Claremore Skilled Nursing And Therapy
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremore, Oklahoma.
- Location
- 920 East 16th Street, Claremore, Oklahoma 74017
- CMS Provider Number
- 375375
- Inspections on file
- 26
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Claremore Skilled Nursing And Therapy during CMS and state inspections, most recent first.
The facility failed to ensure resident council concerns were addressed in writing by responsible departments and administration. Resident council forms documented concerns about slow call light response, dietary issues such as lack of fresh fruit and menu variety, housekeeping issues including clothing labels and unclean rooms, and administrative issues involving unsecured exterior doors. Although the SSD recorded these concerns and forwarded them to the DON, dietary manager, housekeeping supervisor, and administrator with specified response deadlines, the forms showed no written responses. Staff interviews confirmed that department heads did not always provide written responses, and one supervisor acknowledged signing and returning a form without documenting a response, affecting all residents in the facility.
The facility failed to provide adequate staffing to ensure scheduled showers were completed for three cognitively intact residents who required staff assistance with bathing. One resident, with significant medical conditions and dependent on staff for shower transfers, received only one documented shower over an extended period despite being scheduled for twice-weekly showers and reported not having bathed in over a week. Two other residents, each scheduled for two showers per week, received only three showers in a month, missing multiple scheduled opportunities and reporting that showers were not provided as often as expected. Several CNAs reported they could not complete all assigned showers due to short staffing and lack of time, one noting they were assigned six showers but completed only two, while an LPN stated the charge nurse was responsible for ensuring showers were done and the DON acknowledged ongoing staffing issues.
Surveyors found multiple food service and sanitation deficiencies, including a dietary staff member with an uncovered beard and no hair restraint while working at the stove, a deep fryer with dark grease and accumulated food particles that was reportedly cleaned several days earlier without a documented cleaning schedule, and a pan of sausage kept in the refrigerator beyond the facility’s 24-hour leftover policy. Grease buildup was observed around oven wheels and on the stove exterior, along with food debris under the stove from a prior meal, and the cook reported the area had not been cleaned for about a month and was unaware of a current cleaning schedule. Meals prepared under these conditions were served to numerous residents.
The facility failed to provide scheduled showers according to the care plans for three cognitively intact residents who required staff assistance with bathing. One resident, dependent on staff for shower transfers and scheduled for twice-weekly showers, received only one documented shower during a month and reported going more than a week without a bath. Two other residents, each scheduled for two showers per week, received only three showers each over the month and reported that showers were not being given as often as expected. Multiple CNAs stated that residents were supposed to receive two showers weekly but that showers were often missed due to short staffing and lack of time, while an LPN and the DON acknowledged that charge nurses were responsible for ensuring showers were completed and that residents should be receiving two showers per week.
A resident with intact cognitive function had only one documented comprehensive care plan meeting following admission, with no evidence of required quarterly care plan meetings thereafter. The resident did not recall attending any care plan meetings. The MDS Coordinator, responsible for care plan meetings for LTC residents, reported not knowing that quarterly meetings with residents or their representatives were required. The DON stated there was no formal care planning policy and that they relied on CMS guidelines, while a corporate nurse consultant was identified as the MDS Coordinator’s supervisor and trainer for tracking care-plan meetings.
Two residents with severe cognitive impairment and dependent on staff for transfers suffered injuries when mechanical lift transfers were not properly supervised or equipment failed. In one case, a sling detached with only one staff member present, resulting in a rib fracture. In another, a sling strap broke, causing fractures to the resident's arm and hip.
Two residents who required assistance with bathing did not consistently receive the scheduled number of showers, as documented in care records and confirmed by staff and resident interviews. Both residents were supposed to receive showers twice weekly, but records showed multiple missed opportunities over several months.
A resident with multiple mental health diagnoses was allegedly forcefully pushed in their wheelchair by a CNA, resulting in contact with a wall. The facility did not obtain statements from those involved, could not confirm witness accounts or timing, and lacked documentation to show a thorough investigation or QAPI committee monitoring of the abuse allegation.
