Gracewood Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 6201 East 36th Street, Tulsa, Oklahoma 74135
- CMS Provider Number
- 375438
- Inspections on file
- 25
- Latest survey
- January 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Gracewood Health & Rehab during CMS and state inspections, most recent first.
The facility failed to provide privacy curtains in certain rooms, affecting residents' privacy during personal activities. Observations showed rooms without curtains, and a resident reported a lack of privacy. The DON confirmed the issue, noting maintenance had removed curtains after work was done. Maintenance staff acknowledged the absence of curtain tracks, leaving residents without privacy.
The facility failed to provide adequate activities for four residents with unique needs, including one with mobility issues due to a damaged wheelchair and others with dementia requiring structured programs. Staff were unaware of specific needs, and documentation did not reflect care plans, indicating a lack of oversight and personalized care.
The facility failed to conduct monthly medication regimen reviews for several residents, as required by its policy. Residents with various diagnoses, including schizoaffective disorder, dementia, and anxiety, had missing reviews for multiple months. Interviews revealed issues with medical records and the accuracy of medication orders, with the pharmacist facing challenges in accessing lab results and relying on unreliable records.
The facility failed to secure and properly manage medications across several carts. Medication carts were left unlocked and unattended, and medications were not dated when opened or discarded after 28 days. Expired medications were also found on a cart. The DON acknowledged these oversights.
The facility failed to maintain complete and accessible records for several residents, including those with dementia and schizoaffective disorder. Records were missing current physician's orders, medication regimen reviews, and lab results. The DON and MDS coordinator were responsible for record completeness but lacked a monitoring system. The pharmacist faced challenges accessing accurate orders and lab results, indicating systemic issues in record-keeping practices.
The facility failed to ensure operational call lights for residents, as multiple rooms were observed without call light cords and some had exposed wires. Despite a policy requiring call systems, maintenance logs and staff interviews revealed ongoing issues, with residents reportedly removing call lights and replacements delayed. The administrator did not provide a solution for residents needing assistance without call lights.
The facility failed to implement enhanced barrier precautions for a resident with a PEG tube during medication administration and site care. The policy requires gowns and gloves for high-contact activities, but RN #1 only used gloves. There was no signage indicating precautions near the resident's room, and the DON was unaware of the policy.
A resident with dementia, dependent on staff for ADL care, did not receive adequate nail care as per facility policy. Despite the requirement for daily cleaning and regular trimming, the resident's records showed minimal documentation of nail care being offered or provided. Observations revealed long, debris-filled nails, and staff interviews confirmed the resident's dependency on staff for nail care. The DON acknowledged the lack of documentation and monitoring, indicating a failure in policy adherence.
A resident with dementia and delusions had a bruise on their neck that was not documented or monitored by the facility. Despite staff awareness and previous reports, the bruise was not addressed according to protocol, and no documentation was found to support any intervention by the medical director. The facility failed to follow its protocol for reporting and assessing the resident's condition.
A facility failed to properly assess and document the use of bed rails for a resident with dementia and hemiparesis. The resident was observed with bed rails, but the assessment was incomplete, and there was no documentation of medical necessity, alternative interventions, or informed consent. Staff were unaware of the necessity for the rails, and the care plan did not reflect their use.
The facility did not post nurse staffing information for public view as required. Although staffing numbers were generally adequate, the administrator admitted that the total number of nursing hours was not posted. The DON stated that the daily schedule book, which was supposed to be at the nurses' desk, was in their office and lacked the total nursing hours.
A facility failed to ensure proper monitoring and documentation for a resident receiving psychotropic medications, including Risperdal, without evidence of side effect monitoring or a medication regimen review. The care plan was not updated to include Risperdal, and the DON cited issues with medical records as the reason for the lack of documentation. The pharmacist had no record of a recent order for Risperdal, indicating a communication and documentation failure.
The facility failed to complete physician-ordered lab tests for two residents. A resident with schizoaffective disorder did not have a valproic acid level obtained as ordered, and another resident with vascular dementia did not have a CMP completed as scheduled. The DON acknowledged responsibility but did not provide additional lab reports.
