Drumright Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Drumright, Oklahoma.
- Location
- 701 N Bristow Ave, Drumright, Oklahoma 74030
- CMS Provider Number
- 375466
- Inspections on file
- 22
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 8 (2 serious)
Citation history
Health deficiencies cited at Drumright Nursing Home during CMS and state inspections, most recent first.
A resident with dementia repeatedly physically assaulted other cognitively impaired residents, including slapping and hitting, sometimes causing injuries. Staff did not consistently notify law enforcement or families, failed to update care plans, and did not provide post-incident education or conduct safety assessments, contrary to facility policy.
A resident with severe cognitive impairment and a history of exit-seeking behaviors repeatedly eloped from the facility, including being found walking near a highway, due to inadequate supervision and lack of timely care plan updates. Staff were aware of the resident's risk but did not consistently implement or document increased monitoring, and several staff reported not receiving specific training on elopement prevention. Facility doors could be bypassed, and there was no specific elopement policy in place.
A resident with severe cognitive impairment and a history of elopement was not consistently care planned for each incident of leaving the facility unsupervised. Despite multiple episodes of elopement, the care plan was either delayed or not updated to reflect these events, contrary to facility policy and assessment requirements.
The facility failed to conduct thorough investigations after abuse allegations involving two residents. One resident, with intact cognition, reported fear of a CNA, but the investigation lacked interviews and external notifications. Another resident, with moderately impaired cognition, complained about a CNA's actions, but the investigation did not notify adult protective services or the nurse aide registry. The DON confirmed the investigations were incomplete.
The facility failed to ensure proper treatment and monitoring of pressure ulcers for two residents, resulting in the worsening of their conditions. Despite physician orders for daily wound care, there was no documentation of wound care being performed on multiple occasions, leading to the deterioration of the wounds. Observations confirmed that wound care was not consistently provided, and the wounds worsened over time. Additionally, there was a lack of documentation for repositioning the residents every two hours as per physician orders, contributing to the worsening of the pressure ulcers.
The facility failed to ensure their social worker met the required qualifications for a facility licensed for 133 beds. The social worker had an associate in arts and six years of experience as a case manager at a prison, but did not have the required bachelor's degree. This was confirmed by the ADON and DON during an interview.
A resident with anxiety and agitation received Ativan beyond the 14-day limit specified in the physician's order. The medication was administered in February and March 2024, and the ADON and DON acknowledged that the order should have been stopped and reassessed.
The facility failed to maintain an infection control program for two residents with pressure ulcers. An LPN did not clean a metal pan after it came into contact with a resident's personal belongings and bedside table, and another LPN did not clean the bedside table or the metal pan after wound care. These actions were against the facility's infection control policy.
The facility failed to ensure food was served at an appetizing temperature, with multiple residents reporting that their meals were often cold and unappetizing. A food test tray confirmed the issue, with breaded squash served at 108 degrees Fahrenheit.
The facility failed to maintain sanitary food preparation and serving practices. A dietary aide did not wash their hands when entering the kitchen multiple times, and a dietary cook used hand sanitizer instead of washing hands with soap and water while serving food. The dietary manager was unaware that hand sanitizer could not be used in the kitchen.
The facility failed to ensure a resident's code status was accurate. A resident with heart disease, COPD, a pacemaker, chronic pain, and CKD had a DNR consent form, but a physician order documented CPR. The ADON and DON confirmed the resident was supposed to be a DNR, indicating a discrepancy.
The facility failed to provide a resident with the required SNF ABN and/or NOMNC notices upon discharge from Part A skilled services, despite having benefit days remaining. The resident, who had multiple diagnoses including COPD and heart failure, was hospitalized, and there was no documentation that the necessary notices were given to the resident or their legal representative.
The facility failed to ensure a discharged resident's clinical record contained a discharge summary. The resident had multiple diagnoses, including COPD and heart failure. A physician order documented the resident was discharged home, but no discharge summary was completed. The ADON confirmed the summary was not completed within the required timeframe.
A resident with multiple diagnoses was discharged home without a written 30-day notice. The ADON confirmed that only a verbal notice was given by the administrator, despite the resident's Medicaid case still pending.
The facility failed to allow a resident to return after hospitalization, despite having a bed-hold policy of five days. The resident, with multiple diagnoses, was hospitalized due to a drop in oxygen saturation. The family was incorrectly informed that the resident had no skilled service days remaining, and the resident was not permitted to return.
The facility failed to refer a resident with newly diagnosed serious mental illnesses, including bipolar type schizophrenia disorder and borderline personality disorder, to the OHCA for a level II PASRR evaluation, despite the initial level I PASRR indicating no serious mental illness.
