Brentwood Extended Care & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskogee, Oklahoma.
- Location
- 841 North 38th Street, Muskogee, Oklahoma 74401
- CMS Provider Number
- 375174
- Inspections on file
- 28
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Brentwood Extended Care & Rehab during CMS and state inspections, most recent first.
The facility did not submit required PBJ staffing data to CMS for a full quarter when 55 residents were present, due to the departure of the employee responsible for the submission and the lack of another staff member able to complete the task.
A facility administrator, who was new and untrained in abuse investigation procedures, failed to properly investigate an allegation of physical abuse involving a resident with intact cognition. The administrator did not conduct required interviews, failed to restrict the accused staff member's contact with the resident, and did not notify authorities within mandated timeframes, resulting in a deficient investigation.
A resident with intact cognition reported being slapped by a staff member, but the facility did not notify OSDH within the required timeframe and failed to contact law enforcement. The administrator stated these actions were not taken due to lack of training and awareness of reporting requirements.
A resident with intact cognition reported being slapped by a staff member, but the facility did not conduct timely interviews with staff or other residents as part of its abuse investigation. The administrator, who was new and untrained in the process at the time, acknowledged the investigation was incomplete.
A resident who was severely cognitively impaired and dependent on staff for bathing did not receive scheduled baths as required by facility policy. Over a three-month period, only six baths were documented, with multiple scheduled bath days lacking any record of completion or refusal. Staff interviews confirmed that all baths and refusals should be documented, but no additional records could be found to verify care was provided.
A facility failed to notify the legal representatives of three residents about inappropriate sexual behavior involving a resident with PVD and hypertension. Incident reports documented the behavior, but clinical records lacked family notification. The facility's policy required family notification, but an LPN did not find it necessary.
A resident with a history of CVA and PVD, dependent on staff for transfers, reported being handled roughly by staff, resulting in a red area and pain in the right upper arm. The resident also reported verbal abuse. An investigation revealed improper use of a mechanical lift by a CNA, leading to significant bruising. The CNA was terminated, and another was suspended.
A facility failed to submit the results of an abuse investigation to the SSA within the required timeframe. A resident with PVD and Diabetes Mellitus type two was reported for inappropriate behavior, and while an initial report was made, the final results were not submitted. The administrator admitted the oversight, believing the DON had completed the task.
The facility failed to assess two residents after an allegation of inappropriate sexual behavior by a resident. Despite the facility's policy requiring assessments, there was no documentation in the clinical records of the affected residents, who had conditions such as anxiety, depression, and dementia. Staff interviews confirmed the lack of assessments.
An IJ situation was identified due to the facility's failure to protect residents from falls resulting in major injuries. One resident fell twice, resulting in a broken neck, and another resident fell twice, resulting in a broken back. The facility did not document or implement required fall prevention interventions.
The facility failed to maintain a safe and clean environment, with issues including missing and cracked tiles, unrepaired damage in a resident's room, and leaking washing machines in the laundry room. Maintenance staff were unaware of these issues due to a lack of logged maintenance requests.
The facility failed to ensure that quarterly resident assessments were completed within 14 days of the assessment reference date for two residents. One resident's assessment was delayed by nearly a month, and another's by over a month. The administrator confirmed the assessments should have been timely but could not explain the delays.
The facility failed to document mental health diagnoses in the PASARR for two residents with major depressive disorder, anxiety, and delusional disorders. The administrator confirmed that these diagnoses should have been documented and OHCA notified.
The facility failed to ensure that baths were given as scheduled for two residents and that assistance with eating was provided for one resident. One resident did not receive documented showers for nearly a month, and another resident went one to two weeks without a shower. Additionally, a resident with hemiplegia and hemiparesis was observed eating with their hands in a dark dining room without staff assistance or supervision.
A resident with COPD and chronic pain did not receive prescribed pain medication and nebulizer treatments due to a mix-up in medication delivery and lack of coordination with hospice. Staff confirmed the absence of necessary medications, and the resident reported missing treatments since admission.
A resident with chronic pain and opioid dependence did not receive their prescribed pain medication for five doses due to a delay in receiving the medication from the pharmacy. The resident experienced severe pain and was unable to perform usual activities. The facility's policy to reorder medication in advance was not followed.
