Elmwood Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Wewoka, Oklahoma.
- Location
- 300 South Seminole, Wewoka, Oklahoma 74884
- CMS Provider Number
- 375423
- Inspections on file
- 19
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Elmwood Manor Nursing Home during CMS and state inspections, most recent first.
A resident who was cognitively intact and dependent on staff for mobility, with a care plan requiring use of a mechanical lift for transfers, fell from the lift during a transfer performed by two CNAs. Facility policy required proper sling use, two trained staff, and adherence to manufacturer instructions. During the transfer, a sling loop came off the lift, and the resident was later found on the floor under the lift, reporting pain and subsequently diagnosed with a nondisplaced distal femur fracture. CNAs reported they were expected to inspect the lift, ensure correct sling placement, and secure hooks or straps before use, and the administrator noted multiple residents in the facility depended on mechanical lifts, with no documentation that quality assurance was involved.
A resident with a history of inappropriate sexual behaviors inappropriately touched another resident in a public area, despite prior documented incidents and complaints from other residents. The care plan for the resident exhibiting these behaviors lacked sufficient interventions, and staff failed to conduct timely investigations or complete required abuse surveys, resulting in multiple residents feeling violated or uncomfortable.
A resident with hemiplegia, hemiparesis, and a history of choking incidents was left unsupervised while eating in their room, despite a care plan requiring meal assistance and a modified diet. The resident choked on food, and staff were not present to intervene immediately, resulting in the resident's death.
A treatment cart containing insulin and other medical supplies was repeatedly observed unlocked and unsupervised near the nurse's station, with LPNs away from the cart and out of view. Facility policy required medication carts to be locked when not in use, and staff acknowledged responsibility for securing the cart.
The facility did not conduct a thorough investigation after an incident where one resident was observed inappropriately touching another. Required steps such as obtaining written witness statements and interviewing all relevant staff were not completed, as confirmed by facility leadership.
A facility did not track or monitor a choking incident involving a resident, resulting in the resident's death. The QA group failed to document or review the event, despite policy requiring such oversight.
The facility failed to ensure physician responses and rationales for medication regimen reviews (MRR) for two residents. One resident, with multiple diagnoses, had no documented physician response to a pharmacist's GDR recommendation. Another resident's physician disagreed with a GDR request but did not document the rationale. The DON was unaware of the MRR process, and the MDS coordinator confirmed the lack of physician documentation.
A facility failed to ensure a resident receiving antipsychotic medications had an appropriate diagnosis. The resident, diagnosed with dementia and depression, was prescribed cariprazine and Invega for unspecified dementia without psychotic or behavioral disturbances. An assessment showed severe cognitive impairment with no depression or behaviors, yet antipsychotic medication was continued. Staff confirmed dementia was not an appropriate diagnosis for these medications, indicating a deficiency in medication management.
The facility failed to adhere to food service safety standards, with raw hamburger patties stored improperly with pre-cooked meat, undated and unlabeled liquids, and spoiled zucchini found in the kitchen. Additionally, the kitchen floor had debris and food particles. A staff member acknowledged the improper storage and labeling practices.
A facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to a deficiency. A resident with cervical spine fusion and muscle weakness used bed rails for repositioning, as per a physician's order and care plan. However, the facility did not maintain records of regular inspections of these bed rails, as confirmed by the administrator.
A resident with schizophrenia did not receive clozapine as ordered due to discrepancies in medication records. The facility's MAR and pharmacy logs showed the resident received more tablets than documented as received. Staff interviews suggested that leftover medication from a discharged resident may have been used, and the issue was not reported to the administrator.
A resident with COPD had a physician's order for oxygen therapy, but the care plan was not updated to reflect this. The resident was observed receiving oxygen, yet the care plan lacked documentation of this treatment. The MDS coordinator acknowledged the oversight.
A facility failed to obtain informed consent before using bed rails for a resident with cervical spine fusion, central cord syndrome, and muscle weakness. Although a physician order and care plan allowed the use of half rails for repositioning, there was no documentation of informed consent in the medical record. The corporate nurse consultant confirmed the oversight.
Resident Fall and Femur Fracture During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a resident did not fall from a mechanical lift during a transfer, resulting in a fall and injury. The facility had a Safe Lifting & Mechanical Lift Policy dated 01/01/25 that required use of proper sling and equipment, two trained staff for transfers, and adherence to manufacturer instructions. The resident’s care plan for activities of daily living, dated 10/30/25, specified the need for a mechanical lift for transfers, and a quarterly assessment dated 12/31/25 documented that the resident was cognitively intact with a BIMS score of 15 and was dependent on staff for mobility. On 11/13/25, a late entry nursing progress note recorded that an LPN found the resident on the floor under the mechanical lift, with the resident complaining of pain all over, and the resident was sent to the emergency room for evaluation. A hospital imaging report from the same day showed a nondisplaced fracture deformity of the distal femur in the resident’s right leg. A facility incident report dated 11/14/25 documented that the resident fell from a mechanical lift while being transferred by two CNAs. The resident’s fall care plan, dated 11/17/25, stated that the resident had been up in a mechanical lift when a sling loop came off the lift, causing the resident to fall to the floor toward the right lower corner of the sling, and that the resident was sent to the hospital for evaluation and treatment. CNAs interviewed later stated they were responsible for inspecting the lift before use, ensuring the resident was correctly positioned in the sling, and confirming that hooks or straps were properly secured. The administrator identified that 19 residents in the facility were dependent on mechanical lifts for transfers and there was no documentation that quality assurance was involved in the process.
Failure to Protect Residents from Sexual Abuse and Inadequate Investigation of Incidents
Penalty
Summary
The facility failed to protect residents from sexual abuse and psychosocial harm, resulting in an incident where one resident inappropriately raised another resident's shirt and grabbed their breast in a public area. Prior to this event, there were documented behavioral issues involving the same resident, including making other residents uncomfortable, using vulgar language, and inappropriate physical contact such as kissing another resident. Despite these documented behaviors, the care plan for the resident exhibiting inappropriate sexual behaviors did not include sufficient interventions beyond medication management, and there was a lack of comprehensive measures to prevent further incidents. Multiple residents with cognitive impairments and communication deficits were involved or affected by the inappropriate behaviors. One resident had diagnoses including bipolar disorder, Alzheimer's, and moderate cognitive impairment, while the resident who committed the abuse had severe cognitive impairment and a history of inappropriate sexual behaviors. Other residents reported feeling violated or uncomfortable due to the actions of the same resident, and there were staff observations of ongoing inappropriate comments and behaviors directed at both residents and staff. The facility did not conduct timely or thorough investigations into reported incidents of sexual abuse. For example, after a reported incident of inappropriate touching, the administrator acknowledged that no investigation had been conducted. Additionally, staff interviews revealed that safe surveys regarding abuse were not completed, and there was a lack of documentation and follow-up on previous incidents. These failures contributed to an environment where residents were not adequately protected from abuse, neglect, and exploitation.
Removal Plan
- General Manager completed the Process for Completion of a State Reportable.
- Administrator completed training on Abuse and Neglect and on Conducting an Abuse Investigation.
- In-service provided to Administrator and Corporate Nurse on Abuse investigation, Reporting, Completion, Conducting and the updated abuse policy.
- All staff educated on abuse, neglect, and exploitation by Administrator.
- Resident #2 educated on abuse and resident's rights.
- All staff educated on the reporting structure and provided contact information for the administrator of record.
- Resident #2 placed on one-on-one monitoring with direct care staff or designee when out of resident's room.
- Resident #2 medications to be reviewed by Psych NP and MD to assist with potential reduction and behaviors due to side effects if applicable.
- All findings and audits to be reviewed by Director of Nursing, Administrator and/or designees.
- Review of residents to list any residents at risk for inappropriate unwanted behavior, list to be done by Director of Nursing.
- All at risk residents will not be placed near Resident #2.
- All at risk residents will be care planned with interventions of maintaining placement when out of room away from Resident #2.
- All at risk residents who are at risk for unwanted behavior will be added to the shift monitor report so that the charge nurse and staff are aware to maintain distance from Resident #2.
- Facility will work with active family member to restructure visit times to be scheduled during high aggressive times once identified.
- Resident #1 will be monitored by the charge nurse for any psychosocial alterations.
- All staff and current residents interviewed to rule out abuse, neglect or exploitation using a safe survey.
- Abuse, neglect and exploitation policy updated to include specific verbiage on inappropriate sexual behaviors in the screening, training, prevention, and identification components.
- A QA was created and implemented pertaining to the inappropriate behaviors of Resident #2 with interventions.
- A monitoring form for interventions for Resident #2 was created and implemented.
- Education provided to activities/social services staff to do 1:1 activities with Resident #2 after lunch.
- Care plan for Resident #2 updated to include the interventions put into place.
- Care plan for Resident #1 updated to include the psychosocial monitoring and an order placed in the EMAR to be monitored by nurses.
- Resident #2's medication reviewed and Prevera dosage increased.
- Non-verbal/incapacitated residents interviewed using observation for facial expressions, gestures, and emotional cues/reactions.
- All staff instructed via electronic in-service to keep Resident #2 away from all residents identified as vulnerable or at risk of inappropriate behavior.
- When Resident #2 is out of room, staff instructed to move Resident #2 away from all identified at-risk residents in public areas, assigned to all staff and documented on daily monitoring form by charge nurse.
- Exception documentation if behavior occurs in the nursing notes and behavior record, to be completed by charge nurses.
- In-service documentation showed clinical staff attended in-person and via telephone training by the administrator over the facility's abuse policy.
- Resident #2's care plans updated to show 1:1 intervention and medication dosage increased to reduce behaviors.
- Resident #2 observed to ensure 1:1 intervention by clinical staff.
- Residents #1, #4, and #5 observed to ensure they maintained a safe distance from Resident #2.
- A list for residents with unwanted behaviors posted at the nurse's station.
- QA documentation showed the facility had a meeting where they addressed the abuse incident.
- General manager documentation for in-service completion for state reportable training reviewed.
Failure to Supervise Resident with Choking Risk During Meals Resulting in Death
Penalty
Summary
A deficiency occurred when staff failed to provide required supervision and assistance during mealtime for a resident with a known history of choking incidents and an established care plan requiring assistance with dining. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, and was cognitively intact. The care plan specified a mechanical soft diet with chopped meats and required staff assistance with meal setup and feeding due to previous episodes of choking and difficulty with certain food textures. Despite these documented needs, the resident was left unsupervised while eating in their room. Multiple nursing notes and care plan entries indicated the resident had previously choked on meats, had been observed coughing frequently during meals, and had expressed concerns about getting 'strangled' on tough meat. On the day of the incident, the resident was found alone in their room, in distress and choking, with no staff present to provide immediate assistance. Staff were occupied distributing meal trays in the hallway at the time. When the resident activated the call light, a CNA responded and found the resident choking, attempting to perform the Heimlich maneuver with assistance from another CNA and an LPN. Despite these efforts, the resident was pronounced dead by EMS. Interviews with staff confirmed that the resident was not being monitored during the meal, contrary to the care plan and facility policy, which required supervision and assistance for residents at risk of choking.
Removal Plan
- Review all residents' nutritional care plans and diets for choking risk, non-compliance with diets, therapeutic diets, and assisted feeding needs.
- Identify residents at risk of choking or non-compliance with diet orders/recommendations or who require assistance with feeding.
- Update nutritional care plans for all residents identified as choking risk by clinical staff.
- Create a quick reference chart (diet reference list) for all clinical and dietary staff, including meal location preferences, diet (including consistency), portion, and protein supplements; place the chart at the nurse's station, in the nurse shift book, in the kitchen on the bulletin board, and in the CNA shift report book.
