Clinton Therapy & Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton, Oklahoma.
- Location
- 2316 Modelle, Clinton, Oklahoma 73601
- CMS Provider Number
- 375253
- Inspections on file
- 25
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Clinton Therapy & Living Center during CMS and state inspections, most recent first.
The facility did not provide a SNF ABN to two residents who were discharged from skilled services but continued to reside in the facility, even though they had Medicare benefit days remaining. The administrator stated she was unaware of the need to issue the ABN in these circumstances.
The facility did not submit MDS assessment data to CMS within the required timeframe for four residents. Assessments were completed but not transmitted within the mandated period, and the DON confirmed these submissions were late according to CMS guidelines.
A resident prescribed levothyroxine for hypothyroidism did not consistently receive the medication as ordered, with multiple missed doses recorded over several months. Facility staff confirmed that blanks on the medication administration record indicated the medication was not given, and there was no documentation explaining the omissions, contrary to facility policy.
Two residents had inaccuracies in their MDS assessments: one had an annual assessment with unassessed pain and functional status despite being on routine pain management, and another had a quarterly assessment that failed to document ongoing hospice services, even though a physician order confirmed hospice admission. The DON acknowledged both assessment errors.
A resident with end stage COPD was receiving continuous oxygen therapy without a current physician order. Documentation showed the resident was on 4L/min oxygen with an oxygen saturation of 88%, but the only order for oxygen had been discontinued months earlier. The DON confirmed there were no active orders for the ongoing oxygen use.
A resident with neuromuscular bladder dysfunction and alcoholic cirrhosis was found with an indwelling catheter in place, but no physician's order for the catheter was present in the medical record. The DON confirmed that an order should have been obtained.
A multidose vial of Tuberculin PPD was found opened and not dated in the medication storage room. The ADON confirmed that the vial should have been dated when opened. This occurred in a facility with 28 residents.
A resident with dementia and a history of wandering was repeatedly identified as high risk for elopement, but the care plan was not updated to address these behaviors until after the resident left the facility twice, once being found a significant distance away on a busy road. Staff awareness and training on the resident's risk were inconsistent, and exit door alarms were reported as malfunctioning or not heard during the incident, resulting in inadequate supervision and interventions.
A resident with dementia and other cognitive impairments, identified as high risk for wandering and elopement, did not have a care plan updated to address these risks despite repeated incidents and assessments indicating ongoing danger. The care plan only included diversionary activities and was not revised to include appropriate interventions until months after the resident's admission, with staff confirming the lack of timely updates.
The facility failed to report abuse allegations to the OSDH within the required timeframe for three residents. A resident with intact cognition experienced repeated incidents of another resident entering their room naked, which was not reported as sexual abuse until prompted. Another resident alleged physical abuse by staff, but the facility delayed reporting to OSDH and suspending the accused staff due to staffing issues.
A resident with intact cognition reported frequent incidents of another resident with cognitive impairment entering their room naked and taking belongings. Despite staff awareness and reports to the administrator, the facility failed to investigate these incidents as potential abuse, only reporting them as misappropriation after prompting by the survey agency.
The facility failed to submit MDS assessments for two residents within the required timeframe. The assessments, completed on a specific date, were submitted late, exceeding the 14-day period allowed by CMS guidelines. The MDS coordinator confirmed the delay during an interview.
The facility did not monitor or log dish machine temperatures, sanitizer concentration, and refrigeration temperatures as required by policy. The dietary manager admitted to not performing these tasks, which are essential for safe food handling and storage.
A facility failed to inform a resident and/or their legal representative in writing about the treatments and side effects of psychotropic medications. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed several psychotropic medications, but their EHR lacked documentation of consents, education, and alternative treatments. The DON admitted to not completing these necessary steps.
The facility failed to maintain a safe and comfortable environment, with temperatures in common areas and resident rooms below the required range, causing residents to wear coats and use blankets for warmth. Additionally, a damaged wall with a sharp metal strip posed a safety risk, as acknowledged by staff, including the maintenance supervisor and DON.
