Coweta Care & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coweta, Oklahoma.
- Location
- 30049 East 151st Street South, Coweta, Oklahoma 74429
- CMS Provider Number
- 375304
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Coweta Care & Rehab Center during CMS and state inspections, most recent first.
Two residents received inaccurate MDS assessments: one was incorrectly coded as having taken an anticoagulant instead of an antiplatelet, and another's discharge status was inaccurately documented as a facility death rather than a hospital transfer following a pulmonary embolism.
A resident with a newly identified diagnosis of bipolar disorder did not receive a required referral for a PASRR Level II evaluation after a significant change in status. The initial screening showed no mental health disorder, but the diagnosis was later added to the medical record, and no documentation of a referral was found.
A medication cart was left unlocked and unattended in a hallway with keys hanging from the lock, while residents were present in the area. An LPN also left multi-dose medication packages unsecured on the cart while administering medication to a resident, contrary to facility policy requiring medications to be locked or attended by authorized personnel.
A resident requiring a pureed diet was served meatloaf that was not properly blended, resulting in a chunky and grainy texture that required chewing. The dietary staff and dietician failed to ensure the puree met the required consistency before it was placed on the serving line.
A facility failed to adhere to infection control protocols during incontinent care for a resident with acute respiratory failure. Two CNAs did not wear gowns or change gloves and perform hand hygiene after cleansing the perineal area, contrary to facility policies. The lapse was confirmed by the CNAs, an LPN, and the DON.
The facility failed to ensure that three shower rooms containing hazardous chemicals were locked and secure. Observations revealed that the rooms had various unsecured chemicals, and staff interviews indicated that the locks had been malfunctioning for weeks without corrective action. Additionally, a room near the nurses' station containing hand sanitizer was also found to be unlocked.
The facility failed to conduct required AIMS assessments for three residents on antipsychotic medications, leading to a deficiency. Staff interviews revealed inconsistencies and misunderstandings about the responsibility and frequency of these assessments.
The facility failed to ensure that evening snacks were offered to residents as per their policy. Observations and interviews revealed that residents had to go to the nurses' station to request snacks, and staff were not consistently offering snacks to residents in their rooms. Seven residents reported not being offered an evening snack, and staff interviews confirmed the inconsistency in offering snacks.
The facility failed to follow infection control protocols during medication administration. An LPN did not properly sanitize a glucometer before checking a resident's blood sugar and did not sanitize their hands before drawing and administering insulin. An RN confirmed the protocol was to let the device air dry for two minutes before and after use.
The facility failed to ensure mail delivery to residents on Saturdays. Four residents reported not receiving mail on Saturdays. The activity director and administrator confirmed that mail was only delivered from Monday through Friday, affecting the 73 residents in the facility.
A resident with type two diabetes was transferred to a hospital without proper documentation or notification to the physician or resident representative. The transfer occurred during a transition to an electronic medical record system and was not documented by the nurse on duty over the weekend.
The facility failed to ensure accurate assessments for a resident with hypertension. The quarterly assessment documented anticoagulant use, but the Medication Administration Record did not show any anticoagulant medication administered. The MDS coordinator incorrectly coded the use of an anticoagulant because the resident was given Plavix, an antiplatelet medication.
The facility failed to ensure that a dependent resident received baths according to their care plan. Despite the care plan indicating the need for assistance with bathing, only eight out of 14 scheduled bathing opportunities were completed, with no refusals documented. Observations and staff interviews revealed inconsistencies in the bathing schedule and documentation practices, and the administrator was unaware of the issue.
A facility failed to implement range of motion (ROM) interventions for a resident with limited ROM and contractures. Despite a physician order for restorative therapy and a care plan indicating ROM exercises three times per week, the resident did not consistently receive these services. The restorative aide was unaware of any interventions, and the MDS coordinator confirmed the care plan was incorrect.
The facility failed to ensure the proper positioning of a urinary drainage bag for a resident with a nephrostomy tube, as specified in the care plan. Multiple observations showed the bag placed on the bed by the resident's feet, contrary to instructions. Staff miscommunication and lack of documentation of the resident's preference contributed to this deficiency.
A resident with adult failure to thrive and dementia experienced a significant weight loss of 20 pounds over 30 days. The registered dietitian recommended weekly weights, but this recommendation was missed by the facility's administration. The issue of potentially inaccurate weights was acknowledged by the administrator, but the recommendation was not implemented until identified during the survey.
The facility failed to ensure medications were securely stored for two of the four medication carts observed. On multiple occasions, medication carts on the 100/200 and 500/600 halls were found unlocked and unattended. Staff members acknowledged that medication carts should be secured when unattended, but failed to consistently follow this protocol.
