Beacon Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Sapulpa, Oklahoma.
- Location
- 102 East Line Avenue, Sapulpa, Oklahoma 74066
- CMS Provider Number
- 375572
- Inspections on file
- 21
- Latest survey
- January 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Beacon Ridge during CMS and state inspections, most recent first.
A facility failed to provide a resident with a 30-day written notice of transfer or discharge, as well as necessary documentation and information about appeal rights. The resident, with multiple diagnoses, was transferred to a hospital without receiving proper notice or assistance in appealing the decision. The facility did not adhere to its policies, resulting in a lack of communication with the resident, their representative, and the ombudsman's office.
A resident with multiple diagnoses was transferred to a hospital without receiving the required bed-hold policy documentation. The resident, who expressed a desire to leave the facility and refused treatment, was aggressive towards staff. The facility failed to document any interventions or referrals to address the resident's behavior. Upon the resident's return, the facility refused to accept them, leaving them in cold weather without proper documentation or notification to relevant parties.
A resident with multiple diagnoses was not allowed to return to the facility after hospitalization due to aggressive behavior and refusal of care. The facility failed to provide necessary documentation for the resident to appeal the discharge decision and did not notify the required parties. The LPN did not provide the resident with transfer forms, and the social service director was unaware of their documentation responsibilities.
The facility did not ensure that three residents were offered the right to formulate an advance directive, as their medical records lacked the necessary documentation. This issue was confirmed by the corporate nurse, who stated that the forms were not completed.
The facility did not conduct a thorough investigation after an abuse allegation, as required by their policy. An incident was reported, but lacked documentation of an investigation. The administrator acknowledged the need for personal statements and safe surveys, but could not find any investigation records.
The facility failed to complete quarterly MDS assessments on time for three residents. The assessments were not completed within the required 14 days after the ARD, with delays ranging from several days to over a month. The MDS coordinator noted that the facility had been without an MDS coordinator for about five months, contributing to the issue.
The facility failed to develop comprehensive care plans for residents, resulting in deficiencies in addressing medical needs. A resident with diabetes and atrial fibrillation lacked care plans for diabetic monitoring and anticoagulant therapy. Another resident's care plan did not document ADLs. A resident with a new pressure ulcer had no care plan for it, and a resident with psychosis had no care plan for their diagnosis or antipsychotic medication. These omissions were acknowledged by the corporate nurse.
The facility failed to conduct entrapment risk assessments and obtain informed consent for bed rail use for several residents. Observations revealed that residents were using bed rails without proper documentation, including physician orders and care plan entries. Interviews with staff indicated a lack of awareness of the facility's policy on bed rail use.
A significant medication error occurred when a resident with adrenocortical insufficiency and hypothyroidism was administered an incorrect dosage of fludrocortisone. The resident was prescribed 0.5mg daily (5 tablets of 0.1mg each), but only one tablet was given daily over multiple administrations. This error was confirmed by the corporate nurse and pharmacy technician, highlighting a failure to follow physician's orders.
The facility failed to store food according to professional standards, with several open bottles of thickened liquids past their discard dates or not dated. The walk-in freezer had significant ice accumulation, indicating improper storage. Additionally, the dish machine failed to sanitize dishes, as shown by multiple tests with no chlorine reaction. The DM acknowledged these issues, affecting the safety and quality of food services for 57 residents.
The facility did not maintain a water management program to prevent Legionella growth, as required by their policy. The maintenance supervisor was unaware of the program and had not monitored the water system, and the corporate nurse confirmed the absence of such a program.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, posing potential safety hazards for residents with conditions like morbid obesity and muscle weakness. Despite a policy requiring routine maintenance, the facility lacked documentation of inspections, as confirmed by the DON.
The facility did not report an abuse allegation involving an LPN to OSDH within the required two-hour timeframe, as per their policy. The incident was documented, but the report was delayed by a day. The MDS coordinator acknowledged the failure to meet the reporting deadline.
