Forrest Manor Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dewey, Oklahoma.
- Location
- 1410 North Choctaw, Dewey, Oklahoma 74029
- CMS Provider Number
- 375501
- Inspections on file
- 16
- Latest survey
- September 17, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Forrest Manor Nursing Center during CMS and state inspections, most recent first.
The facility failed to transmit MDS assessment data to CMS within the required timeframe for six residents. The ADON, who recently took over MDS coordinator duties, was aware of overdue assessments, while the administrator was unaware of the issue. This resulted in non-compliance with submission timelines.
The facility did not have a full-time DON, as required by their staffing policy. The DON had resigned suddenly, and the facility was actively seeking a replacement. No other RN had been assigned the DON's duties since the resignation.
The facility did not submit direct care staffing information to CMS on time. A PBJ report indicated that the data for the third quarter of 2024 was not received. The administrator was responsible for sending the data to a corporate employee, who claimed to have submitted it but lacked proof. The administrator suggested the issue might stem from using different quarter schedules.
The facility failed to provide two residents the opportunity to create advance directives, violating their rights. One resident, with chronic pain and pressure ulcers, had no documentation of their code status or advance directive discussion. Another resident also lacked documentation and did not recall discussing an advance directive. The ADON and BOM confirmed these deficiencies during record reviews.
The facility failed to provide prescribed dietary interventions for two residents, one with end-stage renal disease and another with spina bifida and pressure ulcers. A resident did not receive a diet limiting phosphorus and calcium, while another did not receive double portions of protein for wound healing. The dietary manager and assistant director of nursing acknowledged the oversight in meeting these dietary needs.
A facility failed to conduct post dialysis assessments for a resident with end stage renal disease, who was scheduled for dialysis three times a week. Although pre-dialysis assessments were documented, post dialysis assessments were missing on several occasions. RN #1 confirmed the absence of documentation for post dialysis assessments, which should include checking weight, vital signs, dialysis site, and bruit.
The facility failed to ensure GDR requests were attempted and/or addressed by the physician for two residents receiving psychotropic medications. One resident with PTSD and major depressive disorder had no GDR attempts documented for their antidepressant and antianxiety medications. Another resident with dementia and anxiety disorder had a GDR recommended for risperidone, but it was not addressed by the physician, and no other GDR attempts were documented.
The facility failed to comply with regulations for psychotropic medications for two residents. A resident with anxiety was given Ativan PRN without a documented rationale for extending use beyond 14 days. Another resident with dementia and anxiety was prescribed risperidone without an appropriate diagnosis. The ADON acknowledged the oversight.
The facility failed to provide therapeutic diets as ordered for two residents. One resident with end-stage renal disease did not receive a diet with low sodium, less phosphorus, and no calcium, as the facility did not have a diet ordered. Another resident with spina bifida and pressure ulcers did not receive double portions of protein as prescribed, leading them to purchase their own supplements. The dietary manager and assistant director of nursing acknowledged the oversight and failure to meet dietary needs.
The facility failed to update dietary menus, provide nutritionally equivalent meal alternatives, and have a Registered Dietitian review the menus for nutritional adequacy. The Dietary Manager, new to the position, found the extended menu dated November 2022. The Business Office Manager created weekly menus based on outdated menus and resident requests, which were not reviewed by the RD. Residents could choose from an alternate menu that was not nutritionally equivalent to the served meals.
The facility failed to maintain sanitary meal service and use professional-grade kitchen equipment. Staff were observed handling food improperly, not changing gloves, and using household appliances. The dish machine was not reaching required temperatures, and staff were unsure of sanitizing procedures. These issues affected meal service for 61 residents.
The facility failed to accurately document the code status for two residents, leading to discrepancies in their medical records. One resident had conflicting stickers indicating both DNR and Full Code status, while another had a DNR form signed by a physician despite being listed as Full Code in other documents. The ADON acknowledged these issues, noting that staff relied on stickers for code status, which contributed to the confusion.
The facility failed to monitor trends related to infectious diseases due to missing documentation in their infection surveillance records for January, February, and March 2024. Despite having an infection control policy, the facility did not track infectious diseases or trends during these months. This was confirmed by the ADON, who acknowledged the lack of documentation.
A resident was allowed to self-administer medications without a completed assessment to ensure their safety. The facility's policy requires an interdisciplinary team to assess the resident's abilities before allowing self-administration, but this was not done for the resident who was prescribed albuterol and ipratropium via nebulizer and tiotropium bromide inhalations.
