Emerald Care Center Southwest Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 5600 South Walker, Oklahoma City, Oklahoma 73109
- CMS Provider Number
- 375135
- Inspections on file
- 32
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Emerald Care Center Southwest Llc during CMS and state inspections, most recent first.
A resident with vascular dementia was admitted and eloped from the facility within several hours, later being found by police down the road. Facility policy required completion of an elopement risk data collection at admission or within eight hours, but the Nursing Admission Data Collection, including the elopement risk assessment, was not completed until several days after admission. During interview, the admission nurse acknowledged the assessment was not done within the required timeframe, citing being off for a holiday.
A resident with cognitive impairment did not have a physician-ordered urinalysis completed after only one unsuccessful attempt to collect a specimen, with no further documented efforts. Later, after a hospital visit for a fall and UTI diagnosis, the resident's antibiotic order was inaccurately transcribed, resulting in administration at a lower frequency than prescribed. The resident subsequently developed hypoglycemia and sepsis due to UTI.
The facility did not ensure safe and appropriate administration of IV therapy for two residents. One resident's PICC line dressing was not changed as ordered, remaining in place beyond the required interval, while another resident's IV fluids were administered at a rate higher than prescribed until an LPN adjusted it to the correct rate. These actions were not consistent with physician orders or professional standards of practice.
During a meal service, staff did not follow the prescribed menu or serving sizes, resulting in meals being served with incorrect portions and missing required components, such as pureed vegetables for a resident on a pureed diet. The cook acknowledged not adhering to the menu, and 63 residents received meals from the kitchen during this time.
Staff failed to follow infection control protocols during care for two residents, including improper sterile technique during a PICC line dressing change by an LPN and failure to change gloves or bag soiled linens during incontinent care by a CNA. Both residents had significant medical needs and required staff assistance, and staff acknowledged not following proper procedures.
A resident with moderate cognitive impairment refused to provide a urine specimen for urinalysis, and neither the physician nor the emergency contact were notified of this refusal. Additionally, when the resident experienced a low blood sugar, the physician was not notified as required by physician order. Staff interviews and documentation review confirmed these notifications were not made or recorded, contrary to facility policy.
A resident with a history of bladder dysfunction had a physician order for a urinalysis with culture and sensitivity, but the urine specimen was not collected until three days after the order was placed. Staff interviews confirmed that the expectation was for same-day collection, and there was no documentation explaining the delay.
A facility failed to update a care plan for a resident with autism who was identified as a smoker. Despite being listed on the facility's smoking list and reporting smoking three to five times a day, the resident's care plan did not include smoking. The DON confirmed this omission, which is against the facility's policy requiring immediate care planning for high-risk areas.
A facility failed to conduct a smoking assessment for a resident with autism who smoked three to five times daily. Despite being listed as a smoker, the resident's electronic medical record lacked the required assessment to determine the necessary supervision and equipment for safe smoking. The DON confirmed the absence of this documentation.
The facility failed to provide correct medication administration for three residents. An LPN gave an inhaler to a resident that belonged to another, and two residents did not receive antibiotics as ordered. One resident missed doses after an ER visit, and another did not receive a full course of antibiotics due to unavailability. The DON and ADON acknowledged the issues, but the documentation did not accurately reflect the medication administration.
A medication cart was found unlocked and unattended in the main lobby of the facility, contrary to the facility's policy requiring secure storage of medications. An LPN confirmed that the cart should have been locked, highlighting a failure to adhere to established procedures for medication security.
The facility failed to maintain food safety and hygiene standards, with dietary aides not wearing hair nets properly, an unclean kitchen with mouse droppings and expired items, and improper hand hygiene and glove usage by staff. The dietary manager admitted to lapses in daily cleaning and non-compliance with handwashing protocols.
The facility did not follow its antibiotic stewardship policy by failing to complete a standardized tool for a resident treated for UTIs. Despite multiple antibiotic prescriptions, there was no documentation of the required McGeer form in the resident's records. The ADON confirmed the absence of this documentation.
