Emerald Care Center Tulsa
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 2425 South Memorial, Tulsa, Oklahoma 74129
- CMS Provider Number
- 375094
- Inspections on file
- 30
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Emerald Care Center Tulsa during CMS and state inspections, most recent first.
A resident with intact cognition was transferred to a hospital for evaluation and treatment of seizure-like activity, high blood pressure, and elevated pulse, but did not receive the required written notice of transfer. The facility’s policy required written notice when practicable before transfer, including in urgent situations. Documentation showed the resident was sent to the hospital and a family member was notified, and the resident later confirmed the hospitalization. In an interview, the DON described the paperwork typically sent with residents but did not include a written transfer notice and acknowledged that staff did not provide such notice for this transfer and that they were unaware of the requirement.
A resident was admitted and had an MDS admission assessment completed that identified needs related to ADL functioning, urinary incontinence, nutritional status, and pressure ulcers, which were selected to be care planned. The EMR contained only a baseline care plan and no comprehensive care plan, despite facility policy requiring timely development of such plans based on the RAI process. The DON confirmed that a comprehensive care plan should have been in place and acknowledged that it had not been completed.
A resident with a right upper chest permacath had physician orders and facility policy requiring assessment of the dialysis access site every shift for bleeding and dressing integrity. Review of the Treatment Administration Record showed four missed entries for these scheduled assessments over the month. An LPN reported that catheter checks were performed each shift and before dialysis and should have been documented in the EMR, but acknowledged that several entries were not recorded and may have been missed due to a documentation error. The DON confirmed that while they believed the assessments were completed, there was no documentation to support this, resulting in a deficiency for failure to document required dialysis catheter assessments.
Surveyors found that the facility failed to follow its own food safety policy and professional standards for food storage and labeling in the kitchen that provided nourishment to 58 residents. During a kitchen tour, they observed two plastic pitchers of red juice on a prep table near the serving area that were opened, undated, and unlabeled; an opened bottle of soy sauce on the bottom shelf of the prep table that was undated and unlabeled; and an opened paper bag of grits on the same shelf that was undated, unlabeled, and unsealed. The facility’s Food Safety Requirements Policy required safe and sanitary storage, preparation, distribution, and serving of food, but these items were not labeled, dated, or stored in a sealable container as acknowledged by the food service director.
A resident with anxiety, depression, and diabetes was left wet all night without assistance, leading to a deficiency in care. Despite using their call light, staff did not respond, prompting the resident to call their pastor and the police. The facility's staff reported conducting regular rounds, but the administrator acknowledged a lapse in communication and monitoring during the night shift.
A facility failed to maintain infection control during wound care for a resident with pressure ulcers. Staff did not wear gowns or sanitize hands between glove changes, contrary to the facility's MDRO PPE-Enhanced Barrier Precautions policy. The resident had stage three pressure ulcers and was assisted by an RN and a CNA who did not adhere to proper infection control practices.
A resident with end-stage renal disease missed multiple dialysis sessions due to behavioral issues at the dialysis center, leading to hospitalization for metabolic acidosis. The facility did not provide a sitter as required by the dialysis center, and there was no documentation of the resident attending dialysis after being returned to the facility. The facility lacked a dialysis policy and failed to communicate the missed sessions to the physician.
The facility failed to document an accurate code status for a resident and did not offer the choice to formulate an advanced directive for two other residents. One resident had a signed DNR form but was documented as a full code, while two other residents had no documentation indicating they were offered the option to formulate an advanced directive.
The facility failed to replace a resident's missing laptop, despite confirming the misappropriation and initiating an investigation. The resident reported the laptop missing, and the corporate administrator acknowledged the delay in replacement, stating they would discuss it with the finance department and purchasing.
The facility failed to develop and implement comprehensive care plans for residents with urinary catheters, pain management needs, and cardiovascular conditions. One resident lacked a current physician order and documentation for catheter care, another had no care plan for pain despite frequent pain, and a third had no care plans for cardiovascular status or diabetes.
A resident with peripheral vascular disease and diabetic foot ulcers did not receive wound care as ordered on multiple occasions. Observations and interviews revealed that the dressing was not changed as required, and the Treatment Administration Record was not properly documented. The Director of Nursing confirmed the failure to follow physician's orders and the lack of proper documentation.
The facility failed to ensure proper physician orders and care for a resident with an indwelling urinary catheter, leading to inadequate catheter care and increased risk of infection. The resident experienced burning pain and a urinary tract infection, which was confirmed to be associated with improper catheter positioning. Staff were unaware of the need for physician orders and consistent catheter care, resulting in significant lapses in the resident's care.
The facility failed to administer the correct amount of water via PEG tube as ordered by the physician, did not maintain the required HOB elevation during water flushes and tube feeding, and did not communicate dietary recommendations to the physician for a resident with a PEG tube. The LPN administered only 60 ml of water instead of the ordered 185 ml and initially did not elevate the HOB, which was corrected after being prompted.
The facility failed to post the required staffing information daily. Residents were confused about which staff members were working on their hall. Observations revealed inconsistencies in the posting of staffing information, and the regional director of scheduling acknowledged that the posted schedule should include census dates and the number of hours worked.
A facility failed to administer medications in accordance with physician orders for a resident with diabetes mellitus and anxiety. The MAR/TAR for February 2024 showed multiple blanks for the administration of Depakote, Humalog, and Insulin Glargine, indicating that the medications were either not administered or not documented. The DON acknowledged the issue but was unaware of the cause.
The facility failed to maintain comprehensive policies for monthly drug regimen reviews, resulting in delayed follow-up on medication orders for a resident with hypertension and missing physician responses for a resident with depression and anxiety.
The facility failed to ensure that two residents did not receive unnecessary psychotropic medications and did not properly monitor for side effects of antidepressant therapy. Despite requests for gradual dose reductions, one resident continued to receive the same doses without documented physician responses. Another resident's care plan included monitoring for adverse reactions, but there was no documentation of such monitoring.
The facility failed to monitor food cooking and holding temperatures, affecting 52 residents. A review of the food temperature log revealed missing documentation for 10 out of 33 meals. The Dietary Manager stated that the cook was responsible for logging temperatures, and the DM was responsible for ensuring this task was completed.
The facility failed to adhere to food safety standards, including not recording temperature logs for coolers and freezers, not dating food items, and not maintaining the dish machine log. Additionally, the Dietary Manager was observed without a beard guard, and the ice machine was found to be dirty.
The facility failed to ensure proper garbage disposal. A trash can near the handwashing sink was observed with a box full of garbage on top of the lid, causing garbage to fall onto the floor. The Dietary Manager confirmed that trash should not be piled up on the trash can lid. The ADON reported that 52 residents received services from the kitchen.
The facility failed to maintain a comprehensive infection control program, with missing documentation and no monthly analysis of infection data. The water management program to prevent Legionella was not implemented, and the laundry room was found in disarray with significant hygiene issues. Additionally, improper handling of soiled linen was observed, increasing the risk of cross-contamination.
