Callaway Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sulphur, Oklahoma.
- Location
- 1300 West Lindsey, Sulphur, Oklahoma 73086
- CMS Provider Number
- 37E624
- Inspections on file
- 22
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Callaway Nursing Home during CMS and state inspections, most recent first.
A resident re-admitted after hospital treatment for bacterial pneumonia did not receive multiple new and changed medications as ordered by the hospital physician. The medications were not added to the resident's orders or administered during the stay, as confirmed by the DON, until the resident was transferred back to the hospital for respiratory concerns.
A resident with a history of constipation, cerebral palsy, and intellectual disabilities experienced several days without a bowel movement, followed by symptoms of nausea and vomiting. Despite care plan instructions, staff did not perform a nursing assessment or intervene appropriately, and there was confusion among staff regarding reporting and monitoring bowel movements. The resident's condition deteriorated, resulting in hospital admission for a high-grade small bowel obstruction.
A resident with cognitive impairment and multiple diagnoses was ordered a wrist restraint and referred to an inpatient psych facility. The facility failed to notify the resident's designated representative/POA of these significant changes, instead contacting another family member, which was not in accordance with facility policy.
A resident with cognitive impairment and physical disabilities was repeatedly placed in a wrist restraint due to self-harm and aggressive behaviors, without documented discussion or written consent from the resident or their representative, contrary to facility policy. Family members observed the resident in distress while restrained, and staff reported that restraints were not to be used in the facility.
The facility did not have a registered nurse serving as the full-time DON, as required by policy and regulation. Staff interviews and record review confirmed that after the previous DON resigned, no RN was designated to fulfill this role, despite the facility having 44 residents.
The facility did not provide or document advance directive information for three residents, including those who were cognitively intact and those with severe cognitive impairment, despite their full code status and complex medical histories. The Business Office Manager confirmed that there was no process in place to address or educate residents about advance directives, and the facility lacked a specific policy on this matter.
The facility did not perform required weekly blood pressure checks for a resident with hypertension and failed to follow hold parameters for blood pressure medication for another resident, resulting in medication being administered despite low systolic blood pressure readings. These deficiencies were confirmed by staff review of documentation and medication records.
The facility did not maintain adequate nursing and direct care staffing, with multiple days lacking RN hours and several shifts without 24-hour licensed nurse coverage. Agency staff were used for nearly all CNA, CMA, and licensed nurse roles, and aides were often required to perform housekeeping duties in addition to resident care. Staffing levels varied with census and call-ins, sometimes leaving only one CNA per hall, and there was no consistent core RN coverage.
The facility did not have a Legionella water management program or policy in place, and no Legionella testing had been conducted. The maintenance supervisor had not received training on Legionella, and only an information packet was available, affecting 44 residents.
The facility did not follow its antibiotic stewardship protocols, as antibiotics were prescribed to three residents with severe cognitive impairment for various infections without completing the required assessment forms. The MDS coordinator confirmed that the necessary documentation was missing for all residents, indicating the program was not implemented as outlined in facility policy.
Surveyors observed persistent uncleanliness and disrepair in common areas, including stained floors, trash, and soiled items left for days, as well as a strong urine odor and a door with a missing knob. Housekeeping was provided by agency staff with no weekend coverage, and CNAs reported cleaning duties often conflicted with resident care responsibilities. Facility policy required all staff to maintain cleanliness, but this was not consistently followed.
A resident with multiple medical conditions did not receive scheduled showers as required, instead resorting to cleaning themselves with wet wipes. The resident reported only receiving showers about every two weeks despite being scheduled for twice weekly, and staff were unable to provide documentation of completed showers. The resident expressed dissatisfaction with late evening shower times and had made several complaints without resolution.
The facility did not designate a qualified staff member as the infection preventionist, as required by its own policy and national standards. Review of the staff roster and confirmation from the DON showed that no one was assigned to oversee the infection prevention and control program, despite 44 residents being present.
A facility failed to issue a timely refund of a resident's personal funds within the required 30 days after discharge. The resident was transferred to another LTC facility, but refund checks were issued nearly two months later. The administrator was unaware of the delay's cause, as the business office manager had left the facility.
The facility failed to report abuse allegations involving two residents to the State Agency as required. One resident, with severe cognitive impairment, was involved in an incident where they became aggressive during care, resulting in scratches. Despite internal reporting, no incident report or notification to the State Agency was made. Another resident, with moderate cognitive impairment, reported verbal abuse by a CMA. The administrator's investigation deemed the claim unsubstantiated, leading to no incident report or notification. These actions violated the facility's reporting policy.