The facility failed to complete comprehensive MDS assessments within the required time frame for two residents. A significant change MDS for a resident was delayed by over a month, and another resident's admission assessment was not completed timely. The MDS coordinator acknowledged the facility had been without an MDS coordinator for about five months, contributing to the issue.
A facility failed to develop a baseline care plan within 48 hours of a resident's admission, as required. The MDS coordinator admitted that the facility had been without an MDS coordinator for about five months, resulting in issues with care plans.
A resident with chronic kidney disease, hypertension, and chronic pain syndrome had a care plan that was not updated to include the use of a Hoyer lift for transfers and the presence of an indwelling catheter. Despite a physician's order and a significant change assessment, the care plan remained unchanged, as observed during a survey. A corporate nurse confirmed the care plan should have been revised.
A facility failed to obtain a physician's order for a catheter for a resident with chronic kidney disease, hypertension, and chronic pain syndrome. The resident was observed with a catheter draining to gravity, but their record lacked a physician's order and the care plan did not document the catheter. The corporate nurse acknowledged the need for a physician's order and a care plan.
A facility failed to maintain a medication error rate below 5%, with two errors identified during a medication pass. A resident received incorrect doses of fludrocortisone and vitamin D3, as confirmed by staff interviews and pharmacy verification. The errors resulted in a medication error rate of 6.67%.
The facility did not ensure the QAA committee met quarterly, with the last meeting documented in February 2024. A meeting was missed in August 2024 due to the absence of a DON and staff shortages. The interim administrator confirmed the lack of documentation for the required meetings.
The facility failed to conduct and document a facility-wide assessment necessary to care for 56 residents competently during both day-to-day operations and emergencies. The BOM and the stand-in administrator were unable to provide a facility assessment and were unsure of its requirements.
The facility failed to implement its infection control program effectively during an influenza outbreak, leading to the spread of the virus among residents and staff. Observations revealed inconsistent mask usage, lack of available masks and alcohol gel, and failure to notify the OSDH. Several residents with respiratory symptoms were not placed under droplet precautions, and staff were not adequately trained on precautionary measures. Infection control logs and tracking maps were also found to be blank.
A resident admitted with dental caries and other diagnoses did not have a comprehensive care plan developed for their dental status, including necessary teeth extractions. The DON confirmed the care plan was not completed as required.
The facility failed to maintain complete and accurate medical records for a resident, including documentation of medical appointments, dental extractions, and follow-up care, as confirmed by the DON.
Failure to Provide Proper Transfer/Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a 30-day written notice of transfer or discharge to a resident and their representative, as well as to the ombudsman's office. The resident, who had diagnoses including fetal alcohol syndrome, schizophrenia, intellectual disabilities, and bipolar disorder, was transferred to a hospital without receiving the necessary documentation or information about their rights to appeal the transfer. The facility's policy required that such notices be given in advance, but this was not adhered to in the case of the resident. The resident was initially admitted to the facility from another nursing home and was noted to be pleasant and oriented. However, the resident later expressed a desire to leave the facility and refused treatment, which led to aggressive behavior towards staff. Despite these circumstances, the facility did not provide the resident with the required documentation or assistance in appealing the transfer decision. The facility also failed to contact relevant agencies or make referrals for the resident's intellectual disabilities. Additionally, the facility did not provide the resident with information on how to obtain an appeal form or assist them in completing and submitting an appeal hearing request. The facility's failure to follow its own policies and procedures resulted in a lack of proper documentation and communication with the resident, their representative, and the ombudsman's office. This oversight was further compounded by the facility's inability to provide evidence of any interventions or referrals made to support the resident's care and cooperation.
