Cleveland Care And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Oklahoma.
- Location
- 900 N Division St, Cleveland, Oklahoma 74020
- CMS Provider Number
- 375443
- Inspections on file
- 18
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Cleveland Care And Rehab Center during CMS and state inspections, most recent first.
A resident with documented candidiasis of the skin and nails and intact cognition had a physician order for Nystatin powder to be applied to skin folds, abdomen, and neck every shift. Review of the medication administration record for a given month showed that the Nystatin powder was not documented as given on multiple night shifts. During interview, the ADON confirmed that if the medication administration record checkbox was not marked, they assumed the treatment had not been completed, indicating the ordered topical antifungal was not administered as prescribed.
A resident who was bedbound, on continuous O2, and receiving hospice care was repeatedly observed in bed with multiple vape/e-cigarette devices on the bedside table, while using an oxygen concentrator via nasal cannula. The resident reported vaping in the room and stated staff were aware but did not intervene because the resident could not go outside. A CNA confirmed the resident’s in-room vaping and possession of e-cigarettes, and the ADON acknowledged the resident hid under a blanket to vape despite being on continuous O2. The facility’s smoking policy and smoking safety assessments did not address vaping/e-cigarettes, and leadership confirmed that vaping was not included in smoking evaluations, even though residents were not permitted to use vapes/e-cigarettes inside the facility.
A resident receiving continuous tube feeding was repeatedly observed with the head of the bed flat and not elevated, despite having severe protein calorie malnutrition, GERD, and moderate cognitive impairment. Over several observations, staff, including an LPN, reported not seeing the bed elevated, while the resident stated they preferred the bed flat to sleep. The ADON acknowledged the bed should be elevated to 45 degrees to prevent aspiration and that the resident would lower the bed, and also confirmed the resident had not been educated on the possible complications of refusing head-of-bed elevation.
Surveyors found that a resident with CHF, anemia, moderately impaired cognition, and orders for continuous O2 and routine nebulizer treatments had a nasal cannula left loose on a recliner and a nebulizer mask with tubing left on a cart, both unbagged despite orders to store tubing and mask in a dry protective cover when not in use. An LPN confirmed the resident’s respiratory orders and acknowledged the cannula should not have been left on the chair, and the ADON confirmed that both the cannula and nebulizer mask were not bagged and stated they should have been bagged for infection control.
A resident with a known latex allergy received a latex urinary catheter instead of the ordered silicone type, resulting in skin irritation. The allergy was documented in the medical record and care plan, but staff did not verify allergies prior to catheter insertion, leading to the use of the incorrect catheter material.
A resident with paraplegia and multiple Stage 4 pressure ulcers was not provided with a bed wide enough for safe repositioning or with requested adaptive devices such as side rails and a trapeze bar. The resident reported being unable to reposition independently and feeling unsafe, while the facility cited policy restrictions and delays in providing the necessary equipment.
A facility failed to involve a resident with chronic obstructive pulmonary disease and kidney failure in the development of their person-centered care plan. Despite the resident's intact cognition and desire to participate, there was no documentation of their involvement. The DON relied on the MDS coordinator for scheduling, but meetings were not conducted due to staff being too busy, contrary to the policy requiring quarterly meetings.
Failure to Administer Ordered Topical Antifungal Medication Every Shift
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed topical antifungal medication as ordered by the physician for one resident. A physician order dated 07/09/24 directed that Nystatin powder be applied to the resident’s skin folds, abdomen, and neck every shift. A significant change assessment dated 11/17/25 documented that the resident had candidiasis of the skin and nails and a BIMS score of 15, indicating the resident was cognitively intact for daily decision making. Review of the November 2025 medication administration record for the night shift showed that the resident did not receive the ordered Nystatin powder on multiple specified dates throughout the month. During interview, the ADON stated that if the checkbox on the medication administration record was not marked to indicate completion, they assumed the task had not been done. These findings show that, despite an active physician order and documented skin candidiasis, the ordered Nystatin powder was not administered on numerous night shifts as required, and the facility relied on unchecked MAR boxes as an indication that the treatment had not been provided.
Failure to Assess and Control Vaping/E-Cigarette Use for Oxygen-Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to evaluate and manage a resident’s vaping/e-cigarette use as part of its smoking safety program. On multiple observations, the resident was seen in bed using continuous supplemental oxygen via nasal cannula from an oxygen concentrator, with three pink vape/e-cigarette devices on the bedside table. The facility’s Smoking Protocol policy, dated 10/25/22, did not address vaping or e-cigarettes, and the resident’s Smoking Safety Evaluation, dated 11/05/25, documented that the resident did not smoke. The comprehensive assessment dated 11/17/25 showed the resident had COPD, hypoventilation syndrome, intact cognition with a BIMS score of 15, required substantial to maximum assistance with bed mobility, was dependent for bed transfers, used supplemental oxygen, and was documented as not a tobacco user. During interviews, the resident stated they were bedbound, used continuous supplemental oxygen, and vaped e-cigarettes in their room, adding that staff “turned their heads” because the resident could not go outside. The resident also reported being told by the ADON not to smoke in the room but believed this was related to their inability to get out of bed. A CNA confirmed the resident used e-cigarettes/vapes, kept them on the bedside table, did not like to get out of bed except for showers, and had confided that they vaped in the room despite nurses’ requests not to. The ADON acknowledged the resident was bedbound, on continuous oxygen, on hospice, required three to four staff for transfers, used e-cigarettes/vapes in their possession, and hid under a blanket to vape in the room, and further stated that vaping/e-cigarettes were not included on smoking assessments. The administrator also confirmed that vaping/e-cigarettes were not included in the smoking assessment or smoking policy, and stated that residents were not allowed to use vapes/e-cigarettes inside the facility.
