Cedarcrest Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Broken Arrow, Oklahoma.
- Location
- 1306 East College, Broken Arrow, Oklahoma 74012
- CMS Provider Number
- 375233
- Inspections on file
- 22
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Cedarcrest Care Center during CMS and state inspections, most recent first.
The facility did not complete required initial competency and skills checklists for multiple newly hired CNAs. Review of personnel records showed that several CNAs lacked documented competency assessments corresponding to their hire dates, despite the DON identifying multiple licensed staff who should have had initial competencies completed. The business office manager confirmed that no skills checklists or competency documents were available for the requested files, and the DON acknowledged that initial skills competencies should have been done but could not explain why they were not completed.
Staff did not recognize or report a resident-to-resident altercation as abuse within the required two-hour window, instead initially reporting it as an injury. The DON later confirmed the incident should have been reported as abuse according to facility policy.
A resident with Alzheimer's and dementia was found with a swollen and discolored lip with bite marks, but the facility failed to conduct a thorough investigation. The DON did not document discussions with day shift staff, did not speak with night shift staff, and did not perform a skin assessment, contrary to the facility's abuse prevention policy.
The facility failed to prevent abuse, with incidents involving resident-to-resident aggression and staff-to-resident abuse. A resident with Alzheimer's exhibited aggressive behaviors, including choking another resident. Another resident with a memory deficit was harmed during an altercation. Additionally, a resident with dementia was abused by a CNA, resulting in physical injuries. Staff noted insufficient interventions, particularly during evening shifts, to prevent these incidents.
A facility failed to prevent resident-to-resident abuse and staff abuse. A resident with Alzheimer's dementia exhibited aggressive behaviors, including choking another resident with a memory deficit. Despite staff attempts to redirect and engage residents, interventions were insufficient. Additionally, a CNA was observed hitting a resident with a towel after being spat on, following antagonistic behavior. The DON acknowledged the incidents and the lack of effective interventions.
The facility failed to update care plans for two residents involved in abuse incidents. One resident with Alzheimer's dementia exhibited aggression, including choking another resident who wandered into their room. Staff noted a lack of evening activities to mitigate such behaviors. Another incident involved a resident with dementia being abused by a CNA, who hit the resident with a towel after being spat on. The facility's intervention of having two staff present during showers was ineffective, as multiple staff were already present during the incident.
A facility failed to report an abuse allegation within the required timeframe. A CNA allegedly abused a resident with dementia by hitting them with a wet, soapy towel and making derogatory comments. The incident was reported to administration a day late, delaying notification to authorities. Additionally, the report to the Nurse Aide Registry was not completed in a timely manner.
The facility failed to report abuse allegations within the required timeframe, involving both resident-to-resident and staff-to-resident incidents. A resident was found choking another, and a CNA allegedly abused a resident with a towel. Delays in reporting to authorities and ineffective interventions were noted, with the DON acknowledging the inadequacy of current measures.
Failure to Complete Initial Competency Assessments for Newly Hired CNAs
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had appropriate initial competency assessments completed upon hire, as required to maximize each resident’s well-being. Record review showed that three certified nurse aides (CNA #5, CNA #10, and CNA #11) did not have completed competency/skills checklists corresponding to their hire dates of 04/11/25, 12/02/25, and 09/25/25, respectively. The Director of Nursing (DON) identified a total of 14 licensed staff members who should have had initial competencies completed. On 03/04/26 at 9:28 a.m., the business office manager confirmed there were no skills checklists or competencies available for the requested employee files. Later that day, at 11:03 a.m., the DON stated that the facility should be conducting initial skills competencies on staff and did not know why these were not completed.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to recognize and report an incident of potential abuse within the required two-hour timeframe for two residents involved in a resident-to-resident altercation. According to facility policy, all allegations of abuse, neglect, mistreatment, or misappropriation of resident property must be reported immediately, but no later than two hours after the allegation is made. In this case, an unwitnessed incident occurred in which one resident was found on the ground in another resident's room after staff heard a noise. The resident was assessed and found to have no injuries, while the other resident was sent for psychiatric evaluation. The incident was initially reported as an injury rather than abuse, and the Director of Nursing later acknowledged that it should have been recognized and reported as abuse within the required timeframe.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident diagnosed with Alzheimer's disease, dementia, anxiety, and delusional disorders. The resident was found with a discolored and swollen top lip with bite marks underneath, which was not present the day before. The incident was reported to the Oklahoma State Department of Health, and the resident's family was notified. However, the investigation process was incomplete as the Director of Nursing (DON) did not document discussions with the day shift staff, did not speak with the night shift staff, and did not conduct a skin assessment during the investigation. The facility's undated Abuse Prevention Policy and Procedure required an immediate investigation into any allegation of abuse, neglect, or misappropriation of resident property. Despite this policy, the DON, who was responsible for the investigation, did not follow through with a comprehensive investigation. The lack of documentation and communication with all relevant staff members, as well as the absence of a skin assessment, contributed to the failure to determine the cause of the resident's injury. This deficiency highlights a gap in the facility's adherence to its own policies regarding the investigation of potential abuse or neglect incidents.
