Fountain View Manor, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Henryetta, Oklahoma.
- Location
- 107 East Barclay, Henryetta, Oklahoma 74437
- CMS Provider Number
- 375462
- Inspections on file
- 18
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Fountain View Manor, Inc during CMS and state inspections, most recent first.
The facility did not complete criminal history background checks for two LPNs, even though its policy required screening employees for histories of abuse, neglect, or mistreatment through prior employer information and checks of licensing boards and registries. Employee file reviews showed no background check results for an LPN hired in late 2024 and another hired in mid-2025, while the administrator reported believing that nurses with valid licenses overseen by the state nursing board did not require separate background checks. At the time of the survey, 80 residents were identified as residing in the facility.
Staff failed to follow proper infection control practices during a noon meal service involving about 80 residents. A dietary aide placed a sanitizing bucket on a food prep table next to a food processor used for puréed items, wiped a prep table with a rag from the sanitizing bucket, and then handled food trays without handwashing. In a separate instance, a cook used a sanitizing rag as a potholder to remove a pan of burritos from the oven and then prepared meal trays without performing hand hygiene.
Surveyors identified that all occupied rooms on the memory care unit lacked operational call lights, despite facility policy requiring a calling system for each resident. During a unit tour, each of the 14 observed rooms was found without a call light, and staff interviews revealed that CNAs and the ADON reported call lights were not installed because they were considered a strangulation risk and safety hazard, leaving residents to holler out if they needed staff assistance.
Surveyors found that two residents were not provided documented opportunities to create advance directives. Review of their electronic health records showed no advance directive acknowledgment forms, despite their admissions having occurred earlier. A social services staff member confirmed the absence of these forms in the charts and explained that the forms were likely omitted from the admission packet when new copies were made.
A resident with dementia, depression, and moderately impaired cognition (BIMS score of 10) had an inaccurate quarterly assessment related to antipsychotic medication use. Although a physician order had discontinued the resident’s Olanzapine, the assessment documented that the resident received an antipsychotic daily during the seven-day look-back period. During interview, the DON acknowledged that the assessment information was inaccurate.
A resident dependent on supplemental O2 with a history of acute respiratory failure and other comorbidities was observed multiple times receiving humidified O2 via nasal cannula with undated tubing and a humidifier bottle and storage bag that had not been changed since late November, despite a physician order and facility policy requiring monthly replacement. The resident’s assessment did not reflect current O2 therapy, while the care plan documented continuous O2 use. An LPN acknowledged the lack of dating on the tubing and misinterpreted the frequency for changing equipment, and the DON confirmed that the equipment should have been dated and changed monthly but was not.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions policy requiring both gown and gloves for high-contact care activities, including wound care. An LPN performed wound care on two residents with documented open wounds using only gloves and no gown, despite physician orders for ongoing wound treatments. During interviews, the LPN and the DON stated that enhanced barrier precautions, including gowns, were used only when residents had active infections such as hepatitis C, which conflicted with the written policy specifying gown and glove use for any wound care requiring a dressing.
The facility failed to ensure that posted staffing information contained the required components and was accessible to all residents. On multiple occasions, the posted staffing information at the nursing station did not include the facility name and staffing hours. Additionally, there was no posted staffing information in the Alzheimer's unit. The DON confirmed the absence of posted staffing information in the Alzheimer's unit and admitted to being unaware of the requirements for posting staffing information.
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks for 9 out of 65 employees hired between 2016 and 2024. The HR manager could not provide the necessary clearance letters or explain the absence of these checks, and the employee roster did not list these employees as current eligible employees.
The facility failed to ensure accurate MDS coding for several residents, including errors in documenting diuretic use, falls, insulin use, and antipsychotic medication. These inaccuracies were confirmed by the MDS coordinator and the DON.
The facility failed to date multidose vials upon opening. During an observation, one vial of Tuberculin Purified Protein and two vials of Influenza vaccine were found opened and not dated. The ADON confirmed that the bottles should have been dated.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for two residents. One resident with chronic pain and morbid obesity and another with hemiplegia and vascular dementia were observed with bed rails in use, but there was no documentation of regular inspections. The DON and administrator confirmed the lack of documentation, indicating a gap in the facility's maintenance program.
The facility failed to ensure residents' personal privacy in the Alzheimer's unit. A resident with dementia complained about wandering residents entering their room. Observations confirmed unsupervised wandering, and staff admitted difficulty in redirecting residents. The administrator acknowledged the issue, stating that wandering is common and families are advised not to bring valuable items.
A resident with urinary incontinence and morbid obesity did not receive scheduled baths or showers as required. The electronic bathing records showed significant gaps, and the resident confirmed irregular bathing. Staff interviews revealed a lack of proper documentation, making it impossible to verify if the resident received the appropriate care.