The facility failed to administer insulin and blood pressure medication per physician's orders for two residents, leading to significant medication errors. One resident received insulin despite low blood sugar levels, and another was prepared to receive Metoprolol despite a low diastolic blood pressure reading. Staff admitted to not following prescribed guidelines.
The facility failed to ensure proper infection control measures, including disinfecting a blood pressure machine between residents, preventing soiled linens from being placed on the floor, and correctly storing a nebulizer mouthpiece. Additionally, the facility lacked an infection surveillance system and a water Legionella prevention program.
The facility failed to implement a system to assess residents for infections using standardized tools before initiating antibiotics. Despite having a policy and new assessment forms, the facility had not tracked antibiotic use since December 2023, and it was unclear if the tools were used for residents administered antibiotics in early 2024.
The facility failed to provide a SNF ABN to a resident who was discharged from skilled services but remained in the facility. The MDS Coordinator confirmed that the resident was not given the required ABN form.
The facility failed to complete a significant change resident assessment within the required 14-day timeframe. The assessment, dated October 19, 2023, was not signed until November 9, 2023. The administrator acknowledged the delay but could not provide an explanation.
The facility failed to ensure accurate resident assessments for two residents. One resident was incorrectly documented as being on an anti-coagulant instead of an anti-platelet medication. Another resident was inaccurately documented as requiring restraints despite assessments indicating otherwise.
The facility failed to refer a resident with new mental health diagnoses to OHCA for a PASRR level II evaluation. The resident had a history of traumatic brain injury and was later diagnosed with a mood disorder and major depressive disorder with psychotic symptoms. The facility did not notify OHCA as required.
A facility failed to document hospice services and pain management interventions in a baseline care plan for a resident with chronic pain. The resident did not receive pain medication due to a delivery error, and the administrator confirmed the oversight.
The facility failed to assist a resident with limited range of motion in wearing their splint. The resident, with left-sided hemiplegia and contractures, reported that staff did not help with exercises or applying the splint, which had not been worn for about two months. Observations and interviews confirmed the lack of assistance, despite the resident's desire to wear the splint to prevent further contracture.
The facility failed to have physician orders for maintaining an indwelling urinary catheter for a resident admitted with urinary retention and kidney calculus. The facility's policy required a physician's order for catheter and bag changes at 30-day intervals, but no such order was present, and the catheter had been in place for over 30 days. The administrator confirmed the oversight.
The facility failed to follow the physician's orders for oxygen therapy for a resident with acute respiratory failure and tracheostomy. The resident's oxygen was consistently set at 2.5 liters per minute instead of the prescribed 3.5 liters per minute, and an LPN was unaware of the correct setting.
The facility failed to document and retain the required staffing information. White boards at each nursing station displayed the facility name, date, census, and staff titles, but did not include staffing hours worked. The administrator was unaware of the requirements and identified 49 residents in the facility.
A resident with ESRD was prescribed Eliquis with an incorrect diagnosis of hypertension. Despite a pharmacy review and physician concurrence, the diagnosis was not updated. The administrator confirmed the medication was for preventative use due to a dialysis fistula.
The facility failed to maintain a functional microwave for heating resident food after hours. A resident reported the issue, and dietary staff confirmed the lack of a working microwave. An attempt to replace it with a dirty, unusable microwave was made, which the administrator acknowledged should not be used.
A facility failed to provide a call light in the room of a resident with mobility issues, despite the facility's policy requiring every resident to have a functioning bedside call light. The resident confirmed the absence of the call light since moving into the room, and the administrator acknowledged the oversight.
Failure to Submit PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required Payroll-Based Journal (PBJ) staffing data to CMS for the second quarter of fiscal year 2025. Record review showed that no staffing data was provided for the period from January 1, 2025, through March 31, 2025, despite 55 residents residing in the facility during that time. During an interview, the office manager explained that the employee responsible for submitting the PBJ data was no longer employed at the facility, and at the time, there was no one available who could complete the submission.
Administrator Lacked Training, Leading to Inadequate Abuse Investigation
Penalty
Summary
The facility failed to ensure that the administrator was knowledgeable about and followed the facility's abuse policy, resulting in a substandard investigation of an abuse allegation involving one resident. The facility's policy required staff to be informed about abuse prevention, intervention, detection, and reporting requirements. A quarterly MDS assessment indicated that the resident involved had intact cognition at the time of the incident. An incident form documented an allegation of physical abuse, but the investigation records provided by the administrator did not include interviews with staff or other residents regarding the alleged abuse. During interviews, the administrator confirmed that they were responsible for conducting abuse investigations but admitted to being unaware of all investigation requirements at the time, as they were new to the organization and had not received training. The administrator did not conduct interviews with staff or residents, did not suspend or otherwise restrict the accused staff member from contact with the resident during the investigation, and failed to notify the state health department and local law enforcement within the required timeframes. These omissions resulted in a deficient response to the abuse allegation.
