Community Health Care Of Gore
Inspection history, citations, penalties and survey trends for this long-term care facility in Gore, Oklahoma.
- Location
- 503 South Main Street, Gore, Oklahoma 74435
- CMS Provider Number
- 375295
- Inspections on file
- 23
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Community Health Care Of Gore during CMS and state inspections, most recent first.
A resident with major depressive disorder experienced trauma when another resident with cognitive impairment entered their room and engaged in inappropriate behavior. The facility failed to notify physicians, address interventions, or consult psychiatric services, leaving the affected resident without necessary support and care plan adjustments.
A facility failed to update a high fall risk resident's care plan with new interventions after multiple falls, including one resulting in a nasal bone fracture. Additionally, the facility did not assess a resident who smoked for safety, allowing them to smoke unsupervised without proper evaluation. These oversights highlight the facility's failure to adhere to safety protocols.
A resident experienced psychosocial harm after another resident entered their room and engaged in inappropriate behavior. Despite the resident's distress, the facility failed to notify their physician, address interventions, or consult psychiatric services. The other resident had a history of disturbed behaviors, but the facility did not adequately monitor or refer them to mental health services, contributing to the incident. The facility's policy on resident-resident altercations was not followed, leading to a deficiency in protecting residents from abuse.
A facility failed to update care plans for a resident who experienced multiple falls, resulting in harm, and did not ensure interdisciplinary team participation in care plan revisions for another resident. Despite several falls, including one causing a nasal bone fracture, the care plan for a resident was not updated with new interventions. Additionally, another resident's care plan lacked documentation of interdisciplinary team involvement, and the resident reported not participating in a care plan meeting.
A resident experienced a traumatic incident when another resident entered their room naked and engaged in inappropriate behavior. Despite the incident, the facility failed to notify the resident's physician, assess for psychosocial injury, or consult psychiatric services. The facility's policies on abuse and resident altercations were not followed, and no interventions or care plan changes were documented. The resident reported ongoing distress and fear, and the family confirmed no psychological counseling was arranged.
A facility failed to report an allegation of neglect involving a CMA who allegedly did not administer medications to residents as ordered. Despite residents' complaints and discrepancies in medication records, the DON did not report the incident to the state agency within the required timeframe, believing it was a patient education issue. The administrator later instructed the DON to report the incident, but it was unclear if this was done promptly.
The facility did not provide two residents with the required bed-hold policy upon their transfer to a hospital, despite the facility's policy mandating this. Both residents, diagnosed with urinary tract infections, were hospitalized without receiving the necessary documentation. The administrator was unaware of this requirement, and the ADON confirmed the omission.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their care plans. One resident's fall history was inaccurately reported, while another resident's dental condition was not properly assessed, resulting in missed care areas. The MDS coordinator acknowledged the inaccuracies and the lack of proper assessment.
The facility failed to develop comprehensive care plans for two residents, one with an anxiety disorder and another with a psychotic disturbance. Both residents were receiving medications for their conditions, but their care plans did not address these diagnoses or the use of the medications, as confirmed by the MDS coordinator.
A resident with severe cognitive impairment was administered medications without documented informed consent. The resident's POA reported insufficient communication from the facility regarding care plans and medication risks. The MDS coordinator confirmed the absence of documentation in the resident's record, indicating a failure to complete the informed consent process.
A facility failed to assess a resident for the use of a geriatric chair as a restraint, leading to a deficiency. The resident, with significant cognitive impairment and mobility limitations, was observed with facial bruising while in the chair. The facility's policy required a pre-restraining assessment, which was not conducted before the chair's use. An LPN confirmed the lack of assessment, and the administrator acknowledged the oversight.
A resident was discharged from hospice services, but the facility failed to conduct a significant change assessment within the required timeframe. The MDS coordinator was unaware of the discharge until weeks later, resulting in a deficiency due to non-compliance with the facility's policy.
A facility failed to complete a Level I PASARR for a resident after a new diagnosis of bipolar disorder. The resident was initially admitted with cerebral infarction and dementia. The MDS coordinator acknowledged that a PASARR should have been conducted following the new diagnosis but was not.
