Baptist Village Of Oklahoma City
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 9700 Mashburn Blvd, Oklahoma City, Oklahoma 73162
- CMS Provider Number
- 375381
- Inspections on file
- 21
- Latest survey
- October 1, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Baptist Village Of Oklahoma City during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral challenges was physically abused by a CNA during care, resulting in visible injuries and fear. The abuse was witnessed by another CNA, who delayed reporting the incident. Documentation and staff interviews confirmed the resident was not protected from abuse, as required by facility policy.
A resident who was unable to bear weight and required total assistance was transferred by three CNAs using an unsafe method, with a loose gait belt and lifting under the arms, resulting in pain and distress. Staff had reported the resident's decline and the need for a mechanical lift, but the care plan and transfer procedures were not updated, and interdisciplinary team meetings did not address the change in transfer needs.
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices, leading to a deficiency in infection prevention and control. Staff were unaware of the need for these precautions, and residents reported incomplete use of PPE during care.
A CNA in a memory care unit was found to have physically restrained a resident with Alzheimer's and cognitive impairments by grabbing them to force them into a seated position. The resident, who was independent in ambulation, showed no physical harm upon assessment. The CNA was terminated following an investigation that confirmed the abuse allegation.
An Immediate Jeopardy situation was identified in a memory care unit due to unsafe conditions in the shower room. The door failed to close and lock automatically, allowing residents unsupervised access. The room had a wet floor, a plugged-in hair dryer, numerous bottles of personal care products, and an unlocked cabinet with razors. Emergency call lights were looped around grab bars, making them unusable. An LPN confirmed these conditions were against protocol, and 28 residents were potentially affected.
A resident with parkinsonism and pain experienced a fall resulting in a fractured finger. Despite orders for buddy taping and a recommendation for a splint, the facility failed to document the application of the buddy tape and did not provide range of motion exercises or physical therapy. The resident reported not receiving therapy or seeing an orthopedic surgeon for two months, leading to a decline in hand functionality.
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for residents on psychotropic medications, as required by their policy. Four residents were not reviewed for GDR, despite being on multiple psychotropic medications. For instance, a resident with dementia and depression was on escitalopram and trazodone without any documented recommendation for a GDR. Another resident with emotional lability and anxiety was prescribed multiple medications, and although the pharmacist suggested a GDR, no changes were made. Additionally, a resident with Alzheimer's disease and dementia was on several medications, and despite experiencing a fall, there was no documentation of a GDR review.
The facility did not post the breakfast menu as required by their policy, which states that menus should be posted at least one week in advance and in a readable font size. This was observed on two occasions, and the Registered Dietician was unsure if the menu was posted. The facility houses 101 residents.
The facility did not inform residents of their right to hold resident council meetings without staff presence, as required by their policy. During interviews, nine residents expressed unawareness of this right, and a social service staff member admitted to not knowing the policy, indicating a need for review.
The facility did not ensure the ombudsman's contact information was accessible to residents, interfering with their rights to communicate with the state's ombudsman office. Residents were unaware of the ombudsman's role or contact details. The information was posted in small print and out of view for wheelchair users, with no information board on the skilled halls.
The facility failed to distribute mail to residents on weekends. Nine members of the resident council reported that mail was not distributed on weekends, and social services staff confirmed that mail delivered on Saturdays was not passed out until Monday. This affected the 101 residents residing in the facility.
The facility did not ensure survey results were easily accessible to residents and visitors. Resident council members were unaware of the location of the state inspection book, and while a sign on the LTC halls indicated survey results were at the front desk, there was no such information in the skilled halls.
The facility did not ensure residents and their representatives could file grievances anonymously or were informed about the grievance official. Despite a policy stating the provision of a grievance mechanism without fear of retaliation, residents were unaware of how to file grievances, and social services staff were unsure of the grievance official's identity.
A resident with parkinsonism and pain experienced a fall resulting in a fractured finger. Despite a physician's order for ice packs and an orthopedic referral, the resident did not receive timely care. The resident was not seen by a provider for nearly a month, and the orthopedic consultation was delayed for over two months. An LPN acknowledged the failure to set up the appointment, and the DON confirmed the delay, noting that only ice packs and Tylenol were provided during the interim.
