First Shamrock Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingfisher, Oklahoma.
- Location
- 1415 South Main Street, Kingfisher, Oklahoma 73750
- CMS Provider Number
- 375416
- Inspections on file
- 20
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at First Shamrock Care Center during CMS and state inspections, most recent first.
Two residents, both with cognitive and psychiatric diagnoses, were involved in an incident where one physically struck the other, resulting in minor injury. Despite care plan interventions for agitation and aggression, the event occurred and was not reported to the DON or state health department as required. The facility's abuse prohibition policy was not effectively implemented, leading to a failure to protect residents from abuse.
A resident with severe cognitive impairment and psychiatric diagnoses physically struck another resident, and although staff intervened and assessed both individuals, the incident was not reported to the Oklahoma State Department of Health as required by facility policy. Facility leadership later acknowledged that the event should have been reported.
A resident with severe cognitive impairment and psychiatric conditions was witnessed striking another resident, resulting in minor redness. Although immediate separation and assessment occurred, the facility did not conduct the thorough investigation required by policy after the abuse allegation.
A resident with severe cognitive impairment and a history of agitation and aggression was involved in a physical altercation with another resident. Despite ongoing behavioral symptoms and a documented incident, the care plan was not updated to include new interventions addressing the aggressive behaviors.
A resident with severe mental illness and behavioral symptoms did not receive a scheduled antipsychotic injection as ordered, resulting in a significant decline in condition and increased aggressive behaviors. The omission was confirmed by facility records and staff, and additional medication was required to stabilize the resident.
A facility failed to accurately complete a quarterly MDS assessment for a resident with mood and schizoaffective disorders. Despite a recent Medication Regimen Review recommending a GDR, the quarterly assessment inaccurately documented past GDR and contraindication dates. The MDS coordinator confirmed the inaccuracy and was unaware of the facility's policy on assessment accuracy.
A facility failed to complete a discharge summary for a resident discharged against medical advice, despite policy requirements. The resident, with multiple health issues, signed an Against Medical Advice form. The facility manager acknowledged the discharge summary was not completed.
The facility did not follow its policy for labeling, dating, and storing opened food items, affecting the nutrition of 38 residents. During a kitchen tour, several opened items were found without labels or dates, including whipped topping, salad mix, shredded cheese, sliced cheeses, and dressings. The cook and CDM acknowledged the policy was not followed.
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices, as required. Observations showed no precaution notifications posted, and interviews revealed that CNAs and the DON were unaware of the precautions. The facility manager admitted to a lack of staff training and signage, despite being informed about the precautions two weeks prior.
The facility failed to ensure a full-time RN was designated as the DON. Despite having 35 residents, the facility's policy requiring the DON to be a licensed RN was not met. Interviews revealed that the nurse manager, identified as the DON, was an LPN. The nurse consultant did not provide a clear answer when asked about the DON.
The facility failed to manage and safeguard residents' personal funds, resulting in unaccounted amounts for two residents. The nurse manager acknowledged discrepancies in the logs and admitted there was no proper system in place prior to her taking over.
The facility failed to manage and safeguard residents' personal funds, leading to discrepancies in the balances for two residents. The nurse manager acknowledged the lack of a proper system and multiple people filling out logs, resulting in unaccounted amounts and potential misappropriation.
Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by an incident in which one resident with severe cognitive impairment, agitation, and aggressive behavior physically struck another resident. The care plan for the aggressive resident included interventions such as separating them from stressful situations and monitoring for signs of frustration, but these measures did not prevent the incident. The resident's assessment documented daily verbal behavioral symptoms and significant risk for physical illness or injury due to their condition. Following the incident, the resident who was struck was found to have slight redness behind the left ear and expressed concern about being hit again, despite stating they felt safe overall. The Director of Nursing (DON) was not aware of the incident at the time of interview and confirmed that an incident report had not been completed or reported to the state health department as required. The facility's policy prohibits all forms of abuse, but the failure to implement and follow reporting procedures contributed to the deficiency.