A resident with intact cognition was repeatedly subjected to inappropriate behavior by another resident with impaired cognition, who frequently entered their room naked. Despite staff awareness and documentation of these incidents, the behavior persisted, indicating a failure to prevent sexual abuse as per the facility's policy.
The facility failed to implement its abuse policy, as evidenced by two incidents involving residents. One resident was repeatedly subjected to another entering their room naked and attempting to take personal items, with no immediate action taken to prevent further occurrences. In another case, a resident alleged physical abuse by staff, but the facility did not report the incident promptly or suspend the accused staff immediately. These incidents highlight deficiencies in the facility's handling of abuse allegations.
A facility failed to include hospice services in the care plan for a resident with senile degeneration of the brain and dementia, despite having a physician order for hospice. The facility's policy required care plans to be complete and current, but the MDS Coordinator confirmed that hospice services were not added to the resident's care plan as required.
A resident with multiple diagnoses did not receive their prescribed clonidine due to a failure in reordering the medication. The facility's policy requires medications to be reordered three days before the last dose, but there was no documentation of this being done. The CMA responsible did not reorder the medication, and the DON was not informed of the shortage until it was identified during a survey.
A resident with dementia and bipolar disorder continued to receive incorrect dosages of Risperdal and Zyprexa despite a physician's order to adjust the medications. The facility's policy required the nurse or DON to input new orders into the system, but this was not done, resulting in the resident receiving the wrong medication regimen.
A resident with dementia and a history of elopement was inadequately supervised, leading to multiple elopement incidents. Despite being identified as an elopement risk, the care plan was not promptly updated after the first incident. The resident managed to leave the facility twice, once crossing a railroad track and a freeway. The facility failed to involve the IDT in decision-making, and monitoring documentation was inconsistent.
A resident with dementia and other mental health disorders was identified as an elopement risk, but the facility failed to update their care plan after multiple elopement incidents. Despite assessments indicating high risk, the care plan lacked additional interventions, and the DON was unaware of previous elopements, leading to inadequate monitoring and protection.
A resident with Alzheimer's and dementia eloped from the facility multiple times due to inadequate supervision and incomplete documentation. Despite being on 1:1 supervision, the resident left the facility without staff knowledge, leading to a police report. The care plan lacked elopement prevention measures, and staff failed to communicate incidents to the DON and Administrator.
The facility failed to maintain effective pest control, resulting in bed bug and cockroach infestations affecting several residents. Despite having policies in place, there was inadequate documentation of interventions and room changes. Residents reported seeing pests, and treatments were not properly documented, leading to deficiencies in pest management.
A resident with acute respiratory failure and depressive disorder was verbally abused by an LPN, who made demeaning comments. Another LPN witnessed the incident and laughed, while a CNA who also witnessed it failed to report the altercation to the Administrator, violating the facility's abuse policy.
The facility failed to post resident rights in common areas accessible to all residents. During tours, it was observed that the resident rights were not posted, and the Administrator confirmed this oversight. This deficiency had the potential to affect all 35 residents in the facility.
The facility failed to assess a resident's physical limitations and follow their abuse policy to investigate and report allegations of neglect. A resident with limited mobility and terminal prognosis reported that staff refused to assist with putting on their shoes, causing emotional distress. The incident was not properly reported or investigated, leading to a deficiency in protecting the resident from harm.
A facility failed to ensure medications were available for a resident with multiple diagnoses, leading to several supplements not being administered over a period of several months. The clinical record lacked signed physician orders to hold the medications, and the DON confirmed that the medications were not available due to incorrect documentation by a medication nurse.
The facility failed to coordinate care and services with mental health providers for a resident diagnosed with depression. Despite physician orders for behavior monitoring and mental health evaluations, the clinical record showed no follow-up services after an initial visit. The DON confirmed the lack of documentation and coordination with mental health providers.