The facility failed to investigate and document allegations of abuse involving two residents. One resident, with severe cognitive impairment, was found with scratches after an aggressive incident during care, but the investigation lacked documentation and witness statements. Another resident, with moderate cognitive impairment, reported verbal abuse by a CMA, but the investigation was incomplete, lacking resident interviews and proper documentation.
The facility did not transmit MDS data to CMS within the required 14 days, as assessments from May to July 2024 were delayed. An LPN, who started as the MDS coordinator in July, reported transmission issues that were resolved by October, allowing for a batch submission of 200 assessments.
The facility failed to ensure RN coverage for at least eight consecutive hours daily and did not have a full-time DON. Staff schedules for August, September, and October 2024 showed multiple days without RN or DON coverage. Interviews confirmed inconsistent RN presence, with no RN assuming DON duties. A new DON was expected to start soon.
The facility did not provide EMR access to surveyors during a complaint investigation, despite being informed of the requirement. The administrator indicated that the receiver refused to comply, offering to print documents instead, leading to a deficiency in compliance.
Failure to Administer Hospital-Ordered Medications Upon Readmission
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident who was re-admitted from the hospital after treatment for bacterial pneumonia. Upon re-admission, the resident's hospital discharge medication list included several new and changed medications, such as bronchodilators, diuretics, antipsychotics, cardiac medications, anticonvulsants, supplements, and other treatments. These medications were not added to the resident's physician orders in the facility, and none of them were administered as ordered during the resident's stay following re-admission. Documentation shows that the resident was re-admitted to the facility with specific medication orders from the hospital, but these were not implemented. The Director of Nursing confirmed that the medications listed on the hospital discharge papers were not given to the resident from the time of re-admission until the resident was transferred back to the hospital due to respiratory concerns. The failure to follow physician orders for medication administration was identified through record review and staff interview.
Failure to Assess and Intervene for Bowel Obstruction
Penalty
Summary
A deficiency occurred when the facility failed to assess, monitor, and intervene for a resident who had not had a bowel movement for several days, despite the resident's care plan indicating the need to check bowel sounds and notify a physician if no bowel movement occurred for three days. The resident, who had diagnoses including constipation, cerebral palsy, and intellectual disabilities, was always incontinent of bowel and required staff assistance for activities of daily living. Bowel elimination records showed the resident had no bowel movement for five consecutive days, followed by a single medium-sized bowel movement, and then again no bowel movement for two days. During this period, the resident began experiencing symptoms such as nausea and vomiting, which were documented in progress notes. Despite these symptoms and the absence of bowel movements, there was no documented nursing assessment related to the vomiting or constipation. Staff interviews revealed that CNAs were expected to report lack of bowel movements to nurses, but there was confusion about the process and lack of access to electronic medical records for some staff. The ADON confirmed that there was no policy in place for assessing and monitoring bowel movements at the time, and that intervention should have started at the beginning of the fourth day without a bowel movement. The resident's condition worsened, leading to transfer to the emergency room for self-harm, altered mental status, and low blood pressure. A CT scan at the hospital revealed a high-grade small bowel obstruction, and the resident was admitted for further evaluation. Family members reported that the resident had been complaining of stomach pain and refusing to eat prior to hospitalization, and that these concerns had been communicated to facility staff.
Failure to Notify Resident's Representative of Significant Change and Restraint Use
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition and treatment, specifically regarding the use of a physical restraint and a referral to an inpatient psychiatric facility. According to facility policy, the representative must be immediately informed of significant changes in the resident's physical, mental, or psychosocial status, as well as any significant alterations in treatment. Documentation showed that a nurse practitioner ordered a wrist restraint and a transfer to an inpatient psychiatric facility for a resident with moderately impaired cognition, as indicated by a BIMS score of 09 and diagnoses including cerebral palsy and intellectual disabilities. Although a progress note indicated that a family member was notified of the resident's behaviors, the new restraint order, and the psychiatric referral, the resident's designated representative and POA was not contacted. The responsible party/POA later reported not being informed of these developments. The ADON confirmed that the charge nurse failed to notify the resident's representative/POA and instead contacted another family member, contrary to facility policy.
