Emerald Care Center Claremore
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremore, Oklahoma.
- Location
- 2800 North Hickory Street, Claremore, Oklahoma 74017
- CMS Provider Number
- 375499
- Inspections on file
- 33
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Emerald Care Center Claremore during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow dietician-approved, posted menus for three observed meal services, affecting over one hundred residents who received meals from the kitchen. Instead of the scheduled ham, meatloaf, and tuna melt meals with specified sides and desserts, staff served alternate entrees such as meatballs, kielbasa, and beef pot pie with different sides and desserts. A cook reported that the food service director and supervisor sometimes changed menus at the last minute, likely due to inadequate food supplies. The food service director confirmed choosing alternate meals because required items were not available, while residents reported that posted menus often did not match what was served. The administrator stated they were unaware menus were not being followed, and the dietician reported not being informed of the changes despite regulations requiring adherence to the approved menus.
Surveyors found that meals were not consistently palatable or attractive, as evidenced by a sampled dinner tray with mushy, bland squash and soggy, bland biscuit topping on a beef pot pie, contrary to the facility’s own food preparation policy. Resident council minutes over two months documented ongoing complaints that food was not cooked properly, was getting worse, and that dietary concerns were not being addressed. Multiple residents reported that food never tasted good, vegetables were always mushy, alternatives were rarely offered, and meals were not appetizing in appearance, with food either too salty or too bland. When asked to sample the tray, the administrator rated the meal only 5/10 for taste and appearance, while the food service director maintained that meals were appetizing despite resident complaints about inconsistent seasoning.
The facility did not complete required advance directive acknowledgment forms for two residents. Policy required staff at admission to determine whether a resident had an advance directive or wished to formulate one and to obtain and file all related documents in the chart. Record review showed each of the two residents had physician orders indicating full code status, but neither had an advance directive acknowledgment form in the medical record. The admission director reported that the acknowledgments were missing because staff were waiting for families to provide them.
A resident on chronic Warfarin therapy for atrial fibrillation and thrombophilia sustained a ground-level fall resulting in head bleeding, a T12 vertebral fracture, and bilateral subdural hematomas, and was sent to the ER via ambulance. Facility policy and state regulatory guidance required reporting incidents involving fractures, hospital treatment, and significant head injuries within 24 hours, but the DON and ADON did not report the event to the state health department, with the DON stating it was not considered a major injury and therefore not reportable.
The facility did not complete required annual competency reviews for two CNAs. Record review showed that one CNA hired in the prior year and another hired in the current year had no documented annual competency evaluations for the current year. In an interview, the HR director acknowledged that these reviews had not been done and that the facility did not have a policy for annual competencies.
A resident with thrombocytopenia had a physician’s order for nightly eltrombopag olamine 50 mg, but the medication was not administered on two consecutive days. The MAR documented missed doses, while nurse notes alternately indicated the pharmacy would not dispense the drug and that staff were waiting on delivery, even though an incident report later showed the medication had been received and locked in the narcotic box. One CMA reported being unable to find the medication, marked it as not in the building when a family member requested it, and did not escalate to the ADON as expected, while another CMA could not recall if the medication was given. The ADON stated that the process when a medication cannot be found is for the medication aide to notify the nurse and for the nurse to notify the physician.
A resident with hypertension was prescribed nifedipine ER and later amlodipine for blood pressure control, but the physician orders for these antihypertensive medications did not include hold parameters. Pharmacy drug regimen reviews generated written recommendations to add hold parameters for both medications, which were reported to the DON per facility policy. The DON, who was responsible for processing pharmacy reviews and obtaining necessary physician orders, acknowledged during interview that these recommendations were missed and that the medications continued without the recommended administration parameters.
Two residents were forced to take medication against their will by an LPN and a CMA, violating their rights to refuse treatment. One resident with Alzheimer's was given medication mixed with pudding despite verbal refusal, while another with vascular dementia was physically restrained to administer lorazepam.
A resident with vascular dementia was physically restrained by an LPN during medication administration, violating the facility's policy on restraints. The LPN held the resident's arms and shoulders to prevent them from standing and pushing away medication, which was confirmed by the ADON as a violation of the resident's rights.
A resident with Alzheimer's disease was improperly administered lorazepam as a chemical restraint by an LPN and CMA, violating facility policy. The resident, who repeatedly stood from their wheelchair, was physically restrained and forced to take the medication against their will. The incident led to the termination of the LPN and suspension of the CMA.
A facility failed to ensure timely reporting of an abuse allegation involving a resident with vascular dementia. A CMA witnessed an LPN forcibly administering medication to the resident but did not report the incident until more than 24 hours later, contrary to the facility's policy requiring immediate reporting of abuse allegations. The delay was confirmed by the ADON, highlighting a deficiency in the facility's adherence to reporting protocols.
A facility failed to include necessary interventions for a resident's pressure ulcer in their care plan, despite a physician's order for wound care. The resident had an unstageable pressure ulcer, and staff confirmed that such conditions should be addressed in the care plan.
A resident with obstructive and reflux uropathy was observed with their catheter bag on the floor on two occasions. The facility's RN and ADON confirmed that catheter bags should not be on the ground, highlighting a failure in infection prevention and control practices.
A facility failed to notify a resident's representative about changes in antipsychotic medication for a resident with delusional disorder. The resident was prescribed risperidone and later Nuplazid, but there was no documentation of notification to the representative. The ADON confirmed this oversight, acknowledging it was against facility policy.
The facility failed to thoroughly investigate the disappearance of 60 Oxycodone/APAP tablets. The ADON discovered the discrepancy when attempting to reorder the medication and found it was too soon. Despite attempts to contact the LPN who signed for the delivery, no documentation of a comprehensive investigation was available, and the LPN was unaware of the issue.
A resident with hemiplegia and hemiparesis experienced an unobserved fall and was inadequately assessed by an LPN, who reported no issues despite the resident's complaints of hip pain and an externally rotated leg. The following day, the ADON and a nurse practitioner identified the issues, and the resident was sent to the ER, where a hip fracture was diagnosed. The LPN's failure to follow the facility's Falls Management policy delayed treatment.