The facility failed to attempt appropriate alternatives and perform an entrapment risk assessment before installing bed rails for two residents. Both residents were observed using bed rails without the required documentation and assessments, contrary to the facility's bedrail policy.
A resident with dementia, sleep disorder, and hypertension was inappropriately prescribed Olanzapine for dementia. The DON confirmed that dementia is not an appropriate diagnosis for this medication, indicating a failure to follow guidelines for psychotropic medication use.
Failure to Complete Criminal Background Checks for Nursing Staff
Penalty
Summary
The facility failed to complete required criminal history background checks for two sampled LPN employees, despite having a policy stating that employees would be screened for a history of abuse, neglect, or mistreatment by obtaining information from previous or current employers and checking appropriate licensing boards and registries. Record review showed that one LPN hired on 10/08/24 and another LPN hired on 06/25/25 had no criminal history or background check results in their employee files. During an interview, the administrator stated they believed background checks were not required for nurses because the Oklahoma nursing board managed nursing licenses and that a valid license was sufficient for nurses to work in Oklahoma. At the time of the survey, the administrator identified that 80 residents resided in the facility. This deficiency was identified through review of the facility’s undated abuse/neglect/exploitation policy, undated employee lists, and the personnel files of the two LPNs, as well as the administrator’s statements explaining the facility’s practice regarding background checks for licensed nursing staff.
Improper Hand Hygiene and Sanitizer Use During Meal Preparation
Penalty
Summary
The facility failed to prepare and handle food in a manner that minimized the risk of infection and cross-contamination during the noon meal service, which served approximately 80 residents. During a kitchen tour, dietary aide (DA) #1 was observed preparing puréed dessert while also carrying a bucket of sanitizing water to a sink located beside the prep table used for puréed food. After dumping the sanitizing water into the sink, DA #1 placed the bucket on the prep table next to the food processor used for food preparation. Later, DA #1 was observed wiping down a prep table with a rag from the sanitizing bucket and then handling food trays without performing hand hygiene. In a separate observation, cook #1 removed a large sheet pan of burritos from the oven using a sanitizing rag as a potholder and then proceeded to prepare meal trays without washing their hands. The dietary manager (DM) later stated that staff should have washed their hands and should not have had the sanitizing bucket or rag in the area where food was being prepared.
Failure to Provide Call Lights in Memory Care Unit
Penalty
Summary
Surveyors found that the facility failed to ensure operational and available call lights for all 14 occupied rooms on the memory care unit, where 22 residents resided. During a tour of the unit on 01/13/26 between 9:01 a.m. and 9:14 a.m., each of the 14 observed rooms was noted to have no call light. An undated Call Light Policy stated that a calling system must be available for each resident in the nursing home, but this was not in place on the memory care unit. In interviews, a CNA reported being told that the rooms did not have call lights because they were considered a strangulation risk, and stated that if a resident needed staff assistance they would have to holler out. The ADON similarly stated that the memory care unit did not have call lights because they were viewed as a safety hazard. These observations and statements show that the facility had intentionally not provided call lights in the memory care unit bathrooms and bathing areas despite its own policy requirement that a calling system be available for each resident.
Failure to Offer and Document Opportunity for Advance Directives
Penalty
Summary
The facility failed to honor residents' rights to be offered the opportunity to formulate an advance directive by not ensuring that required advance directive acknowledgment forms were present in the records of two sampled residents. Record review showed that one resident, admitted on an unspecified date, had no advance directive acknowledgment form in the electronic health record. A second resident, also admitted on an unspecified date, likewise had no advance directive acknowledgment form documented in the electronic health record. During an interview on 01/14/26 at 11:33 a.m., a social services staff member confirmed that there were no advance directive acknowledgment forms in these residents' charts and stated that the form must have been left out of the admission packet when additional copies were made. These findings occurred in the context of a census of 80 residents, with 18 residents sampled for review of advance directives, and demonstrated that at least two residents and/or their representatives were not provided the documented opportunity to create an advance directive as required.
Inaccurate Assessment of Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident receiving antipsychotic medications. Record review showed a physician order dated 11/12/25 discontinuing the resident’s Olanzapine, an antipsychotic medication. However, the quarterly assessment dated 11/25/25 documented that the resident had received an antipsychotic medication daily during the seven-day look-back period. The same assessment showed the resident had a BIMS score of 10, indicating moderately impaired cognition for daily decision making, and listed diagnoses including dementia and depression. During an interview on 01/20/26 at 10:39 a.m., the DON stated that this assessment was inaccurate, confirming the discrepancy between the medical record and the assessment documentation. This deficiency involved 1 of 18 sampled residents reviewed for assessments, with the DON identifying that 80 residents resided in the facility at the time of the survey.