A facility failed to provide a CMS-10123 form to a resident discharged from Medicare Part A services. The form, which was undated and unsigned, indicated the end of coverage, but the Business Office Manager admitted to forgetting to provide it. This oversight was identified during a survey, with six residents having been discharged from Medicare Part A in the previous six months.
A facility failed to complete a baseline care plan for a newly admitted resident with diabetes mellitus and hypertension within 48 hours. An RN was unaware of the completion status, and the ADON confirmed the absence of the care plan.
A facility failed to develop a comprehensive care plan for a resident with diabetes mellitus and hypertension. The absence of documentation was confirmed by the ADON during a record review and interview.
A facility failed to include the use of bedrails in the care plan for a resident. The care plan lacked any mention of a problem, goal, or intervention regarding bedrails, despite the resident using a bed with bedrails for about six months. The ADON confirmed that the care plan should have addressed the use of bedrails.
A resident did not receive scheduled showers twice a week, as required for their ADL care. The resident was observed with unkempt hair and reported missing weekend showers. The clinical record lacked documentation for several scheduled showers, and the ADON confirmed the need for proper charting even if a shower is refused.
A resident with bilateral contracted hands did not receive the care plan intervention of having contracture cushions or rolled rags in their hands. Observations showed the absence of these supports, and staff interviews confirmed inconsistent implementation of the care plan. The ADON acknowledged the oversight.
A facility failed to attempt alternatives and obtain informed consent for bed rail use for a resident with severe cognitive impairment. The ADON confirmed the absence of documentation for educating the resident's representative or attempting less restrictive interventions, violating the facility's Bed Safety policy.
A resident was prescribed and administered Macrobid without a prior urine culture to identify the infection-causing organism. The lab report indicated abnormal findings, but no culture was ordered. The ADON confirmed the oversight, acknowledging that determining the organism and effective antibiotics beforehand is best practice.
A facility failed to inspect a resident's bed and bedrails for safety before use, contrary to its Bed Safety policy. The resident was moved to a new room with a bed that had full side rails, unlike their previous bed. The maintenance supervisor admitted that safety inspections were not conducted prior to the use of bedrails, and the ADON acknowledged the oversight.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for six of the twenty sampled residents. The facility's policy, dated 2001, mandates that resident assessments be conducted and submitted in accordance with federal and state submission timeframes. However, a review of the facility's MDS 3.0 Assessment Summary Report revealed that the quarterly assessments for six residents were submitted to CMS beyond the required timeframe. The delays in transmission ranged from several days to over a month past the required submission dates. During interviews, the Assistant Director of Nursing (ADON) acknowledged that they had recently assumed the MDS coordinator duties and were aware of multiple overdue assessments that had not been transmitted. The facility administrator stated they were unaware that the MDS assessments had not been completed and transmitted, expressing an expectation that all MDS assessments would be opened, completed, and submitted in a timely manner. This oversight resulted in the facility's non-compliance with the required assessment submission timelines.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON), which is a requirement for maintaining proper nursing services staffing. The facility's policy stated that a full-time licensed RN or LPN should be appointed as the DON. However, the facility did not have a full-time DON at the time of the survey. The Business Office Manager (BOM) confirmed that the DON had resigned approximately three weeks prior to the survey, and the facility was actively advertising for a new DON. The administrator provided a letter indicating that the former DON had resigned suddenly via text message, and no other RN had been assigned the DON's duties since the resignation.
Failure to Submit Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to provide direct care staff information to CMS within the required time frame. The issue was identified through a PBJ report for the third quarter of 2024, which documented that the direct care staffing data had not been received by CMS. The facility administrator was responsible for sending the staffing data to an employee at corporate headquarters, who was then supposed to submit it to CMS. However, the employee claimed to have sent the data but could not provide documentation to prove it. The administrator acknowledged awareness of the submission time frame and speculated that the discrepancy might be due to the company's use of standard calendar-based quarters, which differed from the government's schedule.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide an opportunity for two residents to create an advance directive, which is a violation of their rights. Resident #9, who was admitted to the facility on an unspecified date, did not have any documentation indicating they were given the opportunity to create an advance directive. Interviews with the Assistant Director of Nursing (ADON) and the Business Office Manager (BOM) confirmed the absence of such documentation in the resident's records. Additionally, Resident #9 stated they did not recall discussing an advance directive with anyone. Similarly, Resident #50, who had diagnoses including chronic pain and pressure ulcers, also lacked documentation regarding the opportunity to create an advance directive. The resident's clinical record did not include their code status in the physician's orders or on the chart cover. During a review of the clinical record with the ADON and BOM, it was found that the facility form addressing advance directives was blank, indicating that the facility had not addressed this issue with Resident #50.
