Cordell Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Cordell, Oklahoma.
- Location
- 1400 North College, Cordell, Oklahoma 73632
- CMS Provider Number
- 375306
- Inspections on file
- 16
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Cordell Nursing And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to justify the use of an antibiotic and obtain a wound culture for a resident with a stage three pressure ulcer. The resident was prescribed Keflex for a coccyx wound, but the infection report lacked culture results, and the infection criteria checklist was incomplete. The IPC nurse admitted that the antibiotic stewardship policy was not followed, as no culture was obtained, and the antibiotic was not reviewed after 48 hours.
The facility did not complete annual competency reviews for two CNAs, as required. The personnel files for these CNAs lacked documentation of such reviews, and the DON confirmed there was no policy for annual competency checks. The Administrator verified the absence of these reviews in the files.
The facility failed to adhere to its food storage policy, with observations revealing expired sour cream, undated hot dog buns, and containers of sausage without preparation dates. Staff were unable to confirm the preparation times, indicating non-compliance with labeling and disposal protocols.
The facility failed to submit accurate PBJ staffing data, lacking 24-hour licensed nursing coverage on several dates. The Administrator suggested the issue might be due to unreported agency staff. The facility had 52 residents.
A resident with multiple health issues experienced persistent nausea and vomiting, leading to confusion and abdominal distension. Despite these symptoms and refusal to eat, the facility failed to notify the physician of the change in condition, resulting in the resident being sent to the emergency room. Staff interviews confirmed the lack of physician notification.
A resident with heart failure and high blood pressure reported a missing vape to the Administrator, which had not been communicated by staff as per policy. The resident had informed staff of the theft on a Saturday, but the Administrator was only made aware by a surveyor days later. The facility's policy required such incidents to be reported to the Administrator or DON.
A resident with a history of cardiovascular issues and other conditions experienced nausea, vomiting, and abdominal pain over several days. Despite these symptoms, the facility staff failed to document bowel sound assessments, and the resident was eventually hospitalized with a bowel obstruction. An LPN admitted to assessing the abdomen but did not chart it, and the DON noted the physician was not notified of the change in condition.
The facility did not follow its smoking policy, which requires quarterly smoking assessments. A resident with high blood pressure and high cholesterol was observed smoking without a recent assessment, as the last evaluation was conducted several months prior. The DON acknowledged the policy was not adhered to.
A facility failed to follow proper procedures for the use of bed rails for a resident with severe cognitive impairment. There was no interdisciplinary assessment, physician order, or notification to the resident's representatives about the risks and benefits of side rails. The use of side rails was not documented in the care plan, despite being observed in use. Staff interviews confirmed the oversight, and the DON acknowledged the lack of required assessments and consents.
The facility failed to read and document the second TB skin test results for two residents, one with Alzheimer's and high blood pressure, and another with high blood pressure and anxiety. The IPC nurse could not find the results, indicating a lapse in the facility's TB screening policy.
A facility failed to offer a pneumonia vaccination to a resident according to its policy. The resident, with a history of type two diabetes, a cardiac pacemaker, and high blood pressure, last received a pneumonia vaccination in 2018. The IPC nurse acknowledged not following up to check if the resident was due for another vaccination, despite the policy requiring reevaluation in line with ACIP recommendations.
Failure to Justify Antibiotic Use and Obtain Wound Culture
Penalty
Summary
The facility failed to ensure that an antibiotic prescribed for a wound was justified and that a wound culture had been obtained for a resident with a stage three pressure ulcer. The resident, who had diagnoses including depressive disorder and high blood pressure, was prescribed Keflex 500 mg TID for seven days for a coccyx wound. However, the resident's infection report was incomplete, lacking documentation of culture results, and the infection criteria checklist was not filled out. A weekly wound observation noted the wound's measurements and condition, but the clinical health record did not show that a wound culture had been obtained. The IPC nurse confirmed that no wound culture had been completed and acknowledged that the antibiotic had not been reviewed after 48 hours to determine if it was justified. The nurse was unsure if the wound was infected, although it was worsening. The IPC nurse admitted that the policy for antibiotic stewardship was not followed, as the nurse responsible for completing the resident infection report and infection criteria checklist did not do so, and the IPC nurse did not follow up to ensure the antibiotic was appropriate.