Failure to Report Resident-to-Resident Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the Oklahoma State Department of Health as required by policy. According to the facility's abuse prohibition policy, the Administrator or DON is responsible for initiating an immediate investigation of alleged abuse and notifying the state department within 24 hours, with a follow-up report within 5 working days. In this incident, a resident with severe cognitive impairment and multiple psychiatric diagnoses was witnessed by staff physically striking another resident near the neck, shoulder, and head area. Both residents were immediately separated and assessed, and the doctor and DON were notified. The resident who was struck did not sustain any injuries. Despite the incident meeting the criteria for reportable abuse, the event was not reported to the Oklahoma State Department of Health. Interviews with the ADON and DON confirmed that the incident should have been reported, and the DON stated they were not notified of the event. The failure to report the incident as required constitutes a deficiency in the facility's abuse reporting procedures.
Failure to Conduct Thorough Investigation After Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving a resident with severe cognitive impairment and multiple psychiatric diagnoses. According to facility policy, an immediate and documented investigation should be initiated and continue for at least 72 hours after any alleged abuse. However, after an incident where one resident was witnessed striking another near the neck, shoulder, and head area, the only documented actions were immediate separation and assessment of the residents, notification of the physician and DON, and initiation of 15-minute checks for the resident who initiated the contact. The Assistant Director of Nursing later confirmed that a thorough investigation should have been completed, indicating that the required investigative process was not followed.
Failure to Update Care Plan for Aggressive Behaviors
Penalty
Summary
The facility failed to update a resident's care plan to include new interventions addressing aggressive behaviors, despite evidence of ongoing behavioral issues. The resident, who had diagnoses including disorganized schizophrenia, expressive language disorder, restlessness, and agitation, was noted to have severe cognitive impairment and daily verbal behavioral symptoms that placed them at significant risk for illness or injury. Although the care plan initially addressed agitation and aggression, no new interventions were added after its initiation. An incident occurred in which the resident physically struck another resident, resulting in slight redness but no reported pain. Documentation showed that the care plan was not reviewed or revised to address this new aggressive behavior, as confirmed by facility staff.
Failure to Administer Antipsychotic Medication as Ordered
Penalty
Summary
A resident with diagnoses including disorganized schizophrenia, vascular dementia, major depressive disorder, and anxiety was prescribed an antipsychotic medication, Uzedy, to be administered as a subcutaneous injection every 28 days for management of schizophrenia. The resident's care plan identified the need for psychotropic drug use and required nursing staff to monitor and report side effects and behaviors to the physician. However, the treatment administration record showed that the scheduled injection was missed on June 1st, and this omission was confirmed by facility documentation and staff interview. Following the missed dose, the resident, who had severely impaired cognition and a history of delusions and daily verbal behavioral symptoms, experienced a significant deterioration in condition. The mental health progress note indicated that the resident continued to display physical aggression toward others despite receiving the missed dose later and being prescribed additional medication. The resident's behaviors interfered with participation in activities and social interactions, and further pharmacological intervention was required to stabilize the resident and return them to therapeutic levels.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to accurately complete a quarterly assessment for one of the twelve sampled residents, specifically regarding the Minimum Data Set (MDS) assessments. The facility's policy on the accuracy of MDS assessments requires that the assessment accurately reflect the resident's status. The resident in question was admitted with diagnoses including mood disorder, bipolar disorder, schizoaffective disorder, and major depression. A Medication Regimen Review conducted on May 14, 2024, recommended a gradual dose reduction (GDR) for medications Venlafaxine, Trintellix, and Lamotrigine, which was denied by the doctor due to concerns that a reduction would worsen or destabilize the resident's condition. However, the quarterly assessment dated May 23, 2024, inaccurately documented the last GDR and contraindication dates as September 5, 2021, and January 4, 2023, respectively. When questioned, the MDS coordinator acknowledged the inaccuracy and was unaware of the facility's policy for accuracy of assessments.
Failure to Complete Discharge Summary for Resident Discharged Against Medical Advice
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged against medical advice. The facility's policy, revised in April 2009, requires that a discharge summary and post-discharge plan be developed when a discharge is anticipated. However, for one resident, who had multiple diagnoses including depression, protein malnutrition, Wernicke's encephalopathy, chronic systolic heart failure, mixed hyperlipidemia, cerebral infarction, and nicotine dependence, no discharge summary was found in their clinical health record. The resident signed an Against Medical Advice form, acknowledging the risks of discharging without medical advice. When asked, the facility manager admitted that they did not complete the discharge summary at the time of discharge.
