Broadway Care & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskogee, Oklahoma.
- Location
- 1622 East Broadway, Muskogee, Oklahoma 74403
- CMS Provider Number
- 375146
- Inspections on file
- 23
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Broadway Care & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses did not have physician-ordered antiplatelet medications held prior to scheduled pacemaker placement procedures. As a result, the resident was unable to undergo the procedures as planned due to the medications not being withheld as ordered.
A resident with severe cognitive impairment eloped from a locked unit by exiting through a window, which was not adequately secured to prevent tampering from inside. The resident was later returned by law enforcement, and facility records did not specify how far the resident traveled or the exact duration of absence.
Two residents with severe cognitive impairment experienced harm due to unsafe practices: one sustained burns after being served excessively hot coffee, and another ingested Pine-Sol left in a Styrofoam cup on a housekeeping cart, leading to hospitalization for respiratory failure. Staff interviews revealed inconsistent knowledge and application of safety protocols regarding hot liquids and chemical storage.
A resident on Enhanced Barrier Precautions for a tracheostomy and catheter was observed receiving tube feeding care from an LPN who failed to wear a gown as required by facility policy, despite PPE being available in the room. The LPN acknowledged not following the EBP protocol, and the DON confirmed the policy and staff training requirements.
A resident with cognitive impairment and high dependency for care was admitted with intact skin and placed on a prophylactic skin care regimen, including zinc oxide and a repositioning program. However, there was no documented ongoing assessment or intervention for skin integrity, and the resident was later hospitalized with deep tissue injuries to the sacrum and heel. The wound care nurse confirmed the presence of redness and the use of zinc, but could not provide documentation of wound progression or interventions.
A resident with severe cognitive impairment was involved in an incident where another resident grabbed them by the neck and was verbally aggressive until staff intervened. The facility did not conduct or document a thorough investigation, as required by policy, and failed to collect or include staff or resident interviews related to the incident.
A wound care nurse provided care to a resident with a pressure ulcer and multi-drug resistance without donning a gown or mask, despite facility policy and signage requiring enhanced barrier precautions. The nurse acknowledged the need for these precautions but did not follow them during the observed wound care.
A resident with severe cognitive impairment was physically restrained by a visitor in their room, despite the resident's attempts to leave and requests for the visitor to be quiet. The incident occurred in the early morning, and staff intervention was required to ensure the resident's safety. The visitor refused to leave the facility, necessitating police involvement to escort them out. The facility's abuse prevention policy was not effectively implemented, leading to this deficiency.
A facility failed to honor a resident's right to receive visitors of their choosing, as they restricted visitation based on the wishes of the resident's POA. Despite the facility's policy allowing 24-hour access to visitors with the resident's consent, the facility informed a friend of the resident that they could not visit, following the POA's instructions. Staff interviews confirmed that the facility should not have restricted visitation based on the POA's wishes.
Failure to Follow Physician Orders for Medication Holds Prior to Procedure
Penalty
Summary
The facility failed to follow physician orders for a resident who was scheduled for two pacemaker placement procedures. Physician orders directed that specific antiplatelet medications, including aspirin EC and Plavix, be held prior to the procedures. However, a review of the resident's records showed that these medications were not discontinued or held as ordered. As a result, the resident was unable to undergo the scheduled pacemaker placement procedures on the intended dates. The resident involved had diagnoses including metabolic encephalopathy and cerebral ischemia, with a BIMS score indicating severe cognitive impairment. The Director of Nursing (DON) confirmed that the medication was not withheld for the appropriate length of time, which led to the missed procedures. The issue was identified after the second missed procedure, and it was noted that the DON had not been informed of the first missed procedure.
Elopement Due to Inadequate Supervision and Window Security
Penalty
Summary
A resident with a diagnosis of unspecified dementia and a BIMS score of 3, indicating severe cognitive impairment, eloped from a locked unit within the facility. The incident report indicated that the resident left the facility through a window and was returned by local law enforcement. The facility's investigation did not document how far the resident traveled after leaving or the exact time frame during which the resident was missing. At the time of the incident, the resident was not accounted for during a routine check, and the facility initiated a search and notified police. Record review showed that the facility did not have adequate measures in place to prevent the resident from leaving through a window, as the window mechanisms allowed for partial opening and could be tampered with from inside. Maintenance logs and resident records were reviewed, but there was no indication that daily checks on windows in the locked unit or weekly checks in the rest of the building were sufficient to prevent such an incident. The resident, when interviewed, could not recall how they exited the building or how far they traveled before being found.
Failure to Prevent Accident Hazards: Hot Liquid Burns and Chemical Ingestion
Penalty
Summary
A deficiency was identified when a resident with severely impaired cognition and a history of dementia, delusional disorders, and lack of coordination sustained burn injuries to both thighs after spilling hot coffee on themselves. The resident required supervision for eating and was observed to have shaky hands while feeding. Coffee was served at temperatures exceeding 150 degrees Fahrenheit, with staff and surveyors noting that the beverage was very hot and could cause burns. There was no consistent documentation that all staff had been in-serviced on safe coffee temperatures, and staff interviews revealed uncertainty about proper procedures for checking beverage temperatures before serving. Another deficiency occurred when a resident with severe cognitive impairment, intellectual disability, and a history of aspiration pneumonitis ingested Pine-Sol that had been left in a Styrofoam cup on a housekeeping cart. The resident required supervision for eating and was able to access the chemical, mistaking it for coffee. Following ingestion, the resident experienced vomiting, respiratory distress, and was subsequently hospitalized with acute respiratory failure and aspiration pneumonitis. Staff interviews indicated that chemicals were supposed to be locked and labeled, but the incident demonstrated a failure to secure hazardous substances. Both incidents involved residents with significant cognitive impairments who required supervision and were exposed to preventable hazards due to lapses in staff adherence to safety protocols. The facility failed to ensure that hot beverages were served at safe temperatures and that chemicals were properly secured, resulting in harm to the residents involved.
