Baptist Village Of Enid
Inspection history, citations, penalties and survey trends for this long-term care facility in Enid, Oklahoma.
- Location
- 5801 North Oakwood Road, Enid, Oklahoma 73703
- CMS Provider Number
- 375406
- Inspections on file
- 22
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Baptist Village Of Enid during CMS and state inspections, most recent first.
A resident with heart failure, HTN, severely impaired cognition (BIMS 06), weakness, and knee buckling was identified as high risk for falls based on a fall risk score of 11. Facility policy and the DON’s stated process required fall risk evaluations at admission, quarterly, annually, on re-admission, and with significant change in condition, but no fall risk evaluation was documented for this resident for several months after the initial high-risk score. During this time, the resident’s care plan identified fall risk related to weakness, knee buckling, and HTN, and the resident experienced a fall during transfer. Leadership later acknowledged that a quarterly fall risk evaluation should have been completed but was not.
A resident receiving Dilantin for seizure prevention had physician orders for specific morning and evening doses. A nursing note documented an elevated Dilantin level and that the PCP was notified, with an order to hold the medication and redraw labs on a specified day. Review of laboratory records showed no documentation that the ordered follow-up lab was obtained. In interviews, an LPN and the DON both acknowledged the lab should have been drawn, but there was no record it was completed.
A resident with hypertension received blood pressure medications despite their blood pressure readings being below the specified parameters. The facility's staff failed to adhere to the medication administration policy, as confirmed by interviews with a CMA and an LPN. This resulted in the resident receiving metoprolol succinate ER and lisinopril when their blood pressure was too low.
The facility failed to properly label a medication on one of the medication carts. A box of ipratropium bromide and albuterol sulfate inhalation solution was found with only a handwritten nickname, lacking essential labeling information. An LPN identified the medication as belonging to a resident but admitted it had been improperly labeled since August. A CMA stated that medications without labels should not be administered, highlighting a failure to adhere to the facility's medication labeling policy.
The facility did not maintain a water management program to prevent Legionella growth in its water system. Although a policy existed, it lacked a system for testing waterborne pathogens. The administrator confirmed the absence of such a system, impacting 63 residents.
The facility failed to notify a physician about a resident's changes in urine condition, despite multiple instances of blood in the urine and a physician order for Eliquis. Additionally, the facility did not inform the family of another resident with Alzheimer's and dysphagia about a change in condition, including a chest x-ray indicating congestive heart failure and a drop in oxygen saturation. The DON confirmed the lack of notification in both cases.
The facility failed to provide a means for residents to file grievances anonymously and did not post information about the grievance official. Observations and interviews revealed a lack of signage and awareness among staff and residents' families about the grievance process, with no anonymous grievance box available and unclear identification of the grievance officer.
A resident reported missing clothing items, but the facility failed to report the misappropriation to the OSDH or conduct a thorough investigation as per their policy. The administrator acknowledged the oversight, admitting that no documentation or state report was filed.
A resident with renal insufficiency and diabetes mellitus exhibited milky thick urine with a foul odor. The facility failed to document monitoring for worsening symptoms, which was confirmed as necessary by the DON.
Failure to Complete Required Quarterly Fall Risk Evaluation for High-Risk Resident
Penalty
Summary
The facility failed to complete required quarterly fall risk evaluations for one resident identified as high risk for falls. The facility’s Fall Prevention Policy, revised 02/2014, required a fall risk evaluation to be completed quarterly, annually, on re-admission, and with significant change in condition. A fall risk evaluation for Resident #3 dated 08/22/24 showed a fall risk score of 11, indicating a high risk for falls, but there was no documentation that any additional fall risk evaluation was completed for this resident between September 2024 and February 2025, despite the facility’s process, as described by the DON, to evaluate residents at admission, quarterly, and upon significant change. During this period, a quarterly resident assessment dated 02/11/25 documented that the resident had heart failure, hypertension, and severely impaired cognition with a BIMS score of 06, and the care plan revised 02/12/25 identified the resident as at risk for falls related to weakness, knee buckling, and hypertension. A Fall Investigation Form dated 02/12/25 showed the resident experienced a fall during transfer. In interview, the ADON confirmed that a quarterly fall risk evaluation had been completed on 08/22/24 and the vice president stated the next evaluation should have been completed in 11/2024, but it was not documented as done.