Failure to Provide SNF ABN to Residents Remaining After Skilled Service Discharge
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents who were discharged from skilled services but remained in the facility, despite having Medicare benefit days remaining. Record reviews showed that both residents were admitted for skilled services and later discharged from those services, yet no ABN was given to inform them of their potential financial liability for services not covered by Medicare. During an interview, the administrator acknowledged being unaware of the requirement to provide the ABN form to residents who stayed in the facility after discharge from skilled services.
Failure to Timely Submit MDS Assessment Data
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for four out of twelve sampled residents. According to the facility's policy, resident assessments are to be conducted and submitted in accordance with federal and state submission timeframes. Record review showed that quarterly and annual assessments for these residents were completed but not submitted within the mandated period, with submission and acceptance dates exceeding the allowed timeframe. The Director of Nursing (DON) confirmed that the assessments for these residents were submitted outside the 14-day window required by CMS guidelines.
Failure to Administer Medication as Ordered and Document Omissions
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for one resident who was prescribed Synthroid (levothyroxine) 25 micrograms in the morning for hypothyroidism. Review of the medication administration records for March, April, and May revealed multiple dates with blanks for levothyroxine, indicating missed doses. The facility's policy required that all physician orders be followed as prescribed and that any deviations be documented in the resident's medical record during the shift. However, both the CMA and the DON confirmed that blanks on the medication administration record meant the medication was not administered, and there was no documentation explaining why the doses were missed. The pharmacy had previously identified these omissions and confirmed with the physician that the administration time should not be changed, but the issue persisted without proper documentation or explanation.
Inaccurate Coding of MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessment data for two of twelve sampled residents. For one resident, the annual assessment dated 03/23/25 had both the functional assessment and pain section marked as not assessed, despite the resident being on routine pain management. The Director of Nursing (DON) confirmed that the assessment was incomplete and not accurate, noting that the corporate nurse had completed the assessment but could have delegated the unassessed areas to a facility nurse. For another resident, the quarterly MDS assessment dated 03/18/25 did not indicate that the resident was on hospice services, even though a physician order dated 06/30/24 documented the resident's admission to hospice. The DON confirmed that the resident had been on hospice since 06/30/24 and that the MDS assessment should have reflected this status.
Failure to Obtain Physician Orders for Oxygen Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure that physician orders for oxygen therapy were obtained for a resident with end stage chronic obstructive pulmonary disease (COPD). Record review showed that the resident was found resting in bed with oxygen administered at 4 liters per minute via nasal cannula, and their oxygen saturation was 88%. The only documented physician order for oxygen had been discontinued several months prior, with no current orders in place for oxygen therapy. The Director of Nursing confirmed that there were no active orders for oxygen, despite the resident consistently requiring oxygen due to their medical condition.
Lack of Physician Order for Indwelling Catheter
Penalty
Summary
A deficiency was identified when a resident with diagnoses of neuromuscular dysfunction of the bladder and alcoholic cirrhosis of the liver with ascites was observed with an indwelling catheter in place, but there was no corresponding physician's order for the catheter in the resident's medical record. The resident was seen sitting on the side of the bed with a catheter bag attached to a walker. Review of the physician orders dated the following day confirmed the absence of an order for the indwelling catheter. The Director of Nursing confirmed that an order should have been present for the catheter.
Undated Multidose Vial of Tuberculin PPD in Medication Storage Room
Penalty
Summary
During an observation of the medication storage room, a multidose vial of Tuberculin PPD was found to have been opened without being dated. The Assistant Director of Nursing (ADON) confirmed that the vial should have been dated upon opening. This observation was made in a facility housing 28 residents. No information was provided regarding the medical history or condition of any specific residents at the time of the deficiency.