The facility failed to include a care plan regarding dietary preferences for a resident diagnosed with vitamin D deficiency and depression. A physician order specified a no added salt vegetarian diet and smoothies with super greens powder, but the ADON acknowledged that these preferences were not included in the care plan.
The facility failed to verify CNA certification for two CNAs, allowing them to work with expired certifications. The ADON indicated that the IP nurse was responsible for this task, but the IP nurse was unavailable for an interview.
The facility failed to ensure the QAA committee met at least quarterly. There was no documentation of meetings from October 2023 through December 2023. The DON confirmed the lack of documentation despite the requirement for quarterly meetings.
The facility failed to offer an influenza vaccine to a resident admitted after a vaccination clinic held at the end of 2023. The resident's vaccination record showed they had not received the vaccine, and the IP confirmed that new admissions were not offered vaccinations post-clinic.
The facility failed to follow the dietitian-approved menu for a meal service, substituting meatloaf for pork chops and devil cake for chocolate cream dessert without notifying the dietitian. This affected 52 residents, including two who rely solely on feeding tubes.
Failure to Protect Residents from Physical Abuse and Inadequate Incident Response
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically involving multiple incidents where one resident with dementia and Alzheimer's disease physically assaulted other residents. The resident in question exhibited repeated aggressive behaviors, including slapping, hitting, and using objects to strike other residents, all of whom had varying degrees of cognitive impairment. Incident reports documented several episodes where this resident slapped or hit others, sometimes causing visible injuries such as a knot on the head or facial soreness. Despite these occurrences, there was no evidence that staff provided education following the incidents, nor were law enforcement or the residents' families consistently notified as required by policy. Care plans for the involved residents were not consistently updated to reflect the incidents or to implement new interventions to prevent further abuse. For example, after a resident was slapped and sustained a head injury, their care plan was not revised to address the new risk. Similarly, other residents who were assaulted did not have their care plans updated to include additional safety measures or interventions. Staff interviews revealed a lack of awareness and documentation regarding post-incident education, law enforcement notification, and the completion of safe surveys to assess and ensure resident safety after each event. The facility's own policy required screening, training, prevention, identification, investigation, protection, and reporting of abuse, but these steps were not followed in practice. Staff and administration admitted to not contacting law enforcement for incidents they deemed minor, such as slapping, and did not conduct safe surveys or provide education after the altercations. There was also no evidence of quality assurance reviews or new interventions being established following the incidents. The repeated failure to follow established protocols and update care plans left residents vulnerable to further abuse.
Removal Plan
- Resident #28 has been referred for inpatient geri-psych services.
- Resident #28 was immediately placed on one-on-one supervision until departure from the facility.
- All staff will receive inservice training regarding abuse prevention including resident to resident abuse.
- Staff will receive training to intervene when resident to resident abuse occurs, report abuse immediately to the Administrator, assess or evaluate the resident who sustained abuse for injury, and document those findings in the resident record.
- An intervention(s) will be established for each episode of resident-to-resident abuse at the time of the occurrence, communicated to staff, and updated to the resident's care plan.
- An intervention communication form will be used to communicate to staff all new occurrences and interventions.
- All staff received inservice either in person or by phone call. For any staff member that could not receive inservice in person or by phone, they will be required to receive inservice before their next scheduled shift.
- Inservice education will be provided by the DON, RN, and Care Plan Coordinator.
- Resident #28 had no access to any other resident outside of the memory care unit.
- All residents on the memory care unit were safe from abuse immediately when one on one supervision was established for resident #28.
- Resident #28 was transferred via EMSA from the building for geri-psych services.
- Each resident on the memory care unit will receive a head to toe assessment for injury and will be asked about their safety.
- The Plan of Removal will be completed.
Failure to Prevent Elopement and Provide Adequate Supervision for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent accidents for a resident with severe cognitive impairment and a known history of exit-seeking behaviors. The resident, diagnosed with Alzheimer's disease, non-Alzheimer's dementia, and a psychotic disorder, had a BIMS score indicating severe cognitive impairment and was assessed as high risk for wandering. Despite multiple documented incidents of the resident attempting to exit or successfully eloping from the facility, the care plan addressing elopement risk was not created until after the first elopement and was not updated following subsequent incidents. The resident was able to leave the facility on several occasions, including escaping through the front door and being found walking down a nearby highway and in the facility lawn. Staff interviews and documentation revealed that doors could be opened by holding them for a period of time, and staff were aware of the resident's risk but did not consistently implement or document increased supervision or interventions. There were also gaps in the documentation of required 15-minute checks following elopement incidents, and staff reported not receiving specific training related to elopement prevention or response. Other residents and staff confirmed that multiple residents exhibited wandering or exit-seeking behaviors, and that the facility's doors, while coded, could be bypassed. The facility lacked a specific elopement policy, relying instead on a missing persons policy, and staff responses to elopement incidents were inconsistent. The infection control nurse identified several residents at risk for elopement, but there was no evidence of systematic involvement of the facility's QAPI process in addressing these incidents.