A facility failed to accurately document medication administration for a resident, as the MAR incorrectly showed that Nuplazid was administered multiple times despite the medication never arriving due to an insurance issue. This error was identified by a CMA and confirmed by the ADON with pharmacy records.
The facility exhibited multiple deficiencies in food safety and sanitation, including improper storage of scoops in flour and corn starch bins, undated and uncovered food in the refrigerator, and a dish machine failing to reach required temperatures. Additionally, the ice machine was inadequately cleaned, and staff did not follow proper infection control practices during meal service. The kitchen environment showed a lack of regular cleaning, with buildup on equipment and sticky floors.
The facility did not create comprehensive care plans for three residents with dementia who were severely cognitively impaired and exhibited wandering behaviors. These residents were observed wandering in wheelchairs on the memory care unit, with one entering another resident's bathroom. The MDS coordinator and ADON admitted that care plans for wandering were not developed, despite the need.
The facility failed to secure chemicals and medications on the memory care unit, leaving them accessible to wandering residents, including those in wheelchairs. Staff acknowledged the need to secure these items, but they were found unsecured. Additionally, the facility did not implement effective fall interventions for a resident with a history of falls and significant medical conditions, resulting in a fall and hip fracture. Another resident with dementia was observed attempting to enter other residents' rooms, indicating a need for supervision.
The facility failed to prevent significant weight loss in three residents, each with different medical conditions, by not implementing necessary nutritional interventions. A resident with morbid obesity experienced a 5.9% weight loss, another with coronary artery disease had a seven-pound loss unreported to the physician, and a third with Alzheimer's faced severe malnutrition. Despite recommendations for nutritional supplements and appetite stimulants, the facility did not adequately address these needs.
The facility failed to notify the physician of significant weight loss in two residents, leading to a deficiency in care. One resident with morbid obesity and breast cancer experienced a 5.9% weight loss, and the facility did not inform the physician or the resident's representative. Another resident with hypertension and coronary artery disease lost seven pounds, which was not reported to the physician, despite the facility's policy to report weight changes of five pounds or more.
The facility failed to provide adequate staffing to meet the bathing preferences of two residents requiring substantial assistance with ADLs. One resident with diabetes and depression received only four showers out of 13 opportunities, while another with hemiplegia and stroke received five out of 12. Staff reported that baths were often left incomplete due to insufficient staffing, and the DON acknowledged the issue, noting efforts to hire additional aides.
The facility failed to monitor side effects for two residents on antipsychotic medications. One resident with dementia was not monitored for side effects of Olanzapine, and AIMS assessments were not conducted. Another resident with anxiety disorder did not receive a physician-approved dose reduction of hydroxyzine, as the DON failed to update the medication order.
The facility failed to address the dental needs of two residents, one with a cracked tooth causing pain and another needing dental care due to missing top teeth. Despite requests and documented needs, appointments were not scheduled, indicating a lapse in the facility's process for managing dental care.
The facility failed to provide meals in a palatable and safe manner, with residents reporting cold and unappetizing food. Observations showed meals served on styrofoam plates without heated bottoms, and milk delivered uncovered and not on ice. Staff did not sanitize hands between passing trays, and a cleaning cart passed by uncovered drinks, contributing to the deficiency.
The facility failed to maintain an effective pest control program, with multiple reports of roaches and ants in resident rooms, the dining room, and the kitchen. Despite contacting pest control services, the issue persisted, with residents and staff reporting sightings of pests. Observations confirmed the presence of ants and roaches, and interviews revealed ongoing concerns about cleanliness and pest control measures.
The facility failed to maintain resident dignity during meal assistance. Two residents, one with Alzheimer's and another with aphasia, were assisted by CNAs who stood instead of sitting, contrary to facility protocol. The DON confirmed that staff should sit to maintain dignity.
The facility failed to ensure safe self-administration of medications for two residents. A resident with dementia had medicated powder unsecured at their bedside, and another with COPD had multiple medications without a physician's order for self-administration. The DON and an LPN confirmed the absence of necessary assessments and orders, highlighting a lapse in medication management policy adherence.
The facility failed to accurately document code status and offer advance directives to residents. One resident's DNR status was not updated in the electronic medical record, while another resident with severely impaired cognition did not have advance directives discussed upon admission. These deficiencies indicate lapses in the facility's processes for managing residents' code statuses and advance directives.
Two residents requiring assistance with bathing did not receive showers as scheduled due to staffing issues. One resident, with diabetes and depression, received only four showers out of 13 opportunities, while another resident, with hemiplegia and stroke, received five showers out of 12 opportunities. Staff acknowledged the shortfall, and the DON confirmed awareness of the issue, citing staffing constraints.
A resident with diabetes, nicotine dependence, and hypertension requested an eye appointment, which was not scheduled despite the request being made through the clinic. The social services director and DON acknowledged their roles in ensuring appointments were arranged, but the resident reported not seeing an eye doctor since admission.
The facility failed to prepare pureed food to meet the needs of residents requiring a pureed diet. During a meal observation, the taco meat and flour tortillas were not pureed to a smooth consistency, with grainy and lumpy textures noted. Despite the dietary manager's assurance, the food was not suitable for residents on a pureed diet.
The facility failed to ensure proper garbage disposal in the kitchen, affecting meal service for 111 residents. Observations revealed the absence of garbage cans at the handwashing sink and lidless large barrel-type garbage cans in critical areas. Despite previous identification of this issue, it persisted, with the dietary manager acknowledging the need for lids and a small garbage can.
The facility failed to follow proper infection control practices during wound care for four residents. An RN was observed using the same gauze to clean wounds multiple times and not changing gloves between removing old dressings and treating wounds, compromising infection control measures.
