Eastgate Village Care & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskogee, Oklahoma.
- Location
- 3500 Haskell Blvd, Muskogee, Oklahoma 74403
- CMS Provider Number
- 375190
- Inspections on file
- 22
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Eastgate Village Care & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia and a documented history of wandering and exit-seeking behaviors was able to leave the facility unsupervised by following a food delivery person out the front entrance. Despite care plan interventions and a wanderguard on the resident's wheelchair, the resident used a walker without a wanderguard to exit and was missing for about an hour before being found by police in a nearby field.
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their medical documentation. A resident with cerebral palsy was incorrectly marked as comatose despite being alert and communicative. Another resident with atrial fibrillation was wrongly documented as receiving anticoagulant medications, and a resident with dementia was inaccurately assessed regarding antipsychotic medication use. These errors were confirmed through record reviews and staff interviews.
A facility failed to update a care plan for a resident with cerebral palsy and quadriplegia, inaccurately listing them as an elopement risk. Despite being bedbound and requiring total care, the care plan did not reflect the resident's true condition, as confirmed by staff and observations.
A housekeeper in the facility failed to follow proper infection control practices by transporting soiled linen without bagging it and without wearing gloves. The linen, which had a red substance later identified as ketchup, was carried from a couch in B hall to the soiled utility room. The DON and infection preventionist were informed of the breach, and it was noted that the staff member was new and needed further education.
A facility failed to notify a resident's legal representative about the treatment for a UTI. The resident, with cerebral palsy and other conditions, was not reported to their representative until the representative called to check on them. A physician's order for Macrobid was documented, but the ADON could not produce notification documentation.
The facility did not provide ABNs to two residents discharged from skilled services who remained in the facility as LTC residents. Both residents had skilled days remaining, but neither they nor their representatives received the required notices. The business office manager, responsible for issuing these notices, confirmed the oversight.
The facility failed to provide bed hold notices to two residents transferred to the hospital, as required by guidelines. One resident with dementia and another with cerebral palsy and ostomy status were affected. Staff interviews revealed confusion about responsibility for issuing notices, and the DON admitted the oversight.
A facility failed to implement a behavioral flow sheet for a resident with dementia, anxiety, and mood disorder, who was on antipsychotic medication. The care plan required behavior monitoring, but the electronic clinical record lacked the necessary documentation. An LPN was unaware of the requirement, and the DON admitted the oversight.
A facility failed to follow its policy requiring weekly weight monitoring for four weeks after a resident's admission. A resident with dementia was admitted, but their weights were only recorded monthly, contrary to the facility's guidelines. The DON acknowledged the oversight, noting the absence of a physician's order for weight frequency, which led to the deviation from the policy.
The facility failed to secure medications on two of six observed carts. An unlocked cart was found unattended on E hall, and another was unlocked by the nurses' station. Staff admitted to forgetting to lock the carts, contrary to protocol requiring carts to be locked when not in use.
