician order on March 24, 2024, required monitoring for side effects of the antianxiety medication. However, upon review, it was found that there was no documentation of side effect monitoring from December 7, 2023, to March 24, 2024. This was confirmed by a corporate nurse consultant who stated there was no documentation available for that period.
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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