The facility failed to update the care plan for a resident with significant changes in condition, including re-admission to Hospice and a change to a pureed diet. The MDS Coordinator acknowledged the care plan had not been updated per facility policy.
The facility failed to follow enhanced barrier precautions during wound care for two residents. An RN did not don a gown before providing wound care to residents with MASD and a stage 2 pressure ulcer. The RN acknowledged not following the facility policy for enhanced barrier precautions.
Failure to Follow Dietician-Approved Menus for Multiple Meal Services
Penalty
Summary
The facility failed to follow the dietician-approved menus for three observed meal services, despite having policies requiring adherence to written menus and standardized recipes. Surveyors observed that the posted Week 3 menus, approved for 2025–2026, specified sliced ham, crispy cubed sweet potatoes, seasoned greens, cornbread, and chocolate cream pie for a Monday lunch; glazed meatloaf, red roasted potatoes, southern green beans, a honey kissed roll, and gelatin parfait for a Tuesday lunch; and a tuna melt sandwich, steak fries, mixed green salad, and apple crisp for a Tuesday dinner. Instead, the kitchen served meatballs, mashed potatoes with gravy, boiled mixed vegetables, and yellow cake with cream cheese frosting for the Monday lunch; kielbasa sausage, mashed potatoes, creamed corn, and Jello for the Tuesday lunch; and beef pot pie, boiled squash, cornbread, and peach cake for the Tuesday dinner. The administrator identified 112 residents receiving meals from the kitchen, with one additional resident receiving nutrition and hydration solely via feeding tube. Staff interviews confirmed that menu changes were made without following the established process or involving the dietician. Cook #1 reported that the food service director instructed preparation of meatballs instead of the scheduled menu item and stated that the food service supervisor sometimes changed the menu at the last minute, possibly due to insufficient quantities of the planned food items. The food service director acknowledged deciding on alternative meals because not all items for the written menus were available and also acknowledged that the written menus had not been followed. During a resident council meeting, residents reported that posted menus were often not the meals actually served. The administrator stated they were unaware that written menus were not being followed and believed kitchen staff should have all required food items to follow the dietician-approved menus daily. The dietician stated the written menus should have been followed per regulations and reported not being informed by the food service director about the menu changes that week.
Failure to Provide Palatable and Attractive Meals
Penalty
Summary
Surveyors identified a failure to ensure food was palatable, attractive, and served appropriately from the kitchen, affecting all residents who received meals from the kitchen. A sampled dinner tray consisting of beef pot pie, boiled squash, cornbread, and peach cake was observed with the pot pie presented as one large scoop of mixed vegetables and ground beef topped with slightly browned biscuits, surrounded by water and pieces of squash. The squash pieces were mushy and bland, and water from the boiled squash had soaked into the biscuit topping, making it soggy and bland. The facility’s Food Preparation Guidelines policy stated that food should be palatable, attractive, and at the proper temperature to ensure resident satisfaction and meet individual needs. Resident council minutes from two consecutive months documented that residents were concerned the food was not being cooked properly, seemed to be getting worse, and that their dietary concerns were not being addressed. Individual residents reported that the food never tasted good, vegetables were always mushy, the food was bad with rarely offered alternatives, and meals were not appetizing in appearance, with vegetables always mushy and food either too salty or too bland. During a resident council meeting, residents again voiced concerns regarding the palatability of meals. When presented with the sampled dinner tray, the administrator rated the meal 5/10 for taste and appearance. The food service director, when informed of the observations, stated they felt the meals served were appetizing and palatable and noted that residents complained meals were either seasoned too much or not enough, making it difficult to prepare consistently tasty meals.
Failure to Complete Advance Directive Acknowledgment Forms for Two Residents
Penalty
Summary
The facility failed to ensure completion of advance directive acknowledgment forms for two sampled residents, as required by its January 2024 Advance Directive Policy and Procedure, which states that upon admission staff must identify whether a resident has an advance directive and, if not, determine if the resident wishes to formulate one, and that all advance directive documents will be obtained and placed in the resident’s chart. Record review showed that one resident, admitted on an unspecified date, had a physician’s order dated 12/09/24 indicating full code status, but there was no advance directive acknowledgment form in the medical record. A second resident, also admitted on an unspecified date, had a physician’s order dated 09/08/25 indicating full code status, with no advance directive acknowledgment form located in the medical record. During interview on 12/16/2025 at 1:42 p.m., the admission director stated the acknowledgments were not in the records because they were waiting for the families to provide them. These findings occurred in the context of a census of 112 residents, with 23 sampled residents reviewed for advance directives, and demonstrated that for at least two residents the facility did not complete the required acknowledgment documentation at or after admission despite having established policy and existing code status orders.
Failure to Report Fall With Major Injury to State Health Department
Penalty
Summary
The deficiency involves the facility’s failure to report a fall with major injury to the state health department as required by its own policy and state regulatory guidance. The facility’s document titled “Long Term Care Reportable Incidents - Regulatory Requirements,” dated 06/28/22, stated that all reports to the Department must be made within 24 hours and that incidents resulting in fractures, injuries requiring hospital treatment, a physician’s diagnosis of closed head injury or concussion, or head injuries requiring more than first aid must be reported. Resident #97’s November 2025 MAR showed the resident was on chronic anticoagulation therapy with Warfarin Sodium for atrial fibrillation and thrombophilia. A nurse’s note dated 12/01/25 documented that a head-to-toe assessment after a fall revealed bleeding from the frontal forehead and the left side of the skull, and the resident was sent to the emergency room via ambulance. A neurosurgery consult progress note dated 12/02/25 documented that the resident, with atrial fibrillation on Warfarin, had a ground-level fall at the facility and was diagnosed with a T12 vertebral fracture and bilateral subdural hematomas. An MDS dated 12/05/25 confirmed the resident’s diagnoses, including atrial fibrillation, heart failure, and thrombophilia. During interviews, the ADON stated that they or the DON were responsible for reporting incidents other than abuse to the state health department. The DON stated that the fall on 12/01/25 was not reported because they did not consider it a reportable incident, asserting there were no stitches or major injury and that the T12 fracture and bilateral subdural hematomas were not considered major injuries since the resident was discharged with no treatment recommendations. The DON later acknowledged, after reviewing the LTC reportable incidents document, that the incident should have been reported.
