Broken Bow Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Broken Bow, Oklahoma.
- Location
- 700 West Jones, Broken Bow, Oklahoma 74728
- CMS Provider Number
- 375165
- Inspections on file
- 21
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Broken Bow Health And Rehab during CMS and state inspections, most recent first.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
Surveyors observed three treatment carts left unlocked and unattended in different areas near the nurse's station and front entrance. An LPN was seen leaving a cart unsupervised while retrieving supplies, contrary to facility policy requiring carts to be locked and supervised at all times. Facility leadership confirmed the expectation that carts remain secured.
A resident's care plan was not updated to include a new breast cancer diagnosis or related interventions, despite facility policy requiring care plans to be revised after significant changes in condition. The omission was confirmed by both the ADON and DON during review.
A resident who missed 77 doses of cancer medication was not included in the facility's QAPI activities. Despite policies requiring ongoing quality monitoring, the missed medications and the resident's cancer diagnosis were not discussed in recent QAPI meetings, as confirmed by interviews with the ADON and DON.
The facility failed to accurately complete MDS assessments for two residents. One resident's hospice care was not documented correctly, despite active orders. Another resident's antipsychotic medication administration was inaccurately reported due to a misunderstanding by the MDS coordinator, who was still in training.
A resident with hemiplegia and other conditions did not receive the required assistance with showers and baths as per their care plan, which stipulated assistance three times a week. Despite a paper schedule indicating showers, the electronic health record showed only one shower per month, and the resident reported not having a shower in five days. Staff interviews revealed a lack of proper documentation and adherence to the care plan.
A resident with major depressive disorder was inappropriately administered Risperdal 0.5 mg daily despite a physician's order to discontinue it. The error occurred due to a lapse in communication and oversight by the DON, who was new at the time, resulting in the medication being administered from November to December 2024.
The facility failed to monitor and log dish machine temperature and sanitizer concentration, and improperly stored food items. Observations included a non-functioning paper towel dispenser, missing documentation in the Dish Machine Temperature Log, and improperly labeled and stored food items. The DM confirmed the need for regular checks and proper storage practices.
The facility did not implement a water management plan to prevent water-borne pathogens. Despite having a policy for Legionella surveillance, the administrator could not provide documentation of monitoring activities. The facility had a census of 55.
A facility failed to assess a resident for self-administration of medication, as required by policy. The resident, with chronic conditions and legal blindness, was found with medications at their bedside without a documented assessment. Both the LPN and DON confirmed the lack of assessment, indicating non-compliance with the facility's policy on medication self-administration and secure storage.
A facility failed to document wound care for a resident with pressure ulcers, despite physician's orders for daily treatment. The resident had multiple pressure ulcers upon admission, and the Treatment Administration Record lacked documentation for specific dates. Interviews with staff revealed that wound care was performed but not recorded, violating the facility's documentation policy.
A resident with a seizure disorder did not receive their prescribed phenytoin medication on seven occasions in November 2024. The DON was unable to explain the missed doses, which could lead to seizures.
The facility failed to provide snacks between meals for two residents who expressed a need for them. One resident, with cerebrovascular disease, dysphagia, and aphasia, stated the importance of having snacks available. Another resident, with cerebral infarction, muscle weakness, and diabetes, reported that snacks were only available at night and had to repeatedly ask for a snack during the day. The Dietary Manager confirmed that snacks were only provided at night unless there was a medical need.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Unlocked and Unsupervised Treatment Carts
Penalty
Summary
The facility failed to ensure that three treatment carts were locked and supervised in accordance with facility policy and professional standards. On multiple occasions, surveyors observed treatment carts left unlocked and unattended in various locations near the nurse's station and the front entrance. One LPN was seen walking away from an unlocked cart to retrieve medication cups, leaving the cart unsupervised and accessible. The facility's policy requires medication carts to be locked at all times when not in use or out of the nurse's view, and this was confirmed by both the ADON and the LPN during interviews. The DON reported that there were no wanderers in the facility at the time.