Failure to Supervise and Implement Interventions for Resident with Exit-Seeking Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement appropriate interventions for a resident with known exit-seeking and wandering behaviors. The resident, who had diagnoses including dementia, impulse disorder, schizophrenia, and gait abnormalities, was repeatedly assessed as high risk for wandering, with multiple documented high scores on the facility's wandering risk scale. Despite these assessments and documented incidents of wandering and exit-seeking, the resident's care plan was not updated to address these risks until after a significant elopement event. The resident was able to leave the facility on two separate occasions. On the first occasion, dietary staff observed the resident exiting through the front door and found them in the parking lot. The care plan was not updated following this incident, and no new interventions were implemented to address the ongoing risk. On the second occasion, the resident eloped and was found approximately half a mile away from the facility on a busy four-lane road. Staff interviews revealed inconsistent awareness of the resident's elopement risk, with some staff unaware of the risk until after the elopement occurred, and others stating they had not received training on wandering until after the incident. Observations and interviews indicated that exit doors were equipped with alarms and egress releases, but there were reports of alarms malfunctioning or not being heard at the time of the elopement. Staff were unclear on how the resident exited the building, and documentation showed that the care plan lacked specific interventions for wandering and elopement until after the second elopement event. The facility's failure to update the care plan and provide adequate supervision and interventions for a resident at high risk for elopement led to the deficiency.
Failure to Timely Update Care Plan for High-Risk Wandering and Elopement
Penalty
Summary
The facility failed to develop and update a care plan with appropriate interventions for a resident identified as high risk for wandering and elopement. Despite multiple assessments and incident reports indicating the resident's ongoing high risk and actual incidents of wandering and elopement, the care plan was not revised in a timely manner to address these risks. The resident, who had diagnoses including dementia, impulse disorder, schizophrenia, and mobility abnormalities, was repeatedly observed ambulating throughout the facility and was even found outside the building on one occasion. Documentation showed that the resident's risk for wandering was consistently high, as reflected in several wandering risk scale assessments. The care plan initially did not address the resident's high risk for wandering and elopement, and only included interventions for diversionary activities. No updates or changes were made to the care plan following incidents of exit-seeking behavior and actual elopement until several months after admission. Staff interviews confirmed that there was a lack of care plan updates and intervention changes, and the DON acknowledged that the absence of a care plan coordinator contributed to the delay in updating the care plan to reflect the resident's needs.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe for three residents. Resident #13, who had intact cognition, experienced repeated incidents where Resident #24, who had significant cognitive impairment, entered their room naked and attempted to take personal items. Despite Resident #13's complaints and the staff's awareness of these incidents, the facility did not report the situation as sexual abuse until prompted by the survey agency. The administrator acknowledged the behavior as sexual abuse but only reported misappropriation initially. Resident #24, diagnosed with dementia and other mental health disorders, frequently entered other residents' rooms naked, taking their belongings. The facility's records documented multiple instances of this behavior, yet no incident reports were filed for these occurrences until much later. Staff interviews revealed that the behavior was considered normal by some, and the administrator admitted to not reporting the incidents as sexual abuse until after being prompted by the survey agency. Resident #82, with moderate cognitive impairment, alleged being physically abused by staff members. The resident called the police, and the facility was made aware of the allegation when the police arrived. However, the abuse was not reported to OSDH within the required timeframe, and the accused staff members were not suspended immediately due to staffing issues. The administrator was not informed of the incident until several hours later, and the facility's abuse policy was not followed, as the incident was reported to OSDH late, and the administrator was not notified promptly.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving two residents. Resident #13, who had intact cognition, reported that Resident #24, who had significant cognitive impairment, frequently entered their room naked and attempted to take their belongings. This behavior was observed by staff and reported by Resident #13, who expressed annoyance and a desire for the behavior to stop. Despite these incidents occurring multiple times daily, the facility did not investigate the situation as a potential case of abuse. Resident #24, diagnosed with dementia and other mental health disorders, was documented in progress notes as repeatedly entering other residents' rooms without clothing and taking their belongings. Staff, including a CNA and an LPN, acknowledged the behavior and reported it to the administrator. However, the administrator only reported the incidents as misappropriation and did not consider them as potential sexual abuse until prompted by the survey agency. This lack of immediate investigation into the allegations of abuse constitutes a deficiency in the facility's compliance with its abuse policy.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for two of the twelve sampled residents. According to the facility's policy, revised in July 2017, resident assessments should be conducted and submitted in accordance with federal and state submission timeframes. However, the quarterly assessments for two residents, completed on September 25, 2024, were not submitted until November 5, 2024, exceeding the required submission period. During an interview on November 7, 2024, the MDS coordinator stated that the policy allowed for a 14-day submission period from the date of completion. Upon reviewing the assessments for the two residents, the coordinator confirmed that the assessments were not submitted within the 14-day timeframe as required by CMS guidelines.