A facility failed to perform or document a gradual dose reduction (GDR) for an antipsychotic medication prescribed to a resident with vascular dementia. Despite pharmacy recommendations and assessments showing severe cognitive impairment and no behaviors, the facility did not attempt a GDR or provide a rationale for its contraindication. The administrator acknowledged the lack of documentation but did not provide further information by the end of the survey.
A resident with broken and missing teeth was not offered dental services, despite facility policy and their expressed need for care. The resident's care plan lacked documentation of dental needs, and their annual assessment inaccurately reported their dental status. Interviews revealed that the facility did not actively offer dental services, relying instead on the dental provider to contact residents. The MDS coordinator admitted to not performing a visual assessment, leading to inaccuracies in the resident's care plan.
The facility failed to maintain the ice machine in a sanitary manner, affecting 44 residents who used ice from the kitchen. A slimy black and brown substance was observed in the crevices and around the pump of the water reservoir. The dietary manager was unaware of who cleaned the mechanical area, although the ice bin was cleaned weekly. The administrator confirmed that the ice machine should be on a regular cleaning schedule for maintenance.
The facility failed to ensure staff conducting COVID-19 testing received appropriate training. The social services director and activities assistant, who sometimes performed testing, did not recall receiving training on infection control or specimen collection. An LPN confirmed that unlicensed activities staff conducted outbreak testing. The DON acknowledged the use of social services and activities staff for testing and could not find documentation of their training.
A resident with a history of falling and dementia experienced a non-injury fall, but the LPN on duty failed to notify the resident's family or physician, contrary to facility policy. This was confirmed by the DON and the administrator, who acknowledged the lapse in communication.
A resident with a history of falling and dementia experienced a non-injury fall, but the LPN did not complete an assessment as required by facility policy. This failure was confirmed by the DON and the administrator, who acknowledged the oversight.
The facility failed to thoroughly investigate abuse allegations for two residents. One resident with severe cognitive impairment had an incomplete investigation after a family reported rough handling by staff. Another resident, cognitively intact, reported being slapped by a staff member, but no interviews with other residents were conducted. The DON and administrator acknowledged the investigations were not thorough.
The facility did not follow the dietary menus planned for residents, failing to provide the specified meal items. On a particular day, the dietary manager reported running out of coleslaw and coconut cake, leading to substitutions with salad and ice cream for four residents. Additionally, the evening menu was changed due to staff oversight in thawing meat, and the dietary manager admitted to frequent menu substitutions.
Failure to Implement Abuse Policy After Resident Incident
Penalty
Summary
The facility failed to implement its abuse policy and procedure following an incident involving two residents. Resident #20, who was admitted with acute and hypoxic respiratory failure and major depressive disorder, experienced an incident where Resident #44 entered their room, exposed themselves, and engaged in inappropriate behavior. Despite Resident #20's intact cognition, the facility did not notify their physician, address interventions, or consult psychiatric services after the incident. This lack of action left Resident #20 without necessary psychological support and care plan adjustments. Resident #44, admitted with acute kidney failure, morbid obesity, and cellulitis, exhibited behaviors indicating cognitive impairment and distress prior to the incident. Their admission assessment showed mild cognitive impairment and physical behaviors directed toward others. Despite these signs, the facility did not notify Resident #44's physician or refer them to mental health services before the incident. The facility's failure to address these behaviors and consult appropriate services contributed to the incident with Resident #20. The facility's policies required staff to notify physicians, review events with nursing supervisors, and document interventions and their effectiveness. However, these steps were not followed, resulting in a deficiency in implementing the abuse policy. The facility's inaction left Resident #20 without necessary support and failed to address Resident #44's behaviors, leading to the incident and subsequent trauma for Resident #20.