Failure to Provide Bed-Hold Policy and Proper Discharge Documentation
Penalty
Summary
The facility failed to provide the bed-hold policy to a resident who was transferred to the hospital. The facility's policy requires that all residents or their representatives receive written information about the bed-hold policy at least twice: once in advance of any transfer and again at the time of transfer. However, in the case of the resident in question, there was no documentation that the resident or their representative received this information. The resident, who had diagnoses including fetal alcohol syndrome, schizophrenia, intellectual disabilities, and bipolar disorder, was transferred to a hospital without receiving the necessary paperwork. The resident was admitted to the facility from another nursing home and was noted to be pleasant and alert. However, the resident later expressed a desire to leave the facility and refused treatment, becoming aggressive towards staff. The facility's staff documented incidents of the resident being a danger to themselves and others, including physical and sexual aggression. Despite these issues, there was no documentation of any interventions or referrals made to address the resident's behavior or to assist with their transfer to a more suitable care setting. When the resident was transported back to the facility by an ambulance service, the facility staff refused to accept the resident, leaving them lightly clothed and strapped to a gurney in cold weather. The ambulance service director reported that neither they nor the resident were informed of the reasons for the facility's refusal to accept the resident back, nor were they provided with any paperwork. The facility also failed to notify the resident's representative, the ombudsman, or the State LTC office about the discharge, as required by policy.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating their own transfer and discharge policy. The resident, who had diagnoses including fetal alcohol syndrome, schizophrenia, intellectual disabilities, and bipolar disorder, was transferred to a hospital due to aggressive behavior and refusal of care. The facility's policy states that residents sent to acute care settings are expected to return unless a discharge is initiated based on the resident's status upon seeking return. However, the facility did not permit the resident's return, citing the resident's behavior as a danger to staff and themselves. The facility did not provide the resident with the necessary documentation to appeal the discharge decision, nor did they notify the resident, their representative, the ombudsman, or the State LTC office as required. The facility's administrator admitted that there was no documentation in the resident's clinical record to show that the facility followed its policies regarding the appeal process and notification requirements. Additionally, the social service director and administrator did not contact the local company that provides services for individuals with intellectual disabilities, nor did they reach out to DHS for assistance. The LPN responsible for the transfer packet stated that the resident did not receive a copy of the transfer forms, and the social service director, who was new to the position, was unaware of their responsibilities in documenting the resident's clinical records. The facility's failure to adhere to its policies and procedures regarding resident transfers and discharges resulted in the resident not being allowed to return to the facility, and the necessary appeal process was not facilitated.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to ensure that residents were offered the right to formulate an advance directive, as evidenced by the absence of such documentation for three of the six sampled residents. Specifically, the medical records for residents #107, #32, and #7 did not contain an advance directive or an acknowledgment form indicating that the residents had been offered the opportunity to create one. This deficiency was identified during a review of the residents' medical records and confirmed through an interview with the corporate nurse, who acknowledged that the forms were not completed.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse, as required by their Abuse, Neglect, and Exploitation policy. This policy mandates an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation, including identifying and interviewing all involved parties and providing complete documentation. An incident reported on 10/04/24 documented an allegation of abuse, but the report to the OSDH lacked supplemental documentation of an investigation. On 11/19/24, the administrator acknowledged responsibility for abuse investigations and stated that the investigation should include personal statements and safe surveys, as well as statements from those making the allegations. However, they were unable to locate any documentation of an investigation for the incident in question.
Delayed Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments in a timely manner for three residents. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, quarterly assessments must be completed no later than 14 calendar days after the Assessment Reference Date (ARD). However, for one resident, the assessment with an ARD of October 15, 2024, was not completed until November 18, 2024. Similarly, another resident's assessment with the same ARD was also completed on November 18, 2024. A third resident had an ARD of October 14, 2024, but the assessment was not completed until November 12, 2024. The MDS coordinator acknowledged the issue, stating that the facility had been without an MDS coordinator for about five months, which contributed to the delay in completing the MDS assessments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. One resident with type II diabetes mellitus and atrial fibrillation did not have documented care plans for diabetic monitoring or anticoagulant therapy, despite having physician orders for insulin and anticoagulant medications. Another resident with shortness of breath, weakness, and chronic kidney disease lacked documentation of activities of daily living (ADLs) in their care plan, which was confirmed by the MDS coordinator. Additionally, a resident with chronic kidney disease, hypertension, and chronic pain syndrome developed a new pressure ulcer, but no care plan was created to address this condition. Furthermore, a resident with an unspecified psychosis diagnosis was prescribed Risperdal, an antipsychotic medication, yet their care plan did not document the psychosis diagnosis or the antipsychotic medication therapy. These omissions were acknowledged by the corporate nurse, indicating a failure to ensure that care plans were comprehensive and reflective of the residents' medical needs.