Failure to Monitor and Log Kitchen Equipment Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and logging of dish machine temperature, sanitizer concentration, and refrigeration temperatures, which are essential for safe food handling and storage. During two kitchen observations, it was noted that the facility's Dishwashing Machine Use policy, revised in March 2010, required these parameters to be monitored and recorded in an approved log. However, on November 5, 2024, there were no logs observed for refrigeration equipment temperatures. Additionally, a staff member was seen testing the dish machine temperature and sanitizer concentration, but the October 2024 dish machine temperature document on the wall showed no evidence of being used. The dietary manager admitted that the dish machine should be tested and logged before each meal shift and acknowledged that this had not been done. Furthermore, the dietary manager confirmed that refrigeration temperatures were not being logged as required.
Failure to Inform Resident of Psychotropic Medication Treatments
Penalty
Summary
The facility failed to ensure that a resident and/or their legal representative was informed in writing about the treatments and side effects of psychotropic medications. This deficiency was identified for one of the five sampled residents who were reviewed for education, alternative treatments, and consents for psychotropic medication treatments. The Director of Nursing (DON) acknowledged that they did not complete the necessary consents, education, and alternative treatments for the psychotropic medications, despite being aware that these should have been completed. The resident involved was admitted with multiple diagnoses, including dementia, schizoaffective-bipolar type, delusional disorder, depression, and obsessive-compulsive behavior. The resident's admission assessment indicated severe cognitive impairment and documented the routine use of antipsychotic, antianxiety, and antidepressant medications. The resident's electronic health record (EHR) lacked documentation of consents, education, and alternative treatments for the prescribed psychotropic medications, which included Vistaril, Seroquel, lorazepam, and Depakote.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several observations and interviews. The facility's Safe Environment policy mandates maintaining temperature levels between 71 and 81 degrees Fahrenheit. However, on the morning of November 5th, the temperature in the dining room and several resident rooms was recorded below the minimum required level, with temperatures ranging from 68.3 to 69.3 degrees Fahrenheit. Residents were observed wearing coats and using blankets to keep warm, indicating discomfort due to the low temperatures. The maintenance supervisor confirmed that the heat was not turned on and admitted to not having access to the thermostat program. Additionally, a safety hazard was identified in the form of a damaged wall leading into the dining room from the common area. The wall had missing sheetrock and a protruding sharp metal strip, posing a risk of injury to residents, especially those using wheelchairs. The maintenance supervisor acknowledged the damage, attributing it to residents hitting the wall with their wheelchairs, and admitted that repairs had not been made. Both a CNA and the DON recognized the potential for skin tears and agreed that the damaged wall did not contribute to a safe, comfortable, and homelike environment.