The facility failed to involve two residents in the care planning process. A resident with anxiety was unaware of care plan meetings, and the MDS Coordinator did not document invitations or attendance. Another resident with hypertension, depression, and an over-active bladder also did not participate in care plan meetings, with no documentation of notification or participation.
The facility failed to provide adequate showering services for four residents, leading to infrequent or missed showers. One resident resorted to sink baths due to scheduling issues, while another under hospice care did not receive preferred showers. A third resident, dependent on others for bathing, found the shower chair inadequate, and a fourth resident requiring male staff assistance did not receive a bath in 30 days. Staffing and coordination challenges contributed to these deficiencies.
The facility failed to complete ordered lab work for two residents. One resident with diabetes and hypertension did not have a lipid level collected as ordered, and it was delayed until June. Another resident with atrial fibrillation and a coagulation defect had a critical low potassium level, but the required redraw was not performed, and a complete blood count was ordered by mistake. The facility lacked a system to monitor lab orders for inaccuracies.
A facility failed to ensure the accuracy of an MDS assessment for a resident with acute respiratory failure and hypoxia. The assessment inaccurately indicated the resident required invasive mechanical ventilation while at the facility, despite no orders for a ventilator and the facility's policy of not accepting ventilator-dependent residents. The MDS coordinator noted the coding was based on the resident's pre-admission ventilator requirement.
A facility failed to provide a baseline care plan summary to a resident with kidney failure and sleep apnea and their representative. The MDS coordinator was unaware of the requirement, and the DON confirmed that summaries should be given to all residents and their representatives.
The facility failed to ensure proper communication with the dialysis provider for a resident requiring dialysis. The policy required scheduling and coordinating care, but a review showed that a Dialysis Communication Form had not been completed for over a month. Interviews with staff revealed a lack of awareness and responsibility for completing and sending the form with the resident to the dialysis center, as well as entering the information into the computer upon the resident's return.
The facility did not conduct a thorough investigation into an alleged abuse incident involving a resident and a CNA. The DON failed to interview residents or the nurse on duty during the incident, relying instead on their familiarity with the CNA. The DON later admitted that the investigation could have been more comprehensive.
Failure to Provide Written Responses to Resident Council Concerns
Penalty
Summary
The facility failed to honor residents' rights to have their resident council concerns and recommendations addressed by not obtaining written responses from responsible department heads and administration. A Resident Council Response Form dated 01/08/26 documented council concerns about the nursing department, including slow call light response, with a directive for the DON to respond in writing by 01/22/26; however, no written response from the DON was recorded on the form. The same form also documented concerns about the dietary department, including requests for fresh fruit and a more varied menu, and concerns about the housekeeping department, including the need for clothing labels, with written responses due from those departments by the same date; no written responses from dietary or housekeeping were documented on the form. A subsequent Resident Council Response Form dated 02/05/26 showed additional council concerns regarding administration, specifically that exterior doors could be opened from the outside without a code, and concerns about housekeeping related to resident rooms not being cleaned, with written responses due from the administrator and housekeeping supervisor by 02/17/26; no written responses were documented from either. The SSD reported being responsible for taking resident council minutes, recording concerns on the response form, and providing the form to the appropriate department heads, and stated that department heads did not always respond to the council’s concerns. The housekeeping supervisor stated they signed and returned the response form but did not document a response, and the dietary manager stated they did not always respond to the council in writing. The administrator identified 87 residents residing in the facility at the time of the survey.
