Edmond Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Edmond, Oklahoma.
- Location
- 39 East 33rd Street, Edmond, Oklahoma 73013
- CMS Provider Number
- 375483
- Inspections on file
- 34
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Edmond Health Care Center during CMS and state inspections, most recent first.
A resident with a history of behavioral issues and intact cognition was found in the bed of another resident with severe cognitive impairment and total dependence for care, with staff observing apparent sexual activity. The cognitively impaired resident was nonverbal and unable to consent, and was later diagnosed with sexual assault at the hospital. Facility documentation and staff interviews revealed a lack of awareness and documentation regarding the behavioral contract, prior inappropriate behaviors, and the implementation of 1:1 supervision after the incident.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive the necessary treatment and services tailored to their condition, as required by regulations.
The facility did not have effective or consistently enforced policies and procedures to prevent abuse, neglect, and theft. Surveyors found gaps in staff training, inconsistent documentation, and unclear reporting mechanisms, resulting in inadequate protection for residents.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with hypertension and diabetes alleged verbal abuse by a CNA, who raised their voice during an incident involving a missing TV remote. Although the CNA was suspended and the administrator was notified, the facility did not complete or submit the required final written report of the investigation findings to authorities within the mandated timeframe, and documentation of the investigation's results was missing.
A facility failed to conduct and document a thorough investigation after an allegation of abuse/mistreatment involving a resident with acute medical needs. Although the DON verbally spoke with staff involved, there was no written documentation of staff witness statements as required by facility policy, resulting in an incomplete investigation.
A resident with quadriplegia and post-traumatic disorder was observed seated in a Geri-chair with the call light left on the bed, out of reach. The resident reported needing the call light clipped to their shirt and positioned under their chin to use it, but this was not done. Facility policy and staff confirmed that call lights should be within easy reach, but this was not followed.
The facility did not ensure that two residents receiving dialysis had required pre and post monitoring documented for multiple dialysis sessions. Despite regular dialysis schedules and a policy requiring monitoring before and after treatment, staff failed to complete or document these assessments, as confirmed by the DON and reported by a resident.
A resident with significant cognitive and physical impairments reported feeling sick and vomited, but an LPN failed to assess, administer prescribed Zofran, or provide timely hygiene care, leaving the resident in soiled conditions for several hours until a CNA intervened. Documentation of assessment, intervention, and medication administration was lacking, and staff interviews confirmed the delay in care.
A resident with a history of suicidal ideation and impaired vision was not placed on behavior monitoring and was able to obtain and conceal a box cutter, which was later used to inflict self-harm during the discharge process. Staff were unaware of the resident's possession of the box cutter and did not consistently recognize or address the resident's risk factors, resulting in a serious incident involving self-injury.
A resident with chronic respiratory failure and a court-appointed guardian repeatedly refused to use a prescribed c-pap machine, as documented over several days. Despite facility policy requiring notification, staff did not inform the legal guardian of these refusals until the guardian independently inquired about the resident's condition. Staff interviews confirmed the lack of timely notification, resulting in a deficiency related to required communication with a resident's representative.
A resident with altered mental status and quadriplegia alleged that an LPN left them in vomit after refusing to clean them. The facility did not send the final investigation report to the State Agency within the required timeframe and failed to notify the appropriate licensing board promptly, as confirmed by the administrator.
A facility failed to provide adequate ADL care for a resident requiring maximal assistance with bathing. The resident was not bathed on 13 out of 26 scheduled opportunities, and there was no documentation of refusals or attempts to offer showers. Staff interviews confirmed non-compliance with facility policies, as refusals were not documented, and nursing staff were not notified of missed baths.
A resident with a history of cerebral infarction and diabetes fell from a lift sling during a transfer, resulting in a skin tear and a hospital visit. Despite the facility's policy requiring new interventions to be added to the care plan after such incidents, no updates were made. The ADON and MDS coordinator confirmed the oversight, acknowledging the policy was not followed.
A resident with multiple diagnoses, including paraplegia and quadriplegia, was found to have an inaccessible call light on two occasions. The resident was part of a fall prevention program that required call lights to be within reach. An LPN and an RN confirmed the call light was not accessible, with the RN noting it was stuck behind the resident's pillow.
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies on a resident. Housekeeping staff acknowledged the presence of numerous flies and mentioned that they sprayed to control them. Additionally, a CMA confirmed that there had always been a significant number of flies in a specific hall of the facility.
A resident with quadriplegia and mental health conditions was subjected to verbal abuse by a CNA, as reported by the resident's family who observed video footage of the incident. The CNA was suspended and later terminated after the abuse allegation was substantiated. The facility's QAPI program did not review the incident, as the Administrator stated QAPI involvement would occur only if there were repeated incidents or a pattern.
The facility failed to submit the results of abuse investigations to the State within the required timeframe for two residents. One resident with Alzheimer's disease experienced a delay due to issues in reviewing video footage, while another resident with quadriplegia had a confirmed abuse incident reported late, leading to the CNA's termination.
A resident with hemiplegia required two-person assistance for transfers, as per their care plan. However, the facility failed to adhere to this requirement, resulting in multiple falls during transfers. Observations showed CNAs not using gait belts, contrary to the facility's policy. The resident reported being dropped several times, and staff interviews confirmed inconsistencies in following the care plan.