The facility failed to serve food at a palatable temperature, as reported by three residents and observed by surveyors. The administrator was unaware of any complaints but committed to investigating the issue.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two of twenty-eight sampled residents. For one resident, the MDS assessment incorrectly indicated the use of an anticoagulant during the look-back period, while the resident was actually prescribed and administered an antiplatelet medication, Clopidogrel Bisulfate, for blood clot prevention. The MDS coordinator acknowledged the error, stating that the assessment was miscoded despite efforts to ensure accuracy during completion. For another resident, discrepancies were found in the discharge assessment. The resident, who was cognitively intact and had diagnoses including anemia, urinary tract infection, and arthritis, experienced a medical emergency and was sent to the hospital, where a pulmonary embolism was diagnosed. The resident died at the hospital, but the MDS discharge assessment inaccurately documented the resident as having died in the facility. The MDS coordinator confirmed after reviewing the clinical record that the discharge should have reflected a transfer to the hospital rather than a death in the facility.
Failure to Refer for PASRR Level II After New Mental Health Diagnosis
Penalty
Summary
The facility failed to make a required referral to the Oklahoma Health Care Authority (OHCA) for a Pre-Admission Screening and Resident Review (PASRR) Level II after a resident was newly diagnosed with a serious mental health disorder. Initially, the resident's PASRR Level I form indicated no mental health disorder, and no Level II referral was deemed necessary. However, a diagnosis of bipolar disorder was later added to the resident's medical record. Despite this significant change in the resident's status, as documented in a subsequent assessment showing intact cognition, there was no evidence that a PASRR Level II referral was made. The MDS coordinator confirmed the absence of documentation for such a referral following the new diagnosis.
Failure to Secure Medication Cart and Medications
Penalty
Summary
A deficiency was identified when drugs and biologicals were not stored in locked compartments as required. During an observation, a medication cart was found unlocked in the Southwest corridor with a set of keys hanging from the lock and no staff present. At the time, three residents were independently moving in the hallway, and the unattended cart was accessible. Additionally, during a medication pass, an LPN removed medications from multi-dose pharmacy-prepared packages and left them on the cart while entering a resident's room, leaving the cart and medications unattended. Upon returning, a resident in a wheelchair was observed sitting by the medication cart. Facility policy states that only authorized personnel should have unsupervised access to medications and that medication carts must be locked or attended at all times. The LPN admitted to forgetting to lock the cart and leaving the keys in the lock due to being in a hurry, and was unaware that the multi-dose medication packages were left unsecured. The DON confirmed that medication carts should always be locked when unattended and that as-needed narcotic medications are stored in the medication carts on the halls.
Pureed Food Served with Improper Consistency
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the appropriate consistency for residents requiring this diet. During meal preparation, a cook processed meatloaf with beef base and hot water, then asked the dietician to check the puree. The surveyor tasted the puree and found it to be chunky with bits that required chewing, indicating it was not smooth as required for a pureed diet. The dietician did not taste the puree but told the cook it was acceptable to serve. The puree was then poured into a container and placed on the steam table for serving. The surveyor later stopped the serving of the puree after observing its texture. The dietary manager subsequently confirmed the puree was grainy and not smooth, and the dietician acknowledged it needed further blending.
Infection Control Lapse During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during incontinent care for a resident. Specifically, two CNAs were observed providing care without wearing gowns, which is required under the facility's Enhanced Barrier Precautions policy for high-contact activities like changing briefs. Additionally, the CNAs did not change gloves or perform hand hygiene after cleansing the perineal area, as stipulated in the facility's Incontinent Care policy. The resident involved had diagnoses including gastrostomy status and acute respiratory failure. Interviews with the CNAs and the LPN confirmed that the expected procedures were not followed, and the Director of Nursing acknowledged the lapse in protocol adherence.
Failure to Secure Shower Rooms Containing Hazardous Chemicals
Penalty
Summary
The facility failed to ensure that three of three shower rooms containing chemicals were locked and secure. During observations, it was noted that the shower rooms on hall #2, hall #3, and hall #4 had various unsecured chemicals, including unlabeled spray bottles, hard surface cleaners, body washes, and razors without safety caps. These chemicals were labeled to be kept out of reach of children, yet the rooms were found unlocked. Staff interviews revealed that the locks on these doors had been malfunctioning for weeks, and the issue had been reported to housekeeping and maintenance, but no corrective action had been taken. Additionally, a room near the nurses' station on halls #5 and #6, which contained hand sanitizer, was also found to be unlocked. The Director of Nursing (DON) identified that 73 residents resided at the facility, including a resident known to be a wanderer. The maintenance supervisor acknowledged that the keypads to the showers and supply storage had been unlocked by staff and needed to be reset. Despite the maintenance supervisor locking the hall #2 shower room and the PPE room near the nurses' station, the failure to secure these areas initially posed a significant risk to the residents, particularly those who might wander into these unsecured areas and access hazardous chemicals.