Failure to Complete Annual CNA Competency Reviews
Penalty
Summary
The facility failed to perform required annual nurse aide competency reviews for two certified nurse aides, despite having 112 residents in the facility. Record review showed that one CNA hired on 10/13/23 had no documentation of an annual competency review for 2025, and another CNA hired on 04/17/24 also had no documentation of an annual competency review for 2025. During an interview, the HR director acknowledged that annual competencies for these two CNAs were not completed, stating that the facility tried to get them done but sometimes did not, and confirmed that there were no reviews for these two CNAs. When asked for a policy regarding annual competencies, the HR director stated that the facility did not have one. No additional information was provided in the report regarding specific residents’ medical histories or conditions at the time of the deficiency.
Failure to Administer Ordered Platelet-Stimulating Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a prescribed medication as ordered by the physician. Resident #124 was admitted with thrombocytopenia and had a physician’s order dated 11/14/25 for eltrombopag olamine 50 mg by mouth at bedtime. The November 2025 MAR showed the medication was not administered on 11/14/25, and a nurse note for that date documented that the pharmacy would not dispense the medication. An incident report later indicated the medication had actually been received on 11/14/25 and was locked in the narcotic box on the medication cart, yet the resident did not receive the medication on 11/14 and 11/15. A nurse note dated 11/15/25 stated they were waiting on delivery, and the November MAR also showed the medication was not administered on 11/15/25. Staff statements further described the actions and inactions that led to the missed doses. CMA #1 stated there was a medication for Resident #124 that they could not find and that they must have overlooked it; they reported looking everywhere for it, being unable to find it, and then marking it as not in the building when the resident’s family member wanted the medications immediately. CMA #1 acknowledged they should have called the ADON. An email from CMA #2 to the ADON stated they did not recall if the medication was given. A facility document showed CMA #2 was terminated in part for not administering the medication on 11/14/25. The ADON stated that when a medication cannot be found, medication aides are to notify the nurse and the nurse is to notify the physician, and also stated they had counted the resident’s medication with CMA #2 and did not know why it was not given on 11/15/25.
Pharmacy Drug Regimen Review Recommendations for Antihypertensives Not Implemented
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were implemented for a resident receiving antihypertensive medications. Facility policy titled "Drug Regimen Review-With Consultant Agreement only" (dated 2021) required that the drug regimen review include analysis of prescribed medications and nursing documentation, with findings and recommendations reported to leadership and nursing providing a written response within two weeks. For one resident with a diagnosis including hypertension, a physician’s order dated 09/05/25 for nifedipine ER 30 mg at bedtime for blood pressure did not include administration parameters. A subsequent Director of Nursing (DON) Report from pharmacy dated 09/17/25 documented a recommendation that the nifedipine order needed hold parameters, but the order was not updated to include them. The same resident later had a physician’s order dated 09/19/25 for amlodipine besylate 5 mg once daily, and another order dated 11/25/25 for amlodipine besylate 10 mg once daily for hypertension, neither of which included administration parameters. A DON Report from pharmacy dated 10/08/25 again documented that the amlodipine order needed hold parameters, but this recommendation was also not implemented. During an interview on 12/17/25, the DON stated they were responsible for handling pharmacy reviews, providing those needing physician attention to the physician, and entering orders into the electronic record as needed. When reviewing the pharmacy recommendations for both nifedipine and amlodipine against the resident’s medication list, the DON acknowledged that both medications lacked parameters and stated they "must have missed it," confirming that the pharmacy’s recommendations for hold parameters were not followed.
Violation of Residents' Rights to Refuse Medication
Penalty
Summary
The facility failed to uphold the residents' rights to refuse medication, as evidenced by two separate incidents involving two residents. The first incident involved a resident diagnosed with Alzheimer's disease, who was allegedly forced by an LPN to take medication against their will. A visitor observed the LPN mixing the medication with pudding and attempting to administer it to the resident, who verbally refused and tried to spit it out. The LPN then attempted to force the resident to drink water to swallow the medication, despite the resident's continued objections. The second incident involved a resident with vascular dementia, who was reportedly forced to take lorazepam, an antianxiety medication. A CMA witnessed the LPN holding the resident's arms while the medication was administered, despite the resident's physical resistance. The ADON confirmed that both residents had the right to refuse medication, and the actions of the LPN and CMA violated these rights.
Resident Restrained by LPN During Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by their policy on abuse, neglect, and exploitation. The incident involved a resident diagnosed with vascular dementia, who was allegedly forced to take medication against their will by an LPN. The incident report documented that the LPN physically restrained the resident's arms while attempting to administer medications, which was determined by the facility staff to have occurred. On a separate occasion, a CMA observed the same resident repeatedly standing up from their wheelchair and attempting to walk to the nurses' station. The LPN intervened by holding the resident by their shoulders, moving them back into their wheelchair, and then pushing the wheelchair to a table in the common area. The LPN stood behind the chair to prevent the resident from standing and held the resident's arms to prevent them from pushing away the medication being administered. The ADON confirmed that the LPN violated the resident's rights by using physical restraints, which was against facility policy.
Improper Use of Chemical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a chemical restraint was not used on a resident, leading to a deficiency in care. Resident #2, who had a diagnosis of Alzheimer's disease, was involved in an incident where a narcotic, lorazepam, was administered against their will. On the evening of 11/08/24, the resident repeatedly stood from their wheelchair and was reminded to sit back down. Despite complying with these reminders, the resident later attempted to walk using the window frame for support. LPN #1, upon confirming that the resident had an order for lorazepam, instructed CMA #1 to administer the medication. When the resident resisted, LPN #1 physically restrained the resident by holding their arms and covering their mouth to ensure the medication was ingested. The facility's policy on abuse, neglect, and exploitation clearly states that residents must be free from physical or chemical restraints used for discipline or convenience. The actions of LPN #1 and CMA #1 violated this policy by using lorazepam as a chemical restraint to control the resident's movements instead of employing less restrictive measures. The incident was confirmed by an incident report, and LPN #1's employment was terminated as a result. The ADON acknowledged the violation of the resident's rights and indicated that CMA #1 was also involved in the administration of the medication, leading to their suspension pending further investigation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an employee reported an allegation of abuse within the mandated time frame for a resident diagnosed with vascular dementia. The facility's policy requires that all alleged violations involving abuse be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. If the events do not involve abuse or result in serious bodily injury, they must be reported within 24 hours. However, a Certified Medication Aide (CMA) witnessed a Licensed Practical Nurse (LPN) forcibly administering antianxiety medication to a resident against their will. This incident occurred between 5:30 p.m. and 7:00 p.m. on a specific date, but the CMA did not report the incident until more than 24 hours later. The delay in reporting was confirmed during an interview with the CMA, who stated that they observed the abusive behavior after 5:00 p.m. but did not inform the Assistant Director of Nursing (ADON) until two days later at 9:40 a.m. The ADON confirmed that the CMA did not follow the facility's abuse policy by failing to report the allegation of abuse in a timely manner. This failure to report promptly constitutes a deficiency in the facility's adherence to its own policies and state regulations regarding the reporting of abuse allegations.
Failure to Include Pressure Ulcer Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a pressure ulcer, as required by their policy. The resident, who had a diagnosis of a pressure ulcer in the sacral region and hypertension, was observed to have an unstageable pressure ulcer. Despite a physician's order for wound care to be administered three times a week, the resident's care plan did not include any interventions related to pressure ulcers. This omission was confirmed through interviews with facility staff, including a registered nurse, a licensed practical nurse, and the assistant director of nursing, all of whom acknowledged that pressure ulcers should be addressed in the care plan.
Catheter Bag Placement Deficiency
Penalty
Summary
The facility failed to ensure that catheter bags were not placed on the floor for one of the four sampled residents reviewed for catheters. Resident #12, who had diagnoses including obstructive and reflux uropathy, was observed on two separate occasions with their catheter bag on the floor next to their recliner. A quarterly assessment had documented that Resident #12 had an indwelling urinary catheter. On November 25th and 26th, 2024, the resident was observed with the catheter bag on the floor. Both RN #1 and the Assistant Director of Nursing (ADON) confirmed that catheter bags should not be on the ground, indicating a lapse in infection prevention and control practices.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to notify a resident's representative when a new antipsychotic medication was ordered for a resident diagnosed with delusional disorder. The resident was prescribed risperidone, an antipsychotic medication, on two separate occasions, with the orders being discontinued shortly after. Subsequently, the resident was prescribed Nuplazid, another antipsychotic medication, for delusions and psychosis. A review of the progress notes revealed no documentation indicating that the resident's representative had been informed of these medication changes. The Assistant Director of Nursing (ADON) confirmed the lack of notification and acknowledged that the facility's policy required such notifications to be made.
Failure to Investigate Missing Narcotic Medications
Penalty
Summary
The facility failed to conduct a thorough investigation into the disappearance of a container of narcotic pain medications, specifically 60 unaccounted tablets of Oxycodone/APAP 10-325 mg. The pharmacy manifest indicated that 168 tablets were delivered to the facility, signed by an LPN. However, the discrepancy was discovered when the facility attempted to reorder the medication and was informed by the pharmacy that it was too soon to do so. The Assistant Director of Nursing (ADON) acknowledged the missing pills but lacked documentation of a comprehensive investigation, including interviews with staff or attempts to contact the involved LPN. The ADON stated that they had tried to contact the LPN who signed for the medication, but the LPN had not returned calls or worked at the facility since the incident. The LPN, when interviewed, claimed to be unaware of the missing medications and stated that no one from the facility had contacted them regarding the issue. The ADON admitted that the investigation was completed with the limited information available and that the fate of the missing medication remained unknown.
Failure to Assess and Treat Resident After Fall
Penalty
Summary
The facility failed to assess and promptly treat a resident following an unobserved fall. The resident, who had diagnoses including hemiplegia and hemiparesis, complained of pain in their right hip and exhibited an externally rotated right leg, which they were unable to straighten. Despite these symptoms, the initial assessment by an LPN after the fall reported no issues or pain. It was only the following day that the ADON and a nurse practitioner assessed the resident and identified the pain and leg rotation, leading to the resident being sent to the emergency room where a right hip fracture was diagnosed. The incident report revealed that the LPN's assessment was inadequate, and the failure to properly assess the resident after the fall delayed necessary treatment. The former administrator substantiated a complaint from the resident's family regarding this incident, and the LPN's employment was subsequently terminated. The deficiency was identified as a failure to follow the facility's Falls Management policy, which requires a complete head-to-toe assessment after a fall before moving the resident unless there are life-threatening safety concerns.
Medication Administration Record Error
Penalty
Summary
The facility failed to accurately document medication administration for a resident due to an error in the medication administration record (MAR). Specifically, the MAR for June and July 2024 indicated that Resident #3 had been administered Nuplazid, an antipsychotic medication, multiple times. However, it was later discovered that the medication had never been available at the facility due to an insurance issue. This discrepancy was identified when a certified medication aide (CMA) reviewed the MARs and confirmed that the entries were incorrect. The assistant director of nursing (ADON) corroborated this finding with documentation from the contracted pharmacy, which showed that the medication had never arrived at the facility.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in several areas of its kitchen operations. Observations revealed that scoops were improperly stored inside bins of flour and corn starch, contrary to the facility's policy that required scoops to be stored in sealed bags. Additionally, the walk-in refrigerator contained several undated and uncovered food items, including cornbread, desserts, gelatin, and fish, indicating a lack of adherence to food labeling and dating protocols. The dish machine used for sanitizing kitchenware did not consistently reach the required minimum temperatures for washing and rinsing, as documented in the temperature logs. Despite recent servicing, the machine's wash temperature often fell below the necessary 120 degrees Fahrenheit, compromising the sanitation process. Furthermore, the ice machine was found to have a red, orange, and brown substance on its deflector panel, suggesting inadequate cleaning and maintenance. Infection control practices were also deficient during meal service, with dietary staff failing to use proper hair restraints and handling food with the same gloves used to touch various surfaces. The kitchen environment was observed to have a buildup of dark substances on equipment and sticky floors, indicating a lack of regular and thorough cleaning. The dietary manager acknowledged the absence of a consistent cleaning schedule, contributing to the unsanitary conditions observed.
Failure to Develop Comprehensive Care Plans for Wandering Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with dementia, who were severely impaired in cognition for daily decision-making and exhibited wandering behaviors. Resident #40 was observed wandering in a wheelchair on the memory care unit and had to be redirected by staff. Resident #55, also severely cognitively impaired, was observed wandering in a wheelchair on the same unit. Resident #64, with similar cognitive impairments, was seen wandering and entering another resident's bathroom. Despite these observations, the MDS coordinator and the ADON acknowledged that care plans addressing wandering had not been developed for these residents, although they should have been.
Failure to Secure Hazardous Items and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that chemicals and medications were secured on the memory care unit, which housed residents known to wander. Observations revealed unsecured items such as nail polish remover, vapor rub, peri wash, and Lantiseptic barrier cream in various rooms. These items were accessible to residents who wandered, including those in wheelchairs, posing potential hazards. Staff members, including a CNA and LPN, acknowledged the presence of wandering residents and the need to secure potentially harmful items, but the items were still found unsecured. The DON admitted that monitoring for unsecured items was not frequent enough, and the facility lacked a specific policy for the storage of chemicals. Additionally, the facility failed to implement effective fall interventions for a resident with a history of falls and significant medical conditions, including hemiplegia, hemiparesis, and a history of stroke. The resident had fallen and broken their hip while attempting to transfer themselves alone in their room. The baseline care plan noted the resident's fall risk but did not specify the level of assistance required. The ADON acknowledged that the intervention of observation was ineffective for this resident and did not provide a clear method for ensuring frequent observations were completed. The report also highlighted the case of another resident with dementia and anxiety, who was observed self-propelling in a manual wheelchair and attempting to enter other residents' rooms. This resident's quarterly assessment documented severely impaired cognition, indicating a need for supervision. The facility's failure to secure potentially hazardous items and implement effective fall interventions for residents at risk demonstrates a lack of adequate supervision and safety measures on the memory care unit.
Failure to Prevent Significant Weight Loss in Residents
Penalty
Summary
The facility failed to implement necessary interventions to prevent significant weight loss in three residents, leading to a deficiency in maintaining adequate nutrition and hydration. Resident #12, diagnosed with morbid obesity and malignant neoplasm of the breast, experienced a significant weight loss of 5.9% over less than 30 days. Despite having a care plan to maintain stable weight and nutritional status, the resident's weight fluctuated, and interventions such as healthshakes and Pro-Heal were not effectively managed. The resident's diet was downgraded to mechanical soft due to jaw pain, but no additional nutrition recommendations were made despite continued weight loss. Resident #21, with diagnoses including hypertension and coronary artery disease, also experienced significant weight loss. The resident's weight dropped from 134.6 pounds to 127.4 pounds within a week, a loss that should have been reported to the physician but was not. The resident's admission assessment noted a low BMI, and a healthshake was recommended, but the facility failed to adequately monitor and address the weight loss. Resident #65, diagnosed with Alzheimer's disease and major depressive disorder, was identified with severe protein-calorie malnutrition and significant weight loss over 90 days. Despite recommendations for increased nutritional supplements and an appetite stimulant, the facility did not address these recommendations in a timely manner. The DON acknowledged the responsibility to follow up on the dietitian's recommendations but failed to do so, contributing to the resident's continued weight loss.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss in two residents, leading to a deficiency in care. Resident #12, diagnosed with morbid obesity and malignant neoplasm of the breast, experienced a significant weight loss of 5.9% over less than 30 days. Despite the care plan's goal to maintain stable weight and adequate nutrition, the resident's weight fluctuated, and the facility did not inform the physician of the weight loss. The resident's diet was adjusted to mechanical soft due to jaw pain and swelling, but the facility did not communicate the weight loss to the resident's representative or the physician. Resident #21, with diagnoses including hypertension and coronary artery disease, also experienced a significant weight loss of seven pounds, which was not reported to the physician. The resident's admission assessment noted a low BMI, and a healthshake was recommended. Despite the resident's ability to consume meals without difficulty, the facility failed to notify the physician of the weight loss, as required for changes of five pounds or more. The DON and RN acknowledged the oversight in monitoring and reporting the weight changes.
Inadequate Staffing Leads to Unmet Bathing Preferences
Penalty
Summary
The facility failed to ensure adequate staffing to meet the bathing preferences of two residents, both requiring substantial assistance with activities of daily living (ADLs). Resident #73, diagnosed with diabetes type two and depression, was documented as needing substantial/maximal assistance for most ADLs, including bathing. However, records showed that Resident #73 received only four showers out of 13 opportunities over a month, despite expressing a desire for more frequent showers. Similarly, Resident #93, who had hemiplegia and a history of stroke, required substantial assistance for bathing but only received five showers out of 12 opportunities in the same period. Resident #93 also expressed a preference for more frequent showers. The deficiency was attributed to inadequate staffing levels, as indicated by staff interviews. LPN #4 reported that aides often did not complete baths, leaving them for the next shift, and highlighted the need for more CNAs in areas with residents requiring lifts. The Director of Nursing (DON) acknowledged the issue, noting that a shower aide had been hired but was also required to work the floor due to staffing shortages. The Assistant Director of Nursing (ADON) stated that staffing levels were determined based on state minimum requirements and adjusted daily according to acuity, but no concerns about staffing had been reported to them.
Failure to Monitor Antipsychotic Side Effects and Implement Dose Reduction
Penalty
Summary
The facility failed to adequately monitor side effects for residents receiving antipsychotic medications, specifically for two residents. One resident, diagnosed with dementia, was prescribed Olanzapine, an antipsychotic medication. The facility did not document monitoring for side effects related to this medication in the electronic clinical record. The Director of Nursing (DON) acknowledged that side effect monitoring was previously documented on the Medication Administration Record/Treatment Administration Record (MAR/TAR) but had been removed, assuming it was standard practice. The DON admitted that AIMS assessments, which are crucial for monitoring tardive dyskinesia, were not scheduled or completed for this resident, despite regulatory guidelines requiring such monitoring. Another resident, with diagnoses including major depressive disorder, delusional disorder, and anxiety disorder, was prescribed hydroxyzine for anxiety. A pharmacist recommended a gradual dose reduction, which the resident's physician agreed to. However, the DON, responsible for following up on medication changes, failed to implement the physician-approved dose reduction. This oversight resulted in the resident continuing on the original dosage, contrary to the agreed medication regimen review.
Failure to Provide Dental Care for Residents
Penalty
Summary
The facility failed to provide necessary dental care for two residents, leading to deficiencies in addressing their dental needs. Resident #66, who had diagnoses including hemiplegia, seizures, and anxiety, was noted by a dentist on 03/07/23 to require an oral surgeon for a cracked tooth extraction. However, by 05/14/24, the resident reported experiencing pain while eating due to the cracked tooth, indicating that the necessary referral and appointment had not been made. The social services director, newly employed, was unaware of any referral, and the DON acknowledged that the process for making appointments was not followed, resulting in the resident being overlooked. Similarly, Resident #73, diagnosed with depression, requested a dental appointment on 02/28/23 due to having natural lower teeth but no top teeth, which caused eating difficulties. By 05/16/24, the resident confirmed the need for dental care, but a review of their medical record by an LPN revealed that the request had not been addressed. The receptionist, responsible for scheduling appointments and transportation, found no documentation of a scheduled dental appointment for this resident, highlighting a lapse in the facility's process for managing dental care needs.
Failure to Provide Palatable and Safe Meals
Penalty
Summary
The facility failed to ensure that food and drink were provided in a palatable and attractive manner, as evidenced by multiple observations and resident complaints. Several residents reported receiving cold food, with one resident specifically mentioning that the scrambled eggs were watery and there was no sugar for the tea. Observations on a specific date revealed that meals were served on styrofoam plates without heated bottoms, and milk was delivered uncovered and not on ice, resulting in a temperature of 51.2 degrees Fahrenheit after being out for an hour. Additionally, the scrambled eggs were scorched and cold, and other food items were at room temperature. Staff actions contributed to the deficiency, as they were observed not sanitizing hands between passing trays and leaving meal carts open during meal service. A CNA admitted to typically receiving milk uncovered and not knowing where the lids were kept. The presence of a cleaning cart passing by uncovered drinks further highlighted the lack of attention to maintaining food safety and quality. These actions and inactions led to the failure in providing meals that were safe, appetizing, and at appropriate temperatures.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented instances of pest sightings in resident rooms, the dining room, and the kitchen. The Maintenance Request Log recorded numerous complaints and observations of roaches and ants in various rooms and common areas over several months. Despite contacting pest control services, the issue persisted, with residents and staff reporting sightings of pests, including roaches in the kitchen and dining room. Observations confirmed the presence of ants on window sills and bedside tables, and a roach was seen crawling on the kitchen floor. Interviews with residents and staff further highlighted the ongoing pest problem. A resident reported seeing pests in the kitchen and dining room, while a dietary aide and the dietary manager acknowledged the presence of roaches in the kitchen. The maintenance supervisor attributed the roach problem to the food vendor's cardboard boxes and noted that the pest control company had a policy against treating resident rooms. The administrator admitted the need for improved cleanliness in the kitchen to help eliminate pests, indicating that the facility's pest control measures were insufficient to address the issue effectively.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure staff provided dignity during dining for residents who required assistance with meals. Two instances were observed where staff did not sit while assisting residents with their meals, which is against the facility's protocol for maintaining resident dignity. Resident #65, diagnosed with Alzheimer's disease and severely impaired in cognition, required supervision and touch assistance for eating. On the morning of 05/13/24, CNA #1 was observed standing while assisting this resident with their meal. Similarly, Resident #7, diagnosed with aphasia and also severely impaired in cognition, was dependent on staff for eating. On the noon of 05/13/24, CNA #2 was observed standing while assisting this resident with their meal. On 05/17/24, CNA #1 explained that they did not sit to assist Resident #65 because a chair was not available. The Director of Nursing (DON) confirmed that staff are expected to sit with residents during meal assistance to maintain their dignity and that standing while assisting is not permitted.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safety of residents self-administering medications, as evidenced by the presence of medications at the bedsides of two residents without proper authorization or assessment. Resident #22, who was admitted with dementia, was found with a bottle of medicated powder on their nightstand, which was supposed to be secured and not kept at the bedside. The Director of Nursing (DON) confirmed that the medicated powder should not have been at the resident's bedside, and Licensed Practical Nurse (LPN) #1 was unaware of the powder's origin, noting that medications were often found at residents' bedsides at the start of their shifts. Resident #31, diagnosed with COPD, had multiple medications, including a Ventolin inhaler, Diclofenac cream, Incruse inhaler, Albuterol ampules, and Fluticasone drops, on their nightstand. LPN #1 confirmed that a physician's order was required for self-administration and bedside storage of medications, but upon reviewing the clinical record, found no such order for Resident #31. The DON also confirmed the absence of an assessment or physician order for self-administration in the resident's medical record, indicating a lapse in the facility's adherence to its policy on medication management.