The facility failed to assess and document the use of bed rails for two residents, one with a leg fracture and another with hemiplegia. Both residents used bed rails without documented assessments, physician's orders, or informed consent, as confirmed by facility staff.
The facility failed to comply with its policies on food storage, handling, and sanitization, resulting in several deficiencies. Food items were not labeled or stored properly, and hot food temperatures were not maintained or documented as required. Additionally, staff did not change gloves between tasks, and the dishwasher lacked sanitizer solution, compromising cleanliness. These lapses indicate a failure to adhere to established food safety protocols.
The facility failed to ensure call devices were accessible for two residents in the memory care unit. One resident with dementia and heart failure had a call light cord hanging over the head of the bed, while another with diastolic heart failure and Alzheimer's had cords over the foot of an empty bed. A CNA confirmed the inaccessibility, and the DON stated call devices should always be within reach.
A facility failed to promote resident dignity by not following its policy for meal assistance. A resident with Alzheimer's disease, requiring supervision with eating, was assisted by an LPN who stood while helping the resident, contrary to the policy that staff should be seated. Both the LPN and the DON acknowledged the policy violation.
A facility failed to ensure a resident had a physician order and assessment for self-administering a nasal spray. The resident was observed with the spray on their nightstand and confirmed self-administration. An LPN and the DON acknowledged the absence of required documentation for self-administration.
A facility failed to accurately complete a quarterly MDS assessment for a resident with parkinsonism and a psychotic disorder. Despite a physician's order for Nuplazid, an antipsychotic, and its documented administration, the admission assessment incorrectly noted that the resident had not received antipsychotic medications. This error was confirmed by the MDS Coordinator.
The facility failed to update care plans for two residents to include the use of bed rails, as required by their policies. A resident with a leg fracture and another with hemiplegia had bed rails in use, but their care plans did not document this. The MDS Coordinator confirmed the omission, and the DON acknowledged the presence of bed rails since admission.
A facility failed to follow physician's orders for a resident with chronic respiratory failure and COPD by not changing oxygen tubing and cleaning concentrator filters weekly. Observations revealed outdated tubing and dusty filters, which an LPN confirmed were not maintained as required.
The facility did not post complete nurse staffing information, including actual hours worked and resident census, in a prominent place. Observations on multiple dates revealed that assignment sheets lacked this information, and no RNs were listed. The AIT confirmed the omission of hours and census details.
A facility failed to maintain infection control when a CNA handled wet linens without wearing gloves and carried them down the hall without placing them in a bag, allowing them to touch their clothing. The DON confirmed that wet linens should be bagged and gloves worn when handling soiled linens, as per the facility's infection control policy.
The facility did not update its facility-wide assessment annually as required. The last update was in 2017, and the Administrator confirmed that the assessment had not been revised since then, despite having 101 residents. The process for updating information was acknowledged but not executed.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A resident with severe cognitive impairment, multiple chronic conditions, and a history of behavioral challenges was physically abused by a certified nurse aide (CNA) during care. The resident, who required substantial assistance with transfers and had a BIMS score indicating severe cognitive impairment, was observed to have two red marks on their right leg that were tender to touch. The abuse occurred when the resident became aggressive and resistant to care, leading the CNA to respond by grabbing the resident's face, twisting their head and fingers, pulling their hair, and punching the resident twice in the leg. The incident was witnessed by another CNA, who later reported the abuse to a nurse. The resident was able to recall being hit and having their hair pulled during an assessment, although they could not identify the perpetrator by name but indicated it was a male. Documentation from staff statements and progress notes confirmed the physical abuse, with the nurse and DON both assessing the resident for injuries and noting the presence of red marks and tenderness on the leg. The resident's family was notified of the incident and confirmed that the resident reported being struck by a male staff member. Staff interviews indicated that the resident had not previously complained about staff and that this was the only reported incident of abuse involving the CNA in question. The incident caused the resident to express fear of the CNA involved, and staff also reported feeling afraid of the CNA due to their actions. The facility's abuse policy defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The events leading to the deficiency included the CNA's reaction to the resident's aggressive behavior by inflicting physical harm, the delay in reporting the abuse by the witnessing CNA, and the subsequent identification of physical injuries consistent with the reported abuse. The facility's documentation and staff interviews confirmed that the resident was not protected from abuse as required by policy.
