Corn Heritage Village And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Corn, Oklahoma.
- Location
- 106 West Adams, Corn, Oklahoma 73024
- CMS Provider Number
- 375409
- Inspections on file
- 21
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 4 (2 serious)
Citation history
Health deficiencies cited at Corn Heritage Village And Rehab during CMS and state inspections, most recent first.
A resident on long-term anticoagulant therapy experienced an unwitnessed fall with head injury, but staff failed to notify the physician of the resident's medication status and subsequent changes in condition. Despite developing significant bruising, low blood pressure, and mental status changes, the resident was not promptly assessed or sent to the hospital, resulting in delayed intervention. Staff interviews confirmed that established protocols for monitoring and physician notification were not followed.
Nursing staff did not effectively assess, monitor, or intervene for a resident on a blood thinner who sustained a head injury after a fall. Staff failed to notify the physician of the resident’s anticoagulant use and abnormal vital signs, resulting in delayed hospital transfer and diagnosis of an acute subdural hematoma. Interviews indicated staff were unaware of the need to report such changes, and annual competency checks had not been completed.
A resident on anticoagulation therapy experienced a fall with head injury, but the LPN did not inform the physician of the resident's blood thinner use or subsequent changes in condition, including abnormal vital signs and new injuries. The physician was only notified after the resident's neurological status declined significantly, resulting in hospital transfer and diagnosis of a subdural hematoma.
The facility did not report an allegation of resident-to-resident sexual abuse to OSDH within the required 24-hour period. Two residents with cognitive impairments were involved in the incident, and the DON later confirmed the reporting delay, which was not in accordance with facility policy.
A resident with anxiety disorder did not receive medications as per physician's orders due to a discrepancy between the drug label and the physician's order list. The order specified administration every four hours, but the medication was given four times a day. The inconsistency was noted, but no clarification was sought from the physician.
The facility failed to implement an antibiotic stewardship program for three residents who were prescribed antibiotics without completing the Mcgreer criteria checklist. The DON and infection preventionist acknowledged the oversight, citing staff changes as the reason for the lapse.
A facility failed to report new mental illness diagnoses for a resident to the OHCA as required by PASARR policy. The resident had new diagnoses of anxiety disorder, recurrent depressive disorder, hallucinations, and psychosis, but these were not reported for a level II review. The DON was unaware of the reporting requirement until recently, and a level II screen was not conducted until later, when it was deemed unnecessary.
A resident with congestive heart failure and chronic obstructive pulmonary disease was admitted to hospice care, but the facility failed to include hospice services in the resident's care plan. Despite a comprehensive assessment noting the resident's intact cognition and receipt of hospice services, the care plan did not reflect these services, contrary to the facility's policy requiring updates within seven days of changes in condition.
The facility failed to provide incontinent care every two hours to three dependent residents with impaired range of motion and incontinence. Observations revealed that these residents were left without care for several hours, resulting in grossly saturated briefs. A CNA and RN confirmed the facility's policy was not followed.
The facility failed to provide food handling training to eight out of nineteen dietary staff members, including cooks and dietary aides, which is crucial for preventing foodborne illness. The deficiency was identified during a review, with the Administrator unable to verify training for these staff members, affecting meal preparation for 61 residents.
Failure to Monitor and Intervene After Fall in Resident on Anticoagulant
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper monitoring and intervention for a resident on long-term anticoagulant therapy following an unwitnessed fall. The resident, who had diagnoses including rheumatoid arthritis, atrial fibrillation, hypertension, and a history of transient ischemic attack, experienced a fall from a recliner, hitting their head and developing significant bruising. Despite the facility's policy requiring neurologic assessments and immediate physician notification for head injuries, there was no documentation that the physician was notified of the resident's change in condition after the fall. Subsequent nursing notes indicated the resident had increased bruising, low blood pressure, decreased oxygen saturation, and required more assistance, but these changes were not communicated to the physician. The LPN who reported the fall to the physician's nurse failed to mention that the resident was on a blood thinner, leading to a lack of appropriate medical response. The resident's condition further deteriorated, with pinpoint pupils and a mental status change observed two days after the fall, at which point the physician was finally notified and the resident was sent to the hospital. Interviews with staff confirmed that the resident should have been sent to the hospital immediately after the fall due to their anticoagulant use and head injury. The LPN acknowledged overlooking the resident's anticoagulant therapy and not reporting abnormal blood pressure readings or the development of two black eyes to the physician. The failure to follow established protocols for monitoring and physician notification after a significant change in condition resulted in a delay in appropriate medical intervention.