The facility failed to date and label food items in the kitchen, as required by their Food Storage policy. Inspections revealed undated ice cream, milk, and puree diet snacks, as well as unlabeled foam cups in the refrigerator. A dietary aide confirmed the preparation of the snacks and identified the contents of the foam cups. The dietary manager stated that staff were supposed to label and date foods before refrigeration.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure a safe environment for a resident with a known history of wandering and elopement risk. The resident, who had diagnoses including dementia, hypertension, and heart failure, had previously demonstrated exit-seeking behaviors, including verbal aggression, threats to leave, and attempts to exit through windows and doors. Despite being identified as at risk for elopement and having multiple care plan interventions in place, the resident was able to leave the facility by following a food delivery person out the front entrance. The resident was missing for approximately one hour before being located by police in a nearby field and returned to the facility. Documentation showed that the resident had a history of wandering, including incidents where the resident attempted to leave through windows and was found at exit doors. The resident's care plan included interventions such as disguising exits, using a wanderguard, frequent observation, and diversional activities. However, on the day of the incident, the resident was able to elope using a walker that did not have a wanderguard, as opposed to their wheelchair which was equipped with one. The facility's failure to ensure all necessary elopement prevention measures were in place and to provide adequate supervision directly led to the resident's unsupervised exit from the property.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #1, diagnosed with cerebral palsy, ostomy status, and UTI, was inaccurately marked as comatose on their admission assessment, despite multiple progress notes indicating they were alert and capable of non-verbal communication. Observations and staff interviews confirmed the resident's ability to respond to stimuli and communicate using eye movements, contradicting the comatose coding on the MDS. Resident #52, with a diagnosis of paroxysmal atrial fibrillation, was incorrectly documented as having received anticoagulant and antiplatelet medications during the assessment's look-back period, although the electronic clinical record showed no such administration. Similarly, Resident #60, diagnosed with dementia, had an active order for Quetiapine, an antipsychotic medication, but their annual assessment failed to reflect this medication use since the last admission or prior assessment. These inaccuracies were confirmed through record reviews and staff interviews, highlighting the facility's failure to adhere to the MDS 3.0 policy and RAI User's Manual guidelines for accurate resident assessments.
Failure to Update Care Plan for Bedbound Resident
Penalty
Summary
The facility failed to ensure that a care plan was updated or revised for one of the sampled residents. The resident in question had diagnoses including cerebral palsy, ostomy status, and a urinary tract infection. Despite these conditions, the care plan, last revised on January 9, 2025, inaccurately included a potential for elopement risk or wander risk. However, an Elopement Evaluation conducted on December 23, 2024, showed an elopement score of 0.0, indicating no history of elopement or wandering aimlessly. Observations and interviews with facility staff revealed that the resident was bedbound, required total care, and used a mechanical lift, making them not an elopement risk. The Director of Nursing confirmed that the care plan did not accurately reflect the resident's condition, as the resident had cerebral palsy, quadriplegia with muscle contractures, and was not capable of elopement. This discrepancy between the resident's actual condition and the care plan represents a failure in maintaining an accurate and updated care plan as per the facility's policy.
Infection Control Breach in Linen Handling
Penalty
Summary
The facility failed to adhere to proper infection control practices during the transportation of soiled linen. During an observation, a housekeeper was seen carrying white linen with a red substance on it to the soiled utility room without placing it in a bag and without wearing gloves. The housekeeper admitted to not following the correct procedure, which involves bagging soiled linen at the point of collection and using a leak-proof container for transport. The linen was found on a pillow on a couch in B hall, and the housekeeper initially claimed it was not soiled, later identifying the substance as ketchup. The Director of Nursing (DON) was made aware of the incident and acknowledged that the staff member involved was new and required education. The infection preventionist was also informed of the infection control concern and indicated that they would address it promptly. The facility's handling linen/laundry policy, dated July 2024, outlines the necessary precautions for handling soiled linen, which were not followed in this instance.
Failure to Notify Legal Representative of UTI Treatment
Penalty
Summary
The facility failed to notify a resident's legal representative about the treatment for a urinary tract infection (UTI) for one resident reviewed for notification of change. The resident, who had diagnoses including cerebral palsy, ostomy status, and hyponatremia, was not reported to their legal representative about the UTI until the representative called to check on the resident. A physician's order was documented for Macrobid, an antibiotic, to be administered via peg-tube for the UTI. The Assistant Director of Nursing (ADON) stated that the process for a change in condition involved notifying the medical director, family, Director of Nursing (DON), and hospice if appropriate, and completing a form in the electronic medical record. However, the ADON was unable to produce documentation of notification for the date in question.