Failure to Prevent Unauthorized Use of Physical Restraint
Penalty
Summary
A resident with cerebral palsy, intellectual disabilities, and moderately impaired cognition (BIMS score of 09) was physically restrained multiple times over the course of several hours. The facility's policy required that physical restraints not be used unless there was an emergency, and only after thorough discussion with the resident or their representative and obtaining written consent. Documentation showed that the resident engaged in repeated self-harm behaviors, including putting fingers down their throat to induce vomiting, and was subsequently placed in a wrist restraint following a nurse practitioner's order. The restraint was applied, removed, and reapplied several times as the resident continued to display self-harming behaviors and aggression toward staff. There was no documentation indicating that the required discussion with the resident or their representative occurred, nor that written consent was obtained prior to the use of the restraint. Family members observed the resident restrained and reported that the resident appeared distressed and complained of stomach pain. Facility staff, including the MDS coordinator, indicated that restraints were not to be used in the facility and were unaware of any restraints being available. The use of the restraint was not consistent with facility policy, and the resident's representative was not involved in the decision-making process as required.
Failure to Maintain Full-Time Director of Nursing (DON)
Penalty
Summary
The facility failed to have a registered nurse serving as the full-time Director of Nursing (DON), as required by both facility policy and regulatory standards. Record review and staff interviews revealed that the facility did not have an RN acting in the capacity of DON at the time of the survey. The Assistant Director of Nursing (ADON) confirmed during the entrance conference that there was no current DON, and the administrator reported that the previous DON had resigned the previous week, with their last day worked being 04/14/25. The facility's own policy stated that a registered nurse must be designated to serve as the DON on a full-time basis, but this requirement was not met during the period reviewed. At the time, the facility had 44 residents.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to inform and provide written information regarding advance directives to residents or their representatives, as required. For three sampled residents, there was no documentation in either the hard chart or electronic medical record indicating that advance directive information had been provided. These residents included individuals who were both cognitively intact and severely cognitively impaired, with diagnoses such as congestive heart failure, hypertension, renal insufficiency, diabetes mellitus, depression, schizophrenia, anxiety, bipolar disorder, and a history of traumatic brain injury. All three residents were documented as full code status in their physician orders and care plans, but there was no evidence that advance directive options or information had been discussed or offered. During interviews, the Business Office Manager (BOM) confirmed that the facility did not address advance directives with newly admitted residents or their representatives and did not have a process in place to offer information or education about advance directives to current residents. The BOM also stated that while the admission packet included a section on resident rights, it did not contain specific information related to advance directives. Additionally, the facility was unable to provide an advance directive policy when requested.
Failure to Follow Physician Orders for Blood Pressure Monitoring and Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician orders and medication hold parameters for two residents. For one resident with a history of hypertension, diabetes, mood disorder, dementia, psychosis, and benign intracranial hypertension, there were documented gaps in weekly blood pressure monitoring as ordered by the physician. The resident's care plan required weekly blood pressure checks and documentation, but the facility was unable to provide records of these checks for several months, coinciding with a transition to an electronic medical record system. This lack of documentation was confirmed by the MDS coordinator. For another resident with hypertension and moderate cognitive impairment, the facility did not adhere to the physician's order to hold Carvedilol if the systolic blood pressure was less than 120. The medication administration record showed multiple instances where the medication was given despite systolic blood pressure readings below the specified threshold. Both the ADON and a CMA acknowledged that the medication should have been held according to the order, but it was administered regardless.
Insufficient Nursing and Direct Care Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days with no RN hours and several shifts without 24-hour licensed nursing coverage, according to PBJ Staffing Data Reports from October through December 2024. The Quality of Care Monthly Reports for January, February, and March 2025 further documented numerous shifts across all times of day with insufficient direct care staff for the reported resident census. Interviews revealed that the facility relied almost entirely on agency staff for CNAs, CMAs, and licensed nurses, with no core staff RNs consistently covering specific shifts. The Director of Nursing had resigned in April 2025, and the Assistant Director of Nursing was the only full-time core staff nurse, while the MDS coordinator was shared with another facility. CNA staff reported that, in addition to their care duties, they were often responsible for housekeeping tasks such as emptying trash, cleaning bathrooms, and sweeping floors, especially when housekeeping staff were unavailable or their hours were uncertain. Staffing levels fluctuated based on resident census and staff call-ins, sometimes resulting in only one CNA per hall. The administrator confirmed the lack of consistent RN coverage and the heavy reliance on agency staff, with RN shift coverage varying week to week and no core staff RNs assigned to regular shifts.
