Elmbrook Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ardmore, Oklahoma.
- Location
- 1811 9th Avenue Nw, Ardmore, Oklahoma 73401
- CMS Provider Number
- 375160
- Inspections on file
- 22
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Elmbrook Home during CMS and state inspections, most recent first.
A dependent resident with moderately impaired cognition and chronic pain returned from the ER and was assisted to bed by a CNA and an LPN, who moved the resident up in bed by having the CNA reach across and pull the draw sheet from both sides while the LPN lifted under the knees, rather than positioning one staff member on each side of the bed and using the draw sheet correctly. The resident reported calling out that their arm hurt during the maneuver, but the staff continued the movement, and the resident was later observed with a bandage and dark purple bruising on the forearm. Other CNAs, an LPN, and a restorative aide described the correct repositioning method and indicated that a pain complaint should trigger assessment and appropriate response.
A resident with a history of unspecified pain and moderately impaired cognition, who had PRN Tylenol ordered and a care plan to monitor for pain and skin changes, was moved up in bed by a CNA and an LPN using an improper technique. During the repositioning, the resident cried out that their arm hurt, but the LPN did not perform a pain assessment and instead assumed the complaint was related to chronic pain, while the CNA reported not hearing a pain complaint. Later observations noted a bandage and dark purple bruising on the resident’s forearm, indicating the facility failed to follow its pain protocol requiring assessment of pain characteristics with a standardized tool.
A resident with multiple medical conditions and moderate cognitive impairment was transferred to the hospital for an acute CVA, but the family representative was not notified by facility staff as required by policy. The LPN involved did not document or communicate the transfer, and the family only learned of the event from the medical flight pilot. The DON confirmed the lapse in notification.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A facility failed to refer a resident with newly diagnosed mental illness for a level II PASARR evaluation. The resident was initially admitted with a level I PASARR, but later diagnosed with a mood disorder and unspecified psychosis. The facility did not update the PASARR status, and the regional nurse consultant confirmed the absence of a PASARR policy.
A resident with a history of breast cancer experienced a delay in scheduling a mammography due to the facility's failure to transcribe a physician order in a timely manner. Despite a nurse's note indicating the need for an urgent mammogram, the order was not presented until weeks later, leading to a delay in the referral process. The delay was attributed to the need for a 3-D mammography, which required a specific physician order.
The facility failed to follow its smoking policy, requiring supervision for all residents while smoking. Two residents with Alzheimer's disease were involved in incidents highlighting this deficiency. One resident, assessed as a safe smoker, was allowed to keep cigarettes in their room and smoked independently with oxygen in place. Another resident, with severe cognitive impairment, fell while smoking with family members. Staff confirmed deviations from the policy, and the DON acknowledged the need for policy rewording.
A facility failed to properly dispose of blood-contaminated glucometer strips for a resident with diabetes. The RN disposed of the strips in the resident's trashcan instead of the sharps container, contrary to the facility's policy. The RN admitted to being nervous and stated that they normally would have used the sharps container. The DON confirmed the policy for proper disposal.
A resident with Alzheimer's and other conditions was fed a pureed meal by a CNA who was watching a video on their cell phone, violating the facility's policy against cell phone use during care. The LPN and DON confirmed this was against policy and an ongoing issue.
A resident with multiple health conditions, including Alzheimer's dementia and coronary artery disease, reported feeling cold in their room, which was confirmed by a temperature reading of 67.6 degrees Fahrenheit. Despite the RN reporting the issue to maintenance, no effective action was taken, and the resident continued to feel cold even when the temperature was recorded at 71.4 degrees Fahrenheit. The administrator was unaware of the complaint until later and initiated a grievance report.
A facility failed to complete an MDS discharge assessment for a resident discharged with a right femur fracture. The oversight was identified during a review, and the MDS coordinator acknowledged the missed assessment. The facility lacked a policy for comprehensive assessments, which may have contributed to the issue.
The facility failed to store medications properly as per policy. A resident's medications were found unattended on a counter at the nurses station, contrary to the requirement that they be locked in a medication cart. Both an RN and the ADON confirmed this lapse.