Unsafe Transfer Practices Result in Resident Distress
Penalty
Summary
The facility failed to provide safe transfer procedures for a resident who was unable to bear weight on their lower extremities and required total assistance. During an observed transfer from bed to wheelchair, three CNAs assisted the resident using a loose-fitting gait belt placed around the upper body, while two CNAs lifted the resident under the arms, causing the resident to moan and grimace in pain. The resident's care plan indicated a two-person assist for transfers, but the method used placed undue stress on the resident's arms and shoulders, and the resident was unable to communicate their pain level. Staff interviews revealed that CNAs had reported the resident's decline and the need for a mechanical lift to the charge nurse and hospice staff over the preceding months, expressing concerns for both resident and staff safety. Despite these reports, the care plan and transfer method were not updated to reflect the resident's increased needs. The interdisciplinary team meetings did not document discussion of transfer needs, and there was a lack of timely reassessment and adjustment of the transfer process, even as staff recognized the resident was no longer able to assist in transfers.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices, leading to a deficiency in infection prevention and control. Resident #1, who had diabetes mellitus with peripheral angiopathy and gangrene, was dependent on staff for daily living activities and had a central line for antibiotic administration. Resident #3, diagnosed with cystitis and bacteremia, also relied on staff for daily activities and had an indwelling catheter. Observations revealed that their rooms lacked signage indicating the need for enhanced barrier precautions, and there were no PPE carts nearby. Interviews with staff highlighted a lack of understanding and implementation of enhanced barrier precautions. LPN #1 and LPN #2 were unaware of what enhanced barrier precautions entailed, although they were familiar with standard and isolation precautions. The Director of Nursing (DON) indicated that such precautions were only implemented with a confirmed communicable disease diagnosis. Residents reported that while staff washed hands and wore gloves during care, they did not wear gowns, which are part of enhanced barrier precautions. This oversight was only addressed after it was brought to the facility's attention.
CNA Physically Restrains Resident in Memory Care
Penalty
Summary
The facility failed to prevent a certified nursing assistant (CNA) from physically restraining a resident, which constitutes a deficiency in ensuring residents are free from physical restraints unless needed for medical treatment. The incident involved a resident with Alzheimer's, anxiety, depression, and cognitive communication deficit, who was severely cognitively impaired and had a history of wandering. The deficiency was identified when an incident report documented that, following an allegation of abuse, camera footage showed the CNA grabbing the resident by the arm and shirt to force them into a seated position. The resident, who resided in memory care and was independent with ambulation, did not exhibit any physical harm such as redness, bruising, or swelling upon assessment after the incident. The CNA involved was terminated following the investigation that substantiated the abuse allegation. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property defines abuse as the willful infliction of injury or unreasonable confinement, which was violated in this case.
Immediate Jeopardy Due to Unsafe Shower Room Conditions
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified in a memory care unit due to the facility's failure to ensure the shower room door closed and locked automatically, preventing residents from entering unsupervised. During an initial tour, the shower room was found with a wet and slippery floor, a plugged-in hair dryer placed in the grab bar area, and more than ten bottles of shampoos, conditioners, alcohol-based surface cleaner, and shaving cream covering over half of the shower bench. Additionally, the cabinet in the shower room was unlocked, with razors within reach, and two emergency call lights were looped around grab bars, rendering them unusable for alerting staff for assistance. The Director of Nursing (DON) identified that 28 residents resided on the memory care unit, all potentially affected by these hazards. An LPN confirmed that the shower room door was supposed to be shut and locked, the hair dryer should not have been plugged in, and chemicals should not have been present. The running water was acknowledged as a hazard, and the call lights should not have been wrapped around the grab bar. It was also stated that residents were not to be in the shower room without staff supervision.
Removal Plan
- The shower room door was trimmed to ensure self-closure.
- The hair dryer had been removed from the grab bar and locked in the shower room cabinet. The hair dryers were removed from the locked cabinet and completely removed from the shower room.
- The ten bottles of shampoos, conditioners, alcohol-based surface cleaner and shaving cream were removed from the shower room.
- The cabinet in the shower room was locked.
- All nursing team members in the building were educated, and all remaining team members were educated. Proof of education is attached.