Failure to Develop Legionella Water Management Program
Penalty
Summary
The facility failed to develop and implement a water management program for Legionella, as required for infection prevention and control. Record review showed that no Legionella testing had been conducted according to the maintenance air and water temperature log. When requested, the administrator provided only an information packet on Legionella, which did not include a formal policy. The maintenance supervisor, who was recently hired, reported not having a detailed diagram of the facility, no water management program in place, and no training on Legionella, aside from receiving an information packet. The administrator confirmed that there was no Legionella water management policy available at the time of the survey. A total of 44 residents were reported to be residing in the facility during the time of the deficiency.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, specifically for three residents who were prescribed antibiotics. According to the facility's undated policy, protocols should be in place to optimize infection treatment and ensure antibiotics are prescribed appropriately, with residents assessed using standardized tools and criteria. However, record review showed that for three residents with severe cognitive impairment and diagnoses such as dementia and Alzheimer's disease, antibiotics were prescribed for conditions including urinary tract infection, COVID-19, and other infections. Despite these prescriptions, there was no documentation that the required Loeb minimum criteria forms were completed to justify the initiation of antibiotic therapy. During an interview, the MDS coordinator confirmed that the facility was supposed to use the Loeb minimum criteria forms when starting antibiotic therapy, but no such forms were found for any residents, including the three sampled. The coordinator was unable to account for the missing forms or confirm if they had ever been used, indicating a lack of adherence to the facility's own antibiotic stewardship protocols.
Failure to Maintain Clean and Homelike Environment in Common Areas
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its 44 residents, as evidenced by multiple observations of uncleanliness and disrepair in common areas. During several tours, surveyors noted dirt and brown stains on floors in the main lobby, hallways, dining room, and common areas. A common area at the end of the women's hall was repeatedly observed to have trash, including a fast-food sack, candy wrappers, a soiled brief/diaper, and a crushed soda can on the floor. The area also had a strong urine odor, and a door was found with a plastic bag stuffed into a hole where a doorknob should have been. These conditions persisted over several days, with trash and soiled items remaining in place despite the presence of housekeeping staff in the building. Interviews with staff revealed that all housekeeping personnel were contracted through an agency, with no housekeeping coverage on weekends. CNAs, including agency staff, reported that they were responsible for cleaning tasks such as emptying trash and cleaning bathrooms, but often had to prioritize resident care over cleaning. Housekeeping staff acknowledged the poor condition of the floors and indicated that they had not yet been trained to use a floor stripper, which they believed would help address the stains. Facility policy required all staff to ensure common areas were clean and neat, but observations and staff interviews indicated this was not consistently achieved.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled and requested, resulting in a deficiency related to activities of daily living assistance. Observation showed the resident cleaning themselves with a wet wipe, and the resident reported feeling unclean due to not receiving regular showers. The resident stated they were supposed to receive showers twice a week but only received them approximately every two weeks, despite making multiple complaints to staff. The resident also indicated a preference not to be scheduled for showers late in the evening when they were tired, and reported never being given a reason for the delay. Documentation review revealed a previous refusal of a shower by the resident, but staff interviews indicated the resident did not refuse showers for all staff members. The ADON was unaware of the missed showers, and the MDS coordinator could not provide documentation of completed showers due to missing shower sheets after the previous DON left. The facility's policy emphasized the importance of showers for cleanliness, comfort, and skin observation, but this was not consistently provided to the resident.
Failure to Designate Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified staff member to serve as the infection preventionist responsible for the infection prevention and control program. Review of the facility's undated policy indicated the requirement for an infection preventionist to oversee the infection prevention and control program for all residents, staff, volunteers, visitors, and contracted individuals. However, an undated staff roster did not list an infection preventionist, and during an interview, the DON confirmed that the facility was currently without an infection preventionist. At the time of the survey, there were 44 residents residing in the facility.