Failure to Timely Report Alleged Abuse and Notify Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse by a staff member against a resident to the Oklahoma State Department of Health (OSDH) within the mandated timeframe and did not notify local law enforcement as required. According to the facility's policy, any suspected abuse, neglect, or exploitation must be reported to OSDH and other relevant agencies. Documentation showed that the incident involving the resident was reported to OSDH the day after the allegation was made, as evidenced by the fax receipt. The incident form also lacked documentation indicating that law enforcement had been contacted regarding the allegation. The resident involved had an intact cognitive status, as indicated by a recent BIMS score of 15. During an interview, the administrator acknowledged that the abuse allegation was not reported to OSDH within the required two-hour window and that law enforcement was not contacted. The administrator attributed these failures to a lack of training and awareness of the reporting requirements at the time of the incident.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of physical abuse involving one resident. According to the facility's policy, all allegations of abuse, neglect, and mistreatment are to be investigated in a timely and objective manner. Documentation showed that a resident with intact cognition reported to the activities director that a staff member had slapped them. The incident was reported to the state health department, but the facility's investigation records did not include interviews with staff or other residents regarding the alleged abuse at the time it was reported. Further review revealed that the investigation materials provided by the administrator only included interviews conducted much later, and not around the time of the incident. The administrator acknowledged that, at the time of the investigation, they were new to the organization and had not received training on the abuse investigation process. As a result, the investigation did not include essential steps such as interviewing relevant staff and residents or addressing concerns about the alleged perpetrator.
Failure to Provide Scheduled Bathing and Documentation for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for bathing received baths as scheduled. According to facility policy, residents are to be bathed three times weekly and as needed, with refusals documented in the electronic medical record and on a refusal form signed by the resident, CNA, and charge nurse. Review of the resident's records over a three-month period showed that the resident received only six documented baths, with multiple scheduled bath days lacking any documentation of completion or refusal. The resident, who was severely cognitively impaired with a BIMS score of 99 and dependent on staff for bathing, reported not having received a bath in a while and was unsure of the scheduled days. Interviews with the DON and CNA confirmed that all completed baths should be documented and refusals recorded with appropriate forms. However, no additional bath sheets or refusal forms could be located for the resident, and the DON acknowledged there was no way to prove the resident was bathed more than six times in the last three months. The lack of documentation and missed scheduled baths constituted a failure to provide care and assistance with activities of daily living as required by facility policy.
Failure to Notify Families of Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to notify the legal representatives of three residents about inappropriate sexual behavior involving a resident with diagnoses of peripheral vascular disease (PVD) and essential hypertension. An incident report dated 12/01/24 documented that this resident was sexually inappropriate with two female residents, who had diagnoses including anxiety disorder, depression, dementia, and major depression disorder. The clinical health records for these residents did not contain documentation of family notification regarding the inappropriate behavior. The facility's policy required the charge nurse to complete an incident report and notify the physician and family, but this was not adhered to. The administrator acknowledged that the LPN did not feel it was necessary to notify the families.
Resident Abuse Due to Improper Handling by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a resident who reported being handled roughly by staff during assistance in bed. The resident, who had a history of cerebrovascular accident and peripheral vascular disease, was dependent on staff for transfers and had intact cognition. The resident reported that staff told them they were going to die in the facility, and a red area was noted on the resident's right upper arm, with the resident experiencing pain rated at 6 out of 10. This incident was documented in an Initial Incident Report, and staff were suspended pending investigation. Further investigation revealed that a CNA used a mechanical lift improperly, causing harm to the resident's right upper arm. The resident, who was alert and oriented, reported that the CNA purposefully put the straps on wrong, resulting in significant bruising. The CNA involved was terminated, and another CNA was suspended and educated on reporting suspected abuse. The administrator acknowledged the lack of formal Quality Assurance involvement in the incident, although steps were discussed to prevent further occurrences.