Failure to Prevent Decrease in Range of Motion for Resident's Fractured Finger
Penalty
Summary
The facility failed to prevent a decrease in range of motion for a resident with a fractured finger. The resident, who had diagnoses including parkinsonism and pain, experienced a fall resulting in a fracture of the right ring finger. Despite a physician's order to buddy tape the fingers and a subsequent recommendation for a finger splint and surgical evaluation, there was no documentation that the buddy tape was applied as ordered. The resident reported not receiving therapy for the finger and not seeing an orthopedic surgeon for two months following the injury. Observations confirmed the resident's inability to straighten the ring finger, and the facility did not provide range of motion exercises or physical therapy to address the fracture. The LPN and DON acknowledged the lack of implementation of the buddy tape order and the absence of range of motion or physical therapy interventions. This inaction contributed to the resident's decline in hand functionality, as noted by the LPN, who was unaware of the resident's ability to straighten the finger prior to the fracture.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for residents on psychotropic medications, as required by their policy. The report highlights that four residents were not reviewed for GDR, despite being on multiple psychotropic medications. For instance, Resident #40, diagnosed with dementia and depression, was on escitalopram and trazodone without any documented recommendation for a GDR. The pharmacist stated they were following the resident's wishes, indicating a lack of adherence to the facility's policy. Resident #14, with emotional lability and anxiety, was prescribed multiple medications, including Effexor, Xanax, Seroquel, and lamotrigine. Although the pharmacist suggested a GDR, the resident did not want their medications changed, and the APRN confirmed that no GDR recommendation was made. Similarly, Resident #33, with Alzheimer's disease and dementia, was on several medications, including melatonin, bupropion, Zoloft, risperidone, and Seroquel. Despite experiencing a fall resulting in a fracture, there was no documentation of a GDR review, and subsequent medication reviews did not address the need for GDR. Resident #41, admitted with dementia and behavioral disturbances, was prescribed quetiapine, despite FDA warnings against its use in dementia-related psychosis. The pharmacist deemed it appropriate, but the report notes the increased risk of death associated with such treatment. Overall, the facility's failure to adhere to its policy on GDR and non-pharmacological interventions for psychotropic medications resulted in deficiencies in medication management for these residents.
Failure to Post Breakfast Menu
Penalty
Summary
The facility failed to ensure that the breakfast menu was posted, as required by their policy. The policy, dated January 24, mandates that menus be posted at least one week in advance and in a font size that is easily readable by all residents. On July 12, at 8:31 a.m., it was observed that no breakfast menu was posted. Additionally, on July 16, at 2:08 p.m., the Registered Dietician reported uncertainty about whether the menu was posted. This deficiency affected the facility, which houses 101 residents, as reported by the Director of Nursing (DON).
Failure to Inform Residents of Right to Private Meetings
Penalty
Summary
The facility failed to notify residents of their right to hold resident council meetings without staff presence, which interfered with their ability to organize and participate in such meetings privately. The deficiency was identified through record review and interviews, revealing that the residents were unaware of this right. The facility's policy on Resident Rights: Resident and Family Groups, dated 02/20/24, stated that team members, visitors, and other guests may only attend the meeting upon invitation. However, during an interview on 07/17/24, nine residents in attendance expressed their lack of awareness regarding their right to conduct meetings without staff. Additionally, a social service staff member acknowledged their unawareness of this policy and indicated a need to review it.
Ombudsman Contact Information Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the ombudsman's contact information was accessible and visible to residents, which interfered with their rights to communicate and access the state's ombudsman office. During an interview with nine resident council members, it was revealed that they were unaware of who the ombudsman was, their purpose, or where to find that information. An observation showed that the ombudsman's contact information was posted on an information board by the long-term care halls, but it was written in small print and displayed out of view for residents utilizing a wheelchair. Additionally, there was no information board located on the skilled halls, further limiting access to this important information for residents.
Failure to Distribute Mail on Weekends
Penalty
Summary
The facility failed to provide mail delivery to residents on Saturdays, resulting in a deficiency. On July 17, 2024, at 11:22 a.m., nine members of the resident council reported that mail was not distributed on weekends. At 11:24 a.m., the social services staff confirmed that while mail was delivered on Saturdays, it was not distributed to residents until Monday. This affected the 101 residents residing in the facility, as identified by the Director of Nursing (DON).
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey results were readily accessible and available to residents and visitors. During an observation and interview on July 17, 2024, at 11:28 a.m., nine resident council members stated they did not know where the state inspection book was located. Additionally, at 11:43 a.m., a sign was observed on the information board in the long-term care halls indicating that survey results could be found at the front desk. However, there was no sign or mention of the survey results in the skilled halls.