Delayed Refund of Resident's Personal Funds
Penalty
Summary
The facility failed to ensure a timely refund of a resident's personal funds within 30 days of discharge, as required by their Resident Funds policy. The policy mandates that upon discharge, eviction, or death, the facility must convey the resident's funds and a final accounting of those funds within 30 days, in accordance with State law. A physician's order and progress note documented that a resident was discharged to another long-term care facility. However, the refund checks for the resident's funds were issued nearly two months later, with one check dated March 25 and another dated March 26, despite the discharge occurring on January 29. The administrator was unaware of the reason for the delay, as the business office manager responsible for the refund no longer worked at the facility.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency (OSDH) and other officials as required for two residents. The first incident involved a resident with Huntington's disease, depression, vascular dementia, mood disorder, and anxiety, who was severely impaired with cognition. An incident occurred where the resident became aggressive during care, resulting in scratches on their chest and neck. Despite the incident being reported internally, there was no documentation of an incident report or notification to the State Agency. Interviews with staff and review of camera footage did not substantiate the abuse claim, but the lack of formal reporting and documentation was a deficiency. The second incident involved a resident with schizophrenia, peripheral vascular disease, Type 2 diabetes, bipolar disease, depression, and pain, who was moderately impaired with cognition. The resident reported that a CMA cursed at them and almost hit them with a door. The administrator investigated the complaint, including reviewing camera footage and interviewing the CMA and other employees. The claim was deemed unsubstantiated, and no incident report was completed, nor was the allegation reported to the State Agency. This failure to report was a deficiency in the facility's handling of abuse allegations. In both cases, the facility's policy required immediate reporting of abuse allegations to the State Agency, but this was not followed. The administrator's determination that the allegations were unsubstantiated led to a failure to complete incident reports and notify the required authorities. This lack of adherence to reporting protocols resulted in deficiencies in the facility's compliance with regulatory requirements.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of abuse involving two residents. For the first resident, who had diagnoses including Huntington's disease and severe cognitive impairment, an incident occurred where the resident became aggressive during care, resulting in scratches on their chest and neck. The Assistant Director of Nursing (ADON) assessed the resident and interviewed them, but the resident denied being hurt. Despite interviewing other residents, there was no documentation of these interviews, and a statement from a key witness, CNA #3, was not obtained. The incident was reported to the administrator, but the investigation lacked thorough documentation and follow-up. For the second resident, who had diagnoses including schizophrenia and moderate cognitive impairment, a grievance was filed alleging that a Certified Medication Aide (CMA) cursed at the resident and almost hit them with a door. The administrator suspended the CMA and conducted an investigation, which included reviewing camera footage and employee statements. However, there was no documentation of interviews with other residents, and the claim was deemed unsubstantiated. The administrator admitted to not completing an incident report or documenting all findings, indicating a failure to conduct a comprehensive investigation.
Failure to Timely Transmit MDS Data
Penalty
Summary
The facility failed to electronically transmit completed Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) system within the required 14 days of completion. The facility's policy mandates compliance with quality reporting requirements, including the timely submission of MDS data to the CMS database. However, a review of MDS data revealed that assessments were not submitted from May 1, 2024, to July 8, 2024. During a phone interview, an LPN who began working as the MDS coordinator in July 2024 reported that the facility had been experiencing difficulties in transmitting MDS data, which had only recently been resolved. The LPN managed to transmit a batch of approximately 200 MDS assessments on October 8, 2024.
Failure to Maintain Required RN and DON Coverage
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, and did not have a director of nursing (DON) on a full-time basis. The review of staff time cards and schedules for August, September, and October 2024 revealed multiple days without RN or DON coverage. Specifically, there was no RN or DON coverage on several days in August, and in September, the DON worked only a few days with no other RN coverage documented. In October, the last day the DON worked was early in the month, with numerous days lacking RN coverage thereafter. Interviews conducted on November 14, 2024, with the assistant director of nursing (ADON) and the administrator confirmed the lack of consistent RN and DON coverage. The ADON reported that RN coverage was available on most weekends but was unsure if any RN covered DON responsibilities. The administrator confirmed that RN #1 worked most weekends and occasionally at night but did not assume any DON duties. The administrator also mentioned that the previous DON had last worked in early October and that a new DON was expected to start the following week. No staffing waivers were reported to be in place.
Facility Denies EMR Access to Surveyors
Penalty
Summary
The facility failed to grant access to the Electronic Medical Records (EMR) for the survey team during a complaint investigation. Upon entering the facility, surveyors were informed by the administrator that the facility utilized an EMR system, which staff members were observed using. The surveyors requested access to the EMR for record review, which is a standard requirement during such investigations. However, the administrator reported that the receiver of the facility had instructed that access to the EMR would not be provided to surveyors. Despite being informed of the necessity to grant access to avoid impeding the survey process, the receiver refused to comply, offering instead to print any requested documentation. This refusal to provide EMR access constituted a deficiency in the facility's compliance with regulatory requirements.
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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