Failure to Submit Abuse Investigation Results Timely
Penalty
Summary
The facility failed to ensure the results of an abuse investigation were submitted to the State Survey Agency (SSA) within five business days for a resident involved in an abuse allegation. The incident involved a resident with diagnoses including Peripheral Vascular Disease (PVD) and Diabetes Mellitus type two, who was reported to have been sexually inappropriate with multiple female residents. An initial report was faxed to the state on December 1st, documenting the allegation and the immediate action of placing the resident under one-on-one supervision during the investigation. However, there was no documentation that the final results of the investigation were submitted to the SSA. The facility's administrator acknowledged the oversight, stating that they believed the Director of Nursing (DON) had completed the final report, but it was not done.
Failure to Assess Residents After Allegation of Sexual Misconduct
Penalty
Summary
The facility failed to assess two residents after an allegation of inappropriate sexual behavior. The facility's policy on managing suspected abuse/neglect requires a complete assessment of both residents involved, to be conducted by the charge nurse. An incident report documented an allegation of sexual misconduct by a resident towards multiple female residents. However, there was no documentation in the clinical records of the two affected residents, who had diagnoses including anxiety disorder, depression, dementia, and major depression disorder, being assessed following the allegation. Interviews with facility staff confirmed the absence of assessments in the clinical records, indicating that the assessments were not conducted.
Failure to Prevent Falls Resulting in Major Injuries
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified due to the facility's failure to protect residents from falls resulting in major injuries. One resident had a non-injury fall on 04/11/24, but hourly checks were not documented as completed. This resident subsequently fell again on 04/14/24, resulting in a broken neck. Additionally, on 05/17/24, the resident's call light was found unplugged and placed on top of a dresser, out of reach. Another resident experienced a fall with minor injury on 04/20/24, but no interventions were developed following the fall. This resident fell again on 04/23/24, resulting in a broken back. The intervention to move the resident closer to the nurse's station was not implemented due to room availability, and no new interventions were put in place. The facility's fall policy required nurses to complete an incident report and initiate fall interventions for fall prevention. However, the records showed that these steps were not followed. For the first resident, the hourly checks were not documented, and the call light was not kept within reach, as required by the care plan. For the second resident, there was no incident report or updated care plan following the initial fall, and the intervention to move the resident closer to the nurse's station was not documented or implemented. The deficiencies were confirmed through observations, record reviews, and interviews with staff. The Director of Nursing (DON) identified that 51 residents resided in the facility. The facility's failure to develop and implement appropriate fall prevention interventions led to significant injuries for the two residents involved. The Oklahoma State Department of Health was notified, and the IJ situation was verified and communicated to the facility's administrator.
Removal Plan
- Placing all residents on checks relating to prevention of falls it will be documented on TAR's
- Call light for Res #1 has been secured so it cannot be unplugged.
- Resident #2 have relocated her room across from nurse station.
- All staff has been in-serviced on new policy and procedure for fall prevention and falls.
- All nurses have been in-serviced on development and implementation of fall interventions and updated fall procedure.
- Every resident will have a new Fall Risk Assessment completed.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents. Observations revealed multiple issues with the flooring, including missing and cracked tiles in the dining room, hall entrance, common area, and resident halls, creating uneven surfaces that posed a trip hazard. Maintenance staff acknowledged the problem, noting that the tiles had been in disrepair for two to three months, but no maintenance requests had been logged. Additionally, a resident's room was found to have missing sheetrock, broken window blinds, and torn wheelchair armrests, none of which had been reported for repair. Maintenance staff confirmed they were unaware of these issues, as no maintenance requests had been submitted by the staff responsible for logging such concerns. Further deficiencies were noted in the laundry room, where two washing machines were leaking, and the area behind the machines was not cleaned. The washers had been leaking for an extended period, with one reported to have been leaking for at least a year. The drywall behind the washers was damaged, and the area was dusty and cluttered with laundry detergents and other items stored directly on the floor. Missing tiles were also observed in front of and between the washers and dryers. These conditions indicate a failure to maintain the facility in good repair and free from hazards, as required by the facility's maintenance policies.
Failure to Complete Quarterly Resident Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly resident assessments were completed within 14 days of the assessment reference date for two residents. One resident's quarterly assessment, dated October 12, 2023, was not completed and signed until November 9, 2023. Another resident's quarterly assessment, dated October 22, 2023, was not completed and signed until November 28, 2023. The administrator confirmed that the assessments should have been completed and signed within 14 days and could not provide an explanation for the delay.