Failure to Provide Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide advance beneficiary notices (ABNs) to two residents who were discharged from skilled services but remained in the facility as long-term care residents. Resident #10 was discharged from skilled services on December 26, 2024, and Resident #18 on September 18, 2024. Both residents had skilled days remaining, yet neither they nor their representatives received the required ABNs. The business office manager, responsible for providing these notices, confirmed that ABNs were typically given to residents with Medicare, while Notices of Medicare Non-Coverage (NOMNC) were provided to those with Health Maintenance Organization plans. The administrator also confirmed that the business office manager was tasked with issuing beneficiary notices upon discharge from skilled services.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a notice of bed hold to two residents who were transferred to the hospital, as required by state and federal guidelines. Resident #80, diagnosed with dementia, was discharged to the hospital on two occasions, but the electronic clinical record did not show that a bed hold notice was provided to the resident or their representative. Interviews with facility staff, including the infection preventionist/charge nurse, BOM, LPN, and DON, revealed confusion and lack of clarity regarding the responsibility for providing the bed hold notice. The DON admitted that the facility had not been providing these notices and was unaware of where such documentation was kept. Similarly, Resident #1, who had diagnoses including cerebral palsy and ostomy status, was sent to the hospital, but there was no documentation of a bed hold policy being provided. When questioned, the ADON was unsure about the documentation process, and the DON indicated that the notices were supposed to be kept in a folder at the nurses' station. However, the DON admitted that they did not have the required documentation for Resident #1 and acknowledged the oversight in the presence of the administrator.
Failure to Implement Behavioral Monitoring for Resident on Antipsychotics
Penalty
Summary
The facility failed to implement a care plan intervention for a behavioral flow sheet for a resident diagnosed with dementia, anxiety, and mood disorder. The care plan, dated December 20, 2024, required behavior monitoring for residents taking antipsychotic medications, specifically through a behavior monitoring flow sheet. However, a review of the electronic clinical record revealed that no such flow sheet had been implemented for the resident. During interviews, an LPN was unaware of the requirement for a behavioral flow sheet for the resident, and the DON acknowledged that the behavioral monitoring had not been documented on the treatment record as intended.
Failure to Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to adhere to its Weight and Hydration Management Practice Guidelines policy, which required residents to be weighed weekly for four weeks upon admission. This deficiency was identified for a resident diagnosed with dementia, who was admitted on 10/28/24. The resident's clinical record showed weights were only recorded on 11/04/24, 12/01/24, and 01/01/25, indicating that weekly weights were not obtained as required. The Director of Nursing (DON) acknowledged the oversight, noting that there was no physician's order specifying the frequency of weight monitoring, leading to the resident being weighed monthly instead of weekly as per the facility's policy.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure the security of medications on two of the six medication/treatment carts observed. On February 4, 2025, at 3:40 p.m., an unlocked and unattended medication cart was observed on E hall across from room E1, containing resident medications with no staff nearby. CMA #1 later returned to lock the cart, admitting they forgot to lock it after retrieving a laptop. On February 6, 2025, at 3:36 p.m., the B/C hall treatment cart was found unlocked by the nurses' station, with two nurses having their backs to it and CMA #2 facing it. CMA #2 subsequently locked the cart, and LPN #1 acknowledged the protocol to lock carts when not in use, attributing the oversight to loaning out a glucometer. The DON confirmed that the protocol required carts to be locked when unattended.
Failure to Date and Label Food in Kitchen
Penalty
Summary
The facility failed to ensure that foods were properly dated when opened, as observed during two separate inspections of the kitchen. The Food Storage policy, dated 10/01/18, requires that all opened and bulk items be stored in tightly covered containers, labeled, and dated to ensure freshness. During an inspection on 02/03/25, an uncovered and undated bowl of ice cream was found in the stand-up freezer, along with six cups of undated milk in the refrigerator. A subsequent inspection on 02/06/25 revealed six small, clear containers with a pink/yellow substance, identified as snacks for residents on a puree diet, which were undated. Additionally, two foam cups in the refrigerator were undated and unlabeled, with one containing milk and the other suspected to contain coffee. Dietary aide #1 confirmed the preparation of the snacks earlier that morning and identified the contents of the foam cups. The dietary manager acknowledged that staff were required to label and date foods before refrigeration.
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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