Insufficient Staffing Resulting in Missed Scheduled Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ activities of daily living (ADL) needs, specifically bathing, for three cognitively intact residents who required staff assistance. One resident with respiratory failure and chronic kidney disease required substantial/maximal assistance with bathing and was dependent on staff for transfers to the shower, with showers scheduled twice weekly. Electronic health record (EHR) documentation showed only one shower provided over a period of more than a month, and the resident reported not having had a bath in over a week. A certified nursing assistant (CNA) confirmed they were responsible for the resident’s bath on a specific day but did not complete it due to lack of time during the shift. A second resident, who required partial/moderate assistance with bathing and was scheduled for twice-weekly showers, received only three showers out of seven scheduled opportunities in one month and reported usually receiving only one shower per week. A third resident, who required substantial/maximal assistance with bathing and was also scheduled for twice-weekly showers, received only three showers out of eight scheduled opportunities in the same month and reported that showers were not being given as often as they should be. Multiple CNAs stated that residents were supposed to receive two showers per week but that showers were often not completed because the facility was short staffed or there was not enough time in their shifts to complete all assigned showers. One CNA reported being assigned six showers on a shift but completing only two. An LPN stated the charge nurse was responsible for ensuring showers were given and that incomplete showers should be passed to the night shift, and the DON acknowledged there had been staffing issues, though they stated residents should be getting two showers per week.
Food Service Sanitation and Leftover Handling Deficiencies
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting meals prepared for 87 residents. During a kitchen observation, a dietary aide standing by the stove had a beard and was not wearing a hair restraint or beard guard, despite facility policy requiring hairnets or hair covers at all times and protective coverings for facial hair. The aide acknowledged they should have been wearing these items. Surveyors also observed a deep fryer with dark grease and food particles floating in the oil and piled on the outer edges; the cook reported the fryer was used daily and believed it was last cleaned about three days prior, but could not provide a cleaning schedule for the fryer. Additional observations showed a pan of sausage in the refrigerator labeled and dated several days earlier, beyond the 24-hour retention period specified in the facility’s leftovers policy. The cook confirmed leftovers were to be discarded after 24 hours and stated the sausage should have been thrown away. Surveyors also noted a thick black substance around the wheels of the oven, brown grease drips down the outside of the stove, and a tater tot under the stove from the previous night’s dinner meal. The cook identified the black and brown substances as grease and stated the floor area around the oven wheels had last been cleaned about a month earlier and that they were not aware of a cleaning schedule for the month in question.
Failure to Provide Scheduled Showers According to Residents’ Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing in accordance with residents’ plans of care and scheduled shower routines for three cognitively intact residents who required staff assistance with bathing. One resident with a BIMS score of 15 and assessed as needing substantial/maximal assistance with bathing was care planned to receive staff-assisted showers on Mondays and Thursdays and to be dependent on staff for transfers to the shower. Electronic health record (EHR) task documentation showed this resident received only one shower on 02/17/26 out of eight scheduled opportunities in February, with no documentation of showers on multiple other scheduled dates, and no additional shower documentation was produced upon request. The resident reported not receiving a bath the previous day and stated they had not had a bath in over a week. A CNA later confirmed they had been responsible for this resident’s bath on 03/02/26 but did not complete it due to lack of time during their shift. Two additional residents, both with BIMS scores of 14 and requiring partial/moderate or substantial/maximal assistance with bathing, were also not bathed according to their scheduled shower days. One resident, scheduled for showers on Tuesdays and Sundays, was documented as offered or receiving showers only three times during February, missing four other scheduled opportunities, and reported usually receiving only one shower per week. The other resident, scheduled for showers on Mondays and Fridays, was documented as receiving three showers out of eight scheduled opportunities in February and stated showers were not being given as often as they should be. Multiple CNAs reported that residents were supposed to receive two showers per week but that showers were often not completed due to short staffing and insufficient time during their shifts, with one CNA stating they were assigned six showers on a recent day but completed only two. An LPN stated the charge nurse was responsible for ensuring showers were given and that incomplete showers should be passed to night shift, and the DON acknowledged there had been staffing issues, while stating residents should be getting two showers a week.