Failure to Implement Fall Interventions and Smoking Safety Assessment
Penalty
Summary
The facility failed to implement necessary fall interventions for a resident with severe cognitive impairment who was identified as a high fall risk. Despite multiple falls, including some resulting in injury, the care plan was not updated with new interventions after each incident. The resident experienced several falls, including one that resulted in a nasal bone fracture and blunt head trauma, yet no additional interventions were added to their care plan to prevent further accidents. The resident's Morse Fall Scale assessments consistently indicated a high fall risk, yet the facility did not take appropriate action to mitigate this risk. The MDS coordinator admitted that no interventions were added to the care plan following several falls, and the facility's policy on fall prevention was not followed. The lack of communication and failure to update the care plan contributed to the ongoing risk of falls for the resident. Additionally, the facility failed to assess another resident who smoked for safety, as required by their policy. The resident was allowed to smoke unsupervised without a proper evaluation of their ability to do so safely. The care plan did not include the necessary components of a smoking evaluation, and the resident reported not receiving any instruction on smoking risks or the facility's smoking policy. This oversight further highlights the facility's failure to adhere to its own safety protocols.
Failure to Prevent Resident Abuse and Inadequate Response
Penalty
Summary
The facility failed to prevent abuse for one of the residents, resulting in psychosocial harm. Resident #20, who was cognitively intact and admitted with diagnoses including acute and hypoxic respiratory failure and major depressive disorder, experienced an incident on 02/23/25 where another resident, Resident #44, entered their room, exposed themselves, and engaged in inappropriate behavior. Despite Resident #20's distress and subsequent fear, the facility did not notify their physician, address interventions, or consult psychiatric services as required by their policies. Resident #44, who had a history of disturbed thought processes and behaviors such as wandering and making threats, was not adequately monitored or referred to mental health services despite documented behaviors starting on 02/11/25. The facility's failure to notify Resident #44's physician or make necessary referrals contributed to the incident on 02/23/25. The facility's policy on resident-resident altercations was not followed, as evidenced by the lack of documentation and intervention following the incident. The Director of Nursing (DON) acknowledged that the policy was not adhered to and that Resident #20 was not assessed for psychosocial injury or referred to psychiatric services after the incident. The report highlights the facility's failure to implement and document appropriate interventions and follow-up care for both residents involved, leading to a deficiency in protecting residents from abuse.
Failure to Update Care Plans and Ensure Interdisciplinary Participation
Penalty
Summary
The facility failed to ensure that care plans were updated and revised for a resident who experienced multiple falls, resulting in harm. Resident #3, who had a history of falls and was diagnosed with type 2 diabetes mellitus, syncope and collapse, and chronic kidney disease, experienced several falls without the care plan being updated with new specific interventions. Despite multiple incidents, including a fall that resulted in a nasal bone fracture, the care plan was not revised to include new interventions to prevent further falls. The facility's policy required that care plans be updated with new interventions after each fall, but this was not followed. The MDS coordinator admitted that no interventions were added to the care plan after several falls, citing being busy and not always being communicated about falls. The lack of updated interventions in the care plan contributed to Resident #3 experiencing significant harm, including a broken nose and facial bruises. Additionally, the facility failed to ensure the participation of the interdisciplinary team and the resident or their representative in the revision of care plans. Resident #12's care plan did not document the participation of the interdisciplinary team members, and the resident stated they had not participated in a care plan meeting. The MDS coordinator confirmed that there was no documentation of the participation of social services, activities, or dietary staff in the care plan meeting, highlighting a deficiency in the facility's care planning process.