Lack of Annual Competency Reviews for CNAs
Penalty
Summary
The facility failed to ensure that annual competency reviews were completed for two certified nursing assistants (CNAs) out of three sampled staff members. CNA #2, hired on October 21, 2021, and CNA #3, hired on September 21, 2020, did not have documentation of completed annual competency reviews in their personnel files. During an interview on April 25, 2024, the Administrator confirmed the absence of these reviews after checking the personnel files. Additionally, the Director of Nursing (DON) stated that there was no facility policy in place for conducting annual competency reviews for CNAs, and confirmed that the reviews for CNA #2 and CNA #3 should have been documented in their files.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and timely disposal of food items in accordance with their Dietary Services Food Storage policy. During an observation of the kitchen, it was noted that two tubs of sour cream were past their 'best if used by' date, a container of green beans was dated several days prior, and a package of hot dog buns lacked a date of receipt. Additionally, two stainless steel containers with ground and pureed sausage were found without any date or time of preparation. Staff were unable to confirm when these items were prepared or how long they had been stored, indicating a lack of adherence to the facility's policy on food storage and disposal.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure the accuracy of the information submitted on the Payroll Based Journal (PBJ) for 24-hour staffing coverage. A review of the PBJ Staffing Data Report for the period from October 1, 2024, to December 31, 2024, revealed that the facility did not have 24-hour licensed nursing coverage on several specific dates. The Administrator, upon request, provided documentation of coverage for these dates and indicated that the discrepancy might have been due to agency staff not being reported correctly. The facility had 52 residents at the time of the report.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a physician of a change in condition for a resident with multiple diagnoses, including atherosclerosis of coronary artery bypass graft, chronic rhinitis, hypertension, and hyperlipidemia. The resident was administered Zofran multiple times for nausea and vomiting over several days, but there was no documentation that the physician was notified of the resident's ongoing symptoms and refusal to eat or take medication. The resident's condition worsened, with symptoms including confusion, abdominal distension, and increased weakness, leading to an eventual transfer to the emergency room. Despite the resident's persistent symptoms and refusal to eat, there was no documentation of physician notification or assessment of bowel sounds from the initial complaint of abdominal discomfort until the resident was sent to the emergency room. Interviews with staff, including an LPN and the DON, confirmed that the physician should have been notified due to the change in condition, but there was no evidence in the records that this occurred.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure staff reported an allegation of misappropriation of property involving a resident. The resident, who had diagnoses including heart failure and high blood pressure, reported to the Administrator that a personal vape was missing from their bag kept in a locked file box. The resident stated they had two vapes stolen since their stay and had informed staff on a Saturday morning, but not the Administrator. The Administrator was only notified of the missing vape by the surveyor on the following Tuesday. Upon investigation, the Administrator learned from a housekeeper that the resident had reported the missing vape on Saturday, but it was not communicated to the Administrator or the Director of Nursing (DON) as per the facility's policy. The policy required such incidents to be reported to the Administrator or the DON in their absence.
Failure to Assess Bowel Sounds Leads to Hospitalization
Penalty
Summary
The facility failed to assess bowel sounds for a resident who complained of abdominal discomfort, leading to a deficiency in care. The resident, who had a history of atherosclerosis of coronary artery bypass graft, chronic rhinitis, hypertension, and hyperlipidemia, was administered Zofran multiple times for nausea and vomiting. Despite these symptoms, there was no documentation of bowel sound assessments from April 15 to April 19, when the resident was eventually sent to the emergency room. A CT scan at the hospital revealed distended loops of small bowel, indicating a bowel obstruction. Throughout the week, the resident experienced nausea, vomiting, and abdominal pain, yet the facility staff did not document any assessment of bowel sounds. An LPN admitted to assessing the resident's abdomen but failed to chart it. The Director of Nursing acknowledged that the staff should have notified the physician due to the change in the resident's condition, but there was no documentation of such notification. This lack of proper assessment and communication contributed to the resident's hospitalization.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to adhere to its smoking policy and procedure, which mandates that a safe smoking assessment evaluation be completed at the time of admission, quarterly, and with any significant change in condition. This deficiency was identified for one resident who was reviewed for smoking. The resident, who had diagnoses including high blood pressure and high cholesterol, had their last documented Smoking Safety Evaluation completed in August 2023. However, during an observation in April 2024, the resident was seen smoking under the patio while wearing a smoking apron, indicating that the quarterly assessment had not been conducted as required. The Director of Nursing (DON) confirmed that the smoking policy was not followed, as the last assessment was not completed within the quarterly timeframe.
Failure to Follow Procedures for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed regarding the use of bed rails for a resident. Specifically, there was no interdisciplinary assessment completed for the use of side rails, no physician order obtained, and the resident's representatives were not notified about the benefits and potential hazards associated with side rails. Additionally, the use of side rails was not included in the resident's care plan. The facility's policies on bed safety and the use of restraints require an interdisciplinary assessment, consultation with the attending physician, and informed consent from the resident or their legal representative before using side rails. Resident #4, who was admitted with diagnoses including COPD, unspecified dementia, and anxiety, was observed with upper bed rails raised on one side of the bed. The care plan and physician order summary did not document the use of side rails, and staff interviews confirmed that the bed rail was not included in the care plan for repositioning. The Director of Nursing acknowledged that there was no interdisciplinary assessment, family notification, or signed consent for the use of the bed rail, and it was not care planned for mobility and repositioning.
Failure to Read Second TB Skin Test Results
Penalty
Summary
The facility failed to ensure that the second tuberculin skin test (TST) was read for two residents, leading to a deficiency in their infection prevention and control program. Resident #50, diagnosed with Alzheimer's disease and high blood pressure, received their second TB skin test, but the results were still pending and not documented in the clinical health record. Similarly, Resident #16, who had high blood pressure and anxiety, also had their second TB skin test results pending and not read. The Infection Prevention and Control (IPC) nurse was unable to locate the results for both residents when asked to review the immunization records, indicating a lapse in the facility's adherence to their tuberculosis screening policy.
Failure to Offer Pneumonia Vaccination as per Policy
Penalty
Summary
The facility failed to ensure that residents were offered the pneumonia vaccination according to its policy. Specifically, one resident, who was part of a sample of five residents reviewed for immunizations, was not evaluated for eligibility for a pneumonia vaccination. The facility's policy, which was undated, stated that the administration of the pneumococcal vaccination should be in accordance with the current Advisory Committee on Immunization Practices (ACIP) recommendations. The resident in question had a medical history that included type two diabetes mellitus, a cardiac pacemaker, and high blood pressure. The resident's clinical health record indicated that their last pneumonia vaccination was in 2018. During an interview, the Infection Prevention and Control (IPC) nurse admitted that they had not followed up to determine if the resident was due for another pneumonia vaccination, despite believing that reevaluation should occur after five years.
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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