Failure to Update Care Plan After Resident Elopements
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect each incident of elopement. A resident with severe cognitive impairment, including diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and psychotic disorder, was identified as being at risk for elopement. Despite multiple documented incidents where the resident left the facility unsupervised, the care plan was not updated after each event. The initial care plan addressing elopement risk was not created until two days after the first documented elopement, and subsequent elopements were not reflected in the care plan at all. Record review and staff interviews confirmed that the care plan did not document the actual elopement events, nor was it revised following additional incidents. The facility's policy required the interdisciplinary team to review and update the comprehensive care plan after each assessment, but this was not followed in practice. Staff responsible for updating care plans were either unavailable or assumed updates had been made, and the Director of Nursing confirmed that no updates were found in the care plan after the resident's repeated elopements.
Incomplete Abuse Investigations for Two Residents
Penalty
Summary
The facility failed to conduct thorough investigations following allegations of abuse involving two residents. For the first resident, who had intact cognition, an incident report was filed after the resident expressed fear of a CNA being rough and rushing them. However, the investigation lacked interviews with other residents or staff, and there was no evidence of specific abuse found. Additionally, adult protective services were not notified of the allegation. For the second resident, who had moderately impaired cognition, an incident occurred where the resident did not want to be checked by a CNA, leading to a complaint. The investigation did not include notification to adult protective services or the nurse aide registry. The Director of Nursing confirmed that the investigations were incomplete, as they did not involve interviews with other residents or external notifications, contrary to the facility's policy.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper treatment and monitoring of pressure ulcers for two residents, resulting in the worsening of their conditions. Resident #49, who had peripheral vascular disease and a right lower leg amputation, developed a stage II pressure ulcer on the left heel. Despite physician orders for daily wound care, there was no documentation of wound care being performed on multiple occasions, leading to the deterioration of the wound to a stage I ulcer with significant necrosis. Observations confirmed that the wound care was not consistently provided, and the wound worsened over time, as noted by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The resident also declined hospital transfer despite significant changes in the wound condition, further complicating the situation. Additionally, there was a lack of documentation for repositioning the resident every two hours as per physician orders, contributing to the worsening of the pressure ulcer. Resident #51, who had type 2 diabetes mellitus and other conditions, was admitted with a stage II pressure ulcer on the coccyx and later developed a stage I pressure ulcer on the right heel. The facility's records showed inconsistent documentation and treatment of the wounds. The resident's condition worsened, with the coccyx wound increasing in size and a new pressure ulcer developing below the existing one. Observations and interviews revealed that wound care was not consistently performed, and there was no documentation of treatment orders or assessments for the new wound. The ADON confirmed the lack of documentation and treatment for the resident's pressure ulcers, indicating a failure to follow the facility's policy and procedure for pressure ulcer prevention and treatment.