The facility failed to monitor the nutritional intake of two residents, resulting in numerous undocumented meal and snack records. One resident, with dementia and Parkinson's, had 59 blanks in meal documentation, while another, with hypoxemia, had 28 blanks. Staff interviews confirmed that blanks indicated uncharted consumption, preventing proper nutritional support.
A resident with dementia and Parkinson's disease was observed with a pill on their shirt, indicating a failure to ensure medication swallowing. The CMA admitted the resident spit out the medication and did not verify ingestion, contrary to facility policy.
The facility failed to promote resident dignity during dining for two residents. One resident required assistance due to upper extremity impairment, while the other had severely impaired cognition but could understand and see adequately. A CNA was observed standing over one resident while assisting with breakfast, and the other resident watched before being assisted. The CNA admitted they were instructed not to assist two residents at once and were not trained on whether to sit or stand during assistance.
The facility failed to refer three residents with newly diagnosed serious mental illnesses for a level II PASARR evaluation. One resident with a new diagnosis of major depressive disorder with psychotic symptoms, another with disorganized schizophrenia, and a third with bipolar disorder and unspecified psychosis were not referred for further evaluation. The MDS Coordinator was unaware of the need for new PASARR evaluations following these diagnoses.
The facility failed to provide adequate ADL care for two residents, resulting in deficiencies in personal hygiene and incontinence care. One resident, with aphasia, had their hair matted and cut due to inconsistent hygiene practices. Another resident, with dementia, was found with a saturated brief, indicating a lack of timely incontinence care. Staff interviews confirmed these deficiencies.
The facility failed to monitor and document blood pressures as ordered for two residents. One resident with anoxic brain damage had no blood pressure monitoring documented from March to July, despite an order to hold amlodipine if BP was below 110/65. Another resident with hypertension had no documentation of BP monitoring every eight hours from May to July, despite an order for Clonidine as needed for SBP of 160 or greater.
The facility failed to ensure food was palatable and served at appetizing temperatures, affecting multiple residents. Observations and interviews revealed that residents reported cold or unappetizing meals. Testing showed food temperatures were below standard, and the Dietary Manager admitted to having no control over food once it left the kitchen.
The facility's kitchen was found to have multiple cleanliness and maintenance deficiencies, affecting food service for 79 residents, including three on feeding tubes. Observations included residue on floors and walls, torn door gaskets, missing baseboards, and peeling material. The Dietary Manager indicated daily cleaning and maintenance reporting, but these were inadequate to address the issues.
The facility failed to manage infection control, with staff not bagging soiled linens, neglecting hand hygiene, and reusing uncleaned medical equipment. Enhanced barrier precautions were ignored during wound care for two residents with pressure ulcers, despite clear signage. These actions highlight significant gaps in infection control practices.
A facility failed to document a PASARR level 2 determination for a resident with a serious mental illness. The level 1 PASARR indicated the need for further assessment, but there was no documentation in the resident's chart or on the form. The MDS coordinator acknowledged the oversight, stating the facility was likely informed that a level 2 was not necessary but did not document it.
The facility did not follow its CPR policy, which required 30 compressions to two rescue breaths. CPR was delayed by six minutes for an unresponsive resident, and the Ambu-bag was improperly used, with compressions and rescue breaths not administered as per protocol. The DON confirmed the deviation from the prescribed CPR procedure.
A resident with hemiplegia and hemiparesis following a cerebral infarction was not provided with a hand roll as ordered by a physician to treat a contracture. Observations showed the resident without the hand roll, and staff interviews revealed a lack of awareness and communication regarding the resident's care needs, leading to the deficiency.
A facility failed to administer O2 as ordered for a resident with SOB and failure to thrive. The physician's order required O2 via NC at 3 LPM continuously, but the resident was observed without O2 tubing in place, and the concentrator was set at 1.5 LPM. An LPN was unaware of the correct setting and confirmed the error after reviewing the EHR, noting the resident's O2 saturation was 93.
The facility failed to properly manage and store medications and supplies, as observed during a survey. An undated TB skin test vial, an unsecured lorazepam vial, and a frozen vancomycin solution were found in the medication room refrigerator. The temperature log was incomplete, and expired supplies were present. Staff interviews revealed a lack of clarity and adherence to procedures, with an LPN unable to determine when the TB vial was opened and the DON stating that medication aides should check for expired items weekly.
A facility failed to obtain laboratory tests as ordered by a physician for a resident with multiple diagnoses, including bipolar disorder and CHF. The physician's order required a CBC and CMP to be collected weekly for two weeks. While the first set of tests was completed, the second set was not documented or found in the resident's EMR or the facility's lab system. The ADON confirmed the missing tests.
The facility failed to serve meals on time, with breakfast scheduled for 7:30 a.m. but delivered at 8:31 a.m. Residents reported meals were often late, and the DM stated room service was prioritized, causing dining room delays.
A resident with bipolar disorder and schizophrenia signed an authorization to release their medical records to their representative. Despite the request being acknowledged and records compiled, the facility failed to provide the records within the required one-week period, resulting in a deficiency.
