Chandler Therapy & Living Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Chandler, Oklahoma.
- Location
- 601 West 1st Street, Chandler, Oklahoma 74834
- CMS Provider Number
- 375470
- Inspections on file
- 29
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Chandler Therapy & Living Center Llc during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple diagnoses reported verbal abuse by a CNA. Other staff members indicated they had previously reported the same CNA for similar behavior, but were unsure if those reports were investigated. The facility did not ensure the resident was protected from abuse as required by policy.
A resident with severe cognitive impairment and mental health diagnoses was involved in an incident where a CNA shouted at and antagonized them, as witnessed and reported by multiple staff. Although staff submitted written statements and notified the administrator, no investigation was conducted because the administrator did not consider the incident to be verbal abuse.
Menus were not prepared in advance with serving sizes or therapeutic diets, and there was no documentation of review by a dietitian. Dietary staff estimated portions without guidance, and the dietary manager, who was not certified, confirmed that menus had not been reviewed by a dietitian since a change in food provider. The dietary manager also stated they would not know how to serve a resident with a special diet and would seek guidance from nursing staff or the dietitian.
Surveyors found that the facility did not have a licensed administrator present or posted, as confirmed by the DON, who stated the previous administrator had quit and had not been replaced. At the time, 32 residents were under the facility's care.
Three residents, all cognitively intact and with significant medical histories, were not provided with regular opportunities to participate in their person-centered care plan meetings as required. Despite some documentation of care plan meetings, residents reported not attending or being aware of these meetings, and the Social Services Director confirmed that only one meeting had occurred in the past year, with no evidence of the required quarterly or annual meetings.
The facility did not maintain proper accounting or provide required financial statements for resident trust fund accounts, resulting in at least three residents—each with intact cognition and various medical conditions—not receiving requested account balances or their portion of SSI payments. Trust funds had not been reconciled for several months, and quarterly statements had not been distributed as required.
A resident admitted with COPD, depression, and anxiety disorder did not have a PASARR Level I assessment completed before or on admission. Review of the clinical record showed no documentation of the required screening, and the DON confirmed the assessment was missed.
A resident with anxiety disorder, hypertensive heart disease, and unspecified dementia was administered Lorazepam (Ativan) despite a physician's order to hold the medication. The order, dated early August, required holding Ativan unless behaviors resumed, yet the resident received the medication multiple times without documentation of resumed orders or behaviors. The DON admitted the oversight, suggesting the medication hold likely fell off, but could not locate an order to resume the medication.
A facility failed to include a 14-day stop date for a PRN order of Xanax, prescribed for a resident with anxiety disorder, insomnia, and unspecified dementia. The oversight was confirmed by the DON, who stated the medication should have had a stop date.
A resident with diabetes did not receive a timely annual comprehensive assessment, as it was completed more than 14 days after the ARD. The delay was due to the previous MDS coordinator's failure to complete assessments on time, and the facility's administrator admitted to not monitoring the timeliness of these assessments.
The facility failed to transmit MDS assessments within the required timeframe for two residents. One resident with diabetes had an annual and a discharge assessment submitted late, while another with acute kidney failure and a sacral ulcer had an admission assessment submitted late. The administrator acknowledged the previous MDS coordinator's failure to transmit timely and the lack of monitoring for timely submissions.
The facility did not complete baseline care plans within 48 hours for three residents with complex medical conditions, including congestive heart failure, end-stage renal disease, schizophrenia, and schizoaffective disorder. The care plans were marked 'In Progress' and left blank, and the DON could not explain the oversight.
The facility failed to develop comprehensive care plans for residents with specific medical needs, including end-stage renal disease, schizophrenia, and the use of an indwelling urinary catheter. The DON acknowledged that care plans were incomplete or outdated due to the previous coordinator's departure.
The facility failed to maintain infection control for two residents with urinary catheters. A resident with pressure-induced deep tissue damage had their catheter bag on the floor, contrary to policy. Another resident with acute kidney failure had their catheter bag dragging on the floor, and required catheter care was not documented. Staff were unclear about documentation responsibilities.
The facility failed to document and complete dialysis orders and assessments for three residents with end-stage renal disease. Pre-dialysis weights were often missing, and post-dialysis assessments were conducted by dialysis staff instead of facility staff. Residents reported that access sites were not assessed by facility staff, and the DON acknowledged the absence of a dialysis assessment policy and documented physician orders.