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 were informed about the grievance official. The grievance policy, dated February 2024, stated that the health center would provide a mechanism for filing grievances without fear of retaliation and would inform residents and their representatives about the grievance process and the designated grievance official. However, during an interview on July 17, 2024, resident council members expressed that they were unaware of how to file a grievance, relying instead on staff to address their issues. Additionally, social services staff were uncertain about the identity of the grievance official, indicating a lack of communication and implementation of the grievance policy.
Delay in Care for Fractured Finger
Penalty
Summary
The facility failed to provide timely care to a resident with a fractured finger. The resident, who had diagnoses including parkinsonism and pain, experienced a fall and complained of pain in their right hand. An x-ray confirmed an acute fracture in the right proximal phalanx of the fourth finger. A physician's order was given for ice pack application four times daily and an orthopedic hand specialist referral was made. However, the resident was not seen by any provider until nearly a month later, and the orthopedic consultation did not occur until over two months after the fall. The delay in care was acknowledged by an LPN, who stated that the appointment was not set up and should have been followed up to prevent the delay. The DON confirmed the delay in care and stated that the interventions during the period included ice packs and Tylenol as needed for pain.
Failure to Document Bed Rail Assessment and Consent
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails for two residents. Resident #4, who had a fracture of the right lower leg and required extensive assistance with transfers, was observed with bed rails in use without any documented assessment, physician's order, or informed consent. Despite the resident using the rails for positioning since January, the necessary documentation was not found, as confirmed by the LPN and the Director of Quality. Similarly, Resident #19, admitted with hemiplegia and hemiparesis and severe cognitive impairment, had been using bed rails since admission without any documented assessment, physician's order, or informed consent. The DON confirmed the absence of these critical documents, indicating a failure in the facility's adherence to its own bed rail policy and procedure.
Deficiencies in Food Storage, Handling, and Sanitization Practices
Penalty
Summary
The facility failed to adhere to its policies regarding food storage, handling, and sanitation, leading to multiple deficiencies. Observations revealed that food items such as tater tots, chicken tenders, and bread were not labeled, dated, or stored according to the facility's policy. Additionally, a bowl of sausages was found uncovered on the counter. The facility's policy required that all food items be covered, labeled, and dated, which was not followed. Furthermore, the temperature of bacon was recorded at 125 degrees Fahrenheit, below the required 135 degrees Fahrenheit for hot food service, indicating improper food handling practices. The facility also failed to ensure proper glove use and sanitization practices. Dietary Aide #2 did not change gloves between tasks, such as cracking eggs and handling silverware, contrary to the facility's policy. Additionally, the dishwasher was found without sanitizer solution, preventing the measurement of parts per million (ppm) and compromising dish cleanliness. The facility's policy required a sanitizer solution concentration of 50-100 ppm sodium hypochlorite. Moreover, there was a failure to document hot food temperatures as required by the facility's guidelines, further indicating lapses in adherence to food safety protocols.
Inaccessible Call Devices in Memory Care Unit
Penalty
Summary
The facility failed to ensure that call devices were accessible to residents in the memory care unit, affecting two residents. One resident, diagnosed with dementia and heart failure, was observed with the call light cord hanging over the head of the bed, making it inaccessible. Another resident, with diastolic heart failure and Alzheimer's disease, was found with call light cords hanging over the foot of an empty bed, also out of reach. A CNA confirmed that the call light cords were not within reach for both residents. The Director of Nursing acknowledged that call devices should be within reach at all times.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote resident dignity by not adhering to its policy regarding meal assistance. A resident with Alzheimer's disease, who was severely cognitively impaired and required supervision or touching assistance with eating, was observed being assisted by an LPN while the LPN was standing. This occurred on two separate occasions during the same meal period. The facility's policy mandates that staff should be seated when assisting residents with meals. The LPN acknowledged standing while assisting the resident and confirmed that this was against the facility's policy. The Director of Nursing also stated that staff should be seated when assisting residents with meals.