The facility failed to ensure a resident with dementia, schizoaffective disorder, and bipolar disorder was not involuntarily discharged without proper documentation and communication. The resident was transferred to a psychiatric facility due to behaviors, but the medical record lacked necessary documentation and contact information for the DPOA, violating facility policies.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A resident with a history of behavioral issues, including verbal aggression and manipulative behavior, was admitted to the facility with intact cognition and significant physical care needs. The resident's care plan documented these behaviors, and a behavioral contract was signed after allegations of inappropriate conversations and other disruptive actions. However, there was no documentation in the resident's records of inappropriate sexual conversations, and key staff members, including the DON and MDS coordinator, were unaware of the behavioral contract or any incidents of sexual inappropriateness. The resident was also noted to have left the facility against medical advice on multiple occasions and exhibited signs of possible substance use, but no illicit drugs were found during a room search. Another resident, who was severely cognitively impaired and dependent on staff for most activities of daily living, was found in their room with the first resident. Staff discovered the first resident in the bed with the second resident, with their pants partially down, and appearing to be engaged in sexual activity. The cognitively impaired resident was nonverbal and unable to consent. The incident was reported to the DON, and the residents were separated. The first resident left the facility but was later taken into custody by police. The second resident was sent to the emergency room for evaluation, where a diagnosis of sexual assault was made, and a SANE exam was completed. The facility's documentation revealed that staff were present on the hall shortly before the incident but did not prevent the first resident from entering the second resident's room and closing the door. There was no documentation provided to surveyors regarding the implementation or monitoring of 1:1 supervision for either resident following the incident. Family members of the assaulted resident reported a lack of communication and detail from the facility regarding the incident, and staff interviews indicated a lack of awareness and documentation related to the behavioral contract and prior inappropriate behaviors.
Failure to Provide Appropriate Mental Health and Trauma-Related Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified when the resident did not receive the necessary care and interventions tailored to their mental health and psychosocial needs, as required by their condition and diagnosis. This lack of appropriate services and treatment was observed and documented by surveyors, indicating that the facility did not meet regulatory requirements for addressing the mental health and trauma-related needs of the resident.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility records and interviews, which revealed gaps in staff training, inconsistent documentation, and a lack of clear reporting mechanisms for suspected incidents. As a result, the facility was unable to demonstrate that it had taken adequate steps to protect residents from potential harm related to abuse, neglect, or theft.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Submit Final Abuse Investigation Report
Penalty
Summary
The facility failed to complete and submit a final written report of findings following an allegation of verbal abuse involving a resident with hypertension and type 2 diabetes. The incident involved a CNA raising their voice to the resident, who was upset about a missing TV remote. Although the CNA was suspended immediately after the administrator was notified, there was no documentation of the results of the abuse or mistreatment investigation, nor was there evidence that a final report was provided to the appropriate authorities within the required five working days. The Director of Nursing confirmed that the follow-up and final 5-day investigation documentation could not be found. This deficiency was identified through record review and staff interview, and it was noted that the facility's policy required a written report of investigation findings to be submitted to the appropriate agencies or individuals within five working days of the incident.
Failure to Document Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse or mistreatment involving one of three sampled residents. According to the facility's policy, all reports of abuse, neglect, exploitation, misappropriation, mistreatment, or injuries of unknown source must be promptly reported and thoroughly investigated, including obtaining written witness statements from all staff who had contact with the resident during the period of the alleged incident. In this case, a family member reported concerns regarding a resident who was found vomiting, soiled, and receiving IV fluids without prior notification to the family. The family member also reported delays in staff response to their requests for assistance and ultimately requested the resident be sent to the emergency room. Despite these allegations, there was no documentation of written witness statements from staff members who had contact with the resident during the relevant period. The Director of Nursing (DON) stated that they had spoken with staff involved but did not document these interviews, and the Assistant Director of Nursing confirmed that they had not been instructed to conduct staff interviews. This lack of written documentation and formal witness statements constitutes a failure to follow the facility's abuse investigation policy.
Call Light Not Accessible to Resident with Quadriplegia
Penalty
Summary
A deficiency was identified when a call light was not placed within reach of a resident with quadriplegia and post-traumatic disorder, who was observed seated in a Geri-chair approximately two feet away from their bed, with the call light left on top of a pillow at the head of the bed. The resident stated they could only use the call light if it was clipped to their shirt and positioned under their chin, allowing them to activate it with their chin. Facility policy requires call lights to be within easy reach of residents when in bed or confined to a chair, and staff interviews confirmed this expectation. Despite this, the call light was not accessible to the resident at the time of observation.
Failure to Complete Pre and Post Dialysis Monitoring
Penalty
Summary
The facility failed to ensure that residents receiving dialysis had appropriate pre and post monitoring as required by facility policy. For two of three sampled residents with end stage renal disease, documentation showed that pre and post dialysis monitoring forms were either missing or incomplete for multiple dialysis sessions. One resident had only one completed pre and post monitoring form for the entire month reviewed, despite having regular dialysis appointments scheduled three times per week. The resident also reported that staff did not assess them before or after dialysis sessions. The Director of Nursing (DON) confirmed the lack of completed forms and stated that the process involved nurses filling out pre-dialysis forms, which were then sent with the resident to the dialysis center, and post-dialysis assessments were to be completed upon the resident's return. For another resident, several post-dialysis monitoring forms were missing for multiple dates in the same month. The DON acknowledged that the post-dialysis forms were not completed for these dates. A licensed practical nurse described the monitoring process as including vital signs, weights, and assessment of the dialysis site, but the required documentation was not present in the records reviewed. The facility's policy required monitoring before and after dialysis to ensure residents' conditions were stable, but this was not consistently documented or performed as required.