Improper Repositioning Technique Causing Forearm Injury and Unaddressed Pain Complaint
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper repositioning and safe transfer techniques for a dependent resident who required assistance of two staff for activities of daily living. The resident, who had moderately impaired cognition with a BIMS score of 11 and a diagnosis including unspecified pain, was observed on multiple occasions with a bandage and dark purple bruising on the right forearm. The resident reported that a CNA and an LPN attempted to pull them up in bed, with the CNA leaning over and pushing down on the resident’s arm while moving them up in bed. The resident stated they hollered and told staff their arm was hurting, but the staff continued to move them. Staff interviews confirmed that the resident had just returned from the emergency room when the LPN and CNA assisted them to bed and moved them up in bed. The LPN stated the CNA reached over the resident and grabbed the draw sheet from both sides while the LPN placed an arm under the resident’s knees to move the resident up, and acknowledged hearing the resident say, “Ow my arm,” but assumed it was related to chronic arm pain. The CNA described the same technique and acknowledged that it was not the correct method, stating that one person should have been on each side of the bed using the draw sheet. Other CNAs, an LPN, and a restorative aide described the correct procedure as having one staff member on each side of the bed and using a draw sheet or pad to move a resident up, and nursing staff described that a complaint of pain should prompt assessment and repositioning, with further actions and documentation if pain persisted.
Failure to Assess and Manage Pain During Improper Repositioning
Penalty
Summary
The facility failed to ensure a resident was properly assessed for pain during repositioning in bed. The resident had a diagnosis that included unspecified pain and a physician order for PRN Tylenol Arthritis Pain 650 mg every six hours as needed. A quarterly assessment documented moderately impaired cognition with a BIMS score of 11, and the care plan directed staff to monitor for skin changes and for pain and/or discomfort. The facility’s Pain-Clinical Protocol required staff and the physician to identify pain characteristics, including location, intensity, frequency, pattern, and severity, and to use a consistent, standardized pain assessment tool appropriate to the resident’s cognition level. After returning from the emergency room, the resident reported that a CNA and an LPN attempted to move them up in bed, during which the CNA leaned over and pushed down on the resident’s arm, causing pain. The resident stated they hollered and told staff their arm was hurting, but staff continued to move them up in bed. The LPN later acknowledged hearing the resident say, "Ow my arm," but did not assess for new pain, assuming it was the resident’s chronic shoulder pain, and did not determine the pain’s location or characteristics. The CNA described using an improper technique to move the resident up in bed by reaching across and pulling the draw sheet from one side, while the LPN lifted under the knees. Subsequent observations showed a bandage and dark purple bruising on the resident’s right forearm, and the DON reported being informed of bruising by the resident’s family member.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure that responsible parties were notified of a change in condition for one resident. According to facility policy, a nurse is required to notify the resident's representative within twenty-four hours of a change in the resident's medical or mental condition, unless otherwise instructed by the resident. In this case, a resident with diagnoses including atrial flutter, epilepsy, nutritional disorder, and chronic kidney disease, and with moderately impaired cognition, was sent to the emergency room following a physician's order. Documentation showed that the resident was admitted to the hospital with an acute cerebrovascular accident. Despite the facility's policy, there was no documentation in the resident's progress notes indicating that the family representative was notified of the hospital transfer. The family representative confirmed they were not informed by facility staff and only learned of the transfer from the medical flight transport pilot. The LPN involved acknowledged the lack of notification and documentation, and the DON confirmed that the family was not notified by staff at the time of the transfer.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Update PASARR for Resident with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer a resident with newly diagnosed mental illness to the OHCA for a level II PASARR evaluation. This deficiency was identified for one of two sampled residents reviewed for PASARR. The resident was admitted to the facility with a level I PASARR indicating no need for a level II evaluation. However, after admission, the resident was diagnosed with a mood disorder and unspecified psychosis. Despite these new diagnoses, the facility did not reevaluate the resident's PASARR status. The regional nurse consultant confirmed that the PASARR had not been updated and reported that the facility lacked a policy for PASARR evaluations.
Delayed Mammography Scheduling for Resident with Breast Cancer History
Penalty
Summary
The facility failed to transcribe a physician order and schedule a mammography in a timely manner for a resident with a history of breast cancer. The resident had a past surgical history of a partial mastectomy on the left side and was noted to have a lump in the breast tissue under the left arm. A nurse's note dated December 26, 2024, indicated that a mammogram should be scheduled as soon as possible. However, the physician order for the diagnostic mammogram was not presented until January 16, 2025, indicating a delay in the transcription and scheduling process. During interviews, it was revealed that the referral for the mammography was only sent to the hospital on the morning of January 16, 2025, despite the nurse's note from December 2024. The LPN involved acknowledged the delay, stating it had been 16 or 17 days since the notification to schedule the mammography. The Director of Nursing confirmed that the scheduling had taken a couple of weeks, and the RN involved admitted there had been a scheduling issue. The delay in scheduling the mammography was attributed to the need for a 3-D mammography due to the presence of a lump, which required a specific physician order that was not obtained in a timely manner.
Failure to Supervise Residents While Smoking
Penalty
Summary
The facility failed to adhere to its smoking policy, which mandates supervision for all residents while smoking and prohibits residents from keeping smoking articles unless supervised. Two residents, both with Alzheimer's disease and other health conditions, were involved in incidents that highlighted this deficiency. The facility's policy, dated July 2017, requires quarterly re-evaluation of a resident's ability to smoke safely and stipulates that residents must be supervised at all times while smoking. The first resident, diagnosed with Alzheimer's dementia and other health issues, was assessed as a safe smoker with a risk of 0 and was allowed to keep cigarettes in their room, contrary to the facility's policy. Despite being cognitively intact according to an MDS assessment, the resident was observed smoking independently with oxygen in place, which poses a significant safety risk. Staff confirmed that the resident kept smoking materials in their room and smoked without supervision. The second resident, also with Alzheimer's disease and cognitive impairment, was involved in a fall incident while smoking with family members. Although the resident's smoking assessment indicated they could smoke independently, the MDS assessment documented severe cognitive impairment. Staff reported that the resident's cigarettes were kept at the nurse's station, and the resident was usually supervised while smoking. However, the facility's Director of Nursing acknowledged that the policy might need rewording to reflect actual practices, as some residents were allowed to keep smoking materials and smoke unsupervised based on nursing judgment.
Improper Disposal of Blood-Contaminated Supplies
Penalty
Summary
The facility failed to ensure proper disposal of blood-contaminated glucometer strips for one of the two sampled residents reviewed for finger stick blood sugar levels. The policy for blood sampling, dated 09/14/14, requires the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases, including discarding lancets and platforms into a sharps container. Resident #52, who has a diagnosis of diabetes mellitus, had a physician order for finger stick blood sugar levels twice daily. On 01/14/25, RN #2 was observed gathering supplies for a finger stick blood sugar test and disposed of the bloody glucometer strip in the resident's trashcan instead of the sharps container. The RN repeated the procedure and again improperly disposed of the contaminated strip. The RN admitted to being nervous and stated that they normally would have used the sharps container. The Director of Nursing confirmed that the facility's policy was to dispose of contaminated supplies in the sharps container.
Violation of Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with dignity and respect during assistance with eating. A resident with Alzheimer's disease, depression, and seizure disorder, who had severely impaired decision-making and required assistance with activities of daily living, was observed being fed a pureed meal by a CNA who was watching a video on their personal cell phone. This occurred during the noon meal, and it was noted that the use of cell phones while providing resident care was against facility policy. The LPN and DON confirmed that cell phone use during care was not allowed and acknowledged it as an ongoing issue, with staff frequently reminded to refrain from using phones except during breaks.
Failure to Maintain Comfortable Room Temperature for Resident
Penalty
Summary
The facility failed to maintain a comfortable room temperature for a resident, identified as Resident #16, who was part of a sample of four residents evaluated for environmental conditions. Resident #16 had multiple diagnoses, including atrial fibrillation, Alzheimer's dementia, muscle weakness, anxiety, coronary artery disease, iron deficiency anemia, chronic pain, and diabetes. An MDS assessment indicated that the resident was moderately impaired with cognition and used a wheelchair for mobility. During an observation, the resident was found lying in bed covered with blankets and reported feeling cold. The resident had placed blankets on the windowsill to mitigate the cold. A registered nurse (RN) confirmed that the room was consistently cold and had reported the issue to maintenance the previous week, but no effective action had been taken. A room temperature reading taken in Resident #16's room showed 67.6 degrees Fahrenheit, which was below a comfortable level. Two days later, the temperature was recorded at 71.4 degrees Fahrenheit, but the resident still reported feeling cold and was observed wearing a jacket. The administrator and maintenance staff confirmed the temperature reading. The administrator was unaware of the resident's complaint until the day before and initiated a grievance report. The resident expressed willingness to change rooms when asked by the administrator, indicating that the issue had not been resolved promptly or effectively by the facility's staff.
Failure to Complete MDS Discharge Assessment
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) discharge assessment for a resident who was discharged from the facility. The resident, who had been admitted with a diagnosis of right femur fracture, was discharged on September 7, 2024. However, the MDS discharge assessment was not completed at the time of discharge. This oversight was identified during a review of records and interviews, where the MDS coordinator acknowledged that the discharge assessment for the resident was missed. Additionally, it was noted that the facility did not have a policy in place for comprehensive assessments, which may have contributed to the oversight.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored properly and according to facility policy. During an observation, it was noted that a resident's medications were left unattended on the top of the counter at the north hall nurses station, with no staff in sight. The facility's policy, revised in April 2019, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner. Both an RN and the ADON confirmed that the medications should have been locked in a medication cart, indicating a lapse in adherence to the facility's storage policy.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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