The facility failed to designate an individual as the infection preventionist (IP) responsible for the infection prevention and control program. The DON and corporate administrator were unable to confirm the identity of the IP, and an RN with the required certification stated they had not been asked to perform IP duties. This deficiency was identified in a facility with 53 residents.
The facility failed to document the offer, administration, or refusal of influenza and pneumococcal vaccinations for several residents, as required by their policies. The DON confirmed the absence of this documentation, indicating non-compliance with vaccination protocols.
The facility failed to ensure a kitchen reach-in refrigerator was in good repair, affecting the safe storage of food for 52 residents. The refrigerator's temperature was observed to be 73 degrees Fahrenheit, and the temperature log had not been updated for several days. The refrigerator contained milk, lettuce, and tomatoes, which did not feel cold. The DM stated that the refrigerator was working properly the previous day and that the cook on duty was responsible for logging the temperatures twice a day.
The facility failed to provide necessary assistance with ADLs for three residents, specifically in the areas of bathing and incontinent care. One resident was repeatedly observed with wet clothing and bedding, another reported not receiving routine showers and had to clean themselves, and a third resident did not receive scheduled showers consistently. Staff acknowledged the issues but did not document refusals as required.
The facility failed to provide sufficient staff, resulting in missed medications and inadequate care for several residents. Residents reported not receiving medications on time and missing scheduled showers due to staff shortages. The ADON and other staff confirmed the staffing issues, leading to overburdened nurses and CMAs unable to fulfill their duties.
A resident with major depressive disorder and diabetes mellitus was left in wet clothes and with a coffee-soiled breakfast plate for an extended period after spilling coffee. Staff failed to promptly clean the resident and provide a replacement meal, compromising the resident's dignity.
The facility failed to update the care plan for a resident receiving hospice services. Despite a physician order and a significant change assessment indicating the need for hospice care, the care plan did not reflect this service. Interviews confirmed the oversight.
The facility failed to ensure proper storage of oxygen cylinders, leading to a potential accident hazard. An unattended wheelchair with an oxygen cylinder was observed in the hallway, and a staff member left the cylinder standing upright and unattended. Both an LPN and the DON confirmed that oxygen cylinders should be securely stored in a rack.
The facility failed to complete the required yearly performance review for one of its nurse aides. A CNA hired in 2022 did not have any documentation of a skills performance review in their personnel file. The HR director confirmed the file was missing and noted there was a new administrator and DON at the time the CNA was rehired.
The facility failed to ensure that laboratory tests were completed as ordered for a resident with diabetes mellitus and hypertension. Despite a physician's order for multiple tests, the medical records showed no documentation of the lab results. Interviews revealed confusion among staff about the process for obtaining labs and ensuring their completion.
The facility failed to maintain an antibiotic stewardship program for a resident with COPD and chronic respiratory failure. A physician ordered antibiotics without proper documentation or assessment, and the DON confirmed that the facility's policy was not followed. Additionally, the ADON identified three residents receiving antibiotics without adherence to the infection control policy.
The facility failed to maintain a comfortable room temperature for three residents, resulting in temperatures below the required range of 71 to 81 degrees Fahrenheit. Residents reported the issue multiple times, but it was not addressed. Temperature readings confirmed the rooms were too cold, and the administrator acknowledged the deficiency.
The facility failed to ensure ongoing communication with the dialysis center and did not perform required pre- and post-dialysis assessments for residents receiving dialysis treatments. One resident was transferred to the hospital without the facility's knowledge, and two other residents had numerous undocumented assessments.
The facility failed to include the representatives of two residents in their care plan conferences, despite having a policy that mandates notifying families or legal representatives at least seven days prior. Both residents' families confirmed they were not notified or invited to the meetings, and the Social Services Director acknowledged the policy was not followed.
A resident with type 2 diabetes and a stage 4 pressure ulcer did not receive a requested trapeze for their bed, despite recommendations from physical therapy. The facility failed to follow through on the assessment and installation, leading to a deficiency in accommodating the resident's needs.
A facility failed to notify a resident's POA of multiple falls and changes in condition, despite the resident having serious diagnoses like type 1 diabetes and end-stage renal disease. The DON confirmed that the facility's policy was not followed, as there was no documentation of the required notifications.
The facility failed to complete wound assessments for a resident with stage 2 pressure ulcers and did not follow proper infection control practices during wound care for another resident with chronic ulcers. The RN used the same gauze for multiple wounds and placed wound care materials on non-sterile surfaces before application.
The facility failed to ensure residents received baths as requested and according to schedule, and that medications and blood sugar levels were administered and documented as ordered by physicians. Two residents did not receive baths as per their preferences and schedule, and two residents had missing documentation for multiple medications and blood glucose levels.
A facility failed to report an allegation of sexual abuse involving a resident with COPD and Parkinson's disease to the state health department as required by policy. The incident was reported by a family member to the DON, but no investigation documentation was found, and the incident was not reported within the required timeframe. An APS worker later visited the facility, but the administrator confirmed the lack of investigation documentation.
The facility failed to thoroughly investigate an alleged sexual abuse incident involving a resident with chronic obstructive pulmonary disease and Parkinson's disease. The issue was reported by the resident's family member, but the facility's documentation did not include necessary interviews or identification of the accused aide, and no further investigation records were found.
The facility failed to ensure a resident was not involuntarily discharged without notice and the right to appeal, and failed to document the discharge in the resident's medical record. Despite being cleared to return to the nursing home, the facility decided not to allow the resident back, citing behavioral issues and the refusal of physicians to care for the resident. This decision was made without proper documentation or adherence to the facility's transfer and discharge policy.
The facility failed to provide a notice of transfer and a notice of discharge for a resident with a fracture and schizoaffective disorder. The resident was transferred to an acute care hospital for psychiatric evaluation, and the facility decided not to accept the resident back. No discharge summary or transfer/discharge notices were found, indicating non-compliance with the facility's policy and regulatory requirements.
The facility failed to provide a bed hold policy to a resident with a fracture and schizoaffective disorder before transferring them to an acute care hospital for psychiatric evaluation. The Administrator and DON confirmed the absence of necessary documentation, including the bed hold policy, notice of transfer, notice of discharge, or a discharge summary.
A resident with a fracture and schizoaffective disorder was denied re-entry to the facility after a psychiatric evaluation, despite being cleared to return. The decision was made by the former DON and administrator, citing behavioral issues and physician refusal, without proper documentation or adherence to the facility's transfer and discharge policy.