Failure to Change and Date Oxygen Equipment per Physician Order and Policy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not dating and changing oxygen equipment as ordered for one resident using humidified oxygen. On multiple observations over several days, the resident was seen in bed with humidified oxygen delivered via nasal cannula, with the nasal cannula and oxygen tubing not dated. The humidifier bottle and a storage bag taped or hanging from the oxygen machine were consistently dated 11/26/25, indicating they had not been changed since that date. The facility’s undated oxygen policy stated that oxygen tubing was to be changed at least monthly for infection control, and a physician’s order dated 10/16/23 directed that the resident’s oxygen tubing and humidifier be replaced monthly related to a diagnosis of acute respiratory failure. The resident’s annual assessment dated 10/15/25 documented a BIMS score of 9, indicating moderate impairment in daily decision-making, and listed diagnoses including dependence on supplemental oxygen, acute upper respiratory infection, major depressive disorder, anxiety disorder, and need for assistance with personal care. The assessment did not show that the resident was receiving oxygen therapy, while a care plan dated 01/13/26 documented continuous oxygen administration at 2–3 L/min by nasal cannula and concentrator. During interviews, an LPN confirmed the resident was receiving 4 L of oxygen via nasal cannula, acknowledged the tubing was not dated, and believed the order was to change all equipment weekly, while stating the MAR/TAR would indicate when changes were due. The DON later stated the oxygen tubing should have been dated and that the humidifier bottle and storage bag should have been changed monthly per physician orders but were not.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not using enhanced barrier precautions during wound care for two residents. On 01/14/26 at 9:05 a.m., LPN #3 provided wound care to Resident #49 after gathering supplies and entering the resident’s room. LPN #3 donned gloves but did not don a gown, despite the facility’s undated Enhanced Barrier Precautions policy stating that providers and staff must wear gloves and a gown for high-contact resident care activities, including wound care for any skin opening requiring a dressing. Resident #49’s annual assessment dated 12/17/25 showed severe impairment in daily decision making, memory problems, and diagnoses including dementia, depressive disorder, anxiety disorder, chronic pain, and a disorder of the skin and subcutaneous tissue. A physician order dated 01/02/26 directed Betadine application to both heels and specific wound care to the right buttock involving cleansing, application of Santyl or Anasept, calcium alginate, and bordered gauze until resolved. On 01/14/26 at 9:30 a.m., LPN #3 was again observed providing wound care, this time to Resident #75, and similarly donned only gloves without a gown. Resident #75’s annual assessment dated 11/22/25 showed no cognitive impairment with a BIMS score of 14 and diagnoses including congestive heart failure, anxiety disorder, pain, and an open wound of the left buttock, with no pressure ulcers noted. A physician order dated 01/12/26 directed cleansing of the left buttock wound, patting dry, and applying Medihoney and calcium alginate, then covering with bordered gauze once daily and as needed. During an interview at 9:37 a.m., LPN #3 stated that PPE such as gowns and face shields were needed only if a resident had hepatitis C or an active infection and that only gloves were needed for wound care. At 9:40 a.m., the DON stated that enhanced barrier precautions were used when a resident had an active infection, indicating facility practice inconsistent with the written Enhanced Barrier Precautions policy requiring gown and gloves for wound care as a high-contact activity.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to ensure that posted staffing information contained the required components and was accessible to all residents. On multiple occasions, the posted staffing information at the nursing station did not include the facility name and staffing hours. Additionally, there was no posted staffing information in the Alzheimer's unit. The Director of Nursing (DON) confirmed the absence of posted staffing information in the Alzheimer's unit and admitted to being unaware of the requirements for posting staffing information. This deficiency had the potential to affect all 73 residents residing in the facility.
Failure to Obtain Criminal Background Checks for Employees
Penalty
Summary
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 9 out of 65 employees hired between 2016 and 2024. The employees without background checks included CNAs, dietary aides, a social services assistant, activity assistants, and a housekeeper. The facility's policy required criminal background checks for all prospective employees, but these checks were not documented for the specified employees. The employee roster provided by OK Screen did not list these employees as current eligible employees, and the HR manager could not provide the necessary clearance letters or explain the absence of these checks. On April 24, 2024, the facility provided a clearance letter for one activity assistant, but OK Screen employees reported that the letter was not sent by their agency and that the assistant had not been fingerprinted. The HR manager, who was home sick, reported via phone that they could not provide the email from OK Screen with the clearance letter and that they delete these emails after printing the letters. The HR manager also reported that the employees were in the OK Screen system at one time but did not know why they were not on the current roster. The administrator confirmed that the employees should have had criminal background checks and clearance letters in their files.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of MDS assessments for several residents. Resident #23 was documented as receiving a diuretic and having two falls with no injury, but the medical record showed no order for a diuretic and only one fall without injury. MDS coordinator #1 confirmed these errors. Resident #10 was documented as having a fall with major injury in both an annual and a quarterly assessment, but the medical record did not support this. MDS coordinator #1 confirmed the coding errors for Resident #10 as well. Resident #9 was documented as receiving insulin injections 7 of 7 days during the look-back period, but the medication list showed no insulin injections. The DON confirmed this was a coding error. Resident #17 was documented as taking an antipsychotic 7 of 7 days during the look-back period, but the current medication list showed no antipsychotic medication. The DON confirmed this was also a coding error. These inaccuracies in MDS assessments indicate a failure to ensure accurate resident assessments.