The facility failed to document that pneumococcal vaccines were offered and/or administered to two residents. The facility's policy required assessments of vaccination status within five days of admission, but records for two residents lacked documentation of receiving or being offered the vaccine. Staff interviews revealed confusion about the vaccine ordering process, with an LPN unsure of how vaccines were ordered and the DON stating that vaccination status should be documented upon admission. The ADON/Infection Preventionist could not find the necessary documentation for the residents.
The facility failed to maintain effective pest control, with mouse droppings found in the kitchen and a cockroach observed on a resident. Staff reported occasional sightings of roaches and bedbugs, despite frequent pest control treatments. The administrator noted recent pest control visits and suggested treatments take time to be effective.
A resident with depressive episodes reported being slapped by the Business Office Manager (BOM) during an interaction. The BOM admitted to brushing the resident's hand aside, acknowledging it could be considered abuse. This incident violated the facility's policy ensuring residents' right to be free from abuse.
A facility failed to administer medications as ordered for a resident with a physician's order for oxycodone HCL for pain management. The September TAR showed discrepancies, with entries marked as 'nine' and blanks, indicating uncertainty about medication administration. A progress note mentioned awaiting medication from the pharmacy. The DON could not confirm if the medication was administered, indicating a failure in following the medication administration policy.
The facility failed to provide physician-ordered ulcer care for two residents. One resident with non-pressure chronic ulcers had missing documentation for treatments on several dates, indicating the treatments were not performed. Another resident with a stage four pressure ulcer also had lapses in care, with missing documentation for prescribed treatments. The Wound Care LPN confirmed that the treatments were not completed as required.
A resident with functional limitations and a broken back experienced a significant delay in receiving assistance to get off a bed pan, despite activating their call light. Multiple staff members, including an LPN and CNAs, failed to respond promptly, leaving the resident waiting for over 40 minutes. This incident highlights a deficiency in the facility's adherence to its policy on timely response to call lights.
A resident in an LTC facility experienced a delay in receiving prescribed pain and nausea medications due to communication failures among staff. Despite a request for medication being made, the resident did not receive the necessary medications until over an hour later, which was considered unacceptable by facility standards.
The facility failed to provide ordered pressure ulcer treatment for three residents, resulting in multiple missed wound care treatments as documented in the TARs. The Wound Care Nurse confirmed the treatments were not provided and could not explain the missed treatments.
The facility failed to ensure medications were administered as ordered for two residents. One resident with a stage four pressure wound and GERD had multiple instances of missed medication administrations. Another resident with chronic diastolic heart failure received carvedilol despite having a heart rate below the ordered threshold on several occasions.
A resident with constipation was found to have Ex-Lax and a stool softener at their bedside, brought in by a family member, without any assessment or physician order for self-administration. The facility's policy on medication storage was not followed, and the DON and ADON were unaware of the medications at the resident's bedside.
The facility failed to obtain a physician-ordered urinalysis for a resident with a stage four sacrum wound and intestinal obstruction. The ADON stated that they would not know if a urinalysis was ordered if it was on the physician's liaison order form during rounds. The DON confirmed the order was documented but not obtained.
The facility failed to provide adequate portion sizes during a meal service, using a four-ounce scoop instead of the required six-ounce scoop for beef stroganoff, resulting in residents receiving smaller portions than specified in the menu.
The facility failed to document wound care treatment for a resident with a stage four pressure ulcer. The Wound Care Nurse confirmed that the care was provided but not documented on specific dates due to being assigned other tasks.
Failure to Complete Timely Elopement Risk Assessment on Newly Admitted Resident
Penalty
Summary
The facility failed to ensure timely completion of a Nursing Admission Data Collection, including an elopement risk assessment, for one resident, resulting in noncompliance with its elopement policy. The facility’s written policy on Elopement, Risk Reduction Strategies and Management of Missing Resident, revised 01/2024, required nursing staff to complete an elopement risk data collection on all residents at admission or no later than eight hours after admission. An admission record showed that Resident #1 was admitted at 11:14 a.m. with a medical diagnosis of vascular dementia. A nursing note documented that on the day of admission, the resident was found by police outside the facility down the road, having eloped within 4.5 hours of admission. The Nursing Admission Data Collection, which included the elopement risk data collection, was not signed as completed until five days after admission, after the elopement had already occurred. In an interview, the admission nurse confirmed that the assessment was not completed within eight hours of admission and attributed the delay to being off for the holiday. The administrator reported that 71 residents resided in the facility at the time of the survey, and Resident #1 was the only sampled resident reviewed for elopement. The record review and staff interview confirmed that the required elopement risk assessment was not performed within the policy’s specified timeframe for this resident with vascular dementia, and that the resident left the facility unsupervised and was located by police down the road on the same day as admission.