Failure to Ensure Proper PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). During observation, signage indicating EBP was present on the resident's door, and the resident was receiving tube feeding. An LPN entered the resident's room, wearing gloves but did not don a gown as required by the facility's EBP policy, while accessing the resident's feeding tube. The LPN exited and re-entered the room, again applying only gloves and not a gown, despite PPE supplies being available inside the room. The facility's policy, dated 05/15/24, specifies that both gown and gloves are required for high-contact care activities, including enteral tube care, under EBP. The LPN acknowledged awareness of the policy and admitted to not following the required PPE protocol. The DON confirmed the EBP requirements and stated that staff had been provided with badges containing EBP information and had received in-service training. The deficiency was identified for one of three sampled residents observed for EBP, in a facility with 75 residents.
Failure to Monitor and Intervene for Pressure Ulcer Prevention
Penalty
Summary
A resident with dementia and cognitive communication deficit was admitted to the facility with intact skin and no evidence of pressure ulcers. The resident was dependent on one to two persons for transfers and toilet hygiene. Physician orders were in place to apply zinc oxide ointment to the buttocks and sacrum every shift for skin integrity prophylaxis, and a turn and reposition program was documented. Despite these measures, there was no documentation of ongoing assessment or intervention for skin integrity after the initial admission and subsequent observations. The resident was later transferred to the emergency room due to a change in condition, where a hospital wound assessment identified deep tissue injuries (DTIs) to the sacrum and left heel. The facility's wound care nurse confirmed that redness was noted and zinc was applied, but could not provide documentation of the wound's progression or interventions prior to hospital transfer.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving a resident with severe cognitive impairment and intellectual disabilities. According to the records, an incident occurred in which one resident grabbed another by the neck and was verbally aggressive until a staff member intervened and separated the two. The facility's Abuse Prevention policy requires that all investigations be thorough and that results be reported to the administrator and appropriate officials within five working days. Despite this policy, documentation revealed that the investigation was incomplete. The only evidence provided was a single, unlabeled document summarizing the incident, with no supporting staff or resident interviews included in the records. The administrator confirmed that no additional statements or interviews were conducted or documented beyond what was submitted in the final report.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain infection control and follow evidence-based practices (EBP) during wound care for a resident requiring enhanced barrier precautions. Observation showed that the wound care nurse entered the resident's room, washed hands, donned gloves, and provided wound care without wearing a gown or mask, despite signage and policy indicating the need for these precautions. The resident had a pressure ulcer of the sacral region and was resistant to multiple antimicrobial drugs, with a care plan specifying enhanced barrier precautions to reduce multi-drug resistant organisms. The wound care nurse acknowledged awareness of the need for additional precautions but did not don a gown or mask prior to providing care.
Failure to Protect Resident from Abuse by Visitor
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a visitor who physically restrained a resident. The resident, who had severe cognitive impairment and diagnoses including anxiety and repeated falls, was found by a nurse being held by the wrists by a visitor in the doorway of their room. The incident occurred in the early morning hours when the visitor was being loud, and the resident attempted to leave the room to seek help. Despite the resident's request for the visitor to be quiet and to leave, the visitor refused and physically restrained the resident, preventing them from leaving the room. The nurse intervened by instructing the visitor to release the resident and escorted the resident to the nurse's desk for safety. The visitor refused to leave the facility when asked by the staff, prompting the staff to call the police, who then escorted the visitor out. Interviews with the resident, a CNA, and an LPN confirmed the sequence of events, highlighting the facility's failure to prevent the abuse and ensure the resident's safety. The facility's abuse prevention policy was not effectively implemented in this instance, as the visitor was able to enter the facility and interact with the resident in a harmful manner.
Facility Failed to Honor Resident's Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing, as evidenced by the restriction of visitation based on the wishes of the resident's Power of Attorney (POA). The facility's visitation policy, revised in February 2017, allows residents to receive visitors at any time, subject to the resident's wishes. However, in two documented instances, the facility contacted the resident's POA, who did not want a friend of the resident to visit. The facility then informed the friend that they could not visit, and in one instance, the POA instructed the facility to call the police if the friend attempted to visit. The resident involved had diagnoses including hypertension and anxiety disorder. Interviews with facility staff, including an LPN and the Social Services Director (SSD), revealed that the facility should not have restricted visitation based on the POA's wishes. The Director of Nursing (DON) and the Corporate Administrator acknowledged that the facility could not restrict visitation based on the POA's wishes, as informed by the ombudsman during a care plan meeting. This deficiency highlights a failure to adhere to the facility's visitation policy and respect the resident's rights.
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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