A facility failed to document regular safety inspections of a resident's bed, who had unspecified dementia and hemiparesis, and was using bed rails. The facility's policy required regular inspections to identify risks, but no documentation was found. Observations confirmed the use of bedrails, and interviews revealed that maintenance staff did not document safety checks, addressing issues only when noticed or during rounds.
The facility failed to ensure an RN was licensed in accordance with state laws. An RN was observed working as a charge nurse with a valid Texas license but an expired Oklahoma license. The DON was unaware of the expired license, and the RN had been working full-time since a specified date.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to ensure residents were provided with privacy curtains, compromising their privacy. Observations revealed that certain rooms lacked privacy curtains, affecting the residents' ability to maintain privacy during personal activities. In one instance, a resident expressed that all activities, except using the restroom, were conducted in full view of their roommate due to the absence of a privacy curtain. The Director of Nursing (DON) acknowledged that privacy was not effectively provided in a room where maintenance had removed the curtain following work completed a month prior. Maintenance staff confirmed the absence of curtain tracks in the room and were unsure why they had not been installed, resulting in a lack of privacy for the residents.
Inadequate Activity Provision for Residents
Penalty
Summary
The facility failed to provide adequate activities for four residents, each with unique needs and conditions. Resident #18, who had chronic pain, obesity, and limited mobility, was unable to participate in activities due to an uncomfortable and damaged wheelchair. Despite expressing the need for a better wheelchair, staff were unaware of the issue until it was brought to the attention of the Director of Nursing (DON), who then took action to replace it. The lack of communication and awareness among staff about the resident's needs contributed to the deficiency. Resident #22, diagnosed with dementia and anxiety, was observed to have little engagement in activities despite a care plan that emphasized the need for sensory stimulation and structured programs. The resident was often found in bed, and there was no evidence of activities occurring on the memory unit. The activities director admitted to not monitoring activity documentation and was unaware of the specific goals for Resident #22, indicating a lack of oversight and personalized care. Resident #26, with Alzheimer's disease and dementia, and Resident #42, with vascular dementia, also experienced inadequate activity provision. Both residents had care plans that outlined specific activities and goals, but the documentation did not reflect these interventions. The activities director acknowledged the lack of formal training in dementia care and the absence of proper documentation, which contributed to the failure in meeting the residents' needs. The administrator confirmed that the activities director was responsible for documenting and completing activities, but there was a lack of daily monitoring and tracking by the social services director.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRRs) were conducted by a licensed pharmacist for five residents who were reviewed for unnecessary medications. The facility's policy required the consultant pharmacist to review each resident's medication regimen monthly and provide a written, signed, and dated report to the Director of Nursing Services and Medical Director. However, the clinical records for residents #24, #57, #62, #22, and #59 revealed missing MRRs for various months in 2024, indicating non-compliance with the facility's policy. Resident #24, diagnosed with schizoaffective disorder, bipolar type, did not have MRRs conducted in January, February, March, or July 2024. Resident #57, with unspecified dementia, lacked MRRs for December 2023 and March 2024. Resident #62, diagnosed with vascular dementia, was missing an MRR for January 2024. Resident #22, with Alzheimer's disease/dementia, anxiety, and depression, had missing MRRs for January, February, March, and August 2024. Additionally, the care plan for Resident #22 was not updated to include all current medications. Resident #59, with dementia and anxiety, had missing MRRs for several months in 2024, and the clinical record did not reveal lab results. Interviews with the Director of Nursing (DON) and the pharmacist highlighted issues with medical records and the accuracy of medication orders. The pharmacist reported difficulties accessing lab results and relied on the medication administration record rather than the clinical record due to its unreliability. The pharmacist also mentioned challenges in obtaining lab access and noted that they visited the facility monthly, with reports delivered shortly after. These deficiencies in conducting timely MRRs and maintaining accurate clinical records contributed to the facility's failure to comply with its medication management policies.