- Create a policy addendum on choking or dietary non-compliance and add it to the assistance with meals policy, including key personnel to contact regarding choking or dietary non-compliance events and assessment of the resident to determine the need for treatment such as the Heimlich maneuver.
- Create and implement a CPR policy and procedure specifying when to initiate CPR, training and competency requirements, require all clinical staff to maintain valid CPR/BLS certification, require newly hired staff to obtain CPR certification, require CPR recertification, allow a grace period for renewal, and maintain proof of certification in personnel files.
- Provide in-service education for all clinical staff on supervision during meals, including procedures for meal supervision and 1:1 staff presence for residents requiring feeding assistance or at risk of choking.
- Provide in-service education on how to locate and follow care plans in the electronic health record, and instruct staff to notify the charge nurse if they cannot access needed information.
- Provide in-service education on procedures related to a choking event, including identification of choking risk residents, reporting choking events, and reporting dietary compliance issues.
- Train all clinical staff on CPR and Heimlich maneuver.
- Conduct a Quality Assurance Performance Improvement Project (PIP) to address assisting and monitoring residents named as choking risk and 1:1 supervision of residents during mealtimes until meal is completed.
- Implement quality assurance monitoring: monitor residents at risk for choking by DON/designee.
Unsecured Treatment Cart with Medications Left Unattended
Penalty
Summary
The facility failed to ensure that the treatment cart containing drugs and biologicals, including insulin pens and vials, was locked and supervised when not in use. On multiple occasions, the treatment cart was observed unlocked and unsupervised near the nurse's station, with licensed nursing staff away from the cart and out of sight. Facility policy required that medication carts be securely locked at all times when out of the nurse's view, and staff interviews confirmed awareness of this responsibility. The treatment cart was reported to contain insulin and PEG tube supplies, and the facility had a total of two medication carts and one treatment cart for 39 residents.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident out of eight sampled for abuse. According to facility policy, all reports of resident abuse, neglect, and injuries of unknown source are to be promptly and thoroughly investigated, including obtaining written and signed witness statements, interviewing all relevant staff, witnesses, and reviewing events leading up to the incident. However, following an incident where one resident was observed inappropriately touching another resident, the investigation was incomplete. The general manager acknowledged that a full investigation, including obtaining witness statements, was not conducted, and the administrator confirmed that no witness statements were available for the incident.
Failure to Track and Monitor Choking Incident in QA Process
Penalty
Summary
The facility failed to track and monitor a choking incident involving one resident, as required by its policy on safety and supervision. According to the nursing note, staff responded to a resident who was choking, and paramedics later pronounced the resident deceased. Despite this serious event, there was no documentation in the quality assurance notes regarding monitoring or tracking of the incident. The corporate nurse confirmed that the incident was neither reviewed nor documented by the quality assurance group, contrary to facility policy that mandates QA review of safety and incident reports.
Failure to Document Physician Response and Rationale for Medication Review
Penalty
Summary
The facility failed to ensure that a physician responded to a pharmacist's medication regimen review (MRR) and did not document the physician's rationale for declining a gradual dose reduction (GDR) for two residents. Resident #6, who had diagnoses including dementia, schizophrenia, unspecified psychosis, and insomnia, was prescribed multiple medications such as ramelteon, Trintellix, desvenlafaxine, Vraylar, and olanzapine. An MRR report indicated the need for a GDR for these medications, but there was no documented response from the physician. The Director of Nursing (DON) was unaware of the MRR process, and the MDS coordinator confirmed the lack of physician response. Resident #26, diagnosed with dementia, depression, and insomnia, was prescribed medications including trazadone, Lexapro, Remeron, lamotrigine, and Invega. An MRR report suggested a GDR for these medications, but the physician disagreed with the request without providing a documented rationale. The MDS coordinator and the corporate nurse consultant acknowledged the absence of a documented rationale for the physician's decision. These deficiencies highlight the facility's failure to adhere to its policy requiring physician responses and rationales for MRR recommendations.
Inappropriate Use of Antipsychotic Medication for Dementia
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications had an appropriate diagnosis for the use of antipsychotic medication. The resident, who was admitted with diagnoses including dementia and depression, was prescribed cariprazine and Invega, both antipsychotic medications, for unspecified dementia without psychotic or behavioral disturbances. An annual assessment indicated the resident was severely cognitively impaired, had no symptoms of depression or behaviors, yet continued to receive antipsychotic medication. Interviews with the MDS coordinator and the corporate nurse consultant confirmed that dementia was not an appropriate diagnosis for the use of antipsychotic medications, highlighting a deficiency in the facility's medication management practices.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during an initial kitchen tour. Raw hamburger patties were improperly stored on top of pre-cooked and sliced sandwich meat, and deli-sliced ham was placed on top of raw hamburger patties in a refrigerator. Additionally, two gallon pour top jugs containing brown and orange liquids were not dated or labeled. In the dry storage area, an undated and unlabeled blue bag, identified by staff as containing raisins, was found. Furthermore, zucchini in a refrigerator was covered with a grey and white fuzzy substance, indicating spoilage. The kitchen floor was also noted to have debris and food particles. A staff member acknowledged that raw meat should not be stored with cooked meat and that food items should be labeled and dated when prepared, stored, or opened.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which is part of their maintenance program, to identify potential areas of entrapment. This deficiency was identified during an observation, record review, and interview process. A resident with diagnoses including fusion of the cervical spine, central cord syndrome, and muscle weakness, who was cognitively intact and required extensive assistance with bed mobility, was found to have bilateral half bed rails in the up position for repositioning purposes. Despite a physician's order and care plan allowing the use of bed rails for repositioning, the facility did not maintain records of regular inspections of these bed rails, as confirmed by the administrator.
Medication Administration Discrepancy for Resident with Schizophrenia
Penalty
Summary
The facility failed to administer medication as ordered for a resident diagnosed with schizophrenia, auditory hallucinations, and bipolar disorder. Upon admission, the resident was prescribed clozapine, an antipsychotic medication, with specific instructions to administer two tablets at bedtime and one tablet twice daily. However, discrepancies were found in the medication administration records (MAR) and pharmacy logs, indicating that the resident received more tablets than were documented as received by the facility. Specifically, the records showed that the resident received 323 tablets over three months, while only 237 tablets were documented as received. Interviews with staff revealed that one certified medication aide (CMA) admitted to administering one of the three daily doses, while another CMA, who was unavailable for interview, was responsible for the remaining doses. It was suggested that the second CMA may have used leftover medication from a discharged resident to compensate for the shortage. The administrator and corporate nurse consultant confirmed that the medication was not administered according to physician orders, and the issue was not previously reported to them by the staff.
Care Plan Omission for Oxygen Therapy
Penalty
Summary
The facility failed to update a care plan to include an order for oxygen for a resident diagnosed with COPD. A physician's order, dated August 15, 2024, specified that the resident was to receive oxygen at two to three liters per minute via nasal cannula to maintain oxygen saturation above 90%. On October 21, 2024, the resident was observed in bed with an oxygen concentrator delivering oxygen at two liters per minute via nasal cannula. However, the resident's care plan did not document the administration of oxygen. On October 24, 2024, the MDS coordinator confirmed that oxygen should have been included in the care plan but was not documented.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent before utilizing bed rails for a resident. The resident, who had diagnoses including fusion of the cervical spine, central cord syndrome, and muscle weakness, was cognitively intact and required extensive assistance with bed mobility. A physician order allowed the use of half rails for repositioning, and the care plan documented the resident's ability to use side rails for repositioning and rolling in bed. However, there was no documentation of informed consent for the use of bed rails in the resident's medical record. The corporate nurse consultant confirmed that informed consent was not obtained prior to the use of bedrails.
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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