Removal Plan
- Staff will identify residents on anticoagulants at shift change by notifying oncoming staff at shift change of all residents on anticoagulants.
- Administration will post a roster in the medication room of all residents on anticoagulants.
- Administration will post a roster in the medication room of all anticoagulant medications.
- Will adjust EHR resident dashboard to indicate the use of anticoagulant medication.
- Immediate In-Service Education of medication management with a focus on high-risk drugs like anticoagulants for nursing staff and CMAs.
- Competency assessments will be completed by nursing administration including demonstrations of skills, med-administration, side effects and monitoring requirements.
- All residents were reassessed for changes in condition and care plans were updated for discrepancies.
- Nursing staff were educated on monitoring residents through routine assessments, ongoing observation, and documentation. This includes checking vital signs, evaluating physical and mental status, and noting any changes in behavior, appearance, or function.
- Staff are now trained to recognize both subtle and obvious changes in residents' health, such as increased confusion, changes in mobility, altered appetite, new or worsening pain, or unusual sleep patterns.
- Nursing Staff were educated on promptly notifying the physician whenever there is a significant change in the condition of a nursing home resident on anti-coagulants. This includes any acute medical events, substantial changes in physical or mental status, or any situation that may require a change in treatment or intervention. Notification should occur as soon as reasonably possible after the change has been identified by nursing staff, in accordance with regulatory guidelines and the facility's policies.
- Nursing home nursing staff will receive dedicated training focused on the indications for commonly used medications, with special emphasis on blood thinners. The training will cover: Overview of blood thinners: indications, expected outcomes, and common side effects. Recognizing signs and symptoms of adverse reactions or complications (e.g., bleeding, bruising, changes in mental status, or unexplained pain). Monitoring protocols for residents on blood thinners, including vital signs, laboratory values, and physical assessments. Documentation requirements and communication procedures for reporting changes in resident conditions. Emergency response procedures for suspected medication-related complications.
- The training will be delivered by the facility's Director of Nursing, in collaboration with the facility pharmacist consultant and CHV nurse consultant.
Failure to Ensure Nursing Staff Competency in Change of Condition for Resident on Anticoagulant
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in assessing, monitoring, and intervening for a resident who was on a routine blood thinner and sustained a fall with a head injury. The resident, who had a history of atrial fibrillation and heart failure and was prescribed Xarelto, experienced a fall resulting in a head injury and subsequent acute subdural hemorrhage. Despite facility policy requiring neurological assessments and immediate physician notification for head trauma, staff did not communicate the resident’s anticoagulant use to the physician and did not send the resident to the hospital immediately after the fall. Documentation showed that after the fall, the resident developed a large hematoma, bruising, and later two black eyes and additional bruising, with abnormal blood pressure readings noted. Staff continued to monitor the resident in the facility, performing neuro checks and documenting changes, but failed to recognize or report significant changes in condition, including abnormal vital signs and new injuries, to the physician in a timely manner. The resident’s condition deteriorated over the following days, culminating in confusion, pinpoint pupils, and slow responsiveness, at which point the resident was finally transferred to the hospital and diagnosed with an acute subdural hematoma. Interviews with staff revealed a lack of awareness regarding the importance of reporting anticoagulant use and abnormal vital signs after a fall. The LPN involved admitted to overlooking the resident’s blood thinner status and not communicating critical information to the physician. The DON and ADON acknowledged that the facility’s process for physician notification after a fall was not consistently followed, and that annual competency check-offs for nursing staff had not been completed.
