Capitol Hill Skilled Nursing And Therapy
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 2400 Southwest 55th Street, Oklahoma City, Oklahoma 73119
- CMS Provider Number
- 375151
- Inspections on file
- 17
- Latest survey
- November 20, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Capitol Hill Skilled Nursing And Therapy during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and moderate cognitive impairment was found without access to their call light, which was placed out of reach while they were in a wheelchair. The resident was unable to call for help and needed ice water. A CNA confirmed the facility's policy to keep call lights within reach and rectified the situation by pinning the call light to the resident's blanket.
A facility failed to accurately code the MDS for a resident with end-stage renal disease who received dialysis three times a week. The resident's care plan documented the dialysis treatment, but the quarterly MDS assessment did not reflect this. The MDS Coordinator later confirmed the oversight, acknowledging the inaccuracy.
A facility failed to remove expired medication from circulation, as observed in the medication storage room. A card of Zoloft 100 mg, labeled for a resident with recurrent depressive disorders, was found expired despite procedures for rotating stock and removing outdated medications. The DON and ADON confirmed the oversight.
A facility failed to follow enhanced barrier precautions for a resident at risk of infection due to a PEG tube and MDRO. An LPN performed PEG tube care without wearing a gown, despite the presence of an EBP sign and available gowns. The LPN misunderstood the requirements, believing only handwashing was necessary. The DON confirmed that both gown and gloves were required, highlighting a lapse in the facility's infection control program.
A facility failed to ensure a clean environment for a resident, as moderate dust buildup was observed on the ceiling vent in the resident's room. Despite a housekeeping policy requiring regular cleaning of ceiling vents, the vent had not been cleaned, and a housekeeper admitted to neglecting this task.
A resident with dementia and personal care needs did not have a scheduled care plan meeting due to the departure of the responsible social worker. The facility failed to inform the resident's family about the missed meeting or reschedule it. The last care plan meeting was held months earlier, and the lack of communication contributed to the deficiency.
A resident with dementia and a UTI experienced a delay in urinalysis specimen collection due to a failure in sending the initial sample to the lab. The specimen, collected for lab tests ordered by a physician, remained in the ice box until a family inquiry prompted a new collection. The DON confirmed the need for timely specimen handling.
A facility failed to report an abnormal urinalysis result to the provider in a timely manner for a resident with dementia and a UTI. The urine specimen was collected and reported positive, but there was no documentation of provider notification on the report date. The delay in notification was confirmed by staff interviews, and the facility lacked a lab policy for notifying providers of abnormal results.
A resident with chronic obstructive pulmonary disease required a new upper denture plate, but the facility failed to follow up on a physician's order for a dental referral. Despite the resident reporting the loss of their dentures and a physician issuing an order, the resident had not seen a dentist. The LPN passed the order to the social services worker, but no appointment was made. The activities director, who helped with social services, was unaware of the need for a dental visit as the previous social service worker did not act on the order.
A resident with diabetes and intact cognition was observed without a privacy curtain in their room, which they expressed a desire for. An LPN confirmed that privacy curtains should be used but acknowledged the absence of one in the resident's room.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, leading to a deficiency. Resident #20, who has chronic respiratory failure with hypercapnia and moderate cognitive impairment, was observed without access to their call light. The resident's care plan, revised on 10/17/24, specified that the call light should be within reach and encouraged its use. On 11/06/24, the resident called out to a surveyor for assistance because the call light was placed on a recliner, out of reach, while the resident was seated in a wheelchair. The resident expressed that they could not call for help and needed ice water. CNA #4 confirmed that the facility's policy required the call light to be within reach and acknowledged that it was not in reach upon observation. CNA #4 then pinned the call light to the resident's blanket and provided the requested ice water.
Inaccurate MDS Coding for Dialysis Treatment
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident diagnosed with end-stage renal disease. The resident's care plan, dated July 11, 2024, indicated that they received dialysis at a local facility three times a week. However, during a quarterly assessment conducted on October 1, 2024, the MDS did not reflect that the resident was receiving dialysis. On November 7, 2024, the MDS Coordinator confirmed that the MDS should have been coded to indicate the resident's dialysis treatment, acknowledging the inaccuracy in the assessment.