Failure to Complete Ordered Urinalysis and Accurate Antibiotic Transcription
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis was completed and that an antibiotic was transcribed and administered as ordered for a resident with moderate cognitive impairment following a cerebral infarction. The resident was admitted with orders for a urinalysis, among other tests, but documentation showed that only one attempt was made to collect a urine specimen, which was unsuccessful due to the resident's refusal. There was no evidence of further attempts or documentation that the urinalysis was completed, despite facility policy requiring timely completion of laboratory services as ordered by a physician. Subsequently, the resident experienced a fall and was sent to the emergency room, where they were diagnosed with a urinary tract infection (UTI) and prescribed Keflex 500 mg to be taken four times daily. Upon return to the facility, the antibiotic order was inaccurately transcribed as three times daily, and the resident received the medication at this incorrect frequency. There was no documentation that the facility provider changed the order, and staff confirmed the transcription error. The resident later developed hypoglycemia and sepsis due to UTI, requiring another hospital transfer.
Failure to Follow Physician Orders for IV Therapy and PICC Line Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice and in accordance with physician orders for two residents requiring intravenous (IV) therapy. For one resident with a peripherally inserted central catheter (PICC) line, the dressing was observed to be dated nearly two weeks prior, despite a physician's order to change the dressing weekly and as needed. Staff interviews confirmed that the dressing should have been changed according to the order, but it was not, and the Director of Nursing (DON) acknowledged that nurses are expected to follow physician orders for dressing changes. In a separate incident, another resident receiving IV fluids was observed to have their infusion running at a rate higher than the physician-ordered 75 ml/hr, with the dial set between 80 and 100 ml/hr and the actual rate at approximately 90 ml/hr. The resident was unaware of the infusion rate, and an LPN later adjusted the rate to match the physician's order after being informed. Both incidents demonstrate a failure to administer IV therapy as ordered and in accordance with professional standards.
Failure to Follow Prescribed Menu and Serving Sizes During Meal Service
Penalty
Summary
The facility failed to follow the prescribed menu during an observed meal service, impacting the nutritional adequacy of meals served to residents. During the lunch service, the cook was observed plating meals that did not match the menu specifications for serving sizes and food items. For example, regular diet plates were served with three chicken tenders, one scoop of coleslaw, one scoop of mashed potatoes, and one scoop of gravy, while the mechanical soft diet plate included ground chicken tenders, mashed potatoes, gravy, and cooked cabbage. The pureed diet plate was served with pureed chicken tenders, mashed potatoes, and two scoops of gravy, but no pureed vegetables were included as required by the menu. The facility's policy and the extended menu spreadsheet specified serving sizes and required components for each diet type, including pureed vegetables for residents on pureed diets. The cook acknowledged not following the menu, serving incorrect portion sizes for coleslaw and chicken tenders, and omitting pureed vegetables for the pureed diet plate. The Director of Nursing identified that 63 residents received meals from the kitchen during this service.
Failure to Maintain Infection Control During PICC Line Dressing Change and Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the provision of care for two residents. In one instance, an LPN performed a peripherally inserted central catheter (PICC) line dressing change without adhering to sterile technique. The LPN placed the dressing kit on the resident's bed, used gloves from their pocket instead of sterile gloves for part of the procedure, and did not maintain sterility throughout the process. The LPN also left the room to retrieve a new dressing kit, removing and re-donning personal protective equipment, and continued the procedure without following sterile protocol. The resident involved had a history of orthopedic aftercare following surgical amputation and atherosclerosis with gangrene, and was ordered to have weekly PICC line dressing changes. In another instance, a CNA provided incontinent care to a resident without changing gloves between cleaning the peri area, applying cream, dressing the resident, and handling personal items such as the bed remote and hairbrush. The CNA also transported the resident's soiled clothing to the utility room without placing them in a bag, contrary to facility policy. The resident was dependent on staff for toileting and dressing and had a history of lower limb amputation. Both staff members acknowledged during interviews that their actions did not follow proper infection control procedures, and the DON confirmed the expected protocols for glove changes and handling of soiled linens.
Failure to Notify Physician and Emergency Contact of Resident Condition Changes
Penalty
Summary
The facility failed to notify a resident's emergency contact and physician regarding the resident's refusal to provide a urine specimen for urinalysis, as well as failed to notify the physician of a low blood sugar result as ordered. The resident in question had moderate cognitive impairment and a history of cerebral infarction, with physician orders in place to notify the provider if blood sugar was less than 60 or greater than 250, and to obtain a urinalysis. Documentation showed that the resident refused to provide a urine specimen, but there was no record that the physician or emergency contact were informed of this refusal, nor was there documentation that another attempt was made to collect the specimen. Additionally, when the resident's blood sugar was recorded at 57, insulin was held as per protocol, but there was no documentation that the physician was notified of this low blood sugar, despite an order requiring such notification. Interviews with staff confirmed that the notifications were not made and not documented, and the facility's policy required immediate sharing of changes in a resident's condition or treatment with the resident, their representative, and the attending physician.
Delay in Completion of Ordered Urinalysis
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis with culture and sensitivity was completed in a timely manner for a resident diagnosed with neuromuscular dysfunction of the bladder. The order for the urinalysis was placed on 02/18/25, but the urine specimen was not collected until 02/21/25. There was no documentation explaining the delay in specimen collection. Nursing notes indicated that the resident exhibited behavioral changes, which the resident's representative associated with urinary tract infections, prompting further communication with the nurse practitioner and a new order for the urinalysis. Interviews with facility staff confirmed that nurses were responsible for collecting urine specimens and notifying the laboratory for pick-up, with the expectation that such orders should be completed the same day they are received. The ADON confirmed that the order was entered into the lab system on the day it was written, but the specimen was not collected until three days later, and there was no documentation to account for the delay. The DON also stated that while there is no specific time frame for completing urinalysis orders, the expectation is for same-day completion, and any inability to collect a specimen should be documented in the resident's notes.
Failure to Update Care Plan for Resident Smoker
Penalty
Summary
The facility failed to include and update a care plan for a resident with autism, who was identified as a smoker. The facility's Care Plan Process policy requires that high-risk areas such as smoking be care planned immediately upon identifying risk via evaluation. However, the resident's care plan did not include smoking, despite the resident being listed on the facility's smoking list and reporting smoking three to five times a day. The Director of Nursing (DON) confirmed that smoking was not included in the resident's care plan.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking assessment for a resident, identified as Resident #27, who was part of a sample of 19 residents evaluated for smoking assessments. The facility's Resident Smoking Policy requires that residents who smoke be evaluated to determine the necessary adaptive equipment and level of supervision required for safe smoking. Despite being listed as a smoker on the facility's smoking list, Resident #27 did not have a smoking assessment documented in their electronic medical record. The Director of Nursing (DON) confirmed the absence of this assessment. Resident #27, who has a diagnosis of autism, reported smoking three to five times a day.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure the correct inhaler medication was provided to a resident. An LPN administered an inhaler to a resident with chronic obstructive pulmonary disease, but the inhaler belonged to another resident. The LPN admitted to not following the facility's policy of verifying the five rights of medication administration, and there was no order for the inhaler in the resident's records. Another deficiency involved two residents who did not receive medications according to physician orders. One resident with a history of UTIs and kidney issues did not receive the last two doses of an antibiotic after returning from an ER visit. The ADON acknowledged that the medication should have been completed, but there was no order to restart or continue the missed doses. A third resident with a UTI did not receive the full course of an antibiotic as ordered. The EMAR showed that the resident missed doses, and the CMA confirmed that the medication was not available. The DON was unable to explain why the medication was not administered as ordered, and the documentation did not accurately reflect the resident's medication administration.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that a medication cart was securely locked and attended to, as required by their policy and procedure. The policy mandates that medications and biologicals be stored safely, securely, and properly, accessible only to authorized personnel. On December 10, 2024, at 11:43 a.m., a medication cart located on the North end of the main lobby was observed to be unlocked and unattended. Shortly after, at 11:44 a.m., an LPN confirmed that the medication cart should have been locked, indicating a lapse in adherence to the facility's medication storage policy.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to its policies regarding food safety and hygiene, resulting in several deficiencies. Observations revealed that dietary aides did not wear hair nets properly, allowing hair to be exposed, which could potentially contaminate food. The kitchen was found to be unclean, with mouse droppings on baking soda boxes, an open and undated corn starch box, and expired Worcestershire sauce in the dry storage area. Additionally, the kitchen floor was dirty, and there were unclean containers with dishes. A cup of water with a straw was improperly placed on the dish rack with large pots and pans. The dietary manager admitted to being unaware of the mouse droppings and the condition of the corn starch box, and acknowledged the lack of daily cleaning due to their absence on vacation. Further deficiencies were noted in hand hygiene and glove usage. Dietary aide #1 was observed handling the puree machine with bare hands, contrary to the facility's policy of wearing gloves when handling food. The dietary manager was seen touching a serving cart with gloved hands and then handling food without changing gloves or washing hands. This improper practice was repeated when the dietary manager opened a new package of bread and continued to touch the bread without changing gloves or washing hands. The dietary manager acknowledged the requirement to wash hands and change gloves after touching non-food items, but failed to comply with this standard.
Failure to Follow Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policy by not completing a standardized tool for the initiation of antibiotics for a resident treated for urinary tract infections (UTIs). The policy required the use of McGeer and/or LOEB Criteria to track antibiotic use. The resident, who had a history of congenital occlusion of the ureteropelvic junction, hydronephrosis, obstructive and reflux uropathy, crossing vessel, and stricture of the ureter, was prescribed antibiotics on three separate occasions for UTIs. Despite these prescriptions, there was no documentation of a McGeer form being completed in the resident's infection control book or electronic medical record for the antibiotic use in May, July, or November. The Assistant Director of Nursing (ADON) confirmed the absence of the required documentation during an interview.
Failure to Document Pneumococcal Vaccination Offer and Administration
Penalty
Summary
The facility failed to provide documentation that pneumococcal vaccines were offered and/or administered to two of the five sampled residents reviewed for immunizations. The facility's Infection Control Immunizations policy, dated March 20, 2024, stated that all residents would be offered pneumococcal vaccines, with assessments of vaccination status conducted within five working days of admission. However, a review of the immunization records for two residents did not document that they had received or been offered the pneumococcal vaccination. Interviews with staff revealed a lack of clarity regarding the process for ordering and administering vaccines. An LPN stated they were unsure how vaccines were ordered but administered them if an order appeared during their shift. The DON indicated that upon admission, staff were to document vaccination status and obtain consent to provide the vaccine if the resident desired it. The ADON/Infection Preventionist was unable to locate the necessary documentation for the two residents in question.
Failure to Maintain Effective Pest Control
Penalty
Summary
The facility failed to maintain effective pest control, as evidenced by multiple observations and staff interviews. During an initial tour of the kitchen, mouse droppings were found on four boxes of baking soda in the dry storage area. The dietary manager was unaware of the droppings' nature but acknowledged they should not be present and discarded the affected boxes. Additionally, a cockroach was observed on a resident's hand and prosthetic leg in the dining room. A housekeeper/CNA mentioned that roaches are occasionally seen, and pest control services are used frequently. Another CNA reported seeing roaches and bedbugs, noting that while treatments are applied, the pests return. The administrator stated that pest control had recently visited and suggested that treatments might take 24-48 hours to be effective, attributing the presence of pests to residents bringing them in.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving a resident with a diagnosis of other specified depressive episodes. The incident was documented in an Initial State Reportable Incident form, where the resident was found standing outside the Business Office Manager's (BOM) doorway, yelling that they had been slapped. The BOM was immediately suspended pending investigation. A subsequent Final State Reportable Incident form detailed that during an interaction, the BOM wagged their finger in the resident's face, telling them to shush, and when the resident pointed their finger back, the BOM slapped the resident's hand. The resident then began yelling for the administrator, claiming they had been slapped. Interviews conducted on 10/08/24 revealed that the resident confirmed the BOM slapped their hand during the interaction, while the BOM admitted to brushing the resident's hand aside. The BOM acknowledged that the incident could be considered abuse because they touched the resident, although they denied abusing the resident. This incident highlights a failure in the facility's adherence to its Abuse, Neglect, and Exploitation policy, which mandates that each resident has the right to be free from abuse, including physical abuse such as hitting and slapping.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident reviewed for misappropriation of property. The resident had a physician's order for oxycodone HCL, a narcotic medication, to be administered via peg tube every four hours for pain. However, the September 2024 Treatment Administration Record (TAR) showed discrepancies in medication administration, with entries marked as 'nine' indicating 'other/see nurses notes' and blanks on certain dates and times, suggesting uncertainty about whether the medication was administered. Additionally, a progress note indicated that the medication was awaited from the pharmacy, further complicating the administration process. The Director of Nursing (DON) was unable to confirm if the medication was administered during these instances, highlighting a failure in adhering to the medication administration policy.