Failure to Conduct Bed Rail Assessments and Obtain Consent
Penalty
Summary
The facility failed to perform necessary assessments and obtain required documentation for the use of bed rails for several residents. Specifically, the facility did not conduct entrapment risk assessments for four residents, nor did it obtain informed consent for the use of bed rails for these individuals. Additionally, a physician order was not obtained for one resident, and care plans did not include documentation of bed rail use for two residents. These omissions were identified through observations, record reviews, and interviews. Resident #3, who was admitted with diagnoses including morbid obesity and reduced mobility, was observed using bilateral Halo bed rails without documentation of an entrapment risk assessment, informed consent, or a physician order. Similarly, Resident #5, admitted with weakness and insomnia, had a physician order for bed rails but lacked informed consent documentation. Resident #44, with muscle weakness and reduced mobility, had not had an entrapment risk assessment since June 2022 and also lacked informed consent documentation. Resident #14, with muscle weakness and cerebral infarction, was observed with bed rails but had no documentation of an entrapment risk assessment or informed consent. Interviews with facility staff, including an LPN and the DON, revealed a lack of awareness and adherence to the facility's policy regarding bed rail use. The DON acknowledged that a physician order, entrapment risk assessment, and informed consent should have been completed prior to the use of bed rails for all residents. The DON also stated that entrapment risk assessments should be conducted quarterly and documented in the residents' care plans.
Significant Medication Error Due to Incorrect Dosage Administration
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident with diagnoses of adrenocortical insufficiency and hypothyroidism. The resident was prescribed fludrocortisone, a corticosteroid, at a dosage of 0.5mg (5 tablets of 0.1mg each) to be taken daily. However, the medication administration records revealed that only one tablet was administered daily instead of the prescribed five tablets. This error persisted over multiple administrations, as evidenced by the remaining 71 tablets from a prescription filled for 150 tablets on 09/04/24, indicating that only 79 tablets had been administered over 79 days. The error was identified when CMA #1, responsible for administering the medication, admitted to giving only one tablet during the morning medication pass, unaware of the correct dosage noted on the blister pack. The corporate nurse confirmed that the prescription should have lasted 30 days if administered correctly, acknowledging the significant medication error. The pharmacy technician verified the last refill of the medication, further supporting the discrepancy in administration. This oversight in medication administration was not in accordance with the physician's orders, leading to a significant medication error for the resident.
Deficiencies in Food Storage and Dish Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitation, as observed during an initial tour of the kitchen. Several open bottles of thickened liquids, including nectar thickened water with lemon, nectar thickened orange juice, and honey thickened milk, were found to be past their discard dates or not dated at all. Additionally, the walk-in freezer exhibited significant ice accumulation, with ice on the outside of the door seal, icicles hanging above the door frame, and ice on the floor and back wall. These conditions indicate improper storage and potential safety hazards for food items. Furthermore, the dish machine was found to be ineffective in sanitizing dishes, as evidenced by multiple tests showing no reaction on chlorine strips. The Dietary Manager (DM) confirmed that the dish machine was tested daily, yet it failed to sanitize properly during the survey. The DM acknowledged the issue and mentioned that they would need to use paper products and contact the dish machine service provider. These deficiencies in food storage and dish sanitation could impact the safety and quality of food services provided to the 57 residents receiving services from the kitchen.