Failure to Conduct Required Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure quarterly care plan meetings were held for a sampled resident, as required following the comprehensive assessment. The resident was admitted on 07/03/25 and had a BIMS score of 13, indicating intact cognitive functioning. Record review showed that a comprehensive care plan meeting occurred on 07/11/25, but no additional care plan meeting notes were found in the resident’s EHR thereafter. During interview, the resident stated they did not recall attending any care plan meetings. The MDS Coordinator, who was responsible for conducting care plan meetings for LTC residents, stated they were not aware that quarterly care plan meetings were required with residents or their representatives and confirmed that the only care plan meeting documented for this resident occurred in July 2025. The DON reported that the facility did not have a policy and procedure for care planning and instead just followed CMS guidelines, and it was further identified that the MDS Coordinator was supervised by a corporate nurse consultant who had been involved in training and tracking care-plan meetings.
Failure to Provide Adequate Supervision and Equipment Safety During Lift Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and safe practices during resident transfers using mechanical lifts, resulting in falls and injuries to two residents. In one incident, a resident with severe cognitive impairment and dependent on staff for transfers fell when the sling detached from the lift during a transfer, with only one staff member present instead of the required two. The resident suffered a rib fracture as a result of the fall. Documentation and interviews confirmed that the lift was not properly hooked and that only one staff member was assisting at the time. In a separate incident, another resident with severe cognitive impairment and also dependent on a lift for transfers sustained a fracture to the left arm and hip when a sling strap broke during a transfer. The resident reported feeling safe until the strap broke, which they described as a freak accident. Both incidents involved residents who required full assistance for transfers and had significant cognitive impairments, highlighting lapses in supervision and equipment safety during lift transfers.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide adequate bathing assistance to two residents who required help with activities of daily living, specifically showers. One resident, with a BIMS score of 7 indicating moderate cognitive impairment, was assessed as dependent for showers and was scheduled to receive showers twice weekly. However, documentation showed that in April, only one shower was provided out of nine opportunities, in May four showers out of nine, and in June, no showers had been given as of the 10th. The resident confirmed receiving only one shower per week. Another resident, with intact cognition and moderate dependence for showers, was also scheduled for twice-weekly showers. In April, this resident received four out of nine scheduled showers, in May three out of nine, and in June only one shower as of the 10th. Both the regional nurse consultant and the administrator confirmed that residents should have the opportunity for two showers per week, but records and resident interviews indicated this standard was not met.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident with diagnoses including major depressive disorder, chronic pain, anxiety disorder, and persistent mood disorders. An incident report documented an allegation that a CNA forcefully pushed the resident in their wheelchair away from the nurse station and hit the wall. The facility was unable to provide statements from either the resident or the CNA involved regarding the incident, nor could they confirm if there were any witnesses or the specific time the incident occurred. Additionally, the facility's quality assurance committee report did not show that abuse was monitored for compliance following the incident. The administrator confirmed that there was no documentation or investigation available to demonstrate that a thorough investigation had been completed, and review of QAPI committee documentation did not indicate that abuse had been identified or addressed after the incident.
Failure to Involve Residents in Care Planning Process
Penalty
Summary
The facility failed to ensure that two residents, identified as #58 and #7, were involved in the care planning process. Resident #58, who was admitted with anxiety, stated they were unaware of when care plan meetings were held. The MDS Coordinator confirmed that while invitations were extended, they were not documented, and there was no evidence that the representative for Resident #58 attended the meeting. Similarly, Resident #7, admitted with hypertension, depression, and an over-active bladder, reported not participating in a care plan meeting. The care plan for Resident #7, last updated on 06/21/24, lacked documentation of the resident's or their representative's participation. The MDS Coordinator admitted that notifications and participation were not documented.