Failure to Provide Physician-Ordered Ulcer Care
Penalty
Summary
The facility failed to provide ulcer care as ordered by the physician for two residents. Resident #1, who was admitted with a diagnosis of non-pressure chronic ulcers on the back and right thigh, had several instances where the prescribed treatments were not documented as completed. Specifically, the Treatment Administration Record (TAR) for May and June 2024 showed missing documentation for the application of Hibiclens, calcium alginate with collagen powder, and Nystatin powder on multiple dates. The Wound Care LPN confirmed that the absence of documentation indicated that the treatments were not performed. Similarly, Resident #3, admitted with a stage four pressure ulcer in the sacral region, also experienced lapses in care. The TAR for June 2024 lacked documentation for the prescribed cleansing and application of Triad and hydrophilic paste to the bilateral buttocks, as well as the treatment for other skin changes. The Wound Care LPN acknowledged that these treatments were not completed as required by the end of the shift, as indicated by the blanks in the TAR.
Delayed Response to Resident's Call Light
Penalty
Summary
The facility failed to provide timely assistance for activities of daily living (ADL) to a resident with functional limitations in both lower extremities, who required substantial maximum assistance for bed mobility. On the morning of May 17, 2024, the resident activated their call light to request help getting off a bed pan. Despite the call light being on, staff members, including an LPN and several CNAs, either ignored or failed to respond promptly to the resident's request. The call light was initially activated at 5:23 a.m., but it was not until 6:09 a.m. that the resident received the necessary assistance. During this period, multiple staff members were observed walking past the resident's room without responding to the call light. The resident expressed discomfort and frustration, stating they had been on the bed pan for an extended period and had a broken back in three places. The facility's policy required staff to respond to call lights promptly, yet the resident's call light remained unanswered for over 40 minutes. This delay in providing care highlights a deficiency in the facility's adherence to its policy on timely response to call lights.