Failure to Provide Trauma-Informed Care After Incident
Penalty
Summary
The facility failed to provide trauma-informed care following an incident of sexual abuse involving a resident. Resident #20, who had a fully intact cognition with a BIMS score of 15, experienced a traumatic event when another resident, Resident #44, entered their room naked and engaged in inappropriate behavior. Despite the incident, the facility did not notify Resident #20's physician, assess the resident for psychosocial injury, or consult psychiatric services for further evaluation and support. The facility's policies on abuse and resident altercations were not followed. The policies required notifying the resident's representative and attending physician, reviewing the incident with nursing supervisors, and making necessary changes to the care plan. However, there was no documentation of these actions being taken. Additionally, the facility did not document any interventions or their effectiveness, nor did they consult with psychiatric services to assist in assessing the resident and developing a care plan. Interviews with Resident #20 and their family representative revealed ongoing distress and fear following the incident. Resident #20 reported difficulty sleeping, fear of the opposite sex, and reluctance to be alone. The family representative confirmed that the facility did not arrange for psychological counseling, and the DON acknowledged that the policy was not followed. The lack of appropriate response and support for Resident #20 highlights the facility's failure to provide trauma-informed care after the incident.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe after becoming aware of the allegation. This involved three residents who reported not receiving their medications as ordered. The facility's policy mandates that all allegations of abuse and neglect be reported immediately, defined as within two hours for abuse-related allegations. However, the incident involving a Certified Medication Aide (CMA) who allegedly did not administer medications was not reported until over a month later. The incident began when residents complained about not receiving their medications, which was corroborated by discrepancies in the medication administration records. The Director of Nursing (DON) and other staff members noticed that medications were charted as given, but the physical count of medications did not match. Despite these findings, the DON did not initially report the incident to the state agency, believing it was a patient education issue rather than neglect. The DON removed the CMA from their duties but did not file a report with the state agency as required. The administrator was informed of the situation and instructed the DON to report the incident, but it was unclear if this was done promptly. The failure to report the incident in a timely manner was a violation of the facility's policy and state regulations, which require immediate reporting of such allegations to ensure resident safety and compliance with legal obligations.
Failure to Provide Bed-Hold Policy to Residents
Penalty
Summary
The facility failed to provide a copy of its bed-hold policy to two residents who were transferred out with the intention of returning. The facility's policy, revised in October 2022, mandates that all residents or their representatives receive written information about the bed-hold policy during periods of absence, such as hospitalization or therapeutic leave. Resident #9, diagnosed with a urinary tract infection, was hospitalized in February 2025, and Resident #147, also diagnosed with a urinary tract infection, was hospitalized in March 2025. In both cases, there was no documentation that the residents received the bed-hold policy. The administrator was unaware of the requirement to provide the policy upon a resident's departure, and the ADON confirmed that the policy was not included in the documents sent with residents to the hospital.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their care plans. Resident #3, who was admitted with conditions including type 2 diabetes mellitus and chronic kidney disease, had multiple falls documented in their care plan. However, their annual MDS assessment inaccurately reported no falls since admission. The MDS coordinator confirmed the inaccuracy, acknowledging that the assessment did not reflect the resident's actual fall history, which included several incidents after the quarterly assessment. Resident #13, admitted with dysphagia following a cerebral infarction, was observed with broken and missing teeth, contrary to their annual MDS assessment, which indicated they had all their natural teeth. The MDS coordinator admitted to not performing a visual assessment of the resident's oral condition, as required by the Resident Assessment Tool manual. This oversight resulted in missed care areas in the resident's care plan, as the coordinator did not verify the resident's dental status, which was inaccurately documented.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident, diagnosed with an anxiety disorder, was receiving Buspar, an anti-anxiety medication, as noted in the physician's monthly summary. However, the resident's care plan did not address the anxiety disorder or the use of the medication, as confirmed by the MDS coordinator. Another resident, diagnosed with a psychotic disturbance and receiving Zyprexa, an antipsychotic medication, also had a care plan that failed to address their diagnosis or the use of the medication. This oversight was similarly acknowledged by the MDS coordinator. These deficiencies were identified through record reviews and interviews, highlighting the facility's failure to ensure that care plans were comprehensive and reflective of the residents' current medical treatments and diagnoses.
Failure to Obtain Informed Consent for Medications
Penalty
Summary
The facility failed to provide informed consent for medications for a resident diagnosed with aphasia following a cerebral infarction and vascular dementia. The resident was receiving Depakote for anxiety, Sertraline as an antidepressant, and Zyprexa as an antipsychotic. However, there was no documentation in the resident's clinical record indicating that informed consent for these medications was obtained. The resident's cognition was severely impaired, as indicated by a BIMS score of 03 on the quarterly MDS assessment. The resident's Power of Attorney (POA) reported a lack of communication from the facility regarding care plan meetings, medication risks versus benefits, and possible alternatives to the medication treatment. The POA mentioned that the facility staff occasionally contacted them about the resident falling but provided no further details during visits. The MDS coordinator confirmed that there was no documentation of communication with the family regarding the risks and benefits of the medications in the resident's electronic medical record, indicating that the necessary informed consent process was not completed.