Failure to Date Multidose Vials Upon Opening
Penalty
Summary
The facility failed to ensure multidose vials were dated upon opening. During an observation of the north hall medication refrigerator, it was found that one vial of house stock Tuberculin Purified Protein and two vials of multi-use Influenza vaccine were opened and not dated. The Assistant Director of Nursing (ADON) confirmed that the bottles should have been dated when opened. This deficiency was identified in a facility housing 73 residents.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety hazards for two residents. Resident #51, who had diagnoses including urinary incontinence, chronic pain, and morbid obesity, was observed with a half bed rail in the up position to assist with turning. The resident's care plan documented the use of the bed rail, but there was no evidence of regular inspections. Similarly, Resident #57, who had diagnoses including hemiplegia and vascular dementia, was observed with a half bed rail in the up position. The care plan for this resident did not document the use of a bed rail, and there was no evidence of regular inspections for this resident either. The Director of Nursing (DON) identified four residents with bed rails and confirmed the lack of documentation for regular inspections. The maintenance staff reportedly checked the bed rails routinely, but no records were kept. The administrator and DON both acknowledged the absence of documentation for the regular inspections of bed rails for Residents #51 and #57, highlighting a gap in the facility's maintenance program to ensure the safety of bed equipment.
Failure to Ensure Residents' Personal Privacy
Penalty
Summary
The facility failed to ensure residents' right to personal privacy for one resident sampled for personal privacy. Resident #40, who was admitted with diagnoses of hypertension, dementia, and thyroid disorder, complained about wandering residents entering their room. During an observation of the Alzheimer's unit, residents were seen going in and out of several rooms without supervision. An unknown resident was found sleeping in an unoccupied room. CNA #4 confirmed that only two staff members were assigned to the unit and admitted that they try to redirect wandering residents but are not always successful. Resident #40's roommate also complained about wandering residents trying to take their belongings. The administrator acknowledged the issue, stating that wandering is common in the Alzheimer's unit and that families are informed not to bring valuable personal items upon admission.
Failure to Ensure Scheduled Bathing for Resident
Penalty
Summary
The facility failed to ensure that a resident with urinary incontinence and morbid obesity was bathed as scheduled. The resident, who was moderately cognitively impaired and required substantial assistance with bathing, was supposed to receive a bath or shower three times a week according to the facility's shower schedule. However, the electronic bathing records for February, March, and April 2024 showed significant gaps in documentation, with the resident being bathed only a fraction of the scheduled times and no consistent documentation of refusals. The resident confirmed that they had not received showers regularly and often had to demand assistance from the staff. Interviews with staff, including a CNA and a corporate nurse consultant, revealed that showers should have been documented as either completed or refused in the electronic bathing record. The lack of documentation made it impossible to verify if the resident received the appropriate number of baths or showers. The Director of Nursing (DON) also confirmed that all baths should have been documented, whether completed or refused.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side rails for two residents. Resident #51, who had diagnoses including urinary incontinence, chronic pain, and morbid obesity, was documented to use a left half rail to assist with turning. However, there was no documentation of alternatives prior to the use of side rails or an entrapment risk assessment in the clinical record. The resident was observed with the bed rail in the up position and stated it was used to assist with turning. The facility's bedrail policy required attempts to use alternatives and an entrapment risk assessment before installing bed rails, which was not followed in this case. Resident #57, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction and vascular dementia, was documented to be severely cognitively impaired and dependent on most ADLs. The care plan did not document the use of bed rails, and there was no documentation of alternatives or an entrapment risk assessment in the clinical record. The resident was observed with a half bed rail in the up position and stated it was used to assist with turning. The administrator and DON confirmed that the required documentation and assessments were not completed, as they believed the rails were not used as restraints and thus did not require full compliance with the bed rail policy.
Inappropriate Psychotropic Medication Prescription
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medication without a specific diagnosis condition. A resident admitted with diagnoses of dementia, sleep disorder, and hypertension was prescribed Olanzapine 5mg every evening for dementia. The Director of Nursing (DON) later reported that dementia is not an appropriate diagnosis for Olanzapine and that the diagnosis should be changed. This deficiency was identified during a record review and interview, highlighting the facility's failure to adhere to guidelines for psychotropic medication use.
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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