Delayed Administration of Pain and Nausea Medication
Penalty
Summary
The facility failed to administer pain and nausea medication in a timely manner for a resident, as observed during a survey. The resident had physician's orders for Norco and Ondansetron to be administered every six hours as needed for pain and nausea, respectively. However, the Medication Administration Record (MAR) did not document the administration of these medications. On the morning of the incident, the resident was observed to be in pain and vomiting, and a request for medication was made by the resident's family representative. Despite this request, the resident did not receive the medication until over an hour later. The delay in medication administration was due to a lack of communication and awareness among the staff. The Certified Nursing Assistant (CNA) was informed of the resident's need for medication but did not relay this information to the Licensed Practical Nurse (LPN) responsible for medication administration. The LPN, who was working as a Certified Medication Aide (CMA) that day, was not aware of the request until later and initially confused the resident with another. The Director of Nursing (DON) confirmed that no PRN medication had been given that morning. The LPN eventually administered the medication but acknowledged the delay, which was deemed unacceptable by another LPN who stated that pain and nausea medications should be administered within a much shorter timeframe.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered for three residents. Resident #3, who had a stage four sacrum wound, had multiple instances where wound care was not documented or provided as per the treatment administration record (TAR). Specifically, there were blanks in the November and December 2023 TARs indicating missed treatments on several dates. The Wound Care Nurse confirmed that the treatments were not provided on these dates and mentioned being off duty on some of those days. Resident #5, diagnosed with a stage four pressure wound of the sacrum, also had missed wound care treatments as documented in the December 2023 and January 2024 TARs. The Wound Care Nurse could not explain why the treatments were missed. Similarly, Resident #8, with a stage four pressure ulcer of the sacral region, had missed wound care treatments on specific dates in December 2023. The Wound Care Nurse confirmed that if the wound care was not documented, it was not done and could not explain the missed treatments for Resident #8.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents. Resident #5, who had diagnoses including a stage four pressure wound of the sacrum and GERD, had multiple instances where medications were not documented as administered according to the physician's orders. Specifically, the December 2023 and January 2024 Treatment Administration Records (TAR) showed blanks for the administration of hydrocodone-acetaminophen and Reglan at various times, indicating that the medications were likely not given. An LPN confirmed that blanks on the MAR/TAR would be assumed to mean the medication was not administered, and the policy was to follow physician orders when administering medications. Resident #8, diagnosed with chronic diastolic heart failure, had a physician order for carvedilol to be held if the heart rate was less than 65. However, the January 2024 Medication Administration Record (MAR) documented that carvedilol was administered despite the resident's heart rate being below the specified threshold on multiple occasions. The DON confirmed that staff were supposed to hold the medication if the heart rate was below 65 and acknowledged that the medication was incorrectly administered on the specified dates.
Failure to Ensure Proper Medication Storage
Penalty
Summary
The facility failed to ensure medications were not stored at a resident's bedside for one of three sampled residents reviewed for medication administration. Resident #8, who had a diagnosis of constipation, was found to have Ex-Lax and a stool softener at their bedside, which were brought in by a family member. The resident was observed taking these medications without any assessment or physician order for self-administration, as required by the facility's policy. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware that the resident had these medications at their bedside. The facility's policy on Self-Administration of Medications by Residents, dated 2021, requires an assessment of the resident's ability to safely self-administer medications and a physician order for bedside medication storage. However, this policy was not followed in the case of Resident #8. The DON and ADON confirmed that no assessment had been completed, and no physician order was in place for the resident to self-administer the medications found at their bedside.
Failure to Obtain Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis for a resident with diagnoses including a stage four sacrum wound and intestinal obstruction. The physician's order for the urinalysis was dated 12/20/23, but there was no documentation that the urinalysis was obtained. The Assistant Director of Nursing (ADON) stated that if the urinalysis order was on the order form from the physician's liaison during rounds, they would not know if a urinalysis was ordered or needed to be obtained. The ADON mentioned that they input the prescribed orders into the resident's medical records. The Director of Nursing (DON) provided the physician's order form dated 12/20/23, which documented the order to obtain a urinalysis.
Inadequate Portion Sizes During Meal Service
Penalty
Summary
The facility failed to ensure adequate portion sizes were offered to residents during a meal service. The facility's policy required that menus be followed to meet the nutritional needs of residents. However, during an observation of lunch service, it was found that the Certified Dietary Manager (CDM) used incorrect portion sizes. Specifically, the CDM used a number eight grey scoop, which was identified as a four-ounce scoop, instead of the required six-ounce scoop for beef stroganoff. The CDM acknowledged the error and mentioned that the correct six-ounce scoop was broken and had been ordered. This resulted in residents receiving smaller portions than specified in the menu, which did not meet their nutritional needs as per the facility's policy.
Failure to Document Wound Care Treatment
Penalty
Summary
The facility failed to ensure wound care treatment was accurately documented for one of three sampled residents reviewed for pressure ulcers. Resident #8, who had a diagnosis of a stage four pressure ulcer in the sacral region, had a physician's order for daily wound care. However, the Medication Administration Records (MAR) for December 2023 and January 2024 were found to be blank on specific dates, indicating that the wound care was not documented. The Wound Care Nurse confirmed that they had worked on the dates in question and completed the wound care but failed to document it due to being pulled to perform other tasks in the facility.
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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