Failure to Prevent Sexual Abuse in LTC Facility
Penalty
Summary
The facility failed to prevent sexual abuse for a resident who was repeatedly subjected to inappropriate behavior by another resident. The affected resident, who had a cerebral aneurysm and muscle wasting with atrophy, had intact cognition and reported that another resident frequently entered their room naked, causing distress. This behavior was observed by staff, and the affected resident expressed annoyance and a desire for the incidents to stop. The resident who exhibited the inappropriate behavior was admitted with diagnoses including dementia, schizoaffective/bipolar type, and delusional disorder, and had significantly impaired cognition. This resident was documented to have entered other residents' rooms multiple times while naked, taking belongings and refusing to wear clothes. Staff noted these behaviors in progress notes, indicating that the resident was redirected back to their room multiple times, but the behavior persisted. Staff members, including a CNA and an LPN, acknowledged the frequency of these incidents and reported them to the administrator. The administrator confirmed that the behavior was considered sexual abuse but initially only reported misappropriation. The facility's policy on abuse required documentation and intervention, but the repeated incidents suggest a failure to effectively implement measures to protect residents from such behaviors.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by two significant incidents involving residents. In the first case, a resident with intact cognition was repeatedly subjected to another resident entering their room naked and attempting to take personal items. This behavior was reported to occur multiple times daily since the second resident's admission, yet the facility did not take immediate action to prevent further occurrences or report the incidents as abuse until prompted by the state agency. The administrator acknowledged the behavior as potential sexual abuse but only reported it as misappropriation initially. In the second incident, a resident with moderately impaired cognition alleged physical abuse by two staff members. The resident called the police to report being thrown against a wall, and the police informed the facility staff of the allegation. However, the facility did not follow its abuse policy, as the incident was not reported to the administrator within the required timeframe, and the accused staff members were not suspended immediately due to staffing issues. The administrator was only informed of the allegation hours later when visiting the resident at the hospital. These incidents highlight the facility's failure to adhere to its abuse policy, which mandates immediate reporting and investigation of abuse allegations and the implementation of measures to prevent further abuse. The lack of timely reporting and action in both cases indicates a significant deficiency in the facility's handling of abuse allegations, potentially compromising resident safety and well-being.
Failure to Include Hospice Services in Care Plan
Penalty
Summary
The facility failed to ensure that hospice services were included in the care plan for a resident with diagnoses of senile degeneration of the brain and dementia. The facility's policy stated that care plans should identify priority problems and needs, and be complete and current. An Order Summary Report indicated that the resident had a physician order for hospice services. However, there was no documentation that hospice services were included in the resident's care plan. During an interview, the MDS Coordinator confirmed that hospice services should be added to the care plan immediately and acknowledged that hospice services had not been added to the resident's comprehensive care plan.
Failure to Reorder Medication for Resident
Penalty
Summary
The facility failed to ensure that medications were supplied as ordered for a resident diagnosed with congestive heart failure, bipolar disorder, depression, and hypertension. The resident had a physician's order for clonidine HCL, a blood pressure medication, to be administered three times a day. During a medication pass observation, it was noted that the medication was not available in the medication cart or room. The Certified Med Aide (CMA) responsible for the medication pass confirmed that the clonidine had not been reordered from the pharmacy or hospice, as required by the facility's policy. The facility's policy, revised in July 2023, mandates that medications be reordered at least three days before the last dosage is administered. However, there was no documentation to show that the medication had been reordered. The Director of Nursing (DON) stated that CMAs were responsible for reordering medications and that they would investigate if medications did not arrive on time. The DON was not informed about the shortage of clonidine until after the issue was identified during the survey. This lack of communication and failure to adhere to the medication reordering policy led to the deficiency.