Failure to Assess, Intervene, and Provide Timely Care for Resident with Vomiting
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including altered mental status, quadriplegia, contracture of the left hand, depression, schizoaffective disorder, bipolar type, and anxiety disorder, was not properly assessed, treated, or cared for according to physician's orders and professional standards. The resident, who was dependent on staff for activities of daily living and had moderate cognitive impairment, reported feeling sick and subsequently vomited on themselves. Despite a physician's order for Zofran to be administered as needed for nausea and vomiting, there was no documentation that the medication was given or that the resident was assessed or monitored following the incident. The incident report indicated that the resident informed an LPN of feeling sick and vomiting, but the LPN refused to clean the resident and left them in their vomit until the next shift. The resident's representative confirmed being contacted by the resident about the incident and subsequently called the facility, where staff acknowledged awareness of the situation but delayed providing care. Video review by the administrator confirmed the nurse left the resident in their vomit and later told the resident they would have to wait to be cleaned, though the exact duration was unclear due to the lack of a time stamp. There was no documentation in the nurse's notes regarding the incident, the administration of Zofran, or the resident being cleaned during the relevant time frame. Staff interviews corroborated that the resident was left in their vomit for several hours until a CNA from another hall cleaned them. The administrator and DON acknowledged that the nurse's actions were unacceptable and confirmed the nurse was terminated for failing to provide appropriate care and maintain resident dignity.
Removal Plan
- All staff are educated on reviewing and following physician orders for a change of condition on hire and annually, as well as periodically as a reminder.
- In-service will be completed with all core nursing staff over the following: Acute Change of Condition Policy to include the following interventions to prevent a decline in condition and/or a lack of treatment/care: a. Any resident who is determined to have a change of condition during a nurse's shift will be assessed and a progress note will be placed describing the event and the interventions that were done to prevent further decline. b. Resident will be monitored every shift with documentation on residents condition until stable. c. The resident's provider will be notified in a timely manner as well as the resident's family if applicable, and any orders implemented as required.
- In-service will be completed with all core nursing staff over the following: Following physicians orders as required.
- The Administrator and DON have been in-serviced over events requiring investigations and reports to OSDH and presenting related education to the staff following the event or situation to prevent recurrence.
- Agency will be provided with in-service materials as well.
- Any staff on vacation or unable to reach will be in-serviced before working their next shift.
Failure to Supervise Resident with Suicidal History Resulting in Access to Hazardous Object
Penalty
Summary
A deficiency occurred when a facility failed to adequately supervise a resident with a known history of suicide attempt, allowing the resident access to a box cutter. The resident, who had diagnoses including suicidal ideation, impaired vision, and a recent history of attempting suicide, was not placed on behavior monitoring despite their risk factors. The care plan indicated the resident was manipulative, had a recent suicide attempt, and required two staff members present for all interactions if possible, but there was no documentation of behavior monitoring as of the date prior to the incident. The resident was scheduled for involuntary discharge due to non-payment and was being prepared for transfer to a homeless shelter. On the day of discharge, the resident was left unsupervised in their bathroom, where they used a box cutter to inflict self-harm on both wrists and the side of their neck. Staff were unaware that the resident possessed a box cutter, which the resident later stated had been purchased during a self-initiated trip and hidden from staff. Multiple staff members, including CNAs, LPNs, and the DON, confirmed they were not aware of the resident's possession of the box cutter or that the resident was on behavior monitoring. Interviews revealed that staff did not consistently recognize or act upon the resident's risk factors for self-harm, and there was a lack of clear documentation and communication regarding the resident's behavioral status and supervision needs. The facility did not have a process in place to monitor items brought in from outside or through online deliveries, and staff involved in the resident's care and discharge process were not fully aware of the resident's history or current risk for suicide. This lack of supervision and failure to control access to hazardous objects directly led to the resident's self-harm incident.
Removal Plan
- In-service will be completed with all staff over the following: Suicide Precautions Policy; Supervision of residents exhibiting signs of suicidal ideations to prevent access to sharps, chemicals, and other hazardous objects or materials and if any noted staff are to remove objects of concern and notify the DON or Administrator immediately; Agency staff will be provided with in-service as well; Any staff on vacation or unable to reach will be in-serviced before working their next shift.
- All residents were audited for history or diagnosis of Suicidal Ideations and: Psych Consult and Counseling orders were received for one resident identified as having a history of suicidal ideations; Behavior Monitoring will be implemented on admission for any resident with history of suicidal ideations until resident has been cleared by psychiatric evaluation; Frequent monitoring will be immediately implemented for any resident identified as verbalizing having suicidal ideations to include 1:1 monitoring; Care Plans will be updated to include Suicidal Ideations and interventions for protection and prevention of self-harm or harm to others.
- Trauma Informed Care Assessment will be completed for all residents on admission and if any suicidal ideations are noted Suicide Precautions will be implemented.
- Physician will be notified of any resident noted with immediate concerns of suicidal ideations and they will be placed on 1:1 monitoring until resident can be transferred to a higher level of care.
Failure to Notify Legal Guardian of Resident's Repeated C-PAP Refusals
Penalty
Summary
The facility failed to notify a resident's legal guardian of repeated refusals to use a prescribed c-pap machine, as required by regulation. The resident in question had chronic respiratory failure with hypoxia, bipolar disorder, generalized anxiety, and major depressive disorder, and was under a court-appointed guardian. Despite having intact cognition, the resident frequently refused to use the c-pap device during both evening and night shifts, as documented in the treatment administration records for multiple days. The care plan noted the resident's tendency to remove or hide the c-pap, and staff were instructed to encourage its use. Although the resident's refusals were consistently documented, there was no evidence that the legal guardian was notified of these refusals prior to a specific date in January, when the guardian independently raised concerns about the resident's condition and c-pap use. Interviews with staff confirmed that notification of the guardian did not occur as required, despite facility policy and staff understanding that such notification was necessary when a resident with a legal representative refused treatment.