Removal Plan
- All nursing staff complete Skills Competency proficiency of change of condition with a focus on high-risk drugs like anticoagulants.
- DON and ADON are in-serviced on training and completing nursing skills competency education for nursing staff.
- All residents are reassessed for changes in condition and care plans are updated for discrepancies.
- DON and ADON are educated on auditing nursing staff annual skills competency education.
- DON and ADON are educated on auditing nursing staff new hire skills competency education.
- Nursing staff complete testing regarding changes in condition, medication drug class identification, and recognizing vital signs.
- Nursing staff are educated on what constitutes a significant change in condition that requires reporting, including sudden onset of symptoms, significant changes in vital signs, new or worsening pain, changes in mobility, altered level of consciousness, signs of infection, unexplained weight loss or gain, and changes in skin integrity.
Failure to Notify Physician of Change in Condition After Fall with Head Trauma
Penalty
Summary
The facility failed to ensure timely and appropriate physician notification following a significant change in condition for a resident who experienced a fall with head trauma. The resident, who had a medical history including atrial fibrillation and was prescribed Xarelto (a blood thinner), sustained a head injury after an unwitnessed fall. Facility policy required immediate physician notification and neurological assessment for any head trauma, especially for residents on anticoagulants. However, documentation and interviews revealed that the physician was not informed that the resident was on a blood thinner at the time of the initial notification, and critical details such as abnormal blood pressure readings and the development of new injuries (including two black eyes and additional bruising) were not promptly communicated. Nursing notes indicated that the resident developed worsening symptoms over the following days, including increased bruising, new injuries, and abnormal vital signs. Despite these changes, there was no evidence that the physician was updated about the resident's deteriorating condition or the significance of the blood thinner therapy. The resident continued to receive Xarelto, and neuro checks were performed, but the escalation of symptoms and abnormal findings were not reported as required by facility policy. It was only after a significant decline in neurological status, including confusion and pinpoint pupils, that the physician was notified and the resident was transferred to the hospital, where a diagnosis of acute subdural hematoma was made. Interviews with facility staff, including the LPN and ADON, confirmed that the physician should have been notified immediately after the fall due to the resident's anticoagulant use and that subsequent changes in condition warranted further communication, which did not occur.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to the Oklahoma State Department of Health (OSDH) within 24 hours as required by policy and state law. Specifically, an incident involving two residents, where one resident was observed placing another resident's hands in their groin area over clothing, was not reported to OSDH within the mandated timeframe. The facility's policy requires immediate reporting of any alleged abuse to the administrator and DON, who are then responsible for notifying authorities. However, the initial report to OSDH was made after the 24-hour window had passed. Resident records indicated that one resident involved had moderate cognitive impairment and a history of sexually inappropriate behavior, while the other had severe cognitive impairment and required significant assistance with activities of daily living. During interviews, one resident denied being approached by another resident, and the DON confirmed that the incident should have been reported within 24 hours. The failure to report the allegation in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Medication Administration Discrepancy for Resident with Anxiety Disorder
Penalty
Summary
The facility failed to administer physician-ordered medications correctly for a resident diagnosed with senile degeneration of the brain, anxiety disorder, and polyarthritis. The physician's order, dated November 6, 2024, instructed the administration of 0.5 mg PLO gel every four hours. However, the drug label and the physician's order list documented conflicting instructions, with the label indicating application every four hours and the order list specifying four times a day. This discrepancy was not clarified with the physician, leading to a medication error. The Controlled Narcotic Administration Record showed an accurate count of 53 pre-filled syringes of 0.5 ml medication, but it documented administration four times a day instead of every four hours as ordered. A Medication Error Report noted the inconsistency between the prescription label and the chart order, yet no clarification was sought. The Director of Nursing acknowledged the discrepancy and the need to contact the physician for clarification, but this action was not taken at the time of the report.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for three residents who were sampled for medication review. Resident #17, diagnosed with chronic systolic congestive heart failure, permanent A-Fib, and recurrent depressive disorders, was prescribed Macrobid for a urinary tract infection without the completion of the Mcgreer criteria checklist. Similarly, Resident #39, with chronic obstructive pulmonary disease and acute kidney disease, was prescribed Cephalexin for a urinary tract infection, but the Mcgreer criteria checklist was not completed. Resident #44, who had congestive heart failure and atrial fibrillation, was given Piperacillin-Tazobactam for a severe liver infection, yet again, the Mcgreer criteria checklist was not utilized. The Director of Nursing (DON) and the infection preventionist acknowledged the oversight, citing a change in staff as the reason for the lapse in completing the Mcgreer criteria for residents prescribed antibiotics. The infection preventionist was unaware that the Mcgreer criteria checklist should have been completed for residents receiving antibiotics. This lack of adherence to the antibiotic stewardship program was identified during interviews with the DON and the Assistant Director of Nursing (ADON), highlighting a significant gap in the facility's infection control program.