Failure to Document Code Status and Offer Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation of code status and the offering of advance directives to residents. For one resident with diagnoses including hypertension and depression, there was a discrepancy between the documented DNR status on an advance directives form and the full code status recorded in the electronic medical record and physician's order. The Director of Nursing acknowledged the delay in updating the resident's code status, and the Administrator was unable to confirm who was responsible for following up on advance directives signed at admission. Eventually, the electronic medical record was updated to reflect the correct DNR status. Another resident, with diagnoses including fractures and hemiplegia and severely impaired cognition, did not have advance directives discussed with them or their representative upon admission. This oversight was confirmed by admissions staff, indicating a failure to adhere to the facility's policy of informing and assisting residents in formulating advance directives. These deficiencies highlight lapses in the facility's processes for managing and documenting residents' code statuses and advance directives.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide activities of daily living (ADLs) according to the care plan for two residents, both of whom required assistance with bathing. Resident #73, diagnosed with diabetes type two and depression, was documented to need physical help from one person for bathing. However, between April 15, 2024, and May 15, 2024, Resident #73 received only four showers out of 13 opportunities. The resident expressed a desire for more frequent showers, while staff members, including a CNA and an LPN, acknowledged that showers were not consistently completed due to staffing issues. The Director of Nursing (DON) confirmed awareness of the issue and mentioned efforts to hire a shower aide, although the aide also had to work the floor. Resident #93, with diagnoses including hemiplegia and stroke, was dependent on staff assistance from two aides for bathing. Despite being scheduled for showers three times a week, the resident reported receiving only one shower per week. Documentation showed that only five showers were completed in the last 30 days out of 12 opportunities. The DON acknowledged the shortfall in completing scheduled showers and indicated that staffing constraints were a contributing factor, with attempts being made to build up staff, including hiring a shower aide.
Failure to Schedule Vision Appointment for Resident
Penalty
Summary
The facility failed to ensure that a vision appointment was scheduled for a resident who had requested it. The resident, who had diagnoses including type two diabetes, nicotine dependence, and hypertension, had requested an eye and dental appointment through the clinic on February 28, 2023. The social services note indicated that the request was provided to the receptionist to schedule the appointment and arrange transportation. However, by May 13, 2024, the resident reported not having seen an eye doctor since admission. The social services director confirmed their responsibility for arranging appointments, and the DON stated that the nurse on duty was supposed to enter the order in the electronic record and provide the request to the receptionist. Ultimately, the DON acknowledged it was their responsibility to ensure the process was followed through.
Inadequate Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that pureed food was prepared to meet the needs of residents requiring a pureed diet during the noon meal observation. Specifically, the taco meat and flour tortillas were not pureed to a smooth consistency, as they were observed to be grainy and lumpy with chewable pieces remaining. This inconsistency was noted during the preparation and serving process, as dietary aide #3 was responsible for pureeing the meal, and dietary aide #1 plated the meal for a resident. Despite the dietary manager's assurance that the pureed meal was ready for service, the observation revealed that the food did not meet the required smooth consistency for a pureed diet.
Improper Garbage Disposal in Kitchen
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in the kitchen, affecting the meal service for 111 residents. Observations on multiple occasions revealed the absence of garbage cans at the handwashing sink and the presence of large barrel-type garbage cans without lids in critical areas such as near the stove, at the service line, and in the food preparation area. The facility's policy, dated January 2024, required garbage to be disposed of in containers with plastic liners and lids. Despite previous nutrition services visits identifying the lack of lids on large trash cans as an area for corrective action, the issue persisted. The dietary manager acknowledged the use of lidless garbage cans and the need to order a small garbage can for the handwashing sink and lids for the large garbage cans.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to follow proper infection control practices during wound care for four residents. Resident #8 had a diagnosis of MASD to the sacrum and required daily treatment with clotrimazole cream, zinc, and a large foam dressing. During an observation, RN #1 cleaned the wound by wiping back and forth around the area of skin breakdown five times using the same gauze soaked in normal saline (NS). Resident #4, who had a stage 2 pressure ulcer to the sacrum, was observed having their wound cleaned in up, down, and circular motions nine times using the same gauze soaked in NS. Both residents had no dressing on their wounds when the care began, which further compromised infection control measures. Resident #7, with a surgical wound to the right hip, had their old dressing removed by RN #1, who did not change gloves before treating the wound. The wound was cleaned by wiping up and down the length of the surgical site five times using the same betadine-soaked gauze. Similarly, Resident #6, who also had a surgical wound to the right hip, had their old dressing removed without a change of gloves by RN #1. The resident had two separate surgical wounds, both of which were cleaned using the same betadine-soaked gauze and patted dry with the same dry gauze. RN #1 acknowledged not following proper infection control measures when questioned about the process for cleaning wounds and changing gloves during wound care.
Failure to Update Care Plan with Significant Changes
Penalty
Summary
The facility failed to update the care plan for a resident with significant changes in condition. The resident had diagnoses including senile degeneration of the brain and dementia. A physician's order indicated the resident was to receive a regular diet with pureed texture and thin consistency. A Significant Change MDS assessment documented the resident required a mechanically altered diet and Hospice care. Despite these changes, the resident's care plan was not updated to reflect their re-admission to Hospice or the change to a pureed diet. The MDS Coordinator acknowledged that the care plan had not been updated per facility policy after reviewing the resident's care plan.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow enhanced barrier precautions during wound care for two residents. Resident #8, who had a diagnosis of MASD to the sacrum, and Resident #4, who had a stage 2 pressure ulcer to the sacrum, were both observed receiving wound care from RN #1. During these observations, RN #1 did not don a gown before providing wound care to either resident. When asked about the use of enhanced barrier precautions, RN #1 stated that such precautions were used when providing direct care to residents with catheters, drains, PEG tubes, IVs, and during wound care. RN #1 acknowledged that they had not followed the facility policy for enhanced barrier precautions during the dressing changes for Resident #4 and Resident #8.
Latest citations in Oklahoma
A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