Failure to Timely Report Abuse Investigation Results to State Agency and Licensing Board
Penalty
Summary
The facility failed to ensure timely reporting of the results of an abuse/mistreatment investigation to the State Agency and the appropriate licensing board. According to the facility's policy, findings of all investigations are to be documented and reported. In the case reviewed, a resident with altered mental status and quadriplegia reported to an LPN that they were sick, subsequently vomited on themselves, and alleged that the LPN refused to clean them, leaving the resident in vomit until the next shift. An initial incident report was completed, and it was indicated that the appropriate licensing board had been notified. However, the final investigation report was not sent to the State Agency within the required 10 business days following the incident. There was also no documentation to confirm that the appropriate licensing board was notified on the date of the incident. The administrator confirmed that the final report was only sent after a delay due to issues with the fax machine and acknowledged that the notification to the licensing board was not made in a timely manner.
Failure to Provide ADL Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a dependent resident, specifically in the area of bathing. The facility's policy required documentation of the date, time, and personnel involved in assisting with showers or baths, as well as any refusals by the resident. However, for one resident with significant cognitive impairment and a documented need for maximal assistance with bathing, the facility did not adhere to these protocols. The resident was not bathed on 13 out of 26 scheduled opportunities over a two-month period, and there was no documentation of refusals or attempts to offer showers. Interviews with facility staff revealed a lack of adherence to the established policies. A CNA indicated that the resident had not been offered showers and that refusal documentation was not completed. A corporate nurse confirmed that the facility's policies were not followed, as there was no documentation of refusals or notifications to nursing staff about the missed baths. This oversight in care and documentation represents a failure to meet the resident's needs as outlined in their care plan.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update a resident's care plan with new interventions following a fall incident, which is a deficiency in ensuring a safe environment free from accident hazards. The facility's policy requires that after a fall, pertinent interventions should be identified and added to the care plan to prevent future falls. However, after a resident fell from a lift sling during a transfer and sustained a skin tear, no new interventions were added to their care plan. This oversight was confirmed by the Assistant Director of Nursing (ADON) and the Minimum Data Set (MDS) coordinator, who both acknowledged that the facility's policy was not followed. The resident involved had a medical history that included cerebral infarction, type two diabetes, lack of coordination, muscle weakness, and a contusion of the right lower leg. The resident required substantial to maximal assistance for transfers and was using a mechanical lift with two-person assistance. Despite the fall incident, which resulted in a hospital visit due to a bruised hip, the care plan remained unchanged, lacking any new strategies to prevent future accidents.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that call lights were accessible for a resident reviewed for call lights. The resident had diagnoses including heart failure, emphysema, paraplegia, and quadriplegia, and was part of the Falling Leaves Fall Prevention Program, which required call lights to be within reach and in good working order. On two separate occasions, the resident's call light was found to be inaccessible while they were resting in bed. On the first occasion, a Licensed Practical Nurse (LPN) confirmed that the call light was supposed to be within reach. On the second occasion, a Registered Nurse (RN) noted that the call light was stuck behind the resident's pillow, making it inaccessible.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies on a resident. During an observation, a resident was found with eight flies on different areas of their body. Housekeeping staff acknowledged the presence of numerous flies and mentioned that they sprayed to control them. Additionally, a Certified Medication Aide (CMA) confirmed that there had always been a significant number of flies in a specific hall of the facility.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with quadriplegia, post-traumatic stress disorder, and schizoaffective disorder bipolar type. The incident was reported by the resident's family, who observed video footage of the CNA cursing and arguing with the resident. The CNA was suspended pending an investigation, and the abuse allegation was later substantiated, leading to the CNA's termination. The facility's policy mandates immediate reporting of suspected abuse to the Administrator and Director of Nursing, and the suspension of involved staff pending investigation. Despite the facility's policy, the Quality Assurance and Performance Improvement (QAPI) program was not involved in reviewing this particular abuse incident. The Administrator acknowledged the incident as abuse and confirmed that the facility conducted an investigation and provided in-service training on abuse. However, the Administrator stated that QAPI involvement would occur only if there were back-to-back abuse incidents or a pattern. The facility's QAPI meetings were noted to be a month behind, and the incident had not been reviewed by QAPI at the time of the report.
Delayed Submission of Abuse Investigation Results
Penalty
Summary
The facility failed to ensure the results of abuse investigations were submitted to the State within the required five business days for two residents. The first incident involved a resident with Alzheimer's disease, dysphagia, and anxiety disorder, where a family member reported verbal abuse by a CNA. The initial report was sent promptly, but the final report was delayed due to difficulties in getting the accused to review video footage, resulting in the final report being submitted eight days after the initial report. The second incident involved a resident with quadriplegia, PTSD, and schizoaffective disorder bipolar type, where a family member observed video footage of a CNA cursing and arguing with the resident. The initial report was sent on the day of the incident, but the final report was submitted nine days later, confirming the abuse and resulting in the CNA's termination. The delay in submitting the final report was acknowledged by the Administrator.