Failure to Provide Required Written Notice of Hospital Transfer
Penalty
Summary
The facility failed to provide a resident with a written notice of transfer when the resident was sent to the hospital for evaluation and treatment. The facility’s transfer and discharge policy dated 05/2017 required that a resident be provided a written notice of transfer when practicable before transfer, even when urgent medical needs required immediate transfer. Record review showed that a quarterly MDS assessment for Resident #5 dated 06/18/25 documented an intact cognition with a BIMS score of 15. A progress note dated 09/12/25 at 3:35 p.m. stated that Resident #5 was sent to a hospital for evaluation and treatment related to seizure-like activity, high blood pressure, and elevated pulse, and that a family member was notified of the transfer. In an interview on 09/24/25, Resident #5 confirmed having been transferred to a hospital, and in a separate interview the same day, the DON described the paperwork sent with residents during transfers but did not include a written notice of transfer. The DON acknowledged that staff did not provide Resident #5 with a written notice of transfer on 09/12/25 and stated they were unaware of the requirement to provide such written notice.
Failure to Complete Comprehensive Care Plan After Admission Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident, as required by its policy and the RAI process. The facility’s Care Plan Process policy dated 09/2019 stated that a care plan appropriate to each resident’s needs and wishes would be developed based on assessment and reassessment within required timeframes. For a resident who entered the facility on 06/19/25, an MDS admission assessment dated 06/25/25 identified needs in ADL functioning, urinary incontinence, nutritional status, and pressure ulcers that were selected to be care planned, and the MDS coordinator signed the assessment as completed on 06/25/25. Record review of the resident’s EMR showed only a baseline care plan dated 06/20/25 and no comprehensive care plan in the care plan section. During an interview on 09/24/25 at 11:15 a.m., the DON confirmed that there was no comprehensive care plan for this resident in the EMR and acknowledged that a comprehensive care plan should have been created by that time, consistent with the facility’s policy to complete baseline and comprehensive care plans in a timely manner.
Failure to Document Required Dialysis Permacath Assessments Each Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s dialysis permacath was assessed and documented every shift as required by physician orders and facility policy. The facility’s dialysis policy directed that fistula/shunt sites be checked every shift for bruits, bleeding, increased pain, and signs of infection. A physician order for one resident specified that the right upper chest permacath was to be monitored for bleeding and an intact dressing every shift, with the dialysis center to be notified of any concerns. The resident’s September 2025 Treatment Administration Record (TAR) showed that the permacath was scheduled to be assessed once each shift for bleeding and dressing integrity. Record review of the September 2025 TAR revealed missing documentation of these required assessments on four of the 46 scheduled assessment times: two shifts on one date and single shifts on two other dates. During interview, an LPN explained that they assessed the resident’s chest catheter every shift and before dialysis and documented these checks on the TAR, but upon reviewing the TAR acknowledged that four entries were not documented. The LPN stated they had worked some of those shifts, believed they had performed the checks, and suggested they may have pressed the wrong button in the electronic system, acknowledging they should have ensured the documentation was present. The DON, after reviewing the TAR, stated that nurses enter assessment information into the EMR, expressed confidence that the assessments were done, but acknowledged there was no documentation to prove it and believed a nurse error occurred when entering the information, recognizing the importance of both the assessments and their documentation.
Failure to Label, Date, and Properly Store Opened Food Items in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food storage and labeling practices when, during a kitchen tour, they observed multiple opened food items that were undated, unlabeled, and/or improperly stored. On the morning of 09/22/25, two plastic pitchers with lids containing red juice were found on a prep table near the serving area without any labels or dates. On the bottom shelf of the same prep table, an opened bottle of soy sauce was observed without a label or date, and an opened paper bag of grits was found undated, unlabeled, and unsealed. The facility’s undated Food Safety Requirements Policy stated that the facility would provide safe and sanitary storage, handling, and consumption of all food, including storage, preparation, distribution, and serving in accordance with professional standards for food service safety. The DON reported that 58 residents received nourishment from the kitchen. When shown the items, the food service director acknowledged that the items should have been labeled and dated and that the opened bag of grits should have been stored in a sealable container. This deficiency centers on the facility’s failure to ensure that opened or prepared foods were labeled, dated, and stored correctly in accordance with its own food safety policy and professional standards, affecting the kitchen that provided nourishment to dozens of residents.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident, leading to a deficiency in the care provided. The resident, who had diagnoses including anxiety, depression, and diabetes, reported being left wet all night without assistance. The resident attempted to use their call light for help, but staff did not respond, prompting the resident to call their pastor and the police for assistance. The resident expressed dissatisfaction with the night shift care, stating that they were ignored and not checked or changed throughout the night. The facility's staff, including CNAs and LPNs, reported that they conducted rounds every two hours to check and change residents, documenting their actions. However, the administrator acknowledged that the resident should not have had to call the police and noted a discrepancy in the CNA's report, who claimed to have asked the resident if they needed anything but was told no. The administrator also mentioned that the CNA might not have been aware of how long the call light had been activated, indicating a lapse in communication and monitoring during the night shift.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to maintain infection control and adhere to enhanced barrier precautions during the treatment of pressure ulcers for a resident. The facility's policy on MDRO PPE-Enhanced Barrier Precautions, revised in January 2024, requires staff to use gowns and gloves during high-contact resident care activities, such as wound care, and mandates training on hand hygiene and PPE use. However, during an observation on January 27, 2025, RN #1 and a medical records CNA did not wear gowns while performing wound care on a resident with stage three pressure ulcers. Additionally, RN #1 did not sanitize their hands between glove changes and failed to change gloves consistently between dirty and clean tasks. The resident involved had diagnoses including type two diabetes and COPD and was observed with pressure ulcers on the buttocks and left ischium. During the dressing change, the medical records CNA held the resident on their side and used a dirty gloved hand to hold the dressing in place while RN #1 secured it with tape. RN #1 later acknowledged that they did not follow the facility's expectations for hand hygiene and enhanced barrier precautions during the wound treatment.
Failure to Ensure Dialysis Services Leads to Hospitalization
Penalty
Summary
The facility failed to ensure proper dialysis services for a resident with end-stage renal disease, resulting in hospitalization due to metabolic acidosis from missed dialysis sessions. The resident was scheduled to receive dialysis three times a week, with appointments documented in their care plan. However, on one occasion, the resident was returned to the facility from the dialysis center with a note stating they could not return without a sitter due to behavioral issues. Despite this, there was no documentation of the resident attending dialysis after this incident. The facility did not provide a policy for dialysis when requested, and there was a lack of communication and follow-up regarding the resident's missed dialysis sessions. The resident was eventually hospitalized with a diagnosis of metabolic acidosis, attributed to missing multiple dialysis sessions. The facility's administrator and DON acknowledged the situation, with the administrator stating that the facility was not required to provide a sitter, and the DON confirming the resident was sent to the hospital for dialysis. An LPN involved in the situation admitted to not notifying the physician or ADON about the missed dialysis session.