The facility failed to secure medications and ensure they were dated when opened. The Southwest treatment cart was repeatedly left unlocked and unattended by nursing staff. Additionally, medications on both the Southwest and North hall carts, as well as in the medication room, were found opened but not dated. The DON acknowledged the requirement for medications to be secured and dated but admitted to only monitoring insulins.
The facility failed to maintain qualified dietary staff, impacting meal services for 38 residents. Observations showed only a cook and a dishwasher in the kitchen, with no Dietary Manager for over two weeks after the previous one quit without notice. The facility was also short on cooks and dietary aides, and the administrator confirmed the vacancy and ongoing efforts to fill the position.
The facility failed to provide sufficient dietary staff to meet resident needs, with untrained maintenance and housekeeping supervisors assisting in food service tasks. The administrator confirmed the lack of dietary training and documentation for current staff.
The facility failed to serve food at appetizing temperatures, as observed during an evening meal. Residents complained about cold food, and a test tray revealed that the pizza, fruit cocktail, and salad were at room temperature. The administrator confirmed awareness of the issue.
The facility failed to maintain sanitary practices in food thawing and plate delivery. A ten-pound roll of hamburger meat was improperly thawed in a sink filled with water, contrary to professional standards. Additionally, an LPN delivered plates to residents without sanitizing their hands between deliveries, which was acknowledged as a lapse in protocol by both the LPN and the administrator.
A resident with a history of traumatic brain injury was not allowed to eat in their preferred dining location, the living room, due to the presence of State surveyors. Despite the resident's ability to communicate their preference and no valid reason to eat in their room, the facility staff fed the resident in their room, violating the resident's right to self-determination.
A facility failed to complete a resident's quarterly assessment within the required 14-day timeframe. The resident, who had end-stage renal disease, had their assessment completed more than 14 days after the ARD. The administrator admitted that the previous MDS coordinator did not complete assessments timely and there was a lack of monitoring.
A facility failed to request a level two PASARR for a resident with schizophrenia and unspecified psychosis, despite these diagnoses being present upon admission. The Nursing Facility Level of Care Assessment incorrectly documented the absence of a serious mental illness, and the DON confirmed no documentation of a level two PASARR request. The administrator noted a former employee responsible for these requests claimed they were up to date, indicating a lapse in the process.
A facility failed to review a care plan for a resident with dementia, hypertension, and anxiety. The resident's family was not notified or involved in the care plan meeting, and the clinical record lacked documentation of their participation. The social services coordinator admitted to being behind schedule and not conducting the required care plan meeting.
A facility failed to complete a discharge summary with a recapitulation of a resident's stay. The resident, diagnosed with dementia, was discharged to home with home health. The discharge note included details about the resident's transport and belongings but lacked a recapitulation of the stay. The DON was uncertain about the responsibility and content requirements for discharge summaries.
A facility failed to properly label an enteral tube feeding bag for a resident. The bag was initially observed without a label, and later with an incomplete handwritten label missing the resident's name and prescribed rate. RN and DON confirmed the labeling requirements, which were not met.
A facility failed to monitor a resident's anticoagulant side effects and did not complete a hemoglobin A1C test as ordered. The resident, with diabetes and hypertension, was prescribed Eliquis and required quarterly A1C tests. Staff interviews revealed missing documentation for side effect monitoring and an incomplete A1C test, with the DON confirming these oversights.
The facility did not follow the prescribed menu during an evening meal service, as vegetable soup was not served with the meal. A cook stated the soup could not be found, and the administrator indicated that dietary staff should notify them if a menu item is unavailable.
The facility failed to follow infection control practices, including the use of Enhanced Barrier Precautions (EBP) and proper disinfection of a glucometer. A resident with a tracheostomy and urinary catheter received care without the nurse wearing a gown, and the nurse did not sanitize hands between glove changes. Additionally, an RN used a glucometer on multiple residents without disinfecting it between uses, contrary to protocol.