Failure to Maintain Head-of-Bed Elevation During Continuous Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the head of the bed was elevated for a resident receiving continuous tube feeding. Surveyors observed on multiple occasions that the resident’s bed was flat without elevation while tube feeding was ongoing, including observations on four separate dates and times. The resident had diagnoses of severe protein calorie malnutrition and gastro-esophageal reflux disease and had moderate cognitive impairment with a BIMS score of 10. An LPN who had worked at the facility for one week reported never seeing the resident’s head of bed elevated. The resident stated they did not want the head of the bed elevated because they liked to sleep and could not sleep with the bed raised. The ADON stated the resident should have the head of the bed elevated 45 degrees and could aspirate if it was not elevated, and also stated that the resident would put the head of the bed down if it were elevated and had not been educated on the possible complications of not having the head of the bed elevated. This sequence of observations and statements shows that, despite the resident receiving continuous tube feeding and having relevant medical conditions, the facility did not maintain the required head-of-bed elevation and did not provide education to the resident about the complications of refusing elevation, leading to the cited deficiency.
Improper Storage of Respiratory Equipment and Failure to Bag Oxygen and Nebulizer Supplies
Penalty
Summary
The deficiency involves the facility’s failure to ensure respiratory equipment was properly stored and bagged when not in use, as required by physician orders and infection control practices. During observation, a resident who was not in their room had a nasal cannula lying loose on a recliner and a nebulizer mask with attached tubing lying on a cart under the window, both unbagged. Physician orders dated 01/10/25 directed that the resident receive albuterol sulfate inhalation solution via nebulizer, and orders dated 07/04/25 specified continuous oxygen at two liters via an oxygen concentrator, including instructions to store tubing and mask in a dry protective cover when not in use. The resident’s significant change assessment, dated 11/17/25, documented admission with diagnoses including congestive heart failure and anemia, moderately impaired cognition with a BIMS score of 11, dependence for transfers, wheelchair use for ambulation, and use of oxygen therapy. When interviewed, an LPN confirmed the resident had continuous oxygen and routine breathing treatments and acknowledged the nasal cannula was lying on the chair and should have been hung on the machine. The ADON, after viewing the room, confirmed that both the nasal cannula and nebulizer mask were not bagged and stated they should have been bagged when not in use for infection control and that the resident required staff assistance for transfers and portable oxygen use.
Failure to Prevent Latex Exposure in Resident with Documented Allergy
Penalty
Summary
A resident with a documented latex allergy was given an indwelling latex urinary catheter, contrary to physician orders specifying the use of a silicone catheter. The resident's allergy to latex was clearly indicated in their medical record, care plan, and allergy documentation. Despite this, staff failed to verify the allergy prior to the catheter insertion, resulting in the use of a latex catheter. The resident was cognitively intact and able to communicate their allergy, which had been listed since admission. Following the insertion of the latex catheter, the resident developed redness and irritation on their right thigh where the catheter tubing had been in contact with the skin. The issue was identified when staff noticed the redness and realized the catheter was latex rather than silicone. The physician was notified, and treatment for the skin irritation was ordered. Interviews with staff confirmed that the error occurred due to a failure to check the resident's allergies before the procedure.
Failure to Provide Adequate Bed and Adaptive Devices for Resident with Paraplegia
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with paraplegia, anxiety, depression, and multiple Stage 4 pressure ulcers by not providing a bed wide enough for safe repositioning and by not supplying requested adaptive devices such as side rails and a trapeze bar. Observations showed the resident lying on an air mattress with only about four inches of space from their hips to the edge of the mattress, without side rails or a trapeze bar present. The resident reported being accustomed to using these devices for bed mobility and expressed feeling claustrophobic and restrained due to the bed's size and lack of support, resulting in complete dependence on staff for repositioning and a fear of falling during transfers. The facility's policy required evaluation and ongoing review of residents' needs for adaptive devices and environmental modifications. Despite the resident's requests for side rails upon admission and a trapeze bar shortly thereafter, the facility did not provide these accommodations, citing a policy against full side rails and a delay in providing the trapeze bar. The DON stated they relied on nursing and therapy staff to communicate such needs and were unaware that the resident's bed did not adequately accommodate them.
Failure to Involve Resident in Care Plan Development
Penalty
Summary
The facility failed to ensure a resident and/or their representative participated in the development and implementation of a person-centered care plan. The facility's policy required the Interdisciplinary Team, along with the resident and/or their representative, to identify resident problems, needs, strengths, life history, preferences, and goals. However, for one resident with diagnoses including chronic obstructive pulmonary disease and kidney failure, there was no documentation showing their involvement in care plan meetings. Despite having intact cognition, the resident reported not having had a care plan meeting and expressed a desire to participate. The Director of Nursing admitted reliance on the MDS coordinator for scheduling care plan meetings but acknowledged a lack of follow-up procedures. The MDS coordinator confirmed that care plan meetings were not being conducted due to staff being too busy, despite the requirement for quarterly meetings.
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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