Failure to Conduct Required AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that residents on antipsychotic medications were assessed for tardive dyskinesia as required. Specifically, three residents with diagnoses including paranoid schizophrenia, schizophrenia, and Wernicke's encephalopathy were not given the necessary AIMS assessments quarterly. For Resident #3, the last AIMS assessment was completed in October 2023, despite a physician order for Seroquel in March 2024. Similarly, Resident #34 had their last AIMS assessment in September 2023, even though they were prescribed Zyprexa in March 2024. Resident #32, who was on multiple psychoactive medications, missed AIMS assessments in September 2023, December 2023, and March 2024. Additionally, psychoactive evaluations were not completed for Resident #32 as per the facility's policy. Interviews with staff revealed inconsistencies and misunderstandings regarding the responsibility and frequency of AIMS assessments. RN #1 and the ADON provided conflicting information about who was responsible for completing these assessments and how often they should be done. RN #1 admitted that monitoring for symptoms of tardive dyskinesia was not conducted for Residents #3 and #32, and only behavior and side effect monitoring were performed. This lack of proper assessment and monitoring led to the deficiency identified in the report.
Failure to Offer Evening Snacks to Residents
Penalty
Summary
The facility failed to ensure that evening snacks were offered to residents as per their policy. The Meals and Snacks policy, dated 03/31/21, stated that nursing staff were responsible for distributing snacks to residents in the evening. However, observations and interviews revealed that residents had to go to the nurses' station to request snacks, and staff were not consistently offering snacks to residents in their rooms. Specifically, seven residents reported not being offered an evening snack, and some had to request snacks from the nurses' station. Staff interviews confirmed that snacks were not routinely offered to all residents, and there was a lack of clarity on how bed-bound residents would receive snacks if they did not request them. One CNA admitted to not offering a snack to a resident they had just assisted to bed, despite claiming to have offered snacks to all residents on their hall. An LPN and an RN also confirmed that residents could request snacks at the nurses' station, but there was no consistent practice of offering snacks to all residents in the evening. The deficiency was observed on multiple occasions, with residents in wheelchairs seen requesting snacks at the nurses' station and several residents stating they had not been offered an evening snack. The facility's failure to adhere to its own policy resulted in residents not receiving evening snacks unless they specifically requested them, highlighting a gap in the implementation of the policy by the nursing staff. This inconsistency in offering snacks could potentially affect the nutritional intake and satisfaction of the residents, particularly those who are bed-bound or less mobile.
Infection Control Protocols Not Followed During Medication Administration
Penalty
Summary
The facility failed to ensure infection control protocols were followed during medication administration. Specifically, an LPN did not properly sanitize a glucometer before checking a resident's blood sugar. The LPN used a Sani-wipe but did not wait the full two minutes and wipe it again as required to ensure blood-borne pathogens were eradicated. Additionally, the LPN did not sanitize their hands before drawing insulin into a syringe and administering it to the resident. An RN confirmed that the infection control protocol for glucometers was to follow the manufacturer guidelines, which include letting the device air dry for two minutes before and after use with purple top Sani-wipes.
Failure to Ensure Mail Delivery on Saturdays
Penalty
Summary
The facility failed to ensure mail delivery to residents on Saturdays. During a resident group meeting, four residents reported that they did not receive mail on Saturdays. The activity director confirmed that mail was obtained from the post office and delivered to residents from Monday through Friday, but was unsure if anyone delivered mail on Saturdays. The administrator also confirmed that mail delivery occurred only from Monday through Friday, with no one assigned to deliver mail on Saturdays. This affected the 73 residents residing in the facility.
Failure to Document Resident Transfer
Penalty
Summary
The facility failed to ensure the discharge of Resident #78 was documented in the medical record. Resident #78, who had a diagnosis of type two diabetes, was transferred to a hospital without proper documentation or notification to the physician or resident representative. A nurse's note dated 03/04/24 mentioned a phone call to an unidentified hospital about the resident's condition, but no reason for the transfer was recorded in the medical record. LPN #1 confirmed the absence of documentation regarding the transfer. The administrator later stated that the transfer occurred during a transition to an electronic medical record system and was not documented by the nurse on duty over the weekend.
Inaccurate Resident Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure accurate assessments for a resident with hypertension. The quarterly assessment documented that the resident had received an anticoagulant medication during the seven-day look-back period. However, the Medication Administration Record for the same period did not show that the resident had received any anticoagulant medication. The MDS coordinator reviewed the clinical record and incorrectly coded the use of an anticoagulant because the resident was administered Plavix, an antiplatelet medication, not an anticoagulant.