Failure to Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to ensure the PASARR for two residents with mental health diagnoses was filled out correctly and referred to the OHCA. Resident #18, admitted with major depressive disorder and anxiety, had a PASARR Level I dated 03/04/20 that did not document the mental health diagnosis. Similarly, Resident #41, admitted with delusional disorders and major depressive disorder, had a PASARR Level I dated 06/14/21 that also did not document the mental health diagnosis. The administrator confirmed that the mental health diagnoses should have been documented and OHCA should have been notified.
Failure to Provide Scheduled Baths and Assistance with Eating
Penalty
Summary
The facility failed to ensure that baths were given as scheduled for two residents and that assistance with eating was provided for one resident. Resident #15, who had diagnoses including chronic obstructive pulmonary disease, neuropathy, and rheumatoid arthritis, was supposed to receive showers on Mondays and Thursdays. However, there was no documentation that Resident #15 received a shower from March 1 to March 22, 2024. The resident complained about not receiving a shower for the entire month and reported going three to four weeks without a shower before. The MDS Coordinator and the administrator confirmed that Resident #15 frequently refused baths, but these refusals were not documented, and no alternative days or times were offered to make up for missed showers. Similarly, Resident #16, who had diagnoses including Parkinson's disease, neuralgia, and pain, was supposed to receive showers on Tuesdays and Fridays. There was no documentation that Resident #16 received a shower from March 1 to March 22, 2024. The resident reported not receiving showers on scheduled days and going one to two weeks without a shower. The administrator confirmed that refusals were not documented and no alternative days or times were offered for missed showers. Additionally, the facility failed to provide assistance with eating for Resident #18, who had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease. An assessment documented that Resident #18 had moderately impaired cognition, limited range of motion, and required supervision or touching assistance for eating. On March 20, 2024, Resident #18 was observed eating their meal with their hands in a dark dining room without any staff assistance or supervision. Staff members walked through the dining room but did not turn on the lights or encourage the resident to use utensils. The administrator eventually found a staff member to move the resident to a lighted area, but the resident continued to eat with their hands until a CNA arrived and assisted another resident. The administrator acknowledged that staff had not provided the necessary supervision during lunch on that day.
Failure to Coordinate Care with Hospice and Ensure Medication Availability
Penalty
Summary
The facility failed to ensure care was coordinated with hospice to ensure a resident's medications were available for administration. The resident, who had diagnoses including COPD and chronic pain, was admitted to the facility with orders for Albuterol Sulfate Inhalation Nebulization Solution and oxycodone-acetaminophen oral tablets. However, the resident did not receive their pain medication or nebulizer treatments as prescribed. The pain medication was delivered to the wrong facility, and the nebulizer medication was not available in the building. Staff members, including a CMA and LPN, confirmed the medication mix-up and the lack of administration of the prescribed treatments. The hospice nurse stated that they were notified about the missing medications after the resident had already missed several doses. The facility's policies required reordering medications in advance and coordinating care with hospice, but these protocols were not followed. The resident reported not receiving any nebulizer treatments since admission, and staff confirmed the absence of the necessary medications. This lack of coordination and failure to ensure medication availability led to the resident not receiving essential treatments for their conditions.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that pain medication was administered as ordered for a resident with chronic pain and opioid dependence. The resident was admitted with six oxycodone/acetaminophen tablets and had a physician's order to receive the medication every four hours. However, the resident's clinical record did not contain a pain assessment, and the baseline care plan did not document interventions for chronic pain. The resident missed five doses of their pain medication due to a delay in receiving the medication from the pharmacy, which was sent to the wrong nursing home. The resident reported severe pain and was unable to perform usual activities due to the lack of pain management. The Director of Nursing (DON) acknowledged the delay and stated that the pain medication was on the way. The hospice nurse confirmed that they were notified about the medication shortage the previous day. The resident finally received their pain medication after a significant delay, which caused them considerable discomfort. The facility's policy required reordering medication four days in advance, but this was not followed, leading to the deficiency in pain management for the resident.