Deficiency in Showering Services for Residents
Penalty
Summary
The facility failed to provide adequate showering services for four residents, as observed and documented in the report. Resident #7, who required partial to moderate assistance with bathing, reported not receiving showers as scheduled and resorted to bathing themselves in the sink. The clinical record showed infrequent assistance with bathing, and the CNA responsible for showers indicated that the workload often led to incomplete shower assignments, leaving some residents without showers. Resident #21, who was under hospice care, expressed dissatisfaction with the lack of showers, having not received one in six weeks despite a preference for weekly showers. The hospice records indicated that only bed baths were provided, and the facility's DON acknowledged the responsibility to coordinate care and respect residents' bathing preferences. Similarly, Resident #33, who was totally dependent on others for bathing, had not received a shower in two weeks. The resident found the shower chair uncomfortable and inadequate for proper cleaning, and the CNA confirmed that the resident's need for multiple staff assistance often resulted in missed showers. Resident #37, who required partial to moderate assistance and preferred male staff for showers, had not received a bath in the last 30 days, with no documentation of refusals. The facility's DON stated that male staff were assigned to assist this resident, but availability issues contributed to the lack of showers. Overall, the facility's staffing and coordination challenges led to significant deficiencies in providing necessary bathing care to these residents.
Failure to Complete Ordered Lab Work for Residents
Penalty
Summary
The facility failed to ensure that laboratory work was completed as ordered for two residents. Resident #39, who had diagnoses including diabetes mellitus and hypertension, had a physician's order to repeat a lipid level in April 2024. However, the lipid level was not collected in April, and it was only completed on June 27, 2024, after the issue was identified. The Assistant Director of Nursing (ADON) acknowledged the oversight and stated that the lab work had been addressed by the physician. Resident #33, with diagnoses including atrial fibrillation and an unspecified coagulation defect, had a critical low potassium level documented on January 25, 2024. A handwritten note instructed to administer potassium and redraw the lab on January 29, 2024, to check the potassium level. However, the redraw was not performed, and instead, a complete blood count was ordered by mistake, which does not measure potassium levels. The Director of Nursing (DON) confirmed the error and stated that the facility lacked a system to monitor laboratory orders for inaccuracies.
Inaccurate MDS Assessment for Ventilator Requirement
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for a resident who was reviewed for MDS accuracy. The resident had a diagnosis of acute respiratory failure with hypoxia. A Medicare five-day assessment indicated that the resident required invasive mechanical ventilation while at the facility. However, a review of the resident's orders did not document any orders for a ventilator at the facility. The Director of Nursing (DON) confirmed that the facility did not accept residents requiring ventilators. The MDS coordinator stated that the resident was coded as requiring a ventilator because they needed one before admission to the facility.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to a resident and their representative, which is a requirement. This deficiency was identified during a review of the clinical records and interviews with the staff and resident. Resident #7, who had diagnoses including kidney failure and sleep apnea, reported not receiving a summary of their baseline care plan. Upon reviewing the resident's clinical record, it was confirmed that there was no documentation of a baseline care plan. The MDS coordinator admitted to not providing the summary because they were unaware of the requirement. The Director of Nursing acknowledged that a summary should be given to all residents and their representatives.
Failure in Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure appropriate communication between the facility and the dialysis provider for a resident who required dialysis services. The facility's policy required scheduling visits to the dialysis center and coordinating care accordingly, with a specific intervention to schedule dialysis every Monday, Wednesday, and Friday. However, a review of the resident's medical record revealed that a Dialysis Communication Form had not been completed since late May. Interviews with staff, including LPNs and the DON, indicated a lack of awareness and responsibility regarding the completion and transmission of the communication form. The LPNs and the DON acknowledged that the form should accompany the resident to the dialysis center and be entered into the computer upon the resident's return, but this process was not being followed consistently.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident and a CNA. The facility's policy on Resident Abuse, Neglect, and Misappropriation of Property requires a comprehensive investigation, including interviews with residents and staff. However, the Director of Nursing (DON) could not recall interviewing any residents or the nurse on duty during the night of the alleged incident. Despite having worked with the CNA involved and feeling confident in their character, the DON unsubstantiated the allegation without conducting a complete investigation. The DON later acknowledged that they could have spoken with other residents in the area where the incident occurred, indicating that the investigation was not thorough.
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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