Failure to Assess Geriatric Chair Use as Restraint
Penalty
Summary
The facility failed to properly assess the use of a geriatric chair for a resident, leading to a deficiency in ensuring the resident was free from physical restraints unless medically necessary. Resident #3, who had significant cognitive impairment and required assistance with mobility, was observed in a geriatric chair with facial bruising. The facility's policy required a pre-restraining assessment to determine the necessity of restraints and explore less restrictive interventions. However, there was no documentation of such an assessment for Resident #3 before the use of the geriatric chair. The resident's physician had ordered the use of a geriatric chair for poor balance and trunk control, but the assessment was only conducted after the resident had already been placed in the chair. An LPN confirmed that the resident was not properly assessed for the use of the chair as a restraint, resulting in the resident being removed from the chair until an assessment was completed. The facility administrator acknowledged that the required pre-restraining assessment was not conducted prior to the resident's placement in the geriatric chair.
Failure to Conduct Timely Significant Change Assessment Post-Hospice Discharge
Penalty
Summary
The facility failed to conduct a significant change assessment for a resident who was discharged from hospice services. The facility's policy requires a comprehensive assessment to be completed when a resident experiences a significant change in status, such as being discharged from hospice. Resident #2, who had diagnoses including chronic kidney disease and end-stage renal disease, was admitted to hospice services on April 23, 2024. However, the resident was discharged from hospice on February 27, 2025, as they were deemed no longer appropriate for hospice care. Despite this significant change, the required assessment was not completed within the two-week timeframe stipulated by the facility's policy. The MDS coordinator was unaware of the resident's discharge from hospice services until March 17, 2025, when they were provided with the physician's order indicating the discharge date. The coordinator acknowledged that the significant change assessment was overdue. The lack of awareness and failure to complete the assessment in a timely manner highlights a breakdown in communication and adherence to the facility's policy, resulting in a deficiency in the care provided to the resident.
Failure to Complete PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a Level I Pre-Admission Screening and Resident Review (PASARR) for a resident after a new mental health diagnosis was made. The resident was admitted with diagnoses including cerebral infarction and dementia. On a later date, the resident was diagnosed with bipolar disorder. However, the facility did not conduct a Level I PASARR following this new diagnosis. During an interview, the MDS coordinator confirmed that a PASARR should have been completed after the new diagnosis but was not.
Failure to Document Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to perform a gradual dose reduction (GDR) or document the rationale for not performing a GDR of an antipsychotic medication for a resident with vascular dementia and other mental health diagnoses. The resident was prescribed Zyprexa 5mg at bedtime, and despite pharmacy recommendations to consider a GDR to 2.5mg, the facility did not attempt a dose reduction or provide documentation explaining why it was contraindicated. The resident's assessments consistently showed severe cognitive impairment and no behaviors, yet the facility did not document any attempts or contraindications for a GDR. During the survey, the administrator and MDS coordinator were unable to provide documentation of a prior GDR or a clinical rationale for not performing one. Despite being informed of a possible deficiency related to unnecessary medications, the facility did not provide further documentation by the end of the survey. The administrator acknowledged the lack of documentation and contacted the resident's physician for a rationale, but no additional information was provided before the survey concluded.
