Baptist Village Of Owasso
Inspection history, citations, penalties and survey trends for this long-term care facility in Owasso, Oklahoma.
- Location
- 12600 East 73rd Street North, Owasso, Oklahoma 74055
- CMS Provider Number
- 375382
- Inspections on file
- 22
- Latest survey
- July 16, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Baptist Village Of Owasso during CMS and state inspections, most recent first.
A resident who was dependent on staff for transfers fell from a mechanical lift during a transfer due to a damaged sling that had not been properly inspected, resulting in a head injury and hospitalization. The facility failed to conduct and document required monthly inspections of mechanical lift slings as recommended by the manufacturer, and staff did not identify the damaged sling prior to use.
Three residents were not given accurate CMS-10055 forms regarding the end of their Medicare/Medicaid skilled service coverage. The forms contained incorrect dates, such as admission dates instead of last covered dates, or dates prior to admission, and did not include required cost information. An LPN responsible for the forms was unaware of their correct purpose and completion, and the administrator confirmed the forms were not filled out as required.
A resident diagnosed with dementia without behavioral disturbances was prescribed sertraline, an antidepressant, for dementia. Facility policy required clear documentation of the indication for psychotropic medications, but staff interviews revealed uncertainty about the specific symptoms being treated and whether sertraline was appropriate for dementia. The pharmacist and nurse practitioner confirmed that sertraline is not approved for dementia, and the DON was unsure about its approved uses.
A discharge assessment was not completed for a resident who was discharged, despite the requirement for a discharge MDS. The MDS coordinator confirmed the omission and could not explain why the assessment was not done.
A resident with dementia and a history of falls experienced another fall resulting in injury, but the care plan was not updated to reflect this incident or add new interventions. The LPN responsible for care plan updates was waiting for an incident report, a process that had lapsed after the former DON left, leading to the omission. The DON confirmed this was not in line with facility procedures.
A CNA did not wear a gown while providing catheter care to a resident on Enhanced Barrier Precautions (EBP) with an indwelling urinary catheter, contrary to facility policy. Interviews with the resident, CNA, LPN, and DON confirmed that gowns should be worn during such care, and the resident reported that staff typically did not use gowns.
An Immediate Jeopardy situation occurred when a resident reported being inappropriately touched by another resident in the dining area. The facility failed to implement protective measures, leaving the resident feeling anxious and unsafe. Staff were not adequately instructed on monitoring the involved residents, and the facility's abuse policy was not effectively followed.
The facility failed to ensure that residents did not receive antipsychotic medications without a specific diagnosis condition. Three residents were identified as receiving such medications without appropriate documentation of a psychotic disturbance or mood disorder. The DON and Corporate RN acknowledged the need to consult with the pharmacy consultant, who confirmed that dementia alone was not an appropriate diagnosis for antipsychotic medication use.
The facility failed to complete and submit discharge assessments for two residents who were transferred to the hospital. One resident, with acute and chronic respiratory failure, diabetes type II, and congestive heart failure, expired at the hospital, and their discharge assessment was not completed due to it being an unplanned discharge. Another resident, with malignant neoplasm of the cervix, chronic kidney disease stage III, and type II diabetes, was also discharged to the hospital without a timely discharge assessment, as it was forgotten by the MDS Coordinator.
The facility did not ensure RN certification of resident assessments, affecting four residents. Their electronic clinical records lacked quarterly assessments due to missing RN signatures. One resident's assessment was rejected for a mood miscalculation and required reopening by the RN. The MDS Coordinator confirmed the need for RN signatures and communicated with the RN via email for necessary corrections.