Failure to Implement Physician Orders for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a physician order was completed for a resident reviewed for unnecessary medications. The resident had diagnoses including senile degeneration of the brain, dementia with other behavioral disturbances, and bipolar type. A pharmacy report documented a signed physician order to change the order for Risperdal to 0.5 mg in the morning and 1 mg at bedtime, and to discontinue Zyprexa. However, the order was not implemented as the resident continued to receive Risperdal 0.5 mg twice a day and Zyprexa 2.5 mg at bedtime, as documented in the October and November 2024 MARs. The Director of Nursing (DON) acknowledged that the order was not changed as per the physician's instructions. The facility's policy required that the nurse who received the order or the DON, if they noted the order, input the new order into the computer. Despite this policy, the order to adjust the medication was not followed, leading to the resident continuing on the previous medication regimen. This oversight was identified during a review of the pharmacy document and confirmed by the DON.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as an elopement risk, leading to multiple elopement incidents. The resident, who was admitted with a history of dementia, Alzheimer's disease, and other mental health conditions, was recognized by family as an elopement risk upon admission. Despite this, a care plan addressing the risk was not initiated until several months later, and even then, it was not updated following the resident's first elopement incident. On two separate occasions, the resident managed to leave the facility unsupervised. The first incident occurred when the resident was found several blocks away, and the care plan was not updated to include new interventions. The second incident involved the resident crossing a railroad track and a four-lane freeway, highlighting the inadequacy of the existing supervision measures. The facility's monitoring tools also showed gaps in documentation, indicating that the resident was not consistently monitored as per the care plan. The facility's policy required the involvement of the interdisciplinary team (IDT) in decision-making regarding interventions to prevent elopement, but this was not followed. The Director of Nursing (DON) admitted to making decisions without consulting the IDT and was unaware of the resident's previous elopement history. The lack of clear and updated care plans, combined with insufficient staff training and supervision, contributed to the repeated elopement incidents.
Failure to Update Care Plan for High-Risk Elopement Resident
Penalty
Summary
The facility failed to update a care plan for a resident who was at high risk for elopement, despite multiple documented incidents of the resident going missing. The resident, who had diagnoses including dementia, Alzheimer's disease, and other mental health disorders, was initially identified as an elopement risk with a care plan initiated to address this risk. However, after the resident was found missing on two separate occasions, the care plan was not revised to include additional interventions to ensure the resident's safety. The Director of Nursing (DON) was unaware of the resident's previous elopements and did not understand the interventions outlined in the care plan. Despite assessments indicating a high risk for wandering and elopement, the care plan remained unchanged from its original version, lacking clarity and necessary updates to address the resident's ongoing risk. This oversight resulted in a failure to adequately monitor and protect the resident, as evidenced by the repeated elopement incidents.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident diagnosed with Alzheimer's, dementia, and delusional disorder. The resident, identified as being at low risk for wandering, was able to leave the facility on multiple occasions without proper supervision. On one occasion, the resident signed out and left the facility without informing staff, leading to a police report being filed when the resident was found at a family member's house. Despite being placed on 1:1 supervision, documentation was incomplete, and the resident continued to attempt to leave the facility. The facility's elopement policy required staff to investigate and report all cases of missing residents, but there was a lack of documentation and communication regarding the resident's elopements. The Director of Nursing (DON) and other staff members were unaware of the resident's whereabouts on several occasions, and the care plan did not include measures for elopement prevention. The Administrator and DON were not fully informed of the incidents, and the state incident report was not filed promptly. Interviews with staff and family members revealed that the resident had a history of attempting to leave the facility, and the family was concerned about the resident's safety. The facility's failure to document and communicate the resident's elopements, as well as the lack of a comprehensive care plan, contributed to the deficiency in providing a safe environment for the resident.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of bed bugs and cockroaches affecting multiple residents. The pest control policy was undated, and the bed bug prevention policy was last revised in 2011. Despite having a pest control program in place, there were documented instances of bed bugs and roaches in the facility. A pest control invoice noted bed bug evidence in a specific room, and a maintenance work order documented roaches in another resident's room. Residents reported seeing cockroaches and experiencing bed bug infestations, with one resident noting itching and bed bugs in their room even after treatment. The facility's response to the pest issues was inadequate, as there was no documentation in the clinical health records regarding room changes, resident responses, or interventions implemented. Residents were moved due to bed bug infestations, but the facility failed to document these actions properly. The bed bug service agreement did not specify which areas were treated, and the administrator confirmed that two rooms had been treated for pests. The lack of documentation and effective pest control measures contributed to the deficiency, impacting the residents' living conditions.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure staff followed their policy to report an allegation of abuse to the Administrator. The incident involved a resident with acute respiratory failure and depressive disorder, who was verbally abused by an LPN. The altercation occurred near the nurses' station, where the resident called the LPN a derogatory term, and the LPN responded with demeaning comments comparing the resident to a pig. Another LPN witnessed the incident and laughed, while a CNA who also witnessed it did not report the altercation to the Administrator, as required by the facility's abuse policy.