A resident with dementia and other health issues eloped from an LTC facility, resulting in hospitalization for rhabdomyolysis, acute kidney injury, and a UTI. The resident was last seen around noon and was found the next day at a family member's house after walking an estimated 20 miles. Staff provided inconsistent accounts of the resident's whereabouts, and the facility's elopement policy was not effectively followed.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a certified nursing assistant (CNA). According to the incident report, a resident with moderately impaired cognition, diabetes mellitus, and anxiety disorder alleged that a CNA was verbally abusive. The resident did not initially report the abuse, but the allegation was later brought to the administrator's attention. Interviews with other staff members revealed that they had previously reported the same CNA for verbal abuse, but were unsure if those reports had been investigated. The facility's abuse policy requires protection from all forms of abuse, but the repeated allegations and lack of clarity regarding prior investigations indicate a failure to ensure residents were free from abuse.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with severe cognitive impairment, anxiety, and depression. Multiple staff members, including a CNA and a CMA, witnessed and documented an incident in which a CNA shouted at the resident, with one staff member reporting that the CNA antagonized the resident who had expressed suicidal thoughts. Staff members wrote statements about the incident and slid them under the administrator's door, and the administrator was also notified via text message. Despite these reports and the facility's policy requiring immediate investigation of all alleged abuse, the administrator did not investigate the incident, stating they did not believe it constituted verbal abuse.
Menus Lacked Serving Sizes and Dietitian Review
Penalty
Summary
The facility failed to ensure that menus were prepared in advance with appropriate serving sizes and nutritional adequacy, and that these menus were reviewed by a dietitian. A review of the handwritten dietary menu for a specified week revealed that it lacked documentation of serving sizes and did not include therapeutic diets such as renal or diabetic diets for residents. There was also no evidence that the menu had been approved by a dietitian. Interviews with dietary staff indicated that they did not have guidance on serving sizes and would estimate portions. The dietary manager, who was not certified and had recently assumed the position, confirmed that therapeutic menus with serving sizes had not been reviewed by a dietitian since a change in food provider. The dietary manager also stated they would not know how to serve residents with special diets and would rely on nursing staff or the dietitian for guidance.
Absence of Licensed Administrator for Facility Management
Penalty
Summary
The facility failed to have a licensed administrator present to manage operations. During an entrance on 03/10/25 at 2:00 p.m., surveyors observed that there was no administrator on site and no administrator license posted. The Director of Nursing (DON) confirmed that the previous administrator had quit on 03/07/25 and had not been replaced. At the time of the survey, 32 residents were residing in the facility. These findings were based on direct observation and interview with the DON, who verified the absence of a licensed administrator responsible for the facility's management.
Failure to Ensure Resident Participation in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents were able to participate in the development and implementation of their person-centered care plans. For three residents reviewed, documentation showed that care plan meetings were either not held as required or residents were not given the opportunity to participate. One resident with a history of orthopedic aftercare, chronic pain, renal dialysis dependence, major depressive disorder, and anxiety disorder reported not having had a care plan meeting, despite documentation of a previous meeting. Another resident with epilepsy and anoxic brain damage, who was cognitively intact, stated they had not been having regular care plan meetings as required, even though records indicated meetings had occurred. A third resident with heart failure and bipolar disorder, also cognitively intact, reported not attending any care plan meetings since admission, and documentation showed a refusal to attend one meeting with no evidence of rescheduling or further attempts. The Social Services Director confirmed that residents had only one care plan meeting in the past year, despite the requirement for quarterly and annual meetings. There was no documentation available to show that the required meetings had been completed. These findings indicate that the facility did not consistently provide residents with the opportunity to participate in their care planning process, as required by regulation.
Failure to Maintain and Communicate Resident Personal Funds Accounts
Penalty
Summary
The facility failed to maintain a system that ensured compliance with generally accepted accounting principles for managing residents' personal funds accounts. Specifically, the facility did not provide individual financial records to residents through quarterly statements or upon request, as required by policy. Three residents with trust fund accounts reported issues: one resident stated they had requested their account balance but had not received the information, while two other residents reported not receiving their portion of SSI payments for the past two months. Trust account balance records were available, but the information was not communicated to the residents as needed. Further review revealed that the trust funds had not been reconciled since June 2024, and the last distribution of quarterly statements occurred in April 2024. The business office manager confirmed that 18 residents had trust fund accounts, and the vice president of business administration acknowledged the lapse in reconciliation and statement distribution. The affected residents had varying medical conditions, including orthopedic aftercare, chronic pain, renal dialysis dependence, epilepsy, anoxic brain damage, heart failure, and bipolar disorder, with all demonstrating intact or independent cognitive function at the time of the deficiency.