Failure to Update Care Plan Following New Cancer Diagnosis
Penalty
Summary
The facility failed to update the care plan for one of three sampled residents, specifically neglecting to include a diagnosis and interventions for breast cancer after a physician consultation identified this condition. The facility's policy requires that comprehensive, person-centered care plans be developed and revised as residents' conditions change, including after significant changes such as a new diagnosis. Despite this, the most recent care plan for the resident did not reflect the cancer diagnosis or any related interventions. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed during interviews that the care plan lacked the necessary updates, in contradiction to facility policy.
Failure to Include Missed Cancer Medications in QAPI Activities
Penalty
Summary
The facility failed to include a resident who missed 77 cancer medication doses in its Quality Assurance and Performance Improvement (QAPI) activities. Record review and staff interviews revealed that, despite the facility's policy requiring an ongoing, data-driven QAPI program focused on care outcomes, the resident's missed medications and cancer diagnosis were not discussed or addressed in recent QAPI meetings. The Assistant Director of Nursing (ADON) indicated that the QAPI process was not initiated for the missed cancer medications because the issue was not known at the time. The Director of Nursing (DON) confirmed that the resident's cancer diagnosis and related interventions were not included in the QAPI meetings held during the relevant period.
Inaccurate MDS Assessments for Hospice and Medication Administration
Penalty
Summary
The facility failed to ensure accurate completion of MDS assessments for two residents. For one resident, there was a discrepancy in the documentation regarding hospice services. Despite having an active physician's order indicating the resident was under hospice care, both the significant change and quarterly MDS assessments inaccurately documented that the resident did not receive hospice services. The MDS coordinator and the Director of Nursing (DON) acknowledged the inaccuracies, noting that the assessments were incorrect as the resident was indeed receiving hospice services during the assessment periods. For another resident, there was an error in documenting the administration of an antipsychotic medication. The resident was prescribed Risperdal, with records showing administration of both 0.5 mg and 1 mg doses daily throughout November. However, the quarterly MDS assessment inaccurately reported that the resident had not been administered any antipsychotic medication during the look-back period. The MDS coordinator misunderstood the assessment question, thinking it referred to the initiation of the medication rather than its administration. The DON confirmed the error, attributing it to the MDS coordinator's inexperience and ongoing training.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL), specifically showers and baths, for a resident diagnosed with hemiplegia, hemiparesis, aphasia, and dysphagia following a cerebral infarction. The resident's care plan, dated March 1, 2022, required staff to assist with a bath at least three times a week and as requested by the resident, with a two-person assist for shower transfers. However, the electronic health records for November and December 2024 documented that the resident received only one shower or bath each month, indicating a failure to meet the care plan requirements. Interviews with the resident and staff revealed discrepancies in the documentation and reporting process. The resident reported not having a shower in five days, contrary to the care plan's stipulations. A CNA mentioned a paper shower schedule signed by staff and reviewed by the DON or ADON, but the DON confirmed that the electronic health record lacked documentation of the showers or baths provided. This lack of documentation and adherence to the care plan led to the identified deficiency in providing necessary ADL assistance.
Failure to Discontinue Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident did not receive an antipsychotic medication that had been discontinued by a physician. Resident #12, who had a diagnosis of major depressive disorder with psychotic features, was prescribed Risperdal 0.5 mg once daily. A Pharmaceutical Consultant Report recommended a dose reduction of several psychotropic medications, including Risperdal, and documented a physician's order to stop the use of Risperdal 0.5 mg once daily. Despite this order, the Medication Administration Record (MAR) for November and December 2024 showed that the resident continued to receive the medication daily from November 1 through December 11, 2024. The Licensed Practical Nurse (LPN) confirmed that the physician's order to discontinue Risperdal was included in the pharmaceutical report, but the order remained active in the electronic health record, resulting in the resident receiving the medication daily. The Director of Nursing (DON) acknowledged that the process for handling pharmaceutical reports involved communicating with the appropriate nurse to make any necessary changes. However, the DON, who was new at the time, admitted to missing the order to discontinue the medication, leading to the continued administration of Risperdal to the resident.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to ensure proper monitoring and logging of dish machine temperature and sanitizer concentration, as well as appropriate storage of food items. During an initial kitchen tour, it was observed that the paper towel dispenser at the handwashing sink was not functioning. The Dish Machine Temperature Log for December 2024 lacked documentation for several days, indicating a failure to record the temperature and sanitizer concentration. Additionally, several food items, including prune juice, ranch dressing, whole eggs, pudding, brown sugar, flour, rice, canned pears, and turnip greens, were found without proper labeling of received or opened dates, and some were stored improperly, such as being uncovered or placed on the floor. The Dietary Manager (DM) confirmed that the dish machine's temperature and sanitizer concentration should be checked three times daily and acknowledged the need for repairs to the paper towel machine. The DM also stated that dry goods should be stored off the floor in closed containers, and all food items should be dated upon receipt and opening.