Unqualified Social Worker in Facility with Over 120 Beds
Penalty
Summary
The facility failed to ensure the individual functioning as the social worker met the required qualifications for a facility with more than 120 beds. The facility was licensed for a maximum of 133 beds, but the social worker employed only had an associate in arts and six years of experience as a case manager at a prison, lacking the required bachelor's degree. This was confirmed by the Assistant Director of Nursing (ADON) and Director of Nursing (DON) during an interview, where they acknowledged the social worker's qualifications did not meet the necessary standards for the facility's size.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure a PRN psychotropic medication was limited to 14 days for one of five sampled residents reviewed for unnecessary medications. The resident had diagnoses including anxiety and agitation and had a physician order for Ativan suspension, to be given sublingually every four hours as needed for 14 days. However, the medication was administered beyond the 14-day limit, as documented in the February and March 2024 Medication Administration Records (MAR). The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that the order should have been stopped and reassessed.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain an infection control program to help prevent the transmission of infections for two residents reviewed for pressure ulcers. Resident #2, who had diagnoses including severe sepsis and a need for assistance with personal care, had a physician order to cleanse the area on the inner left foot with Betadine and cover it with a protective dressing daily. An LPN was observed performing wound care for this resident but failed to clean the metal pan used during the procedure after it came into contact with the resident's personal belongings and bedside table. The LPN placed the uncleaned metal pan back into the treatment cart with other supplies, which was against the facility's wound dressings policy that required cleaning or discarding anything brought into the room after use. Resident #51, who had diagnoses including type 2 diabetes mellitus and pressure ulcers, was also subject to improper infection control practices. An LPN performed wound care for this resident without cleaning the bedside table or providing a clean barrier before placing the metal pan on it. After completing the wound care, the LPN placed the metal pan on the resident's bed and then on the treatment cart without cleaning it. This action was contrary to the facility's infection control policy, which required cleaning the metal pan after it touched the resident's personal belongings. Both instances demonstrated a failure to adhere to the facility's infection control protocols, potentially increasing the risk of infection transmission.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food was served at an appetizing temperature and was palatable for the residents. Multiple residents reported that the food was often cold and unappetizing. Resident #5, with intact cognition, stated that the food was sometimes cold when eaten in their room. Resident #7, who was moderately impaired in cognition, mentioned that the food was cold all the time and sometimes excessively salty, making it inedible. Resident #14, with intact cognition, also reported receiving cold food when eating in their room. Similar complaints were echoed by Resident #22, Resident #30, and Resident #40, all of whom had intact cognition and reported that their food was always cold or not good. Resident #155, with intact cognition, also stated that the food was not good. On a specific date, a food test tray was received from the kitchen, and the breaded squash served was found to be lukewarm and flavorless, with a temperature of 108 degrees Fahrenheit. This observation confirmed the residents' complaints about the food being served at an inappropriate temperature. The facility's failure to maintain the food at a safe and appetizing temperature led to dissatisfaction among the residents, impacting their overall dining experience and nutrition intake.
Failure to Maintain Sanitary Food Preparation and Serving Practices
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner. Dietary aide #1 was observed preparing drinks for the lunch meal without washing their hands when entering the kitchen multiple times. They handled various items, including a container of coffee and a gallon of milk, without proper hand hygiene. This lack of handwashing occurred despite moving between the dining room and the kitchen several times during meal preparation. Additionally, dietary cook #2 was observed serving the lunch meal and using an alcohol-based hand sanitizer instead of washing their hands with soap and water. The cook wiped their nose and sweat from their forehead, used the hand sanitizer, and continued serving food without proper handwashing. The dietary manager (DM) admitted to not knowing that hand sanitizer could not be used in the kitchen and confirmed that everyone entering the kitchen should wash their hands with soap and water.
Discrepancy in Resident's Code Status
Penalty
Summary
The facility failed to ensure a resident's code status was accurate. A resident with diagnoses including heart disease, COPD, presence of a pacemaker, chronic pain, and CKD had a DNR consent form dated [DATE], indicating the resident's consent for DNR. However, a physician order dated [DATE] documented CPR for the same resident. When asked to verify the resident's code status, the ADON and DON confirmed that the resident was supposed to be a DNR, indicating a discrepancy between the documented DNR consent and the physician's order for CPR.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to ensure that a resident discharged from Part A skilled services, with benefit days remaining, was issued a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and/or Notice of Medicare Non-Coverage (NOMNC). The deficiency was identified for one of four sampled residents reviewed for beneficiary notices. The Beneficiary Notice worksheet indicated that eight residents were discharged from Part A skilled services with benefit days remaining in the past six months. Specifically, the resident was admitted to the facility for skilled services with multiple diagnoses, including COPD, heart failure, CKD, type 2 diabetes mellitus, amputation of toes, and a history of falling. On a particular date, the resident's health deteriorated, leading to hospitalization, and there was no documentation that the required beneficiary notices were provided to the resident or their legal representative. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were questioned about the resident's last day of skilled service and the provision of beneficiary notice forms. The ADON confirmed that the resident had five days of skilled service left when they were sent to the hospital and acknowledged that the resident's family member was incorrectly informed about the remaining skilled service days. The ADON also stated that the resident should have been provided with the beneficiary notice forms upon their return to the facility and that a two-day notice was required. However, there was no documentation to support that these notices were given, leading to the identified deficiency.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure a discharged resident's clinical record contained a discharge summary. The resident had diagnoses including COPD, heart failure, type 2 diabetes mellitus, panic disorder, and major depressive disorder. A physician order documented the resident was discharged home, but there was no documentation of a discharge summary being completed. When asked, the Assistant Director of Nursing (ADON) stated they had 30 days to complete a discharge summary, but it was not completed within that timeframe.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to notify a resident and/or their representative in writing 30 days before the resident was discharged. The resident, who had diagnoses including COPD, heart failure, type 2 diabetes mellitus, panic disorder, and major depressive disorder, was admitted to the facility and later denied nursing home Medicaid due to not sending in verification. Despite the resident's case still pending with DHS, the resident was discharged home without a written notice. The ADON confirmed that no written notice was provided, and only a verbal 30-day notice was given by the administrator.