Failure to Complete PASARR Level I Assessment Prior to Admission
Penalty
Summary
The facility failed to complete a PASARR Level I assessment for a resident admitted with diagnoses including chronic obstructive pulmonary disease, depression, and anxiety disorder. Upon review of the clinical record, there was no documentation found indicating that the required PASARR Level I screening was performed before or on the resident's admission date. The Director of Nursing confirmed that documentation of the assessment could not be located and acknowledged that the process had been missed.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to a physician's order for a resident diagnosed with anxiety disorder, hypertensive heart disease, and unspecified dementia. The physician's order, dated August 7, 2024, instructed to hold Ativan and call if behaviors resumed. However, the resident was administered Lorazepam (Ativan) multiple times in August 2024 without documentation of resumed orders or any noted behaviors. The Director of Nursing (DON) acknowledged the oversight, indicating the medication hold likely fell off, but could not find an order to resume the medication.
Failure to Include Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure compliance with regulations regarding PRN orders for psychotropic medications, specifically for a resident with anxiety disorder, insomnia, and unspecified dementia. The resident was prescribed Xanax, a benzodiazepine, to be taken orally every 8 hours for anxiety. However, the physician's order did not include a required 14-day stop date for the PRN medication. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the medication should have had a stop date.
Failure to Complete Timely Annual Assessment
Penalty
Summary
The facility failed to complete an annual comprehensive assessment for a resident with diabetes within the required 14-day period following the Assessment Reference Date (ARD). The assessment, dated June 12, 2024, was not completed until June 28, 2024, as documented in the MDS 3.0 NH Final Validation Report dated August 9, 2024. This delay was identified during a review of records and interviews, revealing that the previous MDS coordinator had not been completing assessments in a timely manner. The facility's administrator acknowledged that they had not been monitoring the timeliness of MDS assessments, although the previous Director of Nursing (DON) had been responsible for this task.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required seven days of completion for two residents. Resident #11, who had diagnoses including diabetes, had an annual assessment and a discharge return not anticipated assessment submitted late. Similarly, Resident #92, with diagnoses including acute kidney failure and a sacral ulcer, had an admission assessment submitted late. The issue was identified through a review of the MDS 3.0 NH Final Validation Report dated 08/09/24. The facility's administrator acknowledged that the previous MDS coordinator did not transmit the assessments timely and admitted that there was no monitoring in place to ensure timely transmission, although the previous Director of Nursing (DON) had been responsible for monitoring these assessments.
Failure to Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed for three of the twelve sampled residents whose care plans were reviewed. The facility's policy, dated December 2016, requires a baseline care plan to be developed within 48 hours of a resident's admission to address their immediate needs. However, for Resident #22, who had diagnoses including congestive heart failure and end-stage renal disease, the baseline care plan was documented as 'In Progress' and was blank. Similarly, Resident #27, with diagnoses of schizophrenia and end-stage renal disease, and Resident #92, with conditions including absence of left leg below the knee, absence of right foot, and schizoaffective disorder bipolar type, also had baseline care plans that were marked 'In Progress' and were blank. The Director of Nursing (DON) acknowledged that the baseline care plans were supposed to be completed within 48 hours of admission by the admitting nurse but was unable to explain why these care plans were incomplete. This oversight affected the facility's ability to meet the immediate needs of these residents upon their admission.
Deficiencies in Comprehensive Care Plan Development
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their specific medical needs. Resident #3, diagnosed with end-stage renal disease, did not have a care plan that included goals or interventions related to dialysis, despite receiving this treatment. The Director of Nursing (DON) acknowledged that the previous care plan coordinator had not developed a care plan for this condition, and the DON had not yet audited all care plans. Similarly, Resident #27, who had a diagnosis of schizophrenia and was receiving antipsychotic medication, lacked a care plan addressing this condition and its treatment. The DON admitted that the care plan needed updating to include schizophrenia and the use of antipsychotic medications. Additionally, Resident #92, with acute kidney failure and a sacral ulcer, was observed with an indwelling urinary catheter, yet no care plan was developed to address its use, goals, or interventions. The DON stated that care plans were being completed for other issues, but the use of catheters had not been addressed since the previous coordinator's departure.