Failure to Inspect and Maintain Mechanical Lift Slings Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and had unimpaired cognition, fell from a mechanical lift during a transfer. The incident happened when the resident was being moved from their bed to a chair using a mechanical lift and sling. During the transfer, the resident slid out of the sling and ended up on the floor with their head on the ground and feet still in the sling. Inspection of the sling used revealed a cut or tear approximately three-quarters of an inch in length on one of the blue loops, which was about half the width of the loop. The remainder of the sling showed no other signs of damage or wear. The resident was subsequently transferred to a hospital, where a CT scan revealed a small subarachnoid hemorrhage, and the resident spent several days in the ICU before returning to the facility. The facility failed to ensure that mechanical lift slings were inspected as recommended by the manufacturer. The operator's manual specified that slings should be inspected monthly by nursing or rehabilitation staff, with permanent records of these inspections maintained. However, interviews revealed that while some staff claimed to have performed inspections, there was no documentation of sling inspections prior to June, and maintenance staff did not inspect the slings, believing it was not required for rented equipment. Additionally, monthly checks on the mechanical lifts were not performed in April or May, and the responsibility for inspecting slings was not clearly assigned or documented. Staff involved in the transfer reported that they did not notice the broken loop prior to use, and the resident was wearing slick pajamas at the time, which may have contributed to the fall. The sling was removed from service after the incident. The facility's policy required that all necessary equipment be in working order, but the lack of documented inspections and failure to identify the damaged sling before use directly contributed to the resident's fall and subsequent injury.
Failure to Provide Accurate CMS-10055 Beneficiary Notices
Penalty
Summary
The facility failed to provide residents with accurate and complete CMS-10055 forms, which are required to notify residents of the end of Medicare/Medicaid coverage for skilled services and their potential financial liability for services not covered. For three sampled residents, the forms either listed the admission date instead of the last covered date, provided a date prior to admission, or omitted the cost of continued skilled services. These errors were identified through record review, which showed discrepancies between the dates on the forms and the residents' actual admission and service end dates, as well as missing cost information. Interviews with staff revealed a lack of understanding regarding the purpose and correct completion of the CMS-10055 form. An LPN responsible for reviewing the forms with residents admitted to incorrectly entering admission dates and omitting required cost information. The administrator confirmed that the form should indicate the last covered date and inform residents of the costs and options for continuing services after coverage ends, but this was not done correctly for the sampled residents.
Unnecessary Psychotropic Medication Prescribed for Dementia
Penalty
Summary
A resident with a diagnosis of dementia without behavioral disturbances was prescribed sertraline, a psychotropic medication approved for the treatment of depression, according to a physician's order. The medication administration record showed that the resident received sertraline 25 mg daily for 25 consecutive days. The facility's policy required that the indication for any psychotropic medication be thoroughly documented in the clinical record, including an appropriate supporting diagnosis and identification of behavioral symptoms being treated. However, the documentation indicated that sertraline was prescribed for dementia, and staff interviews revealed uncertainty regarding the specific symptoms being treated and whether sertraline was appropriate for dementia. The contracted pharmacist confirmed that sertraline is not approved for the treatment of dementia and stated an effort was being made to avoid psychotropic use in residents with dementia. The LPN interviewed was unable to specify the symptom for which the medication was prescribed and was unaware of its approval status for dementia. The nurse practitioner acknowledged that the resident was taking an antidepressant for dementia, which is not an approved use, but also noted the resident had signs of depression and was seeing a behavioral health group. The DON was also unsure if antidepressants or psychotropic medications were approved for dementia treatment.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a discharge assessment was completed for one of five sampled residents reviewed for assessments. Record review showed that the resident was discharged on 02/22/25 and had a history of sepsis and anemia. However, there was no documentation of a discharge Minimum Data Set (MDS) in the resident's health record. During an interview, the MDS coordinator confirmed that a discharge MDS had not been completed at the time of the resident's discharge and was unable to provide a reason for this omission.