Checotah Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Checotah, Oklahoma.
- Location
- 321 Southeast 2nd Street, Checotah, Oklahoma 74426
- CMS Provider Number
- 375140
- Inspections on file
- 28
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Checotah Nursing Center during CMS and state inspections, most recent first.
Two residents sustained first- and second-degree burns after spilling excessively hot coffee or tea that had been served without lids and without adherence to the facility’s hot liquid safety policy. One resident with dementia, psychosis, and impaired vision, who could not complete a BIMS interview, was left drinking hot coffee alone without a lid despite a care plan intervention to ensure awareness of hot liquids and provide lids as needed. Another cognitively intact resident with convulsions, reduced mobility, muscle weakness, and tremors treated with propranolol also drank from an unlidded cup and later reported spilling hot tea, resulting in a second-degree burn. Surveyors measured coffee and hot water temperatures well above the policy threshold, and kitchen staff reported they did not temp hot beverages and were unaware of the hot liquid policy.
The facility did not provide quarterly written statements of financial transactions to residents with personal funds managed in a trust, as required by facility policy. Instead, residents were only shown their trust fund ledger when they inquired about their balance.
Surveyors found that the facility did not keep the kitchen clean and served unpasteurized shell eggs that were not fully cooked to residents. The dietary manager confirmed the use of unpasteurized eggs and acknowledged that kitchen floors had not been cleaned for about a week, with the cleaning schedule left incomplete. Meals prepared in these conditions were served to 39 residents.
The facility did not provide RN coverage for eight consecutive hours on multiple days, as shown by the October schedule and confirmed by the administrator. At the time, 43 residents were in the facility.
A resident's room was found to have a large crack in the window and significant dirt and grime buildup. Housekeeping staff indicated windows should be cleaned weekly and cracks reported to maintenance, but maintenance was unaware of the issue. This resulted in a failure to provide a clean, comfortable, and homelike environment.
A resident with severe cognitive impairment, fully dependent on staff for transfers, slipped out of a sit-to-stand mechanical lift when only one staff member assisted, contrary to facility policy requiring two staff for such transfers. Staff interviews confirmed knowledge of the policy, but the required assistance was not provided at the time of the incident.
A facility failed to update a care plan with interventions for a resident with a history of inappropriate sexual behaviors, despite the resident's severe cognitive impairment and previous incidents. The DON acknowledged the lack of a formal plan to prevent such behaviors, although staff knew how to respond.
The facility failed to implement its abuse policy after a CNA was reported for verbal abuse, using offensive language in front of a resident. Despite the substantiated allegation, the CNA was not terminated as per policy and continued working without documented training. This led to a deficiency due to improper handling and documentation of the incident.
The facility failed to document an investigation into abuse allegations, affecting all residents. A resident reported a CNA using offensive language, which was substantiated, resulting in termination. Another allegation of aggression by the same CNA was not substantiated, allowing the CNA to continue working. No witness statements or investigation documentation were available, and employees confirmed the lack of documentation despite claiming an investigation was conducted.
The facility failed to adhere to professional standards for respiratory care by not dating oxygen tubing for residents requiring oxygen therapy. Observations revealed that several residents with chronic respiratory conditions had undated oxygen tubing, despite physician orders for weekly changes. The DON confirmed that staff were expected to change and date the tubing as ordered.
The facility failed to employ sufficient staff in the food and nutrition service, leading to inadequate meal service. Observations showed a lack of staff during meal times, with residents eating from disposable trays due to staff shortages. The Dietary Manager noted that meal menus had to be adjusted due to insufficient staffing, affecting the preparation and service of meals for 28 residents and one resident on tube feeding.
The facility did not have a system in place for surveillance and monitoring to prevent Legionnaires' disease. Although a policy for Legionella surveillance existed, the DON was unaware of any documentation for monitoring efforts. This deficiency was identified despite the presence of 29 residents in the facility.
The facility failed to ensure correct and legal documentation of advance directives for two residents. One resident's care plan lacked documentation of an advance directive, and the DON could not locate the necessary documents. Another resident's POA form was not notarized, making it invalid, and their advance directive was not documented in the care plan.
The facility failed to store food safely as the refrigerator had been dripping for several days, with bowls placed to catch the liquid. The ice machine was also broken, requiring ice to be sourced externally. The refrigerator door gasket was sticking out, indicating a need for repair. The DM acknowledged these issues.