Infection Control Deficiency in Urinary Catheter Care
Penalty
Summary
The facility failed to maintain infection control standards for two residents with urinary catheters. Resident #6, who had pressure-induced deep tissue damage, was observed on multiple occasions with their urinary catheter bag resting on the floor. Despite the facility's policy stating that catheter tubing and drainage bags should be kept off the floor, the bag was found on the floor during observations. LPN #1 acknowledged the improper positioning of the catheter bag and repositioned it, but the facility lacked a specific policy regarding the positioning of urinary catheters. Resident #92, diagnosed with acute kidney failure and a sacral wound, was observed with their catheter bag touching and dragging on the floor while in a wheelchair. The facility's records did not show documentation of the required twice-daily catheter care. Staff interviews revealed confusion about who was responsible for documenting catheter care, with both CNAs and nurses performing the care but failing to document it. The DON confirmed that both nurses and CNAs were responsible for catheter care documentation, but no records were found to support this.
Deficiency in Dialysis Care Documentation and Assessment
Penalty
Summary
The facility failed to ensure proper documentation and completion of dialysis orders and pre/post dialysis assessments for three residents with end-stage renal disease. Resident #3's records showed missing pre-dialysis weight documentation on two occasions and post-dialysis assessments were completed by dialysis staff instead of facility staff on seven occasions. Additionally, there was no documentation for pre/post dialysis assessments on five occasions. Resident #3 confirmed that while vital signs and weight were taken, the access site was not assessed by facility staff. Resident #22's records indicated missing pre-dialysis weight documentation on three occasions and post-dialysis assessments were completed by dialysis staff on ten occasions. The resident reported that weights were not taken due to malfunctioning scales and that the access site was not assessed by facility staff. Resident #27's records showed missing pre-dialysis weight documentation on one occasion and post-dialysis assessments were completed by dialysis staff on eight occasions. The facility's Director of Nursing (DON) acknowledged the lack of a policy for dialysis assessments and the absence of documented physician orders for dialysis in the electronic clinical record.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medications on two medication/treatment carts and in one medication room. On multiple occasions, the Southwest treatment cart was observed to be unlocked and unattended by nursing staff, specifically RN #2 and RN #3, who admitted to being responsible for the cart but failed to secure it. The Director of Nursing (DON) acknowledged that medications should be kept secured by locking the carts and mentioned that they monitored the carts by checking them when passing by. Additionally, the facility did not ensure that medications were dated when opened, as observed on both the Southwest treatment cart and the North hall medication cart. Medications such as docusate sodium, hydrogen peroxide, nystop powder, refresh eye drops, miralax powder, diabetic tussin liquid, and lansaprazole were found opened but not dated. LPN #1 and CMA #4 confirmed that medications were supposed to be dated upon opening. The DON stated that staff were expected to date medications when opened but admitted to only monitoring insulins, not other medications.
Deficiency in Dietary Staffing
Penalty
Summary
The facility failed to ensure there was qualified dietary staff to meet the needs of the residents. On August 12, 2024, observations revealed that only two employees, a cook and a dishwasher, were present in the kitchen. The Director of Nursing identified that 38 residents received meals from the kitchen. Cook #1 reported that there had not been a Dietary Manager (DM) for more than two weeks, as the previous DM had quit without notice. Additionally, the facility was short-staffed on cooks and dietary aides. A review of the facility managers' list confirmed that the dietary manager position was vacant, with no staff name listed. On August 13, 2024, the administrator acknowledged the staffing issues and mentioned that interviews for the DM position were scheduled, with hopes of hiring a new DM by the following week.