Failure to Provide Prescribed Dietary Interventions
Penalty
Summary
The facility failed to provide dietary interventions as ordered by the physician for two residents, leading to deficiencies in their nutritional care. Resident #19, diagnosed with end-stage renal disease, was supposed to receive a diet with less phosphorus and no calcium, as documented in a dialysis communication form. However, the facility did not have a diet ordered for the resident in the monthly physician's orders, and the dietary manager (DM) confirmed that all residents received the same meal options, which did not accommodate the resident's dietary needs. The assistant director of nursing (ADON) acknowledged that the facility was not meeting the resident's nutritional needs, as the available meal choices did not limit calcium and phosphorus intake as required. Resident #50, who had spina bifida and pressure ulcers, was ordered to receive double portions of protein to aid in wound healing. However, the resident reported not receiving the prescribed double portions or protein drinks with meals, leading them to purchase their own supplements. Observations confirmed that the resident's meal trays did not contain the ordered double portions of protein. The DM admitted that the staff overlooked the order on the diet card, and the ADON confirmed that the facility did not follow the physician's order for double portions of protein.
Failure to Perform Post Dialysis Assessment
Penalty
Summary
The facility failed to perform a post dialysis assessment for a resident with end stage renal disease who required dialysis. The resident was scheduled to attend dialysis three times a week as per the physician's orders for August 2024. Although the pre-dialysis assessments and communication from the dialysis unit were documented, there was no record of post dialysis assessments on multiple dates. RN #1 confirmed that the post dialysis assessment, which should include checking the resident's weight, vital signs, dialysis site, and bruit, was not performed. The dialysis log book, intended to facilitate communication between the dialysis center and the facility, lacked documentation of these assessments.
Failure to Ensure GDR Attempts for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Gradual Dose Reduction (GDR) requests were attempted and/or addressed by the physician for two residents who were receiving psychotropic medications. Resident #37, diagnosed with PTSD and major depressive disorder, was prescribed venlafaxine, mirtazapine, and buspirone. Despite the resident's routine use of these medications, there was no documentation of any GDR attempts in the medical records. The Assistant Director of Nursing (ADON) confirmed the absence of GDR documentation for this resident. Similarly, Resident #49, diagnosed with unspecified dementia and anxiety disorder, was prescribed risperidone and sertraline. A GDR was recommended for risperidone, but there was no documentation that the physician addressed this recommendation. The medical records did not contain any other GDR attempts for this resident, and the ADON confirmed the lack of documentation. These findings indicate a failure in the facility's process to ensure GDRs are attempted and documented as per guidelines.
Non-compliance with Psychotropic Medication Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications for two residents. Resident #42, who had a diagnosis of anxiety, was prescribed Ativan, an antianxiety medication, on a PRN basis without an end date. The medication was administered every four hours as needed, starting from February 19, 2024, and continued without a documented rationale or physician's signature for extending the order beyond the 14-day limit. This oversight was noted despite a Consultant Pharmacist Communication to the Physician highlighting the requirement for a clinical rationale and specific duration for extending PRN psychotropic orders. Resident #49, diagnosed with unspecified dementia and anxiety disorder, was routinely administered risperidone, an antipsychotic medication, based on a physician's order dated January 12, 2024. The order cited unspecified dementia as the indication for the medication, which the Assistant Director of Nursing (ADON) acknowledged was not an appropriate diagnosis for antipsychotic use. This lack of appropriate diagnosis for the use of antipsychotic medication was identified during a quarterly assessment conducted on May 3, 2024.
Failure to Provide Therapeutic Diets as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by the physician for two residents. Resident #19, diagnosed with end-stage renal disease, was supposed to receive a regular renal diet with low sodium, less phosphorus, and no calcium. However, the facility did not have a diet ordered for the resident as of August 2024, and the dietary manager (DM) admitted that all residents received the same meal or an alternate choice, leaving it to the residents to make appropriate meal choices. The assistant director of nursing (ADON) acknowledged that the facility was not accommodating the resident's dietary needs, as the available meal options did not allow for the necessary dietary restrictions. Resident #50, diagnosed with spina bifida and pressure ulcers, was ordered to receive double portions of protein to aid in wound healing. However, the resident reported not receiving the prescribed double portions of protein or the protein drink with each meal, leading them to purchase their own supplements. Observations confirmed that the resident's meal trays did not contain the required double portions of protein, and the DM admitted that the staff overlooked the order on the diet card. The ADON confirmed that the facility did not follow the physician's order for double portions of protein.