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure insulin and blood pressure medication were administered per physician's orders for two residents. Resident #31, who had diagnoses including hypertension and diabetes, received insulin Detemir on multiple occasions despite their blood sugar being below the threshold of 100, as specified in the physician's order. Additionally, Metoprolol ER was incorrectly held for this resident when their vital signs did not meet the criteria for withholding the medication. The errors were acknowledged by the staff involved, who admitted to not following the prescribed guidelines and making mistakes in medication administration. Resident #46, diagnosed with hypertension, was also subject to medication administration errors. The resident's blood pressure was recorded with a diastolic reading below the threshold specified in the physician's order for holding Metoprolol Tartrate. Despite this, the medication was prepared for administration. The CMA involved admitted to not reading the blood pressure parameters on the medication label due to nervousness and failing to see the hold directions in the computer. These actions led to significant medication errors, compromising the residents' safety and well-being.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by multiple deficiencies observed during the survey. A blood pressure machine was not disinfected between residents, leading to potential cross-contamination. Specifically, a CMA used the same wrist blood pressure monitoring device on three residents without disinfecting it before or after each use. The CMA admitted to only cleaning the device a couple of times a day and was unaware of the need to disinfect it between each resident. Additionally, soiled linens were found on the floor in a resident's room, and the CNA responsible acknowledged that they did not bring a big enough bag for the linens and were aware that placing soiled linens on the floor was against protocol. Furthermore, a nebulizer mouthpiece was improperly stored on top of the nebulizer machine instead of in a bag, as confirmed by an LPN who stated it should have been stored correctly to prevent cross-contamination. The facility also lacked a comprehensive infection surveillance system, as evidenced by the absence of infection tracking and trending since December 2023. The administrator confirmed that infections had not been tracked, and the IP admitted that although three residents had clostridium difficile infections in March, there was no documentation of monitoring staff for proper PPE use and handwashing. Additionally, the facility did not have a water Legionella prevention program in place, and the maintenance personnel were unaware of any such program. The administrator confirmed the lack of documentation related to the facility's water system management for Legionella prevention.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to have a system in place to assess residents for infections using standardized tools and criteria for the initiation of antibiotics. The facility's undated policy indicated that nurses should perform and document a comprehensive assessment using established protocols when an infection is suspected. However, the facility had not tracked antibiotic use since December 2023. An undated document titled 'Attention All Nurses' introduced new assessment forms for various infections, but it was unclear if these tools were utilized before initiating antibiotics. The Infection Preventionist (IP) confirmed that they could not determine if assessment tools were used prior to antibiotic administration for 13 residents in January 2024, 12 residents in February 2024, and 15 residents in March 2024.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to one of three sampled residents whose beneficiary notices were reviewed. Resident #23 was admitted to skilled services on January 18, 2024, and discharged from skilled services on February 21, 2024, but remained in the facility. A review documented that an ABN was not provided to the resident. On March 20, 2024, the MDS Coordinator confirmed that Resident #23 was not given an ABN form.
Failure to Complete Timely Significant Change Assessment
Penalty
Summary
The facility failed to ensure a significant change resident assessment was completed within 14 days of the assessment reference date for one of four sampled residents whose assessments were reviewed. The facility's Resident Assessment Instrument policy, revised in October 2010, mandates timely resident assessments when there is a significant change in the resident's condition. However, the significant change assessment for a resident, dated October 19, 2023, was not completed and signed until November 9, 2023. The administrator acknowledged that the assessment should have been signed within 14 days but could not explain the delay.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents. One resident with congestive heart failure was incorrectly documented as being on an anti-coagulant instead of an anti-platelet medication in two quarterly assessments. The administrator and MDS Coordinator were unaware of the correct classification of aspirin. Another resident with type 2 diabetes mellitus, recurrent depressive disorders, and chronic viral hepatitis C was inaccurately documented as requiring restraints in an MDS re-admission assessment, despite a side rail assessment indicating no need for bedrails and the administrator confirming the resident never required restraints.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with a new mental health diagnosis to the Oklahoma Health Care Authority (OHCA) for a Pre-Admission Screening and Resident Review (PASRR) level II evaluation. The resident, who was admitted with a diagnosis of diffuse traumatic brain injury with loss of consciousness of unspecified duration, was later diagnosed with a mood disorder due to a known physiological condition and major depressive disorder, recurrent, severe with psychotic symptoms. Despite these new diagnoses, the facility did not notify OHCA as required. This deficiency was identified during a record review and interview, with the administrator acknowledging the oversight.