Failure to Permit Resident's Return After Hospitalization
Penalty
Summary
The facility failed to ensure a resident was permitted to return after hospitalization, violating their bed-hold policy. The resident, who had multiple diagnoses including COPD, heart failure, CKD, type 2 diabetes mellitus, amputation of toes, and a history of falling, was admitted to the facility for skilled services. On 04/01/24, the resident's oxygen saturation dropped, and despite a breathing treatment, their condition did not improve, leading to hospitalization. The facility's bed-hold policy allowed for a five-day hold, but the resident was not permitted to return after hospitalization, and the family was informed that the resident had no skilled service days remaining, which was incorrect according to the ADON's statement. A social service note dated 04/02/24 documented that the resident's family was informed that the resident was in the hospital past their discharge date from skilled nursing services and that it would be up to the family and the hospital to arrange transportation home. The ADON confirmed that the resident had five days of skilled service left when they went to the hospital and did not know why the family was informed otherwise. The resident had no payer source after the skilled days, which contributed to the facility's decision not to permit the resident's return.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly evident or possible serious mental illness to the OHCA for a level II PASRR evaluation. Initially, a level I PASRR dated 06/27/23 documented that the resident did not have evidence or diagnosis of a serious mental illness. However, on 07/28/23, the resident received a new diagnosis of bipolar type schizophrenia disorder, and on 07/29/23, the resident was further diagnosed with borderline personality disorder and mood disorder due to a known physiological condition with depressive features. Despite these new diagnoses, there was no documentation that the resident had been referred to the OHCA for a level II PASRR evaluation. On 05/08/24, the ADON and DON were informed of the oversight and confirmed that the resident had not been referred for the necessary evaluation.
Failure to Include Dietary Preferences in Care Plan
Penalty
Summary
The facility failed to include a care plan regarding dietary preferences for a resident diagnosed with vitamin D deficiency and depression. A physician order dated 04/01/24 specified that the resident required a no added salt vegetarian diet and smoothies with super greens powder as a supplement. However, during an interview on 05/07/24 at 9:24 a.m., the Assistant Director of Nursing (ADON) acknowledged that the resident's food preferences were not included in the care plan, as they should have been. This oversight was identified during a review of the resident's records.
Failure to Verify CNA Certification
Penalty
Summary
The facility failed to ensure verification from the nurse aide registry before allowing two CNAs to work. CNA #4's certification expired, yet they continued to work on multiple dates as documented in the Time & Attendance - Employee Timecard. Similarly, CNA #5's certification also expired, and they were documented to have worked on several dates. The ADON stated that the IP nurse was responsible for ensuring staff had current licenses and certifications, but the IP nurse was unavailable for an interview.
Failure to Ensure Quarterly QAA Committee Meetings
Penalty
Summary
The facility failed to ensure the Quality Assessment and Assurance (QAA) committee met at least quarterly. The administrator identified that 54 residents resided in the facility. There was no documentation that the QAA committee met from October 2023 through December 2023. On May 7, 2023, at 9:33 a.m., the Director of Nursing (DON) was asked to provide documentation of the QAA committee meetings for the specified quarter. At 10:37 a.m., the DON stated there was no documentation of the QAA committee meeting during that period, despite the committee being required to meet quarterly.
Failure to Offer Influenza Vaccine to New Resident
Penalty
Summary
The facility failed to offer an influenza vaccine to a resident who was admitted after a vaccination clinic held at the end of 2023. The resident's vaccination record showed that they had not received the influenza vaccine. The Infection Preventionist (IP) confirmed that vaccinations were not offered to residents admitted after the clinic.
Failure to Follow Approved Menu
Penalty
Summary
The facility failed to follow the menu approved by the facility's dietitian for one meal service observed. Specifically, the lunch menu for 05/07/24 was supposed to include pork chop, broccoli rice casserole, breaded squash, a dinner roll, chocolate cream dessert, and a beverage of choice. However, due to a shortage of pork chops, the menu was changed to meatloaf without notifying the facility dietitian. Additionally, the chocolate cream dessert was replaced with devil cake. This change affected 52 residents who received services from the kitchen, with two residents receiving nutrition and hydration solely through a feeding tube. The dietary manager (DM) confirmed that the administrator made changes as needed without consulting the dietitian.
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.
Trusted by long-term care providers and associations.