Failure to Obtain Ordered Follow-Up Dilantin Level
Penalty
Summary
The facility failed to provide timely, ordered laboratory services for a resident receiving Dilantin for seizure prevention. The resident had physician orders dated 09/01/25 for Dilantin 100 mg, one capsule in the morning and two capsules in the evening. A nursing note dated 11/24/25 documented a Dilantin level of 44.4 and that the primary care provider was notified, with a new order to hold Dilantin and redraw labs on Wednesday. Review of the resident’s November 2025 laboratory results showed no documentation that the ordered follow-up lab was obtained. During interviews on 03/04/26, an LPN stated the lab should have been obtained on 11/26/25 and confirmed there was no record it was done, and the DON also stated the lab should have been obtained on that date. This deficiency occurred in the context of a survey sample of five residents reviewed for falls, with the ADON identifying that 70 residents resided in the facility at the time of the survey.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident with hypertension. The resident had specific medication orders for metoprolol succinate ER and lisinopril, with parameters to hold the medication if the systolic blood pressure was less than 100 and diastolic blood pressure was less than 50. On two occasions, the resident received these medications despite their blood pressure readings being below the specified parameters. On September 27, 2024, the resident's morning diastolic blood pressure was 49, yet they received both metoprolol succinate ER 50 mg and lisinopril 10 mg. Similarly, on November 10, 2024, the resident's evening systolic blood pressure was 81, but they were administered metoprolol succinate ER 100 mg. Interviews with facility staff revealed a lack of adherence to the medication administration policy. CMA #2 acknowledged that blood pressure medications typically have parameters indicating when not to administer them and stated that they would not have given the medications under the circumstances presented. LPN #3 also confirmed that the medications should not have been administered given the resident's blood pressure readings. This indicates a failure in following the established protocol for medication administration, leading to the deficiency.
Improper Medication Labeling on Medication Cart
Penalty
Summary
The facility failed to ensure proper labeling of medications on one of the two medication carts observed. During an observation, a box of ipratropium bromide and albuterol sulfate inhalation solution was found on a medication cart with only a handwritten nickname on the top, lacking a proper label with essential information such as the resident's name, medication name, strength, directions for use, fill date, quantity dispensed, prescriber name, or expiration date. LPN #1 identified the medication as belonging to a specific resident but acknowledged that the medication had been there since August 2024 without a proper label. CMA #1 stated that medications should not be administered if they do not have a label, indicating a discrepancy in the facility's adherence to its medication labeling policy.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. The deficiency was identified during a review of the facility's Legionella policy, dated August 20, 2024, which stated a commitment to the prevention, detection, and control of water-borne contaminants, including Legionella. However, the policy did not specify a system to prevent or detect these contaminants. During an interview on December 4, 2024, at 10:30 a.m., the administrator confirmed that while there was a policy in place, there was no system for testing waterborne pathogens such as Legionella in the facility's water system. This deficiency affected the 63 residents residing in the facility.
Failure to Notify Physician and Family of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician for a resident with renal insufficiency and diabetes mellitus who was experiencing changes in their condition. The resident had a physician order for Eliquis, and there were multiple instances of blood in the urine and changes in urine appearance that were not reported to the physician. Despite documentation of these changes in nursing notes, there was no evidence that the physician was informed, which was confirmed by the Director of Nursing (DON). Additionally, the facility did not notify the family of another resident with Alzheimer's and dysphagia about a change in the resident's condition. The resident had a chest x-ray indicating congestive heart failure and was experiencing a drop in oxygen saturation and a cough. Despite these changes and the involvement of hospice care, the family was not informed, as confirmed by the DON. The family member reported not being notified of changes in the resident's health, which was corroborated by the lack of documentation of family notification.
Failure to Ensure Anonymous Grievance Filing and Identification of Grievance Official
Penalty
Summary
The facility failed to ensure that residents and their representatives could file grievances anonymously and did not post information regarding the name of the grievance official. The grievance procedure, revised in March 2018, indicated that grievances could be filed anonymously in a designated box, but no such box was available. Additionally, there was no signage indicating the person to contact for filing a grievance. Observations revealed that the ombudsman contact name, resident rights, and OSDH complaint poster were displayed in a box with a glass cover near the front entrance, but lacked information on how to file a grievance. Interviews with residents' family members and staff highlighted a lack of awareness and clarity regarding the grievance process. A family member of one resident did not know how to file a grievance, while another thought it might be with the social services director. Staff members, including CNAs and an RN, were unsure of the grievance process and who the grievance official was, often directing residents to other staff members without clear guidance. The Administrator confirmed that there was no anonymous grievance box available and that the social services director was involved in care plan meetings, but did not provide a clear identification of the grievance officer.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property to the Oklahoma State Department of Health (OSDH) for one of the residents reviewed. The facility's grievance procedure, revised in March 2018, mandates that any allegation of misappropriation of property should be reported to the OSDH and the Department of Human Services, and an investigation should be conducted. This investigation should include interviews with witnesses, a search of the resident's room, and a root cause analysis. However, in this case, there was no documentation that such a report was filed or that a thorough investigation was conducted. The incident involved a resident who reported missing clothing items, including slacks, capris, a turtleneck, a sweatshirt, and nightgowns. The resident's complaint was documented in a grievance form, but there was no evidence that the facility followed its policy to report the incident or conduct a comprehensive investigation. The administrator acknowledged that the items were not found after searching the resident's room and laundry but admitted that they did not document the investigation or file a report with the state.
Failure to Monitor Resident's Change in Condition
Penalty
Summary
The facility failed to assess and monitor a resident for a change in condition. The resident, who had diagnoses including renal insufficiency and diabetes mellitus, was noted to have milky thick urine with a foul odor. Despite this observation, there was no documentation indicating that the resident was monitored for any worsening of symptoms. The Director of Nursing confirmed that the resident should have been monitored for worsening symptoms.
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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