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update a comprehensive care plan for a resident after a fall that resulted in injury. According to the facility's policy, care plans must be updated with significant changes in a resident's condition, such as a fall. Record review showed that the resident had a history of falls, with the last documented fall and related interventions in the care plan occurring in January 2025. However, the resident experienced another fall in April 2025, which was witnessed by staff and resulted in the resident striking their left hip and shoulder. Despite this incident, the care plan was not updated to reflect the new fall or to include new goals or interventions for fall prevention. Interviews with staff revealed that the LPN responsible for updating care plans had been waiting for an incident report to provide new interventions, a process that had previously been managed by the former DON. Since the departure of the former DON, the system for communicating incident reports and interventions had lapsed, resulting in the April fall not being incorporated into the resident's care plan. The DON confirmed that the failure to update the care plan after the fall was contrary to facility procedures.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to wear a gown while providing catheter care to a resident who was on Enhanced Barrier Precautions (EBP) due to the presence of an indwelling urinary catheter. The facility's policy required staff to use gowns and gloves during high-contact care activities for residents with indwelling medical devices, regardless of multidrug-resistant organism (MDRO) status. Observations confirmed that the CNA did not wear a gown during catheter care, and interviews with the resident, CNA, LPN, and Director of Nursing (DON) all acknowledged that a gown should have been worn. The resident, who had moderate cognitive impairment and an indwelling urinary catheter, also reported that staff usually did not wear gowns during care.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
An Immediate Jeopardy situation was identified at a facility due to the failure to protect a resident from sexual abuse. The incident involved a resident who reported being inappropriately touched by another resident in the dining area. Despite the report, the facility did not implement measures to ensure the ongoing protection of the affected resident or other residents, leading to the resident feeling anxious and unsafe. The affected resident had a history of anxiety and dementia, with a moderately impaired cognitive status. The resident reported the inappropriate touching to a staff member, but the facility's response was inadequate, as they failed to separate the residents or monitor the situation effectively. The staff, including LPNs and CNAs, were not given clear instructions regarding the monitoring of the involved residents, and they were unaware of the whereabouts of the resident who committed the inappropriate act. The facility's abuse policy required immediate removal of the perpetrator from the situation, but this was not effectively implemented. The Director of Nursing acknowledged the incident as abuse and admitted that continued monitoring should have been ensured. The administrator also recognized that the facility had not taken all necessary actions to address the abuse, highlighting a significant lapse in the facility's duty to protect its residents.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents did not receive antipsychotic medications without a specific diagnosis condition. Three residents were identified as receiving such medications without appropriate documentation of a psychotic disturbance or mood disorder. Resident #37 was prescribed Risperdal for unspecified dementia without any documented diagnosis of psychotic or mood disturbances. Similarly, Resident #55 was given Quetiapine for unspecified dementia, with no documentation of psychotic disturbance, mood disorder, or depression in their health record. Resident #43 was also prescribed Quetiapine for unspecified dementia without any documented diagnosis of psychotic or mood disturbances. The Director of Nursing (DON) and Corporate RN acknowledged the need to consult with the pharmacy consultant to verify if dementia was an appropriate diagnosis for antipsychotic medication use. The pharmacy consultant confirmed that dementia alone was not an appropriate diagnosis for the use of antipsychotic medications.
Failure to Complete and Submit Discharge Assessments
Penalty
Summary
The facility failed to ensure that resident assessments for discharge were completed and submitted to CMS for two residents who were reviewed for resident assessments. Resident #68, who was admitted with acute and chronic respiratory failure, diabetes type II, and congestive heart failure, was transferred to the hospital and expired there. A review of the assessment log revealed that a discharge assessment had not been completed or submitted for this resident. MDS Coordinator #1 acknowledged that the discharge assessment was missing because it was an unplanned discharge and was not noted on their calendar. Similarly, Resident #63, admitted with malignant neoplasm of the cervix, chronic kidney disease stage III, and type II diabetes, was discharged to the hospital. The assessment log showed that a discharge assessment for this resident was also not completed or submitted in a timely manner. MDS Coordinator #1 admitted to forgetting to enter the discharge assessment into the system due to the unplanned nature of the hospital discharge.
Failure to Ensure RN Certification of Resident Assessments
Penalty
Summary
The facility failed to ensure proper coordination and certification of resident assessments for four out of eleven sampled residents. Specifically, the electronic clinical records for these residents were missing quarterly assessments due to the absence of a required RN signature. One resident's assessment was rejected due to a mood miscalculation and needed to be reopened by the RN for correction. The MDS Coordinator acknowledged that the quarterly assessments required an RN's signature before submission and mentioned sending emails to the RN for signatures and when assessments needed reopening for corrections.
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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