Failure to Document Accurate Code Status and Offer Advanced Directives
Penalty
Summary
The facility failed to ensure an accurate code status was documented for one resident and did not offer the choice to formulate an advanced directive for two other residents. Resident #8 had a signed DNR form dated 10/02/23, but the electronic clinical record and face sheet documented the resident as a full code. Staff members, including an LPN and the SSD, confirmed the discrepancy and stated there was no documentation that the resident had revoked the DNR. The ADON also confirmed the lack of documentation regarding the revocation of the DNR upon the resident's readmission from the hospital. Resident #22, who had diagnoses including congestive heart failure and osteoarthritis, did not have documentation in their clinical records indicating that they or their representative were offered the choice to formulate an advanced directive. Similarly, Resident #24, who had diagnoses including spinal stenosis and scoliosis, did not have documentation showing they were offered the option to formulate an advanced directive. The SSD confirmed the absence of such documentation for both residents.
Failure to Replace Missing Laptop
Penalty
Summary
The facility failed to ensure a missing laptop was replaced for a resident who was reviewed for misappropriation of property. The facility's Abuse, Neglect, and Exploitation policy, revised in January 2024, states that each resident has the right to be free from misappropriation of property. An assessment documented that the resident's cognition was intact. An incident report form dated January 24, 2024, indicated that the resident reported their 13-inch MacBook Pro was missing. The electronic store confirmed the purchase details. A follow-up incident report dated January 29, 2024, confirmed that the facility could not locate the missing laptop and was working on replacing it. On April 8, 2024, the resident stated that their laptop was stolen and that the former administrator had investigated the issue and was supposed to replace it. On April 9, 2024, the corporate administrator confirmed that there was no record of the laptop replacement in corporate purchasing and acknowledged that it should not have taken this long to replace the laptop. The corporate administrator mentioned that they would discuss the replacement with the finance department and purchasing.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented to address the needs of residents related to urinary catheters, pain management, and cardiovascular status. Resident #49, who had diagnoses including obstructive and reflux uropathy and benign prostatic hyperplasia, had an indwelling catheter but lacked a current physician order and documentation for catheter care and maintenance since 2/27/24. The resident experienced a severe urinary tract infection and reported intermittent catheter care by the staff. The ADON and LPN confirmed the absence of necessary orders and documentation, and the MDS coordinator assumed that the presence of a catheter on the care plan implied all related interventions would be completed, which was not the case. Resident #24, diagnosed with spinal stenosis and scoliosis, frequently experienced pain but had no care plan addressing pain management despite physician orders for pain monitoring and a referral to a pain management physician. The resident reported inadequate pain management by the facility. The MDS coordinator acknowledged the absence of a pain care plan, attributing it to the resident's occasional refusal of pain medications. Additionally, Resident #22, with multiple cardiovascular conditions and diabetes, had no care plans for cardiovascular status or diabetes. The MDS coordinator admitted to not adding these diagnoses to the care plan, as they had not been informed to do so initially.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to ensure wound care was provided as ordered for a resident with non-pressure related wounds. The resident had diagnoses including peripheral vascular disease, non-pressure chronic ulcer of the right foot, and diabetes. A physician's order required daily wound care for the resident's right shin and knee, but the treatment was not completed on multiple occasions. Specifically, the Treatment Administration Record (TAR) indicated that wound care was not performed on three separate days. Observations confirmed that the dressing on the resident's right shin was not changed as required, and the resident was unaware of the dressing change schedule. The dressing was observed to be dated several days prior to the required change date, and the resident had developed additional blisters on the right shin above the dressing area. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN), and Director of Nursing (DON), revealed that the wound care nurse was usually responsible for completing the wound care. However, when the wound care nurse was not available, the assigned nurse was expected to perform the task. The DON confirmed that the physician's orders for wound care were not being followed and that the TAR was not properly initialed to indicate completion of the wound care. Further interviews with Registered Nurses (RNs) indicated that the wound care was not completed as scheduled over the weekend, and there was no documentation explaining the missed care. The DON acknowledged the failure to follow the wound care orders and the lack of proper documentation in the TAR.
Failure to Ensure Proper Catheter Care and Physician Orders
Penalty
Summary
The facility failed to ensure proper physician orders and care for a resident with an indwelling urinary catheter. The resident, who had diagnoses including obstructive and reflux uropathy and benign prostatic hyperplasia, had several physician orders for catheter care and maintenance that were discontinued upon their hospital admission and not reinstated upon their return. The resident complained of burning pain and exhibited symptoms of a urinary tract infection, which led to a hospital transfer where it was confirmed that the catheter was improperly positioned. Upon the resident's return to the facility, there was no documentation of an order for the urinary catheter or catheter care, and staff were unaware of the need for such orders. Observations and interviews revealed that catheter care was not consistently performed, and the lack of documentation and physician orders contributed to the resident's discomfort and potential health risks. The Assistant Director of Nursing (ADON) acknowledged the oversight and the failure to ensure catheter care was performed routinely. The deficiency highlights a significant lapse in the facility's protocol for managing residents with indwelling urinary catheters, leading to inadequate care and increased risk of infection for the resident involved.
Failure to Administer Correct Water Flush and Elevate HOB During PEG Tube Feeding
Penalty
Summary
The facility failed to ensure the correct administration of water via a PEG tube as ordered by the physician, maintain the head of the bed (HOB) elevation during water flushes and tube feeding, and communicate dietary recommendations to the physician for a resident with a PEG tube. The resident had diagnoses including dysarthria, hemiparesis, and hemiplegia following a cerebral infarction, and was dependent on staff for eating and repositioning. The physician's order specified administering 185 ml of water after each bolus feeding, but the LPN administered only 60 ml of water and did not elevate the HOB initially during the procedure, which was corrected after being prompted. Additionally, the dietary recommendations made by the dietitian were not communicated to the physician, resulting in the recommendations not being followed up on. On observation, the LPN was seen administering only 30 ml of water before and after the tube feeding, significantly less than the ordered 185 ml. The LPN admitted to not following the physician's order and forgetting to elevate the HOB to the required 30 degrees during the procedure. The DON confirmed that the dietary recommendations made on 03/25/24 were not followed up by the physician, and the correct amount of water flush was not administered. This series of actions and inactions led to the deficiency in the care provided to the resident with a PEG tube.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to post the required staffing information daily, as mandated. The Resident Council Meeting minutes documented that staff were not introducing themselves to residents, leading to confusion about which staff members were working on their hall. Despite a proposed action to use a whiteboard for daily nursing assignments, observations on multiple dates revealed inconsistencies. On one occasion, the working schedule was found in a book at the nurse's station, but the census was incorrect. On another occasion, a dry erase board was observed but did not include the resident census. Interviews with staff confirmed that the dry erase boards had only recently been hung and were not fully compliant with posting requirements. The regional director of scheduling acknowledged that the posted schedule should include census dates and the number of hours worked to be up to date.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medications in accordance with physician orders for a resident diagnosed with diabetes mellitus and anxiety. The resident had specific physician orders for Depakote, Humalog, and Insulin Glargine, which were not consistently administered as prescribed. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February 2024 showed multiple blanks for the administration of these medications on various dates, indicating that the medications were either not administered or not documented. This inconsistency was confirmed by an LPN who stated that blanks on the MAR/TAR meant the medication or treatment was either not administered or not documented, and there was no way to verify the completion if it was not documented in the computer. The Director of Nursing (DON) acknowledged the issue, stating they had never seen such blanks on the MAR/TAR before and did not know what it meant when the administration was blank. The corporate administrator identified that 53 residents resided in the facility, with 17 receiving insulin. The failure to administer medications as ordered and the lack of proper documentation led to the deficiency identified in the report.