Failure to Maintain Legionella Water Management Program
Penalty
Summary
The facility failed to maintain a water management program aimed at preventing the growth of Legionella and other opportunistic waterborne pathogens in the building's water system. The Legionella Water Management policy, revised in September 2022, outlined the need for an interdisciplinary water management team, a detailed description and diagram of the water system, identification of areas prone to Legionella growth, and specific measures to control its spread. However, no documentation of such a program was found during the record review. The maintenance supervisor was unaware of the water management program and had not monitored the water system for Legionella as per the policy, indicating a lack of education on this task. Additionally, the corporate nurse confirmed that the facility had not maintained a water management program.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for residents. This deficiency was identified through observations, record reviews, and interviews, affecting four residents who were reviewed for accident hazards. The facility's policy on the proper use of bed rails mandates correct installation, use, and maintenance, including routine preventative maintenance to ensure safety standards are met. However, the facility was unable to provide documentation of regular inspections and maintenance for the bed rails used by the residents. The deficiency involved residents with various medical conditions, including morbid obesity, muscle weakness, reduced mobility, and cerebral infarction. These residents required assistance with bed mobility and used bed rails for positioning and turning. Despite the presence of bed rails, the facility did not adhere to its policy of ensuring compatibility and safety through regular inspections. The Director of Nursing (DON) confirmed the lack of documentation for these inspections, highlighting a lapse in the facility's maintenance program for bed safety equipment.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe. According to the facility's Abuse, Neglect, and Exploitation policy, all allegations of abuse must be reported immediately, but no later than two hours after the allegation is made. An incident report dated October 16, 2024, documented an allegation of abuse involving an LPN. However, the incident report was not sent to OSDH until October 17, 2024, exceeding the mandated reporting period. On November 19, 2024, the MDS coordinator confirmed that the incident report should have been sent within two hours but was not.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for two residents. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a significant change MDS must be completed no later than the 14th calendar day after determining a significant change has occurred, and an admission assessment must be completed no later than the 14th day of the resident's admission. Resident #15 had a significant change assessment with an Assessment Reference Date (ARD) of October 16, 2024, but the MDS was not completed and signed until November 18, 2024. Resident #109 was admitted to the facility, but a comprehensive MDS was not completed until November 18, 2024. The MDS coordinator acknowledged that the facility had been without an MDS coordinator for about five months, which contributed to the issue with the completion of MDS assessments.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which is a requirement for ensuring immediate needs are met. The resident was admitted to the facility, but as of a specified date, there was no active care plan documented in their chart. The MDS coordinator acknowledged that baseline care plans should be completed within 48 hours of admission and noted that the facility had been without an MDS coordinator for about five months, leading to issues with care plans.
Failure to Revise Care Plan for Resident with New Transfer and Catheter Needs
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was admitted with chronic kidney disease, hypertension, and chronic pain syndrome. A significant change assessment noted the resident was frequently incontinent of bladder and required partial to moderate assistance with transfers, but did not document the presence of an indwelling catheter. A physician's order later specified the use of a Hoyer lift for all transfers. However, the care plan was not updated to reflect the use of the lift or the presence of the catheter. This deficiency was identified during an observation where the resident was seen with a catheter draining to gravity at bedside, and confirmed by a corporate nurse who acknowledged the care plan should have been revised accordingly.
Failure to Obtain Physician's Order for Catheter
Penalty
Summary
The facility failed to obtain a physician's order for a catheter for a resident who was admitted with chronic kidney disease, hypertension, and chronic pain syndrome. During an observation, the resident was seen resting in bed with a catheter draining to gravity at the bedside. Upon reviewing the resident's record, it was found that there was no physician's order for the catheter, and the resident's care plan did not document the presence of the catheter. The corporate nurse confirmed that a physician's order should have been obtained and a care plan for the catheter should have been developed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by observations during a medication pass. Out of 30 medication administration opportunities, two errors were identified, resulting in a medication error rate of 6.67%. The errors involved incorrect doses of medication given to a resident. Specifically, the resident was prescribed fludrocortisone 0.1mg tablets, with a dosage of 0.5mg (5 tablets) daily, and vitamin D3 25mg daily. However, during the medication pass, the resident received only one tablet of fludrocortisone and a vitamin D3 dose of 1,000 IU, which was not equivalent to the prescribed 25mg. The errors were confirmed through interviews with the staff involved. CMA #1, who administered the medications, acknowledged administering only one tablet of fludrocortisone and was unaware of the correct dosage. Additionally, CMA #1 was uncertain about the vitamin D3 dosage equivalence. LPN #1 verified the errors after consulting with the pharmacy and reviewing the resident's medication orders. The corporate nurse was informed of these observations and acknowledged the occurrence of the two medication errors.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly, as required. The last documented QAA meeting occurred in February 2024. A form dated August 22, 2024, indicated that a meeting was not held in August 2024 due to the absence of a Director of Nursing (DON) and staff shortages. On November 21, 2024, the interim administrator confirmed that quarterly QAA meetings should have been conducted and acknowledged that documentation for these meetings could not be found.