Failure to Label and Store Opened Food Items
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling, dating, and storage of opened food items in the kitchen, which affected the nutrition provided to 38 residents. During an initial tour of the kitchen, several opened food items were found in the refrigerator without labels or dates, including a bag of whipped topping, a bag of salad mix, a bag of shredded cheese, sliced cheeses, and opened ranch and French dressing. Additionally, sliced cheese and ham were not stored in sealed containers. When questioned, the cook acknowledged the absence of labels and dates on these items, and the Certified Dietary Manager (CDM) confirmed that the facility's policy required all opened food items to be labeled, dated, and stored in sealed bags or containers, which was not followed in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents who required them due to the presence of indwelling devices. Resident #2, admitted with epilepsy and neuromuscular dysfunction of the bladder, had a physician order for a Foley catheter and enteral feeding tube site care. However, during an observation, no enhanced barrier precaution notification was posted outside the resident's room. Similarly, Resident #21, admitted with cerebral infarction and hyperlipidemia, had a gastrointestinal PEG tube replacement, but no notification was observed for enhanced barrier precautions. Interviews with facility staff revealed a lack of awareness and training regarding enhanced barrier precautions. CNA #2 and CNA #1 both stated they had not been trained on the subject and were unaware of the precautions. The Director of Nursing (DON) also admitted to not knowing about enhanced barrier precautions or which residents required them. The facility manager acknowledged being informed about the precautions two weeks prior but confirmed that staff had not been trained and signs had not been posted for the residents in question.
Failure to Designate a Full-Time RN as DON
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was designated to serve as the Director of Nursing (DON) on a full-time basis. A Daily Census report documented that 35 residents resided in the facility. The facility's Director of Nursing policy required the DON to be a licensed RN with experience in nursing service administration, rehabilitation, and geriatric nursing. However, an Employee Changes report did not identify any employee as the DON. During interviews, an RN and a Certified Medication Aide (CMA) both identified the nurse manager as the DON, but the nurse manager was an LPN, not an RN. When the nurse consultant was asked about the DON, they hesitated and walked away without providing an answer.
Failure to Safeguard Residents' Personal Funds
Penalty
Summary
The facility failed to ensure a system was in place to manage and safeguard residents' personal funds for two of three sampled residents whose trust accounts were reviewed. The Trust Fund Policy required proper bookkeeping techniques, including maintaining individual records for each resident with details of transactions and ongoing balances. However, discrepancies were found in the Resident Petty Cash Logs for two residents. For one resident, a balance of $455 was recorded on one date, but only $155 was carried over six days later, leaving $300 unaccounted for. For another resident, multiple discrepancies were noted, including $15 and $2.75 unaccounted for on different dates. The nurse manager, who had been managing the trust accounts since June 2023, acknowledged the discrepancies when reviewing the logs. She stated that the money was usually locked in her office closet and that multiple people filled out the logs. Despite tracking the money on logs, the nurse manager admitted that there was no system in place prior to her taking over and that she did not think any discrepancies had been identified. The lack of a proper system and the involvement of multiple staff members in managing the logs contributed to the unaccounted funds in the residents' trust accounts.
Failure to Safeguard Residents' Personal Funds
Penalty
Summary
The facility failed to ensure a system was in place to manage and safeguard residents' personal funds, leading to the misappropriation of funds for two residents. A review of the Resident Petty Cash Logs revealed discrepancies in the balances for both residents. For one resident, there was a $300 discrepancy between the balance recorded on 08/24/23 and the carry-over balance on 08/30/23. For another resident, there were discrepancies of $15 and $2.75 on different dates. The nurse manager, who has been managing the trust accounts since June 2023, acknowledged the discrepancies but stated that no system was in place before her tenure, and multiple people were responsible for filling out the logs. She also mentioned that the money was usually locked in her office closet, and staff conducted a store twice a week for residents to shop for items, but there was no clear tracking of transactions before her management. The nurse manager was unaware of any discrepancies until they were pointed out during the survey. She admitted that the facility staff kept receipts but did not have a proper system to ensure that funds were not misappropriated. The lack of a systematic approach to managing and safeguarding residents' personal funds led to unaccounted amounts and potential misappropriation. The facility's failure to employ proper bookkeeping techniques and maintain accurate individual records for each resident's transactions contributed to the deficiency.
Latest citations in Oklahoma
A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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