Failure to Prevent Abuse in LTC Facility
Penalty
Summary
The facility failed to provide an environment free of abuse, as evidenced by multiple incidents involving resident-to-resident aggression and staff-to-resident abuse. Resident #1, diagnosed with Alzheimer's dementia, exhibited aggressive behaviors towards other residents, including pushing, throwing water, and choking another resident. These incidents were documented over several months, with staff noting that Resident #1's aggression typically increased in the evening. Despite attempts to separate Resident #1 from others and engage them in activities, the interventions were insufficient to prevent further incidents. Resident #2, who had a memory deficit following a stroke, was a victim of abuse when Resident #1 choked them after they wandered into Resident #1's room. The incident resulted in physical harm to Resident #2, including scratches and a purple complexion. Staff interviews revealed that Resident #1 had a history of aggression, and there were concerns about the lack of organized activities during the evening shift to mitigate such behaviors. The facility's Director of Nursing acknowledged the failure of current interventions to prevent the incident. Additionally, Resident #3, diagnosed with dementia and behavioral disturbances, was subjected to abuse by CNA #1, who repeatedly hit them with a wet, soapy towel after the resident allegedly spat on the CNA. Witnesses reported that CNA #1 antagonized Resident #3, leading to the altercation. The incident resulted in physical injuries to Resident #3, including bleeding and irritation. The facility's response to this incident was to ensure two staff members assist Resident #3 during showers to prevent further abuse.
Failure to Prevent Resident and Staff Abuse
Penalty
Summary
The facility failed to provide an environment free from resident-to-resident abuse and did not ensure that staff accused of abuse were removed from resident access until a thorough investigation was conducted. Resident #1, diagnosed with Alzheimer's dementia, exhibited aggressive behaviors towards other residents, including pushing, throwing water, and choking another resident, Resident #2, who had a memory deficit following a stroke. These incidents occurred over several months, with staff noting Resident #1's aggression typically increased in the evening. Despite attempts to redirect and engage residents in activities, the facility's interventions were insufficient to prevent Resident #1 from attacking Resident #2 when they found them in their roommate's bed. Additionally, the facility failed to protect Resident #3 from staff abuse. An incident report documented that CNA #1 was observed hitting Resident #3 with a wet, soapy towel after the resident allegedly spat on them. Further investigation revealed that CNA #1 had antagonized Resident #3 by flicking their nose and making derogatory comments, leading to the resident's agitation and subsequent spitting. Despite another CNA's attempts to intervene, CNA #1 continued the abusive behavior until another staff member entered the room. The facility's Director of Nursing (DON) acknowledged the incidents and the failure of current interventions to prevent resident-to-resident abuse. The DON also noted the lack of organized activities during the evening shift, which may have contributed to the incidents. The report highlights the facility's inability to effectively manage resident behaviors and ensure a safe environment for all residents.
Failure to Update Care Plans and Prevent Abuse
Penalty
Summary
The facility failed to update care plans for two residents involved in incidents of abuse. One resident with Alzheimer's dementia exhibited aggressive behavior, including choking another resident who had wandered into their room and laid in their roommate's bed. Staff interviews revealed that the aggressive resident had a history of such behavior, particularly in the evenings, and that there were no organized activities scheduled for the evening shift to mitigate these behaviors. Despite attempts to separate the resident from others and engage them in activities during the day, the interventions were insufficient to prevent the incident. Another incident involved a resident with dementia and behavioral disturbances who was physically abused by a CNA. The CNA was observed hitting the resident with a wet, soapy towel after the resident allegedly spat on them. Witnesses reported that the CNA had antagonized the resident, leading to the spitting incident, and continued to abuse the resident despite requests to stop. The resident sustained injuries, including bleeding from the nose, cheek, and above an eye. The facility's intervention to have two staff members present during showers was deemed inappropriate, as multiple staff were already present during the incident. The facility's Director of Nursing (DON) acknowledged the root causes of the incidents, including the failure to prevent resident wandering and the inappropriate response to resident behavior by staff. The DON admitted that the current interventions were inadequate in preventing these incidents of resident-to-resident and staff-to-resident abuse. The facility did not have effective strategies in place to address the behaviors and prevent further occurrences.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy by not reporting an allegation of abuse within the required two-hour timeframe to the Oklahoma State Department of Health. An incident involving a certified nurse aide (CNA) allegedly abusing a resident with dementia and behavioral disturbances was reported late. The incident occurred when a CNA was observed hitting the resident with a wet, soapy towel and making derogatory comments, which agitated the resident. This incident was not reported to the administration until the following day, delaying the notification to the relevant authorities. Additionally, the facility did not report the incident to the Nurse Aide Registry in a timely manner. The Director of Nursing (DON) attempted to fax the allegation to the Nurse Aide Registry from home, but the fax did not complete successfully. It was only resent from the facility two days later. This delay in reporting to the Nurse Aide Registry further highlights the facility's failure to adhere to its abuse policy and ensure timely communication with the appropriate agencies.
Failure to Timely Report and Address Abuse Allegations
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Oklahoma State Department of Health. An incident involving resident-to-resident abuse occurred when one resident was found choking another resident, resulting in physical harm. The initial incident report was not sent until the following day, indicating a delay in reporting. Additionally, the facility did not take adequate corrective action to prevent further risk of abuse for the residents involved. Another incident involved a certified nurse aide allegedly abusing a resident by hitting them with a wet, soapy towel and making derogatory comments. This incident was not reported to the administration until the day after it occurred, and the alleged perpetrator continued to work until the allegation was confirmed. The facility also failed to report this incident to the Nurse Aide Registry in a timely manner, as the initial attempt to fax the report was unsuccessful. The Director of Nursing (DON) acknowledged that the interventions in place were insufficient to prevent the incidents of abuse. The DON admitted that the facility's intervention of having two staff members present during resident showers was not effective, as the abuse occurred despite the presence of multiple staff members. The facility's inability to implement effective interventions and timely reporting contributed to the deficiencies identified in the report.
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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