Insufficient Dietary Staffing and Training
Penalty
Summary
The facility failed to ensure there were sufficient dietary staff to meet the needs of the residents, as observed and reported by various staff members. The Director of Nursing identified that 38 residents received meals from the kitchen. However, the maintenance supervisor and housekeeping supervisor were involved in food service tasks such as putting away deliveries, making plates, cooking, and helping get meals out on time, despite not having received dietary training or holding a food handler's card. The administrator confirmed that they assisted with putting away food deliveries but acknowledged the lack of dietary training for the maintenance and housekeeping supervisors, as well as the absence of training documentation for the current dietary staff.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food was palatable and served at appetizing temperatures during an observed evening meal. This deficiency was identified through observation, record review, and interviews. The Resident Council Meeting Minutes documented a complaint about cold food, and residents expressed dissatisfaction with the temperature and quality of their meals. Specifically, one resident stated that food on the hall trays was cold and not good, while another resident mentioned that hot foods were not served hot and cold foods were not served cold. During a test tray observation, the pizza and fruit cocktail were found to be at room temperature, and the salad was wilted, soggy, and also at room temperature. The administrator acknowledged awareness of the problem with food palatability after tasting the test tray.
Sanitation Deficiencies in Food Thawing and Plate Delivery
Penalty
Summary
The facility failed to ensure that food was thawed and served in a sanitary manner, affecting the quality of care provided to residents. On August 11, 2024, a ten-pound roll of hamburger meat was observed thawing in a sink filled with water, which is not in accordance with professional standards. Both a staff member and the administrator confirmed that meat should be thawed under cold running water or in a refrigerator, not in a sink filled with water. Additionally, on August 13, 2024, an LPN was observed assisting a resident into the dining room and locking the wheelchair brakes, then continued to deliver plates to other residents without sanitizing their hands between each delivery. The LPN acknowledged that they should have sanitized their hands after delivering each plate, and the administrator confirmed that staff should sanitize their hands after each resident's plate delivery.
Failure to Honor Resident's Dining Location Preference
Penalty
Summary
The facility failed to honor a resident's choice of dining location, which is a violation of the resident's right to self-determination. The incident involved a resident with a history of traumatic brain injury who preferred to eat meals in the living room. On the day of the observation, the resident was fed lunch in their room instead of the living room, which was their stated preference. A CNA confirmed that the resident liked to eat in the living room but was instructed to feed the resident in their room because the State was present in the facility. The Director of Nursing also acknowledged that the resident typically ate in the living room and there was no reason for them to be fed in their room, indicating a failure to support the resident's choice.
Failure to Complete Timely Quarterly Assessments
Penalty
Summary
The facility failed to ensure that quarterly assessments for residents were completed within the required timeframe. Specifically, for one resident with end-stage renal disease, the quarterly assessment was not completed within 14 days of the Assessment Reference Date (ARD). The assessment, dated July 16, 2024, was not completed until August 9, 2024, exceeding the 14-day requirement. The MDS 3.0 NH Final Validation Report confirmed this delay. The facility's administrator acknowledged that the previous MDS coordinator had not been completing assessments in a timely manner and admitted that there was a lack of monitoring to ensure timely completion of these assessments, although the previous Director of Nursing had been responsible for monitoring them.
Failure to Request Level Two PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a level two PASARR was requested for a resident who was reviewed for PASARR. The resident had diagnoses of schizophrenia and unspecified psychosis, which were documented in the electronic health record as present upon admission. However, the Nursing Facility Level of Care Assessment incorrectly documented that the resident did not have a serious mental illness. A review of the electronic health record revealed that a level two PASARR had not been requested. The Director of Nursing (DON) confirmed the absence of documentation for a level two PASARR request for the resident. The facility administrator mentioned that a former employee responsible for requesting level two PASARRs had informed them that they were caught up, indicating a lapse in the process.
Failure to Review Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a care plan was reviewed for a resident diagnosed with dementia, hypertension, and anxiety. The resident was admitted on an unspecified date, and the facility did not conduct a care plan meeting within the required timeframe. A family member of the resident reported not being notified or offered an opportunity to participate in the care plan meeting. Upon review of the resident's clinical record, there was no documentation indicating the resident's representative participated in the care planning process. The social services coordinator admitted that they had not conducted a care plan meeting for the resident, acknowledging that they were behind schedule.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary, including a recapitulation of the resident's stay, was completed for a resident who was discharged. The resident had a diagnosis of dementia and was discharged from skilled services to home with home health, as per a physician's order. The discharge summary progress note documented that the resident was transported home by family with all personal belongings, medications, discharge instructions, and information regarding upcoming appointments. However, it did not include a recapitulation of the resident's stay. The Director of Nursing (DON) was unsure who was responsible for completing discharge summaries and what information the facility's discharge summary form contained.