Failure to Report New Mental Illness Diagnoses
Penalty
Summary
The facility failed to report new mental illness diagnoses for a resident to the Oklahoma Health Care Authority (OHCA) as required by the Preadmission Screening and Annual Resident Review (PASARR) policy. The policy mandates that all residents with newly evident or possible serious mental disorders be referred for a level II review upon a significant change in status assessment. Resident #6, who was admitted with primary diagnoses of chronic obstructive pulmonary disease and acute on chronic systolic heart failure, had new diagnoses of anxiety disorder, recurrent depressive disorder, hallucinations, and psychosis documented on various dates. Despite these new mental health diagnoses, the Director of Nursing (DON) reported that they were not aware of the requirement to report these to the OHCA until recently, and a level II screen was not conducted until 11/18/24, when it was determined not to be required.
Failure to Include Hospice Services in Care Plan
Penalty
Summary
The facility failed to include hospice services in the care plan for a resident who was receiving hospice care. The resident had diagnoses of congestive heart failure and chronic obstructive pulmonary disease and was admitted to hospice with a diagnosis of hypertensive heart disease with heart failure. Despite a comprehensive assessment documenting the resident's intact cognition and receipt of hospice services, the care plan did not address or document these hospice services. The facility's policy required comprehensive care plans to be revised and updated within seven days of any new changes in a resident's condition, but this was not adhered to in this case.
Failure to Provide Timely Incontinent Care to Dependent Residents
Penalty
Summary
The facility failed to provide incontinent care to dependent residents at least every two hours, as required by their policy. Three residents, all of whom had impaired range of motion in both upper and lower extremities and were incontinent of bowel and bladder, were observed sitting in the common area and later escorted to the dining room and activity area without receiving incontinent care. These residents were dependent on staff for all activities of daily living (ADLs). During the observation period, the residents were not provided with incontinent care for several hours. When care was finally administered, the residents' briefs and padding were found to be grossly saturated, indicating a significant delay in care. A Certified Nursing Assistant (CNA) confirmed that the facility's policy was to check dependent residents every two hours, acknowledging that this policy was not followed for the observed residents. The Registered Nurse (RN) also confirmed the policy and acknowledged the failure to adhere to it.
Lack of Food Handling Training for Dietary Staff
Penalty
Summary
The facility failed to ensure that all dietary staff received training in safe food handling practices, which is essential for the prevention of foodborne illness. This deficiency was identified during a record review and interview process, revealing that eight out of nineteen dietary staff members, including four cooks and four dietary aides, had not received the required food handlers training. The Director of Nursing (DON) confirmed that 61 residents resided in the facility, all of whom received meals prepared by the dietary department. The deficiency was noted when the Administrator was unable to provide verification of food handlers training for these eight staff members, acknowledging the lapse in training compliance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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