Failure to Use Safe Transfer Techniques for Resident
Penalty
Summary
The facility failed to utilize a safe transfer technique for a resident who required two-person physical assistance. The resident, who had a history of nontraumatic subarachnoid hemorrhage and hemiplegia affecting the left nondominant side, was care planned to require a mechanical lift with two staff assistance for transfers. Despite this, the resident experienced multiple falls during transfers, as documented in incident reports. These incidents occurred when the resident was being transferred by a single CNA, contrary to the care plan requirements. Observations revealed that CNAs were not using gait belts during transfers, which was against the facility's policy for safe lifting and movement of residents. The policy required the use of appropriate techniques and devices, including gait belts, to ensure safety. Interviews with staff indicated a lack of adherence to the policy, with some staff members stating that they were not required to use gait belts during transfers, despite the resident's care plan indicating the need for two-person assistance with a mechanical lift. The resident reported being dropped multiple times in recent weeks, with the most recent fall occurring during a transfer by one staff member. The resident's care plan had been updated several times following these incidents, but the updates did not prevent further falls. Interviews with the facility's staff, including the Regional Nurse and the Director of Nursing, confirmed the resident's need for two-person assistance and highlighted inconsistencies in the implementation of the care plan and the facility's policies.
Failure to Monitor Nutritional Intake
Penalty
Summary
The facility failed to adequately monitor the nutritional intake of two residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. Resident #1, diagnosed with senile degeneration of the brain, dementia, and Parkinson's disease, had a care plan that required documentation of meal consumption. However, the records for July 2024 showed significant gaps, with 59 blanks out of 93 opportunities for meal documentation and 57 blanks out of 86 opportunities for snack and supplement documentation. This lack of documentation meant that staff could not determine whether supplements like mighty shakes were needed when meal consumption was less than 50%. Similarly, Resident #2, with diagnoses including hypoxemia and a history of traumatic brain injury, also had a care plan requiring monitoring and recording of meal intake. The July 2024 records for this resident showed 28 blanks out of 93 opportunities for meal documentation and 31 blanks out of 86 opportunities for snack and supplement documentation. Interviews with CNAs and the DON revealed that blanks in the records indicated a failure to chart meal consumption, leaving staff without the necessary information to provide appropriate nutritional support.
Failure to Ensure Medication Swallowing
Penalty
Summary
The facility failed to ensure that a resident swallowed their medication, as observed when a red circular pill was found on the resident's shirt. The resident, who had diagnoses including senile degeneration of the brain, dementia, constipation, and Parkinson's disease, was prescribed Colace 100mg to be taken orally once a day for constipation. On the day of the incident, the medication was administered around 10:00 a.m., but later, at 12:10 p.m., the pill was found on the resident's clothing. The Certified Medication Aide (CMA) responsible for administering the medication admitted that the resident had spit the pill out and that they were supposed to ensure the resident swallowed the medication. The CMA also mentioned that this was the first time the resident had cheeked the medication. The facility's policy required staff to verify the right medication, resident, dose, time, and route before administration and to sign off on the electronic medical record once the medication was administered. However, the CMA did not ensure the medication was swallowed, leading to the deficiency.
Failure to Promote Resident Dignity During Dining
Penalty
Summary
The facility failed to promote resident dignity during dining for two residents. One resident had intact cognition but required partial to moderate assistance with eating due to upper extremity impairment. The other resident had severely impaired cognition but was able to understand and had adequate vision, also requiring partial to moderate assistance with eating. On the morning of July 8, a CNA was observed standing over the first resident while assisting them with their breakfast meal. The second resident was observed watching this interaction before the CNA assisted them with their meal. The CNA later stated that they were instructed not to assist two residents simultaneously and were not trained on whether to sit or stand while assisting a resident.
Failure to Conduct Level II PASARR Evaluations for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer residents with newly evident or possible serious mental illnesses to the OHCA for a level II PASARR evaluation. This deficiency was identified in three residents. One resident, initially diagnosed with CVA and dementia, was later diagnosed with major depressive disorder with psychotic symptoms, but was not referred for a level II PASARR evaluation. The MDS Coordinator was unaware of the need for referral due to the resident's dementia diagnosis. Another resident, initially without a serious mental illness diagnosis, was later diagnosed with disorganized schizophrenia. The MDS Coordinator admitted to being unaware that a new level I PASARR was required following this new diagnosis. Similarly, a third resident, initially without a serious mental illness diagnosis, was later diagnosed with bipolar disorder and unspecified psychosis, but no new PASARR evaluation was conducted. The MDS Coordinator again stated they were unaware of the requirement for a new PASARR evaluation.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, leading to deficiencies in personal hygiene and incontinence care. Resident #26, who has aphasia, requires substantial assistance with personal hygiene. Observations revealed that the resident's hair was not combed on multiple occasions, and the resident confirmed that their hair had been matted and cut by staff due to improper care. Staff interviews indicated a lack of consistent personal hygiene practices, with some staff unaware of the resident's hair being cut due to matting. Resident #85, diagnosed with cerebrovascular disease and dementia, was found with a saturated incontinent brief, indicating a failure to provide timely incontinence care. The resident's care plan required frequent changes of briefs, but observations and staff interviews confirmed that the resident had not been changed during the shift. This lack of care was observed by the DON and a CNA, highlighting a deficiency in meeting the resident's toileting and hygiene needs.