Improper Labeling of Enteral Tube Feeding Bag
Penalty
Summary
The facility failed to ensure proper labeling of an enteral tube feeding bag for a resident receiving tube feeding management. On two separate occasions, the resident was observed with a tube feeding bag that lacked appropriate labeling. Initially, the bag had no label, and later, it had a handwritten label that only documented the formula and date, but not the resident's name or the prescribed rate. This lack of labeling was confirmed by RN #1, who stated that the bag should have included the resident's name, date, time, formula, and rate. The Director of Nursing also confirmed that the tube feeding bag should contain a label with the resident's name, time the formula was hung, the type of formula, and the rate.
Failure to Monitor Anticoagulant Side Effects and Complete Hemoglobin A1C Test
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen, specifically concerning the side effects of an anticoagulant medication and the completion of a hemoglobin A1C test as ordered by the physician. The resident in question had diagnoses of diabetes mellitus and hypertension and was prescribed Eliquis, an anticoagulant, to be taken twice daily. Additionally, a hemoglobin A1C test was ordered to be conducted quarterly. However, the facility did not document any monitoring for side effects of the anticoagulant, nor did they complete the hemoglobin A1C test in June as required. Interviews with facility staff revealed that the monitoring for side effects was supposed to be documented on the treatment record every shift, but this was not done for the resident. The Director of Nursing (DON) confirmed that the side effects were listed on the treatment record, yet the documentation was missing. Furthermore, the DON acknowledged that the hemoglobin A1C test was not completed and could not provide a reason for this oversight. The responsibility for ensuring that the lab tests were completed as ordered was attributed to the nursing staff.
Failure to Follow Prescribed Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for one of the two observed meal services, specifically the evening meal. The menu, which was documented for several dates including August 13, specified that dinner should include cheese pizza, tossed salad with dressing, vegetable soup, seasonal fruit cup, and milk or a beverage of choice. However, during the observation on August 13, vegetable soup was not served with the meal. Cook #2 explained that the soup was not served because it could not be found. The administrator noted that dietary staff are expected to notify them if an item on the menu is unavailable.
Infection Control Deficiencies in EBP and Glucometer Disinfection
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed, specifically regarding the use of Enhanced Barrier Precautions (EBP) and the disinfection of a glucometer. Resident #6, who had a tracheostomy and a urinary catheter, was observed receiving care without the nurse wearing a gown, which is required under EBP. The nurse also failed to sanitize their hands between glove changes during tracheostomy care. The Director of Nursing (DON) confirmed that EBP should be observed for tracheostomy, catheter care, wound care, or enteral tube care. Additionally, the facility did not ensure the glucometer was disinfected between uses for three residents during glucose monitoring. RN #3 used the glucometer on multiple residents without disinfecting it between uses, as required. The RN admitted to forgetting to disinfect the glucometer and attempted to clean it with a bleach wipe, which was not used according to the manufacturer's instructions. The DON acknowledged the need to disinfect the glucometer with appropriate solutions between each resident and noted the required contact time for effective disinfection.
Resident Elopement Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, which resulted in the resident being hospitalized for rhabdomyolysis, acute kidney injury, and a urinary tract infection. The resident, who had diagnoses including unspecified dementia, psychotic disturbance, mood disturbance, anxiety, and bladder cancer, was identified as having a low risk of elopement. However, on the day of the incident, the resident was last seen around noon and was not accounted for during the evening shift. Multiple staff members provided inconsistent accounts of when they last saw the resident, and it was noted that the resident was able to leave the facility through a door to the smoking area by using a door code. The resident was found the following day at a family member's house after having walked an estimated 20 miles without food or water. The facility's elopement policy required staff to promptly report missing residents and initiate a search, but it appears these procedures were not effectively followed. The incident report and employee statements indicate a lack of communication and coordination among staff, as well as a failure to conduct timely elopement risk assessments. The facility's administrator and DON were unaware of how the resident managed to leave the building and reach their family's house. The deficiency highlights a significant lapse in supervision and adherence to the facility's elopement policy, which ultimately led to the resident's hospitalization.
Removal Plan
- Elopement risk assessments conducted on all residents
- Signs posted on front door to alert visitors not to let anyone out
- All staff inserviced
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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