Failure to Update Menus and Ensure Nutritional Adequacy
Penalty
Summary
The facility failed to update the dietary menu, offer nutritionally equivalent alternatives to planned meals, and have a Registered Dietitian (RD) review the menus for nutritional adequacy. The Dietary Manager (DM), who was new to the position, was unable to locate the extended menu initially and later found it dated November 2022. The Business Office Manager (BOM) acknowledged that residents complained about receiving the same meals repeatedly and that they had requested updated menus from company representatives but did not receive them. Consequently, the BOM began creating weekly menus and substitutions based on the outdated November 2022 menu and resident requests, which were not reviewed or approved by the RD. Additionally, the DM stated that if a resident did not want the served meal, they could choose from an alternate menu offering soup, salad, grilled cheese, or a peanut butter sandwich, which was not nutritionally equivalent to the served meals. This affected 61 residents who ate meals from the kitchen, as identified by the DM.
Deficiencies in Meal Service and Kitchen Equipment
Penalty
Summary
The facility failed to adhere to professional standards in meal service, resulting in unsanitary food handling practices and improper use of kitchen equipment. Observations revealed that the hand washing sink in the kitchen was obstructed by various items, making it inaccessible. A staff member was seen handling food with gloved hands without changing gloves between tasks or residents, and touching various surfaces and their clothing, which compromised hygiene. Additionally, the staff member did not wear a beard guard. The dish machine was operated without reaching the required water temperature or applying disinfectant, and staff were unsure of the correct procedures for using sanitizing agents. Further observations indicated that kitchen staff used household-grade appliances instead of professional-grade equipment, which is not in accordance with professional standards. Staff members were seen using improper techniques to handle and serve food, such as using gloved hands to touch multiple surfaces and food items without changing gloves. One staff member admitted to not being trained adequately for serving food from the steam table, leading to improper handling of food items. These deficiencies affected the meal service for 61 residents who consumed meals prepared and served in the kitchen.
Code Status Documentation Errors
Penalty
Summary
The facility failed to ensure that the code status of residents was clearly identified in their medical records, leading to discrepancies in the documentation for two residents. Resident #9, who had diagnoses including chronic kidney disease and chest pain, had conflicting stickers on their medical chart indicating both 'Do Not Resuscitate' (DNR) and 'Full Code' status. Despite having a signed DNR consent form in the medical record, the sticker indicating 'Full Code' was not removed, which was acknowledged as a problem by the Assistant Director of Nursing (ADON). The ADON stated that staff should have checked the chart for the correct paperwork, but the facility's policy on code status was not provided. Similarly, Resident #18, with diagnoses including muscular dystrophy and vascular dementia, had a face sheet and physician orders indicating 'Full Code' status, while a DNR form signed by a physician indicated otherwise. The ADON confirmed that the resident's chart and paperwork should have documented a DNR status. The reliance on stickers for determining code status, as stated by RN #1, contributed to the confusion, as they were the most convenient method used by staff, despite the presence of a binder at the nurses' station with each resident's code status.
Inadequate Infection Surveillance Documentation
Penalty
Summary
The facility failed to consistently monitor for trends related to infectious diseases, as evidenced by the lack of documentation in their infection surveillance records for the months of January, February, and March 2024. The facility's infection control policy, updated in May 2022, mandates the establishment of an infection control program to investigate, control, and prevent infections. However, upon review, it was found that the facility did not track infectious diseases or look for trends during the specified months. This deficiency was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged the absence of documentation for infection surveillance during the mentioned period.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication. The deficiency involved one resident who was allowed to self-administer medications without a completed assessment to determine their ability to do so safely. The facility's policy on the right to self-administer medications requires an interdisciplinary team to assess the resident's cognitive, physical, and visual abilities before allowing self-administration. However, the Assistant Director of Nursing (ADON) identified that an assessment for self-administration of medication had not been completed for the resident, who was prescribed albuterol and ipratropium via nebulizer and tiotropium bromide inhalations, both of which were kept at the bedside.
Failure to Provide CMS-10123 Form Upon Discharge from Medicare Part A
Penalty
Summary
The facility failed to provide a CMS-10123 form to a resident who was discharged from Medicare Part A services. This deficiency was identified during a record review and interview, where it was found that one of the three sampled residents, referred to as Resident #50, did not receive the necessary form. The CMS-10123 form, which was undated, indicated that Resident #50's Medicare Part A coverage would end on 06/14/24, but the form was not signed. On 09/09/24, the Business Office Manager (BOM) admitted to forgetting to provide the form to Resident #50, who had been discharged from Medicare Part A services on 06/14/24. Additionally, the BOM stated that six residents had been discharged from Medicare Part A services in the previous six months leading up to the survey.
Failure to Complete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to ensure a baseline care plan was completed for a resident within 48 hours of admission. The resident had diagnoses including diabetes mellitus and hypertension. There was no documentation of a baseline care plan for this resident. During interviews, an RN stated they did not complete the resident's admission and were unaware if a baseline care plan was completed. The ADON confirmed that a baseline care plan for the resident was not located.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with diabetes mellitus and hypertension. During a review of records and an interview, it was found that there was no documentation of a completed care plan for this resident. The Assistant Director of Nursing (ADON) confirmed that a care plan had not been completed for the resident.
Failure to Care Plan Bedrail Use
Penalty
Summary
The facility failed to include the use of bedrails in the care plan for a resident, identified as #42, who was reviewed for accidents. The care plan, dated May 23, 2024, lacked any mention of a problem, goal, or intervention regarding the safe use of bedrails. On September 11, 2024, it was observed that the resident's bed had a full side rail attached to each side. A Certified Nursing Assistant (CNA) confirmed that the resident had been using a bed with bedrails for approximately six months. The Assistant Director of Nursing (ADON) acknowledged that the resident's current care plan did not address the use of bedrails, which should have been included.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers as scheduled for a resident who was dependent on staff for activities of daily living (ADL) care. The resident was observed with long, tangled, and greasy hair, indicating a lack of proper hygiene care. The resident reported being scheduled for two showers per week but only receiving one, specifically missing the weekend shower. A review of the resident's clinical record confirmed the absence of documentation for showers on several Saturdays, despite being scheduled. The Assistant Director of Nursing (ADON) acknowledged the issue, noting that a shower sheet should be completed even if the resident refused the shower.
Failure to Implement Care Plan for Contracted Hands
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with bilateral contracted hands. The care plan, updated on 06/04/24, specified that the resident should have contracture cushions or rolled rags in their hands if possible. However, observations on 09/08/24 and 09/10/24 revealed that the resident was not provided with any device or material to protect and support their contracted hands. Interviews with RN #1 and CNA #1 confirmed that the resident had contracted hands and that rolled rags were sometimes used, but there was no consistent implementation of this intervention. RN #1 and the ADON acknowledged that the rolled rags were part of the care plan, but staff had not been following it.
Failure to Obtain Consent and Attempt Alternatives for Bed Rail Use
Penalty
Summary
The facility failed to adhere to its Bed Safety policy by not attempting alternatives to the use of bed rails and not obtaining informed consent prior to their use for a resident. The policy requires an interdisciplinary assessment, consultation with the attending physician, and input from the resident or their legal representative, along with obtaining consent before using bed rails. However, for one resident with severe cognitive impairment due to Alzheimer's disease and atherosclerosis, these steps were not documented or followed. The Assistant Director of Nursing (ADON) confirmed that the resident had bed rails attached to their bed for about six months, but there was no documentation of the resident's representative being educated about the bed rails or providing written consent. Additionally, there was no evidence of less restrictive interventions being attempted in the resident's medical records. This oversight was identified during an observation and interview process, highlighting a deficiency in the facility's compliance with its own safety policies.
Failure to Culture Urine Sample Before Antibiotic Administration
Penalty
Summary
The facility failed to culture a urine sample before prescribing and administering an antibiotic to one of the 24 sampled residents reviewed for antibiotic use. A laboratory report indicated that a urine sample from the resident was collected, showing abnormal findings such as high nitrate and white blood cell levels, suggesting a culture was needed. However, no culture was ordered. Instead, a handwritten note by an RN on the laboratory report prescribed Macrobid, an antibiotic, to be administered twice daily for seven days. The resident confirmed taking the antibiotic, and the ADON later acknowledged that a culture had not been performed to identify the organism causing the infection or to determine the most effective antibiotic, which is considered best practice.
Failure to Inspect Bedrails for Safety
Penalty
Summary
The facility failed to inspect the bed and bedrails of a resident before the use of bedrails, which was identified during a survey. The facility's Bed Safety policy, dated December 2007, mandates regular inspections by maintenance staff to identify risks and problems, including potential entrapment risks. However, it was observed that a resident's bed had full side rails attached, and the maintenance supervisor admitted that bed or bedrail safety inspections were not performed prior to their use by residents. The resident had been moved to their current room about six months before the survey, and the bed they were assigned had rails attached, unlike the previous bed they used. The Assistant Director of Nursing (ADON) acknowledged awareness of the dangers associated with bedrails but confirmed that no safety inspection had been conducted for the resident's bed.
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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