Failure to Document Hospice Services and Pain Management in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan included hospice services and interventions for pain management for a resident who was on hospice. The resident was admitted with diagnoses including chronic pain and was on hospice prior to admission. The baseline care plan did not document the resident's hospice status or interventions for pain management. The resident reported not receiving pain medication since the previous day due to a delivery error. The administrator confirmed that pain interventions and hospice services should have been documented in the baseline care plan.
Failure to Assist Resident with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion was offered assistance with splints. The resident, who had cerebrovascular disease with left-sided hemiplegia and contractures, reported that staff did not assist them with exercises for their arms or hands. Observations confirmed that the resident's left hand was closed, and they were unable to open it without a splint. The resident stated that they had not worn the splint for about two months and that staff had not offered to help them apply it recently. Further interviews revealed that the restorative aide was unsure when they last performed range of motion exercises for the resident, as they were working as a CNA. The occupational therapist (OT) mentioned that the range of motion exercises might have been turned over to the nurse aides and confirmed that the resident's hand was very tight. The OT was observed applying the splint, which was found in the resident's drawer. Despite the resident expressing a desire to wear the splint to prevent further contracture, staff did not offer assistance with the splint on the morning of the observation.
Lack of Physician Orders for Indwelling Urinary Catheter Maintenance
Penalty
Summary
The facility failed to have physician orders for maintaining an indwelling urinary catheter for one resident who was admitted with an indwelling urinary catheter and diagnoses including urinary retention and calculus of kidney and ureter. The facility's policy required a physician's order for the catheter and bag to be changed at 30-day intervals, but no such order was present. The resident's nursing notes did not document any catheter and drainage bag changes, and the indwelling urinary catheter had been in place for over 30 days. The administrator confirmed that the catheter and bag should have been changed and that there should have been a physician's order for the change at least monthly and as needed.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow the physician's orders for oxygen therapy for a resident diagnosed with acute respiratory failure and tracheostomy. The physician's order, dated 04/15/23, specified that the resident should receive oxygen at 3.5 liters per minute via nasal cannula or trach mask, with pulse oximetry checks every shift and adjustments to maintain oxygen saturation above 92%. However, observations on multiple dates revealed that the resident's oxygen was set at 2.5 liters per minute, contrary to the prescribed 3.5 liters per minute. Additionally, an LPN was unaware of the correct oxygen setting and had to refer to the orders to verify it.
Failure to Document and Retain Required Staffing Information
Penalty
Summary
The facility failed to document and retain the required staffing information. During the survey, it was observed that the facility had two white boards at each nursing station with the facility name, date, census, and staff titles documented. However, the staffing hours worked were not documented. The administrator, who was unaware of the requirements regarding posted staffing information and the need to keep staffing information for at least 18 months, identified 49 residents residing in the facility.
Failure to Ensure Drug Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, a resident with a diagnosis of end-stage renal disease (ESRD) was prescribed Eliquis, a blood thinner, with an incorrect diagnosis of hypertension secondary to other renal disorder. A pharmacy review suggested clarification of the Eliquis diagnosis, noting that it is not used for hypertension. The physician concurred with the pharmacy's recommendation but did not change the diagnosis. The administrator confirmed that the Eliquis was not prescribed for hypertension and should have been updated to reflect its use as a preventative medication due to the resident having a fistula for dialysis.
Failure to Maintain Functional Microwave for Resident Food Heating
Penalty
Summary
The facility failed to ensure the microwave used to heat up resident food after hours was in good repair. A resident reported that they were not allowed to have a microwave in their room and that the staff microwave was broken, resulting in their food not being heated the previous night. Dietary staff confirmed the lack of a working microwave and the inability to heat resident food after hours. An attempt to replace the microwave with one from the maintenance building revealed that the replacement was discolored, stained, and could not be cleaned properly. The administrator acknowledged that the replacement microwave should not be used for heating resident food.
Failure to Provide Call Light in Resident's Room
Penalty
Summary
The facility failed to provide a call activation button in the room of a resident who was admitted with diagnoses of acquired absence of the right leg above the knee and unspecified abnormalities of gait and mobility. During an observation, it was noted that the resident's room did not have a call light, and the resident confirmed that they had not had one since moving into the room. The facility's policy requires that every resident should have a functioning bedside call light, which was not adhered to in this case. The administrator acknowledged that every resident should have a call light regardless of room changes.
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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