Failure to Maintain Comprehensive Drug Regimen Review Policies
Penalty
Summary
The facility failed to develop and maintain comprehensive policies and procedures for the monthly drug regimen review, including specific time frames for the different steps in the process. This deficiency was evident in the cases of two residents. For one resident with hypertension, the facility did not follow up on a request made in the monthly drug regimen review to add hold parameters to the orders for carvedilol and losartan until two months later. For another resident with diagnoses including depression and anxiety, the facility did not ensure a physician responded to multiple requests in the monthly drug regimen reviews to add diagnoses for certain medications and to reduce the dosages of olanzapine and Depakote. The medical records did not contain documented responses from the physician for these requests, and the facility staff were unable to locate the documentation when asked by surveyors. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed and revealed gaps in the process. The DON stated that the ADON was responsible for the monthly drug regimen reviews but was unsure where the physician responses would be if they were not scanned into the chart. The ADON, who had only been responsible for the reviews for two weeks, was unaware of the facility's response time for the reviews and did not have access to the relevant policies. This lack of clear procedures and follow-up led to the deficiencies identified by the surveyors.
Failure to Implement GDR and Monitor Antidepressant Side Effects
Penalty
Summary
The facility failed to ensure that two residents did not receive unnecessary psychotropic medications. Resident #22, diagnosed with depression and anxiety, had physician orders for Depakote and olanzapine. Despite requests for gradual dose reductions (GDR) documented in monthly drug regimen reviews, the medical record did not contain documented responses from the physician. The Medication Administration Records (MAR) showed that Resident #22 continued to receive the prescribed doses of both medications without any reduction, indicating non-compliance with the GDR requests. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed a lack of clarity and documentation regarding the physician's responses to the GDR requests, and the ADON admitted to not having access to relevant policies or knowing the facility's response time for these reviews. Resident #17, also diagnosed with depression and anxiety disorder, had a physician's order for sertraline, an antidepressant. The resident's care plan included monitoring for adverse reactions to antidepressant therapy. However, a review of the resident's orders and Treatment Administration Records (TAR) did not document a physician order for side effect monitoring, nor was there any documentation of such monitoring on the TAR. Interviews with LPNs and the ADON confirmed that side effect monitoring should be documented on the TAR, but it was not being done as required. The deficiencies highlight the facility's failure to implement GDR and non-pharmacological interventions before continuing psychotropic medications and to ensure proper monitoring for side effects of antidepressant therapy. The lack of documented physician responses to GDR requests and the absence of side effect monitoring documentation indicate significant lapses in the facility's medication management and monitoring processes.
Failure to Monitor Food Temperatures
Penalty
Summary
The facility failed to monitor food cooking and holding temperatures to ensure safe temperatures were maintained in the kitchen and on the steam table during meal service. The Assistant Director of Nursing (ADON) reported that 52 residents received services from the kitchen. A review of the facility's food temperature log from March 29, 2024, through April 8, 2024, revealed that the facility did not document the holding temperatures for 10 out of 33 meals. On April 10, 2024, at 9:53 a.m., the Dietary Manager (DM) stated that the cook on duty was responsible for logging the holding temperature of each meal in the food temperature log, and the DM was responsible for ensuring the cook logged the temperatures.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Observations revealed that the temperature logs for the reach-in coolers and freezers had not been recorded for three days. Additionally, various food items in the reach-in cooler were found without dates, and the dish machine log had not been updated for over two weeks. The Dietary Manager (DM) admitted that the items in the reach-in cooler should be dated and that temperatures should be recorded twice daily. The DM also acknowledged that the cook on duty was responsible for ensuring the dish machine's temperature and chemical concentration were appropriate. Further inspection showed that the DM was not wearing a beard guard while in the kitchen, which is against the facility's policy. The inside of the ice machine was found to be dirty, with a black substance visible on a paper towel after wiping. The DM stated that they had never seen anyone clean the ice machine and had never instructed any employee to do so. The maintenance supervisor confirmed that the dietary department was responsible for cleaning the ice machine, indicating a lapse in adherence to food safety protocols.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure garbage was disposed of properly. On 04/09/24 at 11:30 a.m., a trash can near the handwashing sink was observed with a box sitting on top of the lid, which was full of garbage and had garbage falling onto the floor. On 04/10/24 at 9:53 a.m., the Dietary Manager (DM) stated that trash should not be piled up on the trash can lid. The Assistant Director of Nursing (ADON) reported that 52 residents received services from the kitchen.
Inadequate Infection Control and Laundry Management
Penalty
Summary
The facility failed to ensure a comprehensive infection prevention and control program was in place, leading to several deficiencies. The infection control surveillance program lacked documentation for several months, and there was no evidence of monthly analysis for the months that were documented. The Director of Nursing (DON) was unable to provide information on the missing documentation or how the existing data was used to monitor infection trends, indicating a lapse in infection surveillance and analysis processes. Additionally, the facility did not have a functioning water management program to prevent the growth of Legionella, as the maintenance supervisor was unaware of the requirement and no measures had been conducted in the past seven and a half months. This highlights a significant gap in the facility's infection control measures related to waterborne pathogens. The laundry room was found to be in a state of disarray and non-compliance with infection control standards. Observations included the absence of paper towels for hand drying, accumulation of debris and dust on and behind washing machines, blocked access to the eye wash station, and a leaking ceiling with water stains. The housekeeping supervisor admitted to being new and still learning the processes, while another supervisor from a different facility acknowledged the need for deep cleaning and organization. These conditions indicate a failure to maintain a hygienic environment in the laundry area, which is crucial for preventing the spread of infections. Furthermore, the handling of soiled linen was inadequate, as observed with an uncovered soiled laundry barrel and clean supplies stored on top of it. A CNA was seen placing soiled linen and clothes on the floor due to the lack of a bag for transport. These practices demonstrate a lack of proper procedures for handling soiled linen, increasing the risk of cross-contamination. The facility's failure to adhere to infection control protocols in these areas compromises the safety and well-being of its residents and staff.
Failure to Designate Infection Preventionist
Penalty
Summary
The facility failed to designate an individual as the infection preventionist (IP) responsible for the infection prevention and control program. During an interview, the Director of Nursing (DON) was unable to confirm the identity of the IP, suggesting it might be a registered nurse (RN) who had the required certification. However, when contacted, the RN stated they had not been asked to perform the duties of the IP and were unsure who the IP was. The corporate administrator also confirmed that both the RN and the DON had the necessary credentials but could not identify who was designated and acting as the IP. This deficiency was identified in a facility with 53 residents.
Failure to Document Vaccination Offers and Administration
Penalty
Summary
The facility failed to offer influenza vaccinations to four residents and pneumococcal vaccinations to five residents, as required by their policies. The policies, revised in January 2024, mandate that influenza vaccines be offered between October 1st and March 31st each year, and pneumococcal vaccines be assessed and offered prior to or upon admission. Documentation of the offer, administration, or refusal of these vaccines was missing for the residents in question. Specifically, the medical records for five residents did not document whether they were offered, received, or declined the influenza and pneumococcal vaccines. The Director of Nursing (DON) confirmed the absence of this documentation when requested. This lack of documentation indicates a failure to adhere to the facility's vaccination policies, potentially compromising resident health and safety.
Failure to Maintain Kitchen Refrigerator in Good Repair
Penalty
Summary
The facility failed to ensure a kitchen reach-in refrigerator was in good repair, affecting the safe storage of food for 52 residents. On 04/08/24 at 7:24 a.m., the temperature of the refrigerator was observed to be 73 degrees Fahrenheit, significantly above the required 41 degrees or less. The temperature monitoring log had not been updated since 04/05/24. The refrigerator contained milk, lettuce, and tomatoes, which did not feel cold. The Dietary Manager (DM) stated that the refrigerator was working properly the previous day and that the cook on duty was responsible for logging the temperatures twice a day. The DM also mentioned that the refrigerator had been recently repaired and that they would contact a repairman and dispose of the contents of the refrigerator.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, specifically in the areas of bathing and incontinent care. Resident #8, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times with wet clothing and bedding, indicating a lack of timely incontinent care. Despite being dependent on staff for toileting and transfers, the resident was not checked or changed by the staff when needed, as confirmed by the Director of Nursing (DON) who stated that incontinent care should be provided every two hours. Resident #16, diagnosed with end-stage renal disease, ischemic heart disease, and type II diabetes mellitus, was dependent on staff for bathing and hygiene. The resident's care plan indicated a preference for bathing three times a week, but records showed that the resident was bathed only once in a two-week period without any documented refusals. The resident reported not receiving showers routinely and having to clean themselves due to the lack of assistance from the staff. The Assistant Director of Nursing (ADON) acknowledged the issue but noted that refusals were not documented as required. Resident #43, who had diagnoses including diabetes mellitus and arthritis, was also dependent on staff for bathing. The resident was scheduled to receive showers twice a week, but records indicated that showers were not consistently provided, with only one documented shower and one refusal over a three-week period. The staff confirmed that CNAs were responsible for giving showers and that the nurse on duty should ensure showers are being given, but this was not consistently happening as per the facility's policies.
Insufficient Staffing Leads to Missed Medications and Inadequate Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of the residents, affecting six of seven sampled residents. The Resident Council Minutes indicated that residents were not receiving their medications on time during weekends, with eight residents sharing this concern. On 03/31/24, the facility's schedule showed only one CMA, one RN, and two LPNs qualified to administer medications, which was insufficient to meet the residents' needs. As a result, several residents did not receive their prescribed medications, including daily vitamins, blood thinners, and pain management drugs. Family members and residents reported missed medications and inadequate care, such as not receiving showers for extended periods. One resident with multiple diagnoses, including end-stage renal disease and diabetes, did not receive a bath from 04/01/24 through 04/11/24, despite being scheduled for showers twice a week. The resident was observed with a strong body odor, indicating a lack of hygiene care. Another resident with diabetes and a right below-knee amputation reported not having a shower for nine days, and staff confirmed that the assigned CNA had gone home sick, leaving the remaining CNAs overwhelmed and unable to provide adequate care. The facility's documentation showed that several residents missed their scheduled showers, and there were no documented refusals, indicating a failure in staff availability and scheduling. The facility's ADON and other staff members acknowledged the staffing issues, with reports of CNAs calling in sick and no replacements being provided. This led to nurses and CMAs being overburdened and unable to fulfill their duties, such as administering medications and assisting with ADLs. The regional director of scheduling confirmed that on 04/09/24, some employees called in, and the remaining staff had to cover multiple roles, further exacerbating the situation. The lack of sufficient staffing directly impacted the residents' care, resulting in missed medications and inadequate hygiene assistance.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure that Resident #44 was treated with dignity. Resident #44, who had diagnoses including major depressive disorder and diabetes mellitus, was observed to spill coffee on their shirt, pants, table, and breakfast plate. Although CNA #1 checked on the resident and covered them with napkins, they did not notice the coffee on the breakfast plate and did not request a new plate for the resident. As a result, the resident remained in wet clothes and with a coffee-soiled breakfast plate for an extended period. Later, the resident expressed that such incidents happen frequently and that they were still hungry and unsure if a new plate had been ordered. It was only after some time that the resident was provided with cereal and milk. Interviews with other staff members, including CNA #3 and LPN #4, confirmed that the resident should have been cleaned up immediately and offered a replacement meal. The DON also acknowledged that the resident should have been offered a change of clothes and a replacement tray.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to update the care plan related to hospice services for a resident with diagnoses including congestive heart failure, atrial fibrillation, and chronic kidney disease. A physician order dated 09/18/23 documented that hospice was to evaluate and treat the resident. A significant change assessment dated 11/27/23 indicated the resident was moderately cognitively impaired, dependent with most ADLs, and received hospice services. However, the care plan revised on 04/08/24 did not document hospice services. Interviews with hospice staff and the ADON confirmed that the resident had been receiving hospice services since 11/13/23, and the MDS coordinator was unaware that this service was not documented in the care plan.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to ensure oxygen cylinders were stored properly, leading to a potential accident hazard. On 04/10/24 at 1:38 p.m., an unattended wheelchair was observed in the hallway with an oxygen cylinder sitting upright in the seat, leaning against the back of the wheelchair. Shortly after, an unknown staff member removed the cylinder from the wheelchair and placed it standing upright in the hallway, leaving it unattended. The staff member then returned with the wheelchair and placed the oxygen cylinder back in the seat. LPN #3 confirmed that oxygen cylinders should be stored securely in a rack to prevent them from being knocked over. The DON also stated that oxygen cylinders should be stored per manufacturers' guidelines and should not be left balanced in the seat of a wheelchair.
Failure to Complete Yearly Performance Review for CNA
Penalty
Summary
The facility failed to complete the required yearly performance review for one of its nurse aides. CNA #1, who was hired on 05/07/22, did not have any documentation of a skills performance review in their personnel file. On 04/11/24, the HR director confirmed that CNA #1's personnel file was missing. The HR director also mentioned that there was a new administrator and Director of Nursing (DON) at the time CNA #1 was rehired.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as ordered for a resident with diagnoses including diabetes mellitus and hypertension. A physician's order dated 12/28/23 required a CBC, CMP, B-12, TSH, A1C, and a lipid panel for the resident, but a review of the medical records showed no documentation of the lab results. Interviews revealed that the MDS coordinator confirmed the labs had not been completed, and an LPN was unsure of the process for obtaining labs. Another LPN stated that the lab company would automatically draw any labs entered into their system, and nursing staff were responsible for ensuring labs were completed. The ADON explained that the nurse taking the order should enter it into the computer for the lab company to collect the sample on the next scheduled lab day, and all nurses were responsible for monitoring lab completion.
Failure to Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an antibiotic stewardship program for a resident diagnosed with COPD and chronic respiratory failure. A physician ordered amoxicillin-potassium clavulanate for the resident, but there was no documentation to support why the antibiotic was ordered or any assessment completed to meet antibiotic stewardship requirements. The Director of Nursing (DON) confirmed that the necessary assessment was not conducted prior to initiating the antibiotic, indicating that the facility's policy was not followed. Additionally, the Assistant Director of Nursing (ADON) identified that three residents were receiving antibiotics, but the infection control policy was not adhered to, as evidenced by the lack of appropriate clinical data review and documentation.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable room temperature for three residents, resulting in temperatures below the required range of 71 to 81 degrees Fahrenheit. Observations revealed that residents were wearing extra clothing and using multiple blankets to stay warm, with cold air blowing from overhead vents. Residents reported that they had repeatedly asked for the temperature to be adjusted, but their requests were not addressed. The maintenance supervisor confirmed that room temperatures were generally checked via hallway thermostats and acknowledged that some vents could be closed, but rooms closer to the units would remain colder. Temperature readings taken in the rooms of the affected residents showed air from the vents at approximately 53 degrees Fahrenheit and room temperatures ranging from 68 to 69.9 degrees Fahrenheit. The administrator confirmed that room temperatures should be between 71-81 degrees Fahrenheit and that random checks should be conducted weekly by maintenance staff. The administrator acknowledged that the temperatures in the residents' rooms were not maintained at a comfortable level, as per the facility's policy.
Failure to Ensure Communication and Assessments for Dialysis Residents
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center and did not perform required pre- and post-dialysis assessments for residents receiving dialysis treatments. Resident #1, who had diagnoses including type 1 diabetes and end-stage renal disease, had no documented pre- or post-dialysis assessments for February and March 2024. Additionally, the facility was unaware of Resident #1's transfer to the hospital from dialysis on 02/28/24, leading to a search involving local hospitals, jails, the resident's family, and the police. The resident was eventually located at the hospital ER by the police. Resident #3, with diagnoses including type 2 diabetes and end-stage renal disease, had no pre-dialysis assessments documented for 13 of 16 opportunities and no post-dialysis assessments for the same number of opportunities between 02/01/24 and 03/15/24. Similarly, Resident #4, also with type 2 diabetes and end-stage renal disease, had no post-dialysis assessments documented for 15 of 16 opportunities in the same period. The Director of Nursing (DON) acknowledged that the facility policy had not been followed, and an LPN indicated that a better system of communication between the dialysis center and the facility was needed.
Failure to Include Residents' Representatives in Care Plan Conferences
Penalty
Summary
The facility failed to facilitate the inclusion of residents' representatives in their care plan conferences for two of three sampled residents. According to the facility's Care Plan Process policy, revised in September 2019, every effort should be made to involve the resident and their family or legal representative in the development, implementation, maintenance, and evaluation of the resident's plan of care. The policy also states that families or legal representatives should be notified of the care planning conference in writing at least seven days prior to the conference. However, this policy was not followed for Resident #1 and Resident #2. Resident #2, who had diagnoses including type 2 diabetes and a stage 4 pressure ulcer of the sacral region, had a care plan conference on March 11, 2024, but their family was not notified or invited to attend. Similarly, Resident #1, diagnosed with type 2 diabetes and end-stage renal disease, had a care plan conference on January 26, 2024, without their family being notified or invited. Interviews with the family members of both residents confirmed that they had never been notified of or attended a care plan meeting. The Social Services Director acknowledged that the facility policy had not been followed after reviewing the documentation from the care plan conferences for both residents.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to accommodate a resident's need for adaptive equipment, specifically a trapeze, which would allow the highest possible level of physical functioning and well-being. Resident #2, who had diagnoses including type 2 diabetes and a stage 4 pressure ulcer of the sacral region, did not have a physician's order for a trapeze on file. Despite the family's request for bed rails and subsequently a trapeze, the facility did not follow through with the necessary assessment and installation. The family member reported that their request was denied upon admission, and although an assessment by physical therapy was mentioned, it was never completed. Observations confirmed that Resident #2's bed did not have a trapeze attached. The Physical Therapist indicated that the resident had been assessed and recommended for a trapeze, but this recommendation was not acted upon by the nursing staff. The Director of Nursing (DON) and the Administrator were both unaware of the recommendation, with the DON stating it might have been before their employment. The Administrator acknowledged awareness of the recommendation but only realized on the day of the survey that the trapeze had not been provided, indicating a lapse in communication and follow-through within the facility's processes.
Failure to Notify Resident Representative of Changes in Condition
Penalty
Summary
The facility failed to ensure resident representatives were notified of changes in condition for one resident who was reviewed for notification of change. The resident had diagnoses including type 1 diabetes and end-stage renal disease. Multiple incident reports documented that the resident experienced several falls and unstable blood sugars, but there was no documentation that the resident's Power of Attorney (POA) had been notified of these incidents. Specifically, the resident slipped out of their wheelchair, fell multiple times, and was found on the floor on several occasions, yet the POA was not informed as required by the facility's policy. The Director of Nursing (DON) confirmed that the facility's policy mandates notifying resident representatives of any falls or changes in condition and documenting these notifications in the resident's clinical record. However, upon review, the DON acknowledged that there was no documentation indicating that the POA had been notified of the falls. The POA reported being unaware of the incidents and only learned about them from the resident. This lack of communication and documentation represents a failure to follow the facility's policy and ensure proper notification of the resident's representative.
Failure to Complete Wound Assessments and Follow Infection Control Practices
Penalty
Summary
The facility failed to ensure wound assessments were completed for one resident with stage 2 pressure ulcers on the left ischium, left hip, and right ischium. Despite having a physician's order for daily wound care, no wound assessments were documented for this resident since January 31, 2024. This lack of documentation is inconsistent with the facility's policy, which requires regular wound assessments to monitor healing progress and identify potential complications. Additionally, the facility did not follow proper infection control practices during wound care for another resident with peripheral venous insufficiency and chronic ulcers. During an observed wound care session, the RN failed to maintain a sterile environment, used the same gauze to pat multiple wounds dry, and placed wound care materials on non-sterile surfaces before applying them to the wounds. The RN also did not cleanse one of the wounds before applying a new dressing. These actions were acknowledged by the RN and the DON, who admitted that proper infection control measures were not followed.