Failure to Provide Scheduled Baths for Dependent Resident
Penalty
Summary
The facility failed to ensure that dependent residents were offered or received baths according to their preferences. Specifically, Resident #15, who had diagnoses including colostomy status and acute kidney failure, required partial to moderate assistance for bathing and was moderately impaired in cognition for daily decision-making. Despite the care plan indicating that Resident #15 should receive assistance with bathing and be offered a bed bath when a shower was not tolerated, the electronic clinical record showed that only eight out of 14 scheduled bathing opportunities were completed, with no refusals documented. Observations and interviews revealed inconsistencies in the bathing schedule and documentation practices among the staff. On one occasion, Resident #15 was observed to have oily hair and stated they received approximately one shower per week, contrary to the care plan. Interviews with CMA #1 and CNA #2 provided conflicting information about the bathing schedule, with one stating the resident should receive three showers a week and the other stating the resident received showers on different days. The administrator was unaware of any issues regarding residents not receiving baths as scheduled, indicating a lack of oversight and communication within the facility.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to ensure that range of motion (ROM) interventions were implemented for a resident with limited range of motion. Resident #47, who had diagnoses including impingement syndrome of both shoulders, had a physician order for restorative therapy dated 09/23/22. However, the resident was removed from the restorative nursing program as documented in a form dated September 2023. Despite the care plan indicating that the resident was on the restorative program three times per week for contractures, observations and interviews revealed inconsistencies in the provision of ROM exercises and the use of splints or devices for the resident's contracted fingers. The resident reported that ROM exercises were not provided consistently, and the restorative aide was unaware of any interventions for the resident's limited range of motion. Further review of the restorative therapy binder did not show that Resident #47 was receiving restorative nursing services, even though the order for restorative therapy was still active. The MDS coordinator confirmed that the care plan was incorrect and that the resident was not on the restorative program at the time of the survey. The resident had been on and off the restorative program and had refused therapy at times. However, the resident had requested restorative therapy earlier on the day of the survey. No additional information was provided by the end of the survey to clarify the interventions in place for the resident's contractures.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure the proper positioning of a urinary drainage bag for a resident with a nephrostomy tube. The resident's care plan specified that the drainage bag should be maintained below the level of the kidney at all times. However, multiple observations revealed that the drainage bag was placed on the bed by the resident's feet, contrary to the care plan instructions. This improper positioning was confirmed by both a CNA and an LPN, who stated they placed the bag on the bed to prevent it from getting smashed between the bed and the wall. The LPN also incorrectly believed that the bag could be placed at the same level as the kidney, which contradicts the care plan requirements. Further interviews revealed that the resident did not prefer the drainage bag to be placed on the bed, despite staff claims to the contrary. The resident's preference regarding the placement of the drainage bag was not documented. The RN acknowledged the need to place the drainage bag below the kidney but was unaware of the resident's actual preference. This lack of adherence to the care plan and miscommunication among staff led to the deficiency in providing appropriate catheter care for the resident.
Failure to Monitor Resident's Weight as Recommended
Penalty
Summary
The facility failed to ensure weights were monitored as recommended by the registered dietitian for a resident diagnosed with adult failure to thrive and dementia. The resident's electronic health record documented a significant weight loss of 20 pounds over 30 days. The registered dietitian recommended weekly weights to address the weight loss, but this recommendation was missed by the facility's administration. The dietitian brought the issue of potentially inaccurate weights to the attention of the administrator, who acknowledged the problem and indicated that the facility was correcting it. However, the recommendation for weekly weights was not implemented until the deficiency was identified during the survey.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure medications were securely stored for two of the four medication carts observed. On multiple occasions, medication carts on the 100/200 and 500/600 halls were found unlocked and unattended. Specifically, on 04/30/24, the 500/600 hall medication cart was left unlocked and unattended near the nurse's station, and later, an LPN had their back to the unlocked cart. On 05/01/24, an LPN left the 100/200 hall medication cart unlocked and unattended while performing a fingerstick blood sugar check for a resident. Staff members, including an LPN and a CMA, acknowledged that medication carts should be secured when unattended, but failed to consistently follow this protocol.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to ensure food was served at a palatable temperature for one noon meal observed for palatability. Resident #69 reported that their food was served cold to their room and that cold salads were placed on plates with hot food, causing the vegetables to wilt. During a resident group meeting, two other residents also stated that their meals were often served cold in their rooms. An observation of the last tray on the back hall cart revealed that the cornbread, broccoli with cheese, and potatoes were not served at a palatable temperature. The administrator stated they had not received any complaints about cold food but would investigate the concern.
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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