The facility failed to administer medications as ordered for two residents, leading to multiple missed doses. One resident with multiple diagnoses had several medications not documented as administered in February 2024, while another resident with atrial fibrillation, hypertension, and depression had missed doses in January 2024. The ADON confirmed the medications were not given as required.
The facility failed to complete a baseline care plan within 48 hours for a resident admitted with multiple diagnoses, including UTI, cerebral infarct, A-fib, dysarthria, heart failure, hemiplegia, and aphasia. The MDS Coordinator confirmed the care plan had not been created yet.
Failure to Control Hot Liquid Temperatures Resulting in Resident Burns
Penalty
Summary
The facility failed to ensure hot liquids were served at a safe temperature and that residents at risk for burns were adequately protected, resulting in burns to two residents. One resident with vascular dementia, behavioral disturbance, unspecified psychosis, and mildly impaired vision, and who was unable to complete a BIMS interview (score 99), was observed sitting alone at a table drinking from a brown coffee cup without a lid. This resident later sustained scalding burns to both thighs and a blister on the left thigh after spilling a hot fluid, with the physician describing the injury as 99% first-degree and 1% second-degree burns. The resident’s care plan included an intervention to ensure awareness of hot liquids and to provide lids as needed, but no lid was observed in use. A state incident report documented the hot fluid spill and resulting burns. A subsequent surveyor temperature check of coffee measured 160.9°F, and food temperature records showed coffee holding temperatures of 180°F on two dates, despite a facility policy stating that hot liquids above 140°F should be held in dietary until they reached an appropriate temperature. A second resident, who was cognitively intact (BIMS 13) but had diagnoses including unspecified convulsions, reduced mobility, impaired cognitive functions and awareness, and muscle weakness, and who was receiving propranolol for tremors, was also observed drinking from a brown coffee cup without a lid. This resident had previously reported spilling hot tea on their lap before breakfast, resulting in a wound measuring 6.0 x 2.5 inches with a blistered area of 4.0 x 1.5 inches; a physician later classified this as a second-degree burn, with updated wound measurements of 6 cm x 2 cm x 0.1 cm. A surveyor-measured hot water temperature was 166.9°F. The assistant director of nursing identified four residents at risk for burns from hot liquids. The cook stated they did not take temperatures of coffee or tea before serving and simply provided drinks to CNAs, and the dietary manager reported not knowing the policy for serving hot liquids, indicating that the facility’s written hot liquid safety policy was not being followed in practice.
Failure to Provide Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly written itemized statements of financial transactions to all 16 residents whose personal funds were managed in a trust by the facility. According to facility documents and policies, residents or their representatives were to receive these statements at least quarterly. However, interviews with the Business Office Manager (BOM) and the administrator revealed that they were unaware of the policy requirements and had not been issuing the required quarterly statements. Instead, residents were only shown their trust fund ledger upon request, rather than receiving regular written statements as stipulated by facility policy.
Failure to Maintain Kitchen Cleanliness and Use Pasteurized Eggs
Penalty
Summary
Surveyors observed that the facility failed to maintain kitchen cleanliness and did not ensure the use of pasteurized eggs for residents' meals. Unpasteurized shell eggs were found stored in the kitchen refrigerator and were used to prepare soft or over-medium eggs for residents, as confirmed by the dietary manager (DM), who was unaware if the eggs were pasteurized. A receipt confirmed the purchase of unpasteurized eggs, and there was no evidence that pasteurized eggs had been ordered. Additionally, the kitchen floor was found to be unclean, with a brown substance present against the walls, around table legs, and under the dish machine. The DM acknowledged that the kitchen floors had not been swept or mopped for about a week, and the cleaning schedule for the month had not been completed. A total of 39 residents were identified as having received meals prepared by the kitchen during this period. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours each day, seven days per week, as required. Review of the facility's schedule for October 2025 revealed that no RN was scheduled to work on six specific days during the month. The administrator confirmed that there was no RN present in the facility on those days. At the time, the facility had 43 residents residing there. This deficiency was identified through record review and administrator interview, with direct evidence that the required RN coverage was not maintained on the specified dates.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
A deficiency was identified when a resident's room was observed to have a 10 to 12 inch crack in the window glass along with a build-up of dirt and grime. The housekeeping supervisor stated that resident windows were supposed to be cleaned weekly and that any cracks should be reported to maintenance for repair. However, the maintenance supervisor reported being unaware of the crack in the window and acknowledged that it should be repaired. These findings indicate that the facility failed to maintain a clean and comfortable environment for the resident as required.
Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate assistance to prevent a resident from sliding out of a mechanical lift. According to the facility's policy, two staff members are required for any transfer involving a sit-to-stand mechanical lift. A resident with severe cognitive impairment, who was totally dependent on staff for transfers, slipped out of the sit-to-stand mechanical lift and was assisted to the ground. The incident report indicated that staff were to be educated on the requirement for two-person assistance during such transfers. Interviews revealed that at the time of the incident, only one staff member was present during the transfer, despite knowing the policy required two. The staff member reported being unable to find another person to assist. Other staff, including a CNA, an LPN, and the assistant director of nursing, confirmed that the facility policy mandates two staff members for transfers using the mechanical lift. This failure to follow established policy resulted in the resident sliding out of the lift.
Failure to Implement Interventions for Resident Safety
Penalty
Summary
The facility failed to implement necessary interventions to protect residents from abuse, specifically in the case of a resident with a history of inappropriate sexual behaviors. This resident, who was severely cognitively impaired and had diagnoses including sexual disorders, depressive disorders, and anxiety, was documented to have inappropriately touched another resident. Despite being admitted to a geri-psych facility for treatment, upon return, the resident's care plan was not updated with interventions to prevent further inappropriate behaviors. The Director of Nursing acknowledged that while staff were aware of how to respond to such behaviors, there was no formal plan in place to prevent them.
Failure to Implement Abuse Policy and Document Disciplinary Actions
Penalty
Summary
The facility failed to implement its abuse policy regarding an allegation of verbal abuse by a certified nursing assistant (CNA) which had the potential to affect all residents. The incident involved a resident who reported that the CNA used offensive language, including profanity, which was particularly upsetting during a gospel singing event. The director of nursing (DON) substantiated the allegation of verbal abuse, and the facility's policy stated that the employee should be terminated if the allegations were true. However, there was no documentation of the termination in the CNA's personnel file, and the employee roster did not reflect the termination. Despite the substantiated abuse, the CNA was allowed to return to work in the dietary department without undergoing any training on proper language use, contrary to what was documented. The CNA was later observed working in the nursing department and was reported by several anonymous employees to have not been terminated as initially decided by the administrator. This failure to adhere to the facility's abuse policy and the lack of proper documentation and follow-through on disciplinary actions led to the deficiency.
Failure to Document Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation regarding an allegation of abuse, which has the potential to affect all residents. The Reporting Resident Abuse policy requires the completion of an incident report form and, when possible, statements from any witnesses. An incident report dated June 2, 2024, documented that a resident reported a CNA using offensive language, which was substantiated, leading to the CNA's termination. Another incident report dated June 27, 2024, accused the same CNA of being aggressive with residents, but the investigation was not substantiated, and the CNA continued to work. There were no documented witness statements, interviews, or investigation records available for review. Interviews with several anonymous employees confirmed that no documentation of their interviews or the investigation was made, despite their claim of conducting an investigation.
Failure to Adhere to Oxygen Tubing Change Protocols
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for four residents who required oxygen therapy. Resident #9, diagnosed with congestive heart failure, chronic respiratory failure, and cerebral infarction, had physician orders to receive oxygen via nasal cannula and to have the oxygen tubing and humidifier changed weekly. However, observations on two separate occasions revealed that the oxygen tubing was not dated, indicating non-compliance with the physician's orders. Similarly, Resident #19, with chronic obstructive pulmonary disease and heart failure, was observed with undated oxygen tubing on two occasions, despite orders to change the tubing weekly. Resident #23, who had pneumonia, chronic obstructive pulmonary disease, and congestive heart failure, also had undated oxygen tubing during two observations, contrary to the physician's orders for weekly changes. Resident #24, diagnosed with chronic obstructive pulmonary disease, was found with oxygen tubing and a humidifier dated several weeks prior, indicating that the equipment had not been changed as required. The Director of Nursing acknowledged that the staff was expected to change and date the oxygen tubing as per the orders, and the lack of dating could lead to uncertainty about whether the tubing was changed as scheduled.