Failure to Administer Baths and Medications as Ordered
Penalty
Summary
The facility failed to ensure that residents received baths as requested and according to schedule, and that medications and blood sugar levels were administered and documented as ordered by physicians. Specifically, two residents did not receive baths as per their preferences and schedule. Resident #9, who had a fracture of the right tibia and end-stage renal disease, received only three baths between October 1 and October 25, 2023, and refused baths twice on the same day. Resident #14, diagnosed with chronic obstructive pulmonary disease and chronic diastolic congestive heart failure, received seven baths in January 2024 and refused a bath on January 20, 2024. Resident #14 also expressed dissatisfaction with the frequency of baths and stated that staff often refused to provide bed baths when requested. Additionally, the facility failed to administer medications as ordered by physicians for two residents. Resident #15, who had end-stage renal disease and type 2 diabetes mellitus, had missing documentation for evening doses of three medications on February 5 and 6, 2024. There was also no documentation of blood glucose levels or insulin administration on January 16, 2024. Resident #17, diagnosed with heart failure and type 2 diabetes mellitus, had multiple missing doses of ten prescribed medications in January 2024 and several undocumented blood glucose levels and insulin administrations. Despite these issues, both residents believed they had received all their medications. The Director of Nursing (DON) acknowledged that there should never be blank spaces in medication administration records, blood sugar records, or bath records unless not scheduled. The DON stated that it could not be determined if the baths and medications were provided as ordered and expected medical records to be filled out as required by policy.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the Oklahoma State Department of Health. A family member reported an alleged incident of sexual abuse involving a resident with chronic obstructive pulmonary disease and Parkinson's disease to the director of nursing. The facility's policy required such allegations to be reported to the state survey agency within five working days. However, the investigation documentation was missing, and the incident was not reported as required. An Adult Protective Services worker visited the facility months later and discussed the incident with an employee, but no further investigative documentation was found. The administrator confirmed that no investigation documentation existed and acknowledged the expectation for prompt investigation and timely reporting as per facility policy.
Failure to Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged sexual abuse incident involving a resident with chronic obstructive pulmonary disease and Parkinson's disease. The incident was reported by the resident's family member, who stated that a male aide had cupped the resident's breast during a shower. The facility's Concern Form documented that the issue was resolved by changing the shower aide to a female, but it did not include any interviews with staff or other residents, nor did it identify the male aide accused of the alleged assault. No further documentation of an investigation was found in the resident's medical records or facility records. The administrator confirmed that there was no documentation of an investigation into the alleged sexual abuse. An APS worker also discussed the allegations with another employee, but no additional documentation was provided. The facility's policy on abuse, neglect, and exploitation requires immediate investigation of suspected abuse, including interviews with residents, staff, and visitors, and thorough documentation of the investigation. However, these steps were not followed in this case, leading to a deficiency in handling the reported incident.
Failure to Document and Provide Notice for Involuntary Discharge
Penalty
Summary
The facility failed to ensure a resident was not involuntarily discharged without notice and the right to appeal, and failed to document the discharge in the resident's medical record. Resident #8, who had diagnoses including a fracture of the right tibia and schizoaffective disorder, was transferred to an acute care hospital for a psychiatric evaluation. Despite being cleared to return to the nursing home, the facility decided not to allow the resident back, citing behavioral issues and the refusal of physicians to care for the resident. This decision was made without proper documentation or adherence to the facility's transfer and discharge policy, which mandates informing the resident of an impending discharge and their right to appeal, as well as documenting the discharge in the medical record. The facility's failure to document the discharge and provide the necessary notices was confirmed through interviews and record reviews. The Director of Nursing (DON) and other staff members were unable to locate any transfer or discharge notices for the resident's transfer or involuntary discharge. Additionally, the decision to deny the resident's return was made during a conference call involving the former DON, former administrator, Director of Admissions, and a liaison, without proper documentation or adherence to regulatory requirements. The hospital staff also confirmed that the resident was scheduled to return but was ultimately denied re-entry to the facility.
Failure to Provide Notice of Transfer and Discharge
Penalty
Summary
The facility failed to provide a notice of transfer and a notice of discharge for one of three sampled residents reviewed for discharges. The resident had diagnoses including a fracture of the right tibia and schizoaffective disorder. According to the facility's policy, a written notice must be given to the resident and their representative before any transfer or discharge. However, a progress note documented that the resident was transferred to an acute care hospital for psychiatric evaluation on the order of an APRN, and a subsequent meeting decided that the facility would not accept the resident back. Despite this, there was no discharge summary or any transfer or discharge notices found for the resident around the time of the transfer and discharge. The deficiency was confirmed through interviews with the current DON and the Administrator, who both stated that they were unable to locate any documentation indicating that the resident had been given a written notice regarding the transfer or the discharge. This lack of documentation indicates a failure to comply with the facility's policy and regulatory requirements for notifying residents and their representatives about transfers and discharges.
Failure to Provide Bed Hold Policy Prior to Transfer
Penalty
Summary
The facility failed to provide a bed hold policy to a resident prior to transfer. Resident #8, who had diagnoses including a fracture of the right tibia and schizoaffective disorder, was transferred to an acute care hospital for psychiatric evaluation. The Administrator and the Director of Nursing (DON) confirmed that there was no documentation indicating that Resident #8 had received a bed hold policy, notice of transfer, notice of discharge, or a discharge summary before or after the transfer. This deficiency was identified during a review of the facility's Length of Stay By Discharge Reason Report, which documented 37 residents discharged during the specified period.
Failure to Allow Resident's Return After Hospitalization
Penalty
Summary
The facility failed to allow a resident's return after being transferred to a local hospital for a mental health evaluation. Resident #8, who had diagnoses including a fracture of the right tibia and schizoaffective disorder, was transferred to an acute care hospital for a psychiatric evaluation. Despite being cleared to return to the nursing home, the facility decided not to accept the resident back. This decision was made during a conference call involving the former DON, former administrator, Director of Admissions, and a liaison, where it was stated that Resident #8 required long-term acute care and was inappropriate for skilled nursing care. However, no documentation was found in the resident's medical records to support this decision or to provide a discharge summary or transfer notices around the time of the transfer. The director of admissions and the liaison confirmed that the resident was denied re-entry due to behaviors and the refusal of the facility's physicians to care for the resident. Despite being informed of the legal aspects of this decision, the former DON and administrator declined to allow the resident back. The hospital staff was informed that the resident could not return to the facility but could go to a sister facility. The lack of proper documentation and adherence to the facility's transfer and discharge policy led to the deficiency identified in the report.
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.