Expired Medication Not Removed from Circulation
Penalty
Summary
The facility failed to ensure that expired medications were removed from circulation in the medication storage room, as observed during a survey. The facility's policy required that medications and biologicals be stored safely and securely, following the manufacturer's recommendations, and that outdated medications be immediately removed from inventory. However, during an observation with the Director of Nursing (DON) present, a card of pill-packed Zoloft 100 mg, labeled for a resident with recurrent depressive disorders, was found to be expired. The fill date and expiration date indicated that the medication was no longer valid for use. The DON and Assistant Director of Nursing (ADON) acknowledged that the medication aides were responsible for rotating the medication stock using a first-in, first-out process. They also stated that expired medications should be pulled and placed with discontinued medications. Despite these procedures, the expired Zoloft was still present in the medication storage room, indicating a lapse in the facility's medication management practices.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions for a resident who was on such precautions due to a risk of infection related to a PEG tube and an in-house MDRO. The resident's care plan, revised in September 2024, documented the need for enhanced barrier precautions, including the use of gowns and gloves during high-contact activities such as PEG tube care. However, during an observation in November 2024, an LPN was seen performing PEG tube care for the resident without wearing a gown, despite the presence of an EBP sign on the door and gowns available in the room. The LPN, upon being questioned, stated that they believed the EBP sign indicated the need for handwashing only and did not notice the gowns in the room. They also expressed the belief that wearing a gown was not necessary during PEG tube care. The Director of Nursing later confirmed that enhanced barrier precautions required the use of both a gown and gloves during such care, indicating a lapse in adherence to the facility's infection prevention and control program.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident, as evidenced by the presence of moderate dust buildup on the ceiling vent in the resident's room. The facility's housekeeping policy, revised in 2012, requires that resident rooms be cleaned from the ceiling down, with ceiling vents specifically mentioned as areas to be dry dusted. Despite this policy, observations on two separate occasions revealed that the ceiling vent in the room of a cognitively intact resident had not been cleaned. The resident confirmed that they had not cleaned the vent themselves. A housekeeper admitted to not paying attention to the ceiling vents during cleaning procedures and acknowledged the need for the vent to be cleaned upon observation.
Missed Care Plan Meeting Due to Staff Turnover
Penalty
Summary
The facility failed to hold a care plan meeting for a resident diagnosed with unspecified dementia and requiring assistance with personal care. The care plan meeting was initially scheduled but not conducted, and the resident's representative was not informed of the cancellation or rescheduling. The facility's administrator indicated that the social worker, who was responsible for organizing care plan meetings, had recently left their position, which contributed to the oversight. The last care plan meeting for the resident was held several months prior, and the facility did not communicate the missed meeting to the family or provide information on rescheduling.
Delayed Urinalysis Specimen Collection
Penalty
Summary
The facility failed to ensure a urinalysis specimen was obtained in a timely manner for a resident diagnosed with unspecified dementia and a UTI. A physician's telephone order on 10/15/24 requested several lab tests, including a urinalysis, due to the resident's generalized weakness. A urine specimen was collected on 10/16/24, but it was not sent to the lab and remained in the ice box. On 10/25/24, after the resident's family inquired about the urinalysis, an LPN discovered the oversight and obtained a new urine specimen, which was then sent to the lab. The DON confirmed that staff are responsible for notifying the lab to pick up specimens promptly and that specimens should be obtained as soon as possible.
Failure to Timely Report Abnormal Lab Results
Penalty
Summary
The facility failed to report an abnormal urinalysis result to the provider in a timely manner for a resident diagnosed with unspecified dementia and a urinary tract infection (UTI). A physician's telephone order was made for several lab tests, including a urinalysis, due to the resident's generalized weakness. The urine specimen was collected and reported positive for a UTI, but there was no documentation that the provider was notified of this abnormal result on the date it was reported. The delay in notification is evident as the physician order for an antibiotic was not documented until several days later. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the provider was not notified promptly. Additionally, the facility lacked a lab policy to guide staff on the notification process for abnormal lab results, as confirmed by a corporate nurse consultant.
Failure to Follow Up on Dental Referral
Penalty
Summary
The facility failed to follow up on a physician-ordered dental referral for a resident who required a new upper denture plate. The resident, who had chronic obstructive pulmonary disease and wore upper dentures, was documented to have broken or loosely fitting dentures. Despite a physician's order for a dental referral, the resident had not seen a dentist. The resident reported losing their dentures about a month prior and informed their physician, who issued an order for a dental referral. However, the order was not acted upon. Interviews revealed that the LPN was aware of the order and had passed it to the social services worker, but the resident had not been scheduled to see a dentist. The activities director, who assisted with social service duties, was unaware of the need for a dental appointment, as the previous social service worker had not acted on the order.
Lack of Privacy Curtain for Resident
Penalty
Summary
The facility failed to ensure privacy for a resident by not providing a privacy curtain in one of the sampled resident rooms. Resident #55, who has a diagnosis of diabetes mellitus type two and intact cognition, was observed sitting on their bed without a privacy curtain available to pull across the room. The resident expressed a desire for a privacy curtain to maintain privacy. An LPN confirmed that curtains should be closed to provide privacy but acknowledged that Resident #55's room lacked such a curtain, despite the resident's expressed need for one.
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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