Failure to Implement Water Management Plan
Penalty
Summary
The facility failed to implement a water management plan to prevent the spread of water-borne pathogens. The facility had a policy titled 'Legionella Surveillance and Detection,' which stated a commitment to the prevention, detection, and control of water-borne contaminants, including Legionella. However, during an interview on December 12, 2024, the administrator reported they were unable to locate any documentation of monitoring for water-borne pathogens. The facility had a census of 55 at the time of the report.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, which is a requirement when a resident is allowed to self-administer drugs. The policy of the facility states that residents have the right to self-administer medications if the interdisciplinary team determines it is clinically appropriate and safe. This determination should be documented in the medical record and care plan, and medications should be stored securely. However, for the resident in question, there was no documentation of an assessment for self-administration of medication in the care plan or medical record. The resident, who had diagnoses including chronic obstructive pulmonary disease, reflux disease, and legal blindness, was observed with medications at their bedside, including an inhaler, cold medicine, and Cortisone cream. The LPN and DON both confirmed that no assessment had been completed for the resident's self-administration of medication, and the DON was unaware of the medications at the bedside. This oversight indicates a failure to adhere to the facility's policy on medication self-administration and secure storage.
Failure to Document Wound Care for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate medical records for a resident with pressure ulcers. The resident, diagnosed with congestive heart failure and urinary incontinence, had one stage II and two stage III pressure ulcers upon admission. Physician's orders required daily wound care for the resident's left ankle, left heel, and coccyx. However, the Treatment Administration Record (TAR) did not document wound care on several specific dates. Interviews with the Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) revealed that wound care was performed but not documented, contrary to the facility's policy that mandates documentation of all treatments and services in the resident's medical record.
Failure to Administer Anticonvulsant Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A resident with a history of epileptic seizures, cerebral infarction, and cognitive communication deficit was prescribed phenytoin, an anticonvulsant medication, to be administered daily via a PEG tube. However, the Medication Administration Record (MAR) for November 2024 indicated that the resident did not receive the prescribed phenytoin medication on seven out of 25 occasions. During an interview, the Director of Nursing (DON) reviewed the MAR and was unable to explain why the medication was not administered, acknowledging that the omission could lead to seizures.
Failure to Provide Snacks Between Meals
Penalty
Summary
The facility failed to provide snacks between meal times for two residents, both of whom were cognitively intact and had expressed a desire for snacks between meals. Resident #2, diagnosed with cerebrovascular disease, dysphagia, and aphasia, stated that having snacks available between meals was very important. Despite this, the resident reported that they would like to have a snack if they were hungry between meals, indicating that snacks were not being provided as needed. Resident #4, with diagnoses including cerebral infarction, muscle weakness, and diabetes, also expressed a need for snacks between meals. The resident reported that snacks were only available at night and recounted an instance where they had to repeatedly ask for a snack during the day, eventually receiving only a package of crackers. The resident decided to stop asking for snacks during the day due to this experience. During a facility tour, no snacks were observed being offered between meals, and the Dietary Manager confirmed that snacks were only provided at night unless there was a medical need, such as diabetes.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