Failure to Conduct and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment necessary to care for residents competently during both day-to-day operations and emergencies. The BOM identified that 56 residents resided in the facility. On multiple occasions, the BOM and the stand-in administrator were unable to provide a facility assessment. Initially, the BOM was unsure what a facility assessment was and referred to the stand-in administrator. The stand-in administrator presented an emergency preparedness book, which was not a facility assessment. Despite being informed of the required components of a facility assessment, the stand-in administrator admitted to never having seen one in any of their buildings and was unable to locate it.
Failure to Implement Infection Control Program During Influenza Outbreak
Penalty
Summary
The facility failed to implement its infection control program effectively to prevent the spread of influenza. Observations revealed that staff members were not consistently wearing masks, and there were no masks or alcohol gel available at the facility's entry. Additionally, the facility did not notify the Oklahoma State Department of Health (OSDH) when residents and staff tested positive for influenza. The facility also lacked a surveillance plan for identifying, tracking, monitoring, and reporting signs and symptoms of influenza among residents and staff. This failure affected six of the seven residents sampled for infection control, as well as several staff members who were out sick with the flu. Resident #1, who had diagnoses including influenza type A, COPD, and obstructive sleep apnea, exhibited respiratory symptoms and was later diagnosed with influenza A. Despite this, droplet precautions were not implemented, and staff were not in-serviced on precautionary measures. Similar issues were observed with other residents, such as Resident #4, who had respiratory infection symptoms and was not placed under droplet precautions. The facility also failed to isolate residents with respiratory symptoms from other residents, including during smoking breaks. The facility's infection control logs and tracking maps for October, November, and December 2023, and January 2024 were found to be blank, indicating a lack of proper documentation and monitoring of infections. Staff members, including CNAs and LPNs, confirmed that they had not been in-serviced on how to implement precautionary measures to reduce influenza symptoms, when to isolate residents, and the type of isolation required. This lack of training and implementation of infection control measures contributed to the spread of influenza within the facility.
Failure to Develop Comprehensive Dental Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident's dental status. The resident, who was admitted with diagnoses including diabetes, dental caries, and hypertension, had an admission assessment indicating obvious or likely cavities or broken natural teeth. Despite this, no comprehensive care plan was created or implemented to address the resident's dental issues, including the need for upper and lower teeth extractions. The Director of Nursing confirmed that a comprehensive care plan had not been completed but should have been.
Incomplete Resident Records
Penalty
Summary
The facility failed to ensure resident records were complete for one of three residents whose records were reviewed. Resident #10, who was admitted with diagnoses including diabetes, dental caries, hypertension, right shoulder pain, and atrial fibrillation, had multiple instances of incomplete documentation. Specifically, there was no documentation of the resident's attendance at orthopedic appointments on two separate occasions, nor was there any record of the resident's condition upon return to the facility or any physician orders that may have been given. Additionally, there was no documentation of the resident undergoing upper and lower teeth extractions, nor any follow-up observations or aftercare provided post-extraction. The Director of Nursing (DON) confirmed that the facility's policy requires nurses to document any significant changes in a resident's condition for at least 72 hours, as well as to document when a resident leaves and returns to the facility and any physician orders given. However, this documentation was not completed for Resident #10, as confirmed by the DON. The lack of proper documentation indicates a failure to maintain complete and accurate medical records in accordance with accepted professional standards.
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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