Failure to Monitor and Document Blood Pressures as Ordered
Penalty
Summary
The facility failed to monitor and document blood pressures as ordered by physicians for two residents. Resident #189, diagnosed with anoxic brain damage, had a physician's order to receive amlodipine 10 mg daily via PEG tube, with instructions to hold the medication if blood pressure was less than 110/65. However, from March to July 2024, there was no documentation of blood pressure monitoring, resulting in 34 missing entries. The Director of Nursing (DON) confirmed that without monitoring, nurses could not appropriately hold the medication as required. Resident #60, diagnosed with hypertension, had a physician's order to administer Clonidine 0.1 mg every eight hours as needed for systolic blood pressure (SBP) of 160 or greater. Despite this order, there was no documentation of blood pressure monitoring every eight hours from May to July 2024. The corporate nurse confirmed that blood pressure should be monitored every eight hours to comply with the physician's order.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was palatable and served at appetizing temperatures during meals, affecting multiple residents. Observations and interviews revealed that several residents, with varying levels of cognitive function, reported that their food was cold or unappetizing. For instance, one resident with intact cognition stated that the food was not warm, while another with moderately impaired cognition described their mechanical soft diet as mushy. Additionally, a resident with intact cognition reported that their eggs were always cold, and another resident with moderately impaired cognition stated that their food was consistently cold. These observations were corroborated by the testing of food temperatures, which showed that meals were served at lukewarm temperatures, below the standard for palatability. Further investigation into the facility's meal service process revealed that the Dietary Manager (DM) acknowledged taking food temperatures and tasting the food prepared in the kitchen. However, the DM admitted to having no control over the food once it left the kitchen on the hall carts. During a specific lunch service, food temperatures were recorded as being significantly below the desired level, with items such as crab cakes and grilled cheese sandwiches being served at temperatures ranging from 104 to 121 degrees Fahrenheit. The DM also admitted to not tasting the crab cake, which was noted as not palatable. These findings indicate a systemic issue in maintaining food quality and temperature from preparation to service, impacting the residents' dining experience.
Kitchen Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and repair standards in the kitchen, affecting the quality of food service provided to 79 residents, including three who rely solely on feeding tubes for nutrition and hydration. During a kitchen tour, several deficiencies were observed, such as a hole in the wall below the two-compartment sink, black and white residue on the floor and wall below the dishwasher area, and gaps between the floor and wall in the same area. Additionally, torn door gaskets were found on the True two-door reach-in cooler and the True three-door reach-in freezer, and baseboards were missing near the microwave rack. Further observations included missing grout between counter tiles at the serve-out window, black and white residue under the ice machine, and a burned-out oven hood light. Cracked plastic lids on bulk dry ingredient containers, missing baseboards behind the dry ingredient table, and peeling material from the wall and ceiling were also noted. Other issues included a leaking faucet, a crack in the ceiling near the ice machine, brown residue on a shelf, warped hand sink cabinet sides, and damaged baseboards and Formica in the dry storage room. The Dietary Manager stated that daily cleaning and maintenance reporting were in place, but these measures were insufficient to prevent the observed deficiencies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage infection prevention and control measures, as evidenced by several observed deficiencies. A staff member was seen removing soiled linens from a resident's room without placing them in a plastic bag, which is against the facility's protocol. Additionally, the same staff member did not sanitize or wash their hands between tasks, which is a critical step in preventing the spread of infection. The Assistant Director of Nursing confirmed that staff are required to sanitize or wash hands before entering a resident's room and to use gloves appropriately. Another deficiency was observed when a Certified Medication Aide used a wrist blood pressure cuff on multiple residents without cleaning it between uses. This practice poses a risk of cross-contamination between residents. Furthermore, the same aide was seen placing a spoon on a mouse pad before using it to stir medication, which is not a sanitary practice. Another staff member was observed improperly using hand sanitizer by wiping their hands on their clothing instead of allowing them to air dry. The facility also failed to adhere to enhanced barrier precautions during wound care for two residents with pressure ulcers. Staff did not wear gowns as required by the facility's policy when performing wound care, despite signage indicating the need for enhanced precautions. This lapse in protocol was noted by the Infection Prevention nurse, who intervened to correct the staff's actions. These observations highlight significant gaps in the facility's infection control practices, particularly in the areas of hand hygiene, equipment sanitation, and adherence to barrier precautions.
Failure to Document PASARR Level 2 Determination
Penalty
Summary
The facility failed to ensure an accurate PASARR screening was completed for a resident with a diagnosis of a serious mental illness. The level 1 PASARR, dated 11/04/21, indicated that the resident had a serious mental illness and a recent history of mental illness or was prescribed a psychotropic medication. However, there was no documentation in the resident's chart or on the form indicating that a determination for a level 2 PASARR was made. On 07/09/24, the MDS coordinator acknowledged that there should have been documentation on the form with the determination for a level 2 PASARR. They stated that the facility was likely informed that a level 2 was not necessary but failed to document this on the form or in the resident's chart.
Failure to Administer CPR According to Policy
Penalty
Summary
The facility failed to administer CPR in accordance with standards of practice and facility policy. The policy required a rate of 30 compressions to two rescue breaths during CPR. However, during an incident involving an unresponsive resident, CPR was not initiated until six minutes after the resident was found unresponsive. Observations revealed that the Ambu-bag was squeezed five times initially, and later four times, with 30 compressions administered followed by a single rescue breath. Compressions were restarted during the administration of the second rescue breath, indicating a deviation from the prescribed CPR protocol. The Director of Nursing (DON) confirmed that compressions and rescue breaths were alternated until emergency medical services arrived, acknowledging the issue with the rescue breaths.