Failure to Offer Dental Services to Resident
Penalty
Summary
The facility failed to offer dental services to a resident, identified as Resident #13, who was observed with broken and missing teeth. Despite the facility's policy indicating that dental services should be offered through a program with Medicaid, Resident #13 reported experiencing tooth pain and stated that they had not been offered dental services since their admission. The resident's care plan did not document the need for dental services, and their annual assessment inaccurately indicated that they had all their natural teeth, which was not the case. Interviews with facility staff revealed a lack of proper assessment and follow-up regarding the resident's dental needs. The Social Services Director (SSD) admitted that the facility did not actively offer dental services, leaving it to the dental service provider to contact residents or their responsible parties. The Minimum Data Set (MDS) coordinator acknowledged that they did not perform a visual assessment of the resident's oral health, which led to inaccuracies in the resident's assessment and care plan. This oversight resulted in the resident's dental needs being overlooked, affecting their overall care plan.
Unsanitary Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain the ice machine in a sanitary manner, affecting 44 residents who utilized ice from the kitchen. During an observation with the dietary manager, a slimy black and brown substance was found in the crevices, along the edges, and around the pump of the water reservoir of the ice machine. The dietary manager acknowledged the presence of the substance and stated that while the ice bin was cleaned weekly, they were unaware of who was responsible for cleaning the mechanical area of the ice machine. The administrator later confirmed that the ice machine should be on a regular cleaning schedule for the maintenance department to perform.
Inadequate Training for COVID-19 Testing Staff
Penalty
Summary
The facility failed to ensure that staff conducting COVID-19 testing received appropriate training. The social services director and activities assistant, who sometimes performed COVID-19 testing on residents, stated they did not remember receiving training on proper infection control techniques or specimen collection. An LPN confirmed that various employees, including unlicensed activities staff, conducted outbreak testing. The Director of Nursing (DON) acknowledged that social services and activities staff were sometimes used for outbreak testing and could not locate any documentation proving that these staff members had received the necessary training related to infection control or test specimen collection.
Failure to Notify Family and Physician of Resident Fall
Penalty
Summary
The facility failed to notify a resident's representative and physician of a fall incident involving a resident with a history of falling and dementia. The facility's policy required the assessment of the resident and notification of the medical director, DON, ADON, administrator, and emergency family contact in such situations. However, when the resident experienced a non-injury fall, the LPN on duty did not contact the physician or the family at the time of the incident. This lapse was confirmed by the DON and the administrator, who acknowledged that the nurse on duty did not notify anyone following the fall.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to assess a resident after a fall, which was identified during a review of records and interviews. The facility's policy requires neuro checks for falls with head injury and unwitnessed falls with possible head injury, including assessing the resident, contacting the medical director, DON, ADON, administrator, and emergency family contact, and obtaining vital signs and assessing the resident's orientation, level of consciousness, pupil size, and reaction to light. A resident with a history of falling and dementia experienced a non-injury fall, but the LPN did not complete an assessment after the incident. This was confirmed by the DON and the administrator, who acknowledged that the LPN failed to assess the resident after the fall.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse for two residents. Resident #1, who had severe cognitive impairment and was dependent on assistance for most activities of daily living, was involved in an incident where the family reported that an agency staff member was rough with the resident. The Director of Nursing (DON) acknowledged that the investigation was incomplete, as only one resident statement was obtained, and the documentation was unsigned and undated. Additionally, a staff member's statement identifying another agency staff member as the accused was provided four days after the allegation, but the investigation was not comprehensive. Resident #3, who was cognitively intact and required moderate assistance with activities of daily living, reported being slapped by a staff member a month prior to the incident report. The DON admitted that no interviews were conducted with other residents who had received care from the accused staff member. Both the DON and the administrator confirmed that a thorough investigation had not been completed for this allegation as well.
Failure to Follow Dietary Menus
Penalty
Summary
The facility failed to adhere to the dietary menus planned for the residents, which is a requirement to meet their nutritional needs. During an observation on June 26, 2024, it was noted that the meal service did not follow the documented menu. The menu specified a meal consisting of a philly steak sandwich, potato wedges, coleslaw, and cheesecake for dessert. However, the dietary manager (DM) reported that they ran out of coleslaw and coconut cake, and as a result, four residents were served a salad and ice cream instead. Additionally, the DM admitted that cheesecake had never been served, and the evening menu was altered because the staff forgot to thaw the meat. The DM also acknowledged that menu substitutions had been frequent recently.
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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