Failure to Obtain Physician Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident had a physician order and an assessment to self-administer medications. This deficiency was identified during an observation where a bottle of saline nasal spray was found on the nightstand of a resident, who stated they self-administered the spray at night. Upon review, there was no documentation of a physician's order or an assessment for the resident to self-administer the nasal spray. An LPN confirmed that the resident did not have the necessary physician order or assessment. The Director of Nursing acknowledged that a self-administration evaluation and physician order were required for medications kept at the bedside.
Inaccurate MDS Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately complete a quarterly assessment for a resident, leading to a deficiency in the accurate completion of Minimum Data Set (MDS) assessments. The resident, who was admitted with diagnoses including parkinsonism and a psychotic disorder with hallucinations, had a physician's order to receive 34 mg of Nuplazid, an antipsychotic medication, at bedtime. However, the admission assessment incorrectly documented that the resident had not received antipsychotic medications, despite the February Medication Administration Record (MAR) showing that Nuplazid had been administered daily during the look-back period. This discrepancy was confirmed by the MDS Coordinator, who acknowledged that the admission assessment was not coded correctly.
Care Plan Deficiency: Bed Rail Use Not Documented
Penalty
Summary
The facility failed to ensure that the care plans for two residents were revised to include the use of bed rails, as required by their policies. Resident #4, who had a diagnosis of a fracture of the right lower leg and required assistance with personal care, was observed with two bed rails up on each side of the head of the bed. However, the care plan for Resident #4 did not document the use of these bed rails. MDS Coordinator #2 confirmed that the use of positioning rails was not documented in the care plan, although it should have been. Similarly, Resident #19, who was admitted with diagnoses of hemiplegia and hemiparesis, had bed rails in use since admission. Despite this, the care plan for Resident #19 also failed to document the use of bed rails. The DON acknowledged the presence of bed rails since admission, and MDS Coordinator #2 confirmed the omission in the care plan documentation.
Failure to Maintain Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders regarding the maintenance of oxygen equipment for a resident with chronic respiratory failure and chronic obstructive pulmonary disease. The physician's order, dated April 10, 2024, specified that the nasal cannula should be changed, and the concentrator filters should be cleaned and dried once a week. However, on July 15, 2024, it was observed that the oxygen tubing on the concentrator was last changed on June 24, 2024, and the tubing on the portable tank was last changed on June 3, 2024. Additionally, the concentrator filters had visible dust buildup. An LPN confirmed that the tubing and filters were not changed or cleaned as ordered, despite the facility's policy requiring weekly changes.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information, including the facility name, date, actual hours worked for RNs, LPNs, CMAs, and CNAs, and the resident census, was posted in a prominent place readily accessible to residents and visitors. During a tour of the memory care unit on 07/15/24, it was observed that a plastic note holder outside the nurses' station contained a daily assignment sheet listing staff members for the 7:00 a.m. to 3:00 p.m. shift, but it lacked the resident census and actual hours worked. Additionally, no RNs were listed on the page. Similar observations were made on 07/17/24, where assignment sheets on each unit also lacked the required information. On 07/19/24, the AIT confirmed that the hours worked were not included on the sheets and that the census was not documented, although RNs were present in the building.
Infection Control Breach in Handling Wet Linens
Penalty
Summary
The facility failed to maintain proper infection control procedures while handling wet linens. During an observation, a wet cloth bed pad, a wet blanket, a wet gown, and a clear trash bag were found on the floor in a resident's room. A CNA entered the room and picked up the dirty linens without wearing appropriate personal protective equipment (PPE), specifically gloves, and carried the wet linens down the hall without placing them in a bag, allowing them to touch their clothing. The CNA acknowledged that gloves should have been worn when handling soiled linens. The Director of Nursing (DON) confirmed that wet linens should be placed in a bag and not on the floor, and that gloves are required when picking up soiled linens. The facility's infection control policy and PPE use policy emphasize the importance of using PPE to prevent the spread of infections, particularly when there is potential exposure to blood, bodily fluids, or pathogens.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to ensure that a facility-wide assessment was updated annually, as required. The last documented update of the Facility Assessment Tool was on November 21, 2017, and the review with the Quality Assurance and Performance Improvement (QAA/QAPI) committee was on December 13, 2017. During an interview on July 19, 2024, the Administrator acknowledged that the facility assessment should be updated annually and stated that their process involved changing any information that required updating. However, upon review, it was confirmed that the facility assessment had not been updated since 2017, despite the presence of 101 residents in the facility.
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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