Failure to Provide Contracture Treatment for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a contracture, as observed during a survey. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was supposed to have a hand roll in their left hand at all times except when showering, as per a physician's order dated 05/17/24. However, during observations on 07/09/24 and 07/11/24, the resident was seen without the hand roll, and their left hand was contracted with the pointer finger extended. The care plan, revised on 07/09/24, also documented the need for a hand roll, but this was not being followed. Interviews with staff revealed a lack of awareness and communication regarding the resident's care needs. The restorative aide confirmed that no services were being provided for the resident, and CNAs expressed uncertainty about the order for a hand roll. One CNA mentioned that they would rely on core staff for information, while another stated they were unsure if an order was in place and would need to check with the nurse. An LPN mentioned that they were supposed to place a washcloth and check the hand and nails every shift, indicating a lack of consistent implementation of the care plan and physician's order.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen (O2) as ordered by the physician for a resident with diagnoses including shortness of breath (SOB) and failure to thrive. The physician's order, dated June 27, 2024, specified that the resident should receive O2 via nasal cannula (NC) at 3 liters per minute (LPM) continuously. On July 12, 2024, at 9:50 a.m., the resident was observed without their O2 tubing in place, as it was found on the floor, and the O2 concentrator was set at 1.5 LPM. At 10:06 a.m., the resident was observed with the O2 tubing in place, but the concentrator remained set at 1.5 LPM. When questioned, an LPN was unaware of the correct O2 setting and initially thought it was set at 2 LPM. Upon reviewing the electronic health record (EHR), the LPN confirmed the order was for 3 LPM and acknowledged the concentrator was incorrectly set at 1.5 LPM, which was the reason for the resident's O2 saturation being 93.
Medication and Supply Management Deficiencies
Penalty
Summary
The facility failed to ensure proper management and storage of medications and supplies, as observed during a survey. An undated opened vial of TB skin test was found in the medication room refrigerator, along with an unopened vial of lorazepam concentrate that was not stored in the clear locked narcotic box, and a bottle of vancomycin solution prepared for enteral administration that was frozen. The temperature log on the refrigerator was incomplete, lacking documentation for the sixth and seventh day of the month. Additionally, expired supplies, including an opened hypodermoclysis kit and several CADD high volume administration sets, were found in the medication room. Interviews with staff revealed a lack of clarity and adherence to procedures regarding medication and supply management. An LPN was unable to determine when the TB skin test vial was opened and acknowledged that the lorazepam should have been secured behind two locks. The DON stated that medication aides should check the medication room weekly for expired items and that the TB skin test solution should have been dated upon opening. Furthermore, the night nurse was responsible for recording refrigerator temperatures every shift, a task that was not consistently performed.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory tests were obtained per physician's orders for a resident reviewed for laboratory testing. The resident had diagnoses including bipolar disorder, major depression, Diabetes Mellitus, and congestive heart failure (CHF). A physician's order dated June 11, 2024, required a complete blood count (CBC) and comprehensive metabolic panel (CMP) to be obtained weekly for two weeks. While the first set of tests was collected on June 12, 2024, there was no documentation of the second set being collected. On July 12, 2024, an LPN was unable to locate the second CBC and CMP in the resident's electronic medical record (EMR) or the facility's lab system. The Assistant Director of Nursing (ADON) confirmed that the second week's tests were missing.
Delayed Meal Service in Dining Room
Penalty
Summary
The facility failed to ensure meals were served as scheduled, affecting the dining experience of residents. An undated schedule indicated breakfast was to be served at 7:30 a.m., but on the observed date, food trays were delivered to the dining room at 8:31 a.m. This delay was corroborated by interviews with four residents, who reported that meals were not always served on time. One resident with intact cognition noted that meals were not always punctual, while another resident with moderately impaired cognition also confirmed the meals were served late. The Dietary Manager (DM) explained that residents eating in their rooms were served first, followed by those in the dining room, aiming to serve within 45 minutes of the scheduled time. However, this practice resulted in delays beyond the scheduled meal times.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide medical records to a resident's representative upon request. The resident, who had diagnoses including bipolar disorder and schizophrenia, signed an authorization form to release their medical records to their representative. Despite this, the facility did not provide the records within the stipulated one-week period. The Medical Records department acknowledged the request during a care plan meeting and compiled the records the next day, but the records were not released in a timely manner. The Administrator was initially unaware of the request and later stated that corporate had informed them that the records were released. However, documentation showed unsuccessful attempts to contact the representative for record pick-up, and there was no evidence that the records were released before the surveyor's inquiry. This failure to provide timely access to medical records constitutes a deficiency in compliance with the facility's policy and federal regulations.
Inadequate Documentation and Communication for Involuntary Discharge
Penalty
Summary
The facility failed to ensure a resident was not involuntarily discharged without adequate documentation and communication. Resident #2, who had diagnoses including dementia, schizoaffective disorder, and bipolar disorder, was transferred to a psychiatric facility due to increased delusions. The resident's medical record lacked documentation regarding the transfer and the reason for not returning to the facility. Additionally, there was no contact information for the resident's DPOA, and it was unclear if the resident or their DPOA were notified about the discharge to a sister facility. The Administrator confirmed that Resident #2 was transferred due to behaviors that endangered the safety of others and that the facility could not meet the resident's needs. However, there was no physician documentation in the medical record to support this decision. The lack of proper documentation and communication violated the facility's policies on transfer and discharge, leading to the deficiency identified by the surveyors.
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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