Failure to Post Resident Rights
Penalty
Summary
The facility failed to ensure that resident rights were posted in common areas accessible to all residents. This deficiency was identified during tours of the common areas on two separate occasions. On both occasions, the resident rights were not located. When questioned, the Administrator confirmed that the resident rights were not posted in any of the common areas. This failure had the potential to affect all 35 residents in the facility, as identified by an LPN who confirmed the census count.
Failure to Assess Physical Limitations and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to assess a resident's physical limitations and follow their abuse policy to fully investigate and report allegations of neglect. Resident #5, who had diagnoses including bipolar disorder, chronic pain, congestive heart failure, and morbid obesity, reported that staff refused to assist with putting on their shoes. Despite the resident's limited physical mobility and terminal prognosis, staff allegedly told the resident to put on their own shoes, causing the resident significant distress. The resident expressed that this neglectful behavior occurred frequently and caused them emotional pain, leading to crying and sobbing during the interview. The facility's policy on abuse, neglect, and exploitation was not followed, as the incident was not reported or investigated properly by the staff involved. On the day of the incident, the resident reported the issue to the Assistant Director of Nursing (ADON), but the grievance was not handled according to the facility's abuse policy. The Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) involved did not report the event immediately, and the Administrator admitted to not considering a neglect investigation. The facility's failure to assess the resident's physical limitations and properly investigate the allegations of neglect and psychological abuse led to a deficiency in protecting the resident from harm and ensuring their dignity and autonomy.
Failure to Ensure Medication Availability
Penalty
Summary
The facility failed to have a system in place to ensure medications were available for one of the three sampled residents reviewed for medication availability. The resident had diagnoses including ankylosing spondylitis, depressive episodes, and anxiety. Physician orders documented that the resident was to be administered several supplements, including Elderberry Immune Complex, Turmeric, and Vitamin E. However, the Medication Administration Record (MAR) showed that these medications were held and not administered on multiple occasions from December 2023 to March 2024. The clinical record did not contain signed physician orders to hold the medication, nor was there an entry indicating that the physician had been notified with the rationale for not administering the medications. On March 13, 2024, an LPN reviewed the MAR documentation and stated they were unaware of any medications being on hold but noted that the resident liked to order their own medications. The Director of Nursing (DON) later confirmed that a medication nurse was aware the resident did not have the medications available and had documented the wrong information in the computer, creating a hold order without a physician's authorization. The medications had not been available to administer to the resident, leading to the deficiency noted in the report.
Failure to Coordinate Mental Health Services
Penalty
Summary
The facility failed to coordinate care and services with mental health providers for a resident diagnosed with depression. Despite having physician orders for behavior monitoring and mental health evaluations, the clinical record showed that the resident had not received mental health services after a visit on 07/23/23. The resident's care plan included instructions for mental health evaluations and treatments, but there was no documentation of follow-up services. The resident exhibited verbal behavioral symptoms and rejected care, which interfered significantly with their care, yet no further mental health services were documented after the initial visit. When questioned, the Director of Nursing (DON) confirmed that the clinical record only contained documentation of the resident being seen on 07/23/23. The DON admitted that the facility did not always know which residents were being visited by mental health providers and usually did not receive progress notes, only orders if changes were made. This lack of coordination and documentation led to the failure in providing necessary behavioral health care and services to the resident.
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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