Staff Shortage in Food and Nutrition Service
Penalty
Summary
The facility failed to employ enough staff to effectively carry out the functions of the food and nutrition service. Observations, record reviews, and interviews revealed that the dietary schedule for August 2024 included only one cook and one dietary aide for the morning shift, one cook and one aide for a split shift, and one cook with no dietary aide for the evening shift. On a specific morning, a cart with eight disposable trays was observed unattended in the resident hall, and three residents were seen eating from disposable trays in the dining room. The Dietary Manager (DM) explained that breakfast was served on disposable trays due to staff shortages, with only one staff member available to serve breakfast that morning. Additionally, the DM provided menus for the week and stated that the lunch and supper menus had been switched because more time and staff were required to prepare the lunch menu. The DM acknowledged the need for more staff in the kitchen to adequately meet the dietary needs of the residents, which included 28 residents receiving meals prepared by the kitchen and one resident receiving nutrition via tube feeding.
Failure to Monitor and Prevent Legionnaires' Disease
Penalty
Summary
The facility failed to implement a system of surveillance and monitoring to identify and prevent Legionnaires' disease. The Director of Nursing (DON) identified that 29 residents resided in the facility. A policy titled 'Legionella Surveillance' was documented, indicating that Legionella surveillance is a component of the facility's water management plans for reducing the risk of Legionella. The policy stated that in the absence of Legionella infections for at least one year, the facility should implement primary prevention strategies, including diagnostic testing. However, during an interview on August 7, 2024, the DON provided a Legionella Policy but was unaware of any documentation for monitoring the prevention of Legionnaires' disease.
Deficiency in Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that information regarding advance directives was correct and legal for two residents. Resident #9, who had diagnoses including congestive heart failure, chronic respiratory failure, type 2 diabetes mellitus, and cerebral infarction, was documented as having a full code status in their care plan dated 12/19/23. However, the care plan did not document an advance directive. An acknowledgment form dated 06/18/24 indicated that the resident had executed an advance directive and a Power of Attorney (POA), but the Director of Nursing (DON) could not locate these documents in the resident's clinical record. Resident #20, with diagnoses including congestive heart failure, type 2 diabetes mellitus, and hypertension, had a care plan dated 08/15/23 that documented a full code status but did not include an advance directive. A POA form dated 03/02/21 was found in the records but was not notarized, rendering it not a legal document. An acknowledgment form dated 08/07/23 indicated that the resident had executed an advance directive and a POA, but the DON confirmed that an advance directive was not available in the resident's records.
Food Storage Deficiency Due to Equipment Issues
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During a kitchen tour, it was observed that the refrigerator had two plastic bowls on the top rack collecting liquid dripping from the ceiling. The Dietary Manager (DM) acknowledged that the refrigerator had been dripping for about four to five days. Additionally, the ice machine was broken, and ice was being sourced externally. During a meal service observation, the refrigerator still had the bowls in place to catch drips, and staff were seen moving the bowls to access other items. The refrigerator door also had a piece of the gasket sticking out, indicating a need for repair. The DM confirmed that both the refrigerator and the ice machine required maintenance.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for two residents, leading to multiple instances of missed doses. Resident #4, who had diagnoses including anxiety, major depression, hyperlipidemia, disc degeneration lumbar region, dementia, and DMII, had several medications not documented as administered on specific dates in February 2024. These medications included baclofen, tramadol hydrochloride, acetaminophen, divalproex sodium extended release, mirtazapine, atorvastatin calcium, trazodone hydrochloride, and levemir. The Assistant Director of Nursing (ADON) confirmed that the lack of documentation indicated the medications were not given, and no records were found in the paper medication administration book either. Similarly, Resident #1, who had diagnoses including atrial fibrillation, hypertension, and depression, also experienced missed medication administrations. The January 2024 Medication Administration Record (MAR) showed no documentation of time given for several medications, including budesonide, ipratropium bromide, refresh celluvisc, senna-plus, eliquis, folic acid, diltiazem hydrochloride, hydralazine hydrochloride, famotidine, levothyroxine sodium, and levalbuterol hydrochloride. The ADON reviewed the MAR and confirmed that the medications were not administered on the specified dates and times. The facility's failure to administer medications as ordered and to properly document medication administration led to significant gaps in the residents' treatment regimens. This deficiency was identified through record reviews and interviews, highlighting a critical lapse in the facility's pharmaceutical services and adherence to physician orders.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was completed within 48 hours for one of seven sampled residents reviewed for baseline care plans. The facility's policy mandates that a baseline plan of care to meet the resident's immediate needs should be developed by the Interdisciplinary Team (IDT) within 48 hours of admission. Resident #7, who was admitted with diagnoses including UTI, cerebral infarct, A-fib, dysarthria, heart failure, hemiplegia on the right dominant side, and aphasia, did not have a care plan located in their clinical record. The MDS Coordinator confirmed that the care plan had not been put together yet.
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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