Medication Management Deficiencies in Facility
Penalty
Summary
The facility failed to ensure the security and proper management of medications across several medication carts. On multiple occasions, the 300 hall treatment cart was left unattended and unlocked by RN #2 and RN #1 during medication administration, contrary to the facility's policy that requires medication carts to be locked when not in use. Additionally, medication cups containing various medications were left unattended on top of the cart. The Director of Nursing (DON) confirmed that medication carts should be locked when unattended. The facility also failed to date medications when opened and did not discard insulin after 28 days as required. Observations revealed that several inhalers and insulin vials on the 200 and 300 hall treatment carts were opened but not dated. Furthermore, expired medications were found on the 100 hall medication cart, including Tussin DM and geri-lanta, which had passed their expiration dates. The DON acknowledged the oversight in monitoring for expired medications and the failure to date opened medications.
Incomplete and Inaccessible Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accessible for four of the 18 sampled residents. The Medication Orders policy required a current list of orders to be maintained in each resident's clinical record, and the Charting and Documentation policy required documentation of all services provided, progress toward care plan goals, and any changes in the resident's condition. However, the records for residents with diagnoses such as dementia, schizoaffective disorder, Alzheimer's disease, anxiety, and depression were found to be incomplete. For instance, Resident #57's records lacked recent dose reductions and lab reports, while Resident #24's records were missing current physician's orders. Resident #22's records were missing several months of medication regimen reviews, and Resident #59's records lacked multiple months of medication regimen reviews and lab results. The Director of Nursing (DON) and the MDS coordinator were identified as responsible for ensuring the completeness and accessibility of clinical records, but they admitted to not knowing how records were monitored. The pharmacist also expressed difficulties in accessing accurate orders and lab results, relying instead on the medication administration record and staff assistance to obtain necessary information. The pharmacist noted that they had not seen certain medication orders and had issues with lab access, indicating a systemic problem with the facility's record-keeping practices. These deficiencies in maintaining complete and accessible records hindered effective communication and care coordination for the residents involved.
Deficiency in Call Light System Availability
Penalty
Summary
The facility failed to ensure that call lights were operational and available for residents, as observed during a survey. The facility's policy, reviewed in May 2024, mandates that all resident rooms be equipped with a call system for staff assistance. However, multiple observations revealed deficiencies in this area. On several occasions, rooms were found without call light cords, and some had exposed wires where the call lights should have been. Specifically, on January 6, 2025, several rooms were noted to lack call light cords, and exposed wires were observed in some rooms. Additionally, on January 8, 2025, a room was found with wires protruding from the wall where the call light should be. The maintenance log indicated that a call light was ripped from the wall in one room on December 28, 2024, with repairs documented on December 30, 2024. Despite this, issues persisted into January 2025. Maintenance staff reported that residents removed call lights and did not replace them, and it had been about a month since new call lights were ordered by the administrator. When questioned about how residents could notify staff without call lights, the administrator did not provide an answer, highlighting a significant gap in ensuring resident safety and communication with staff.
Failure to Implement Enhanced Barrier Precautions for Resident with PEG Tube
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with a PEG tube during medication administration and site care. The Enhanced Barrier Precautions policy, dated August 2022, requires the use of gowns and gloves during high-contact resident care activities, such as device care or use, including feeding tubes. However, during observations, RN #1 was seen administering medications and performing PEG tube site care for Resident #279 without utilizing the required personal protective equipment (PPE) except for gloves. Additionally, there was no signage indicating enhanced barrier precautions or PPE requirements near the resident's room. The nurse manager identified two residents with PEG tubes, and the Director of Nursing (DON) admitted to not understanding what enhanced barrier precautions were, indicating a lack of awareness and implementation of the facility's policy.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident diagnosed with unspecified dementia, who was dependent on staff for activities of daily living (ADL) care. The facility's policy required daily cleaning and regular trimming of nails, with documentation of any refusals and notification to the supervisor. However, the resident's Activity of Daily Living Record showed that nail care was offered or provided only five times out of 93 opportunities in December 2024, and not at all during the first week of January 2025. Observations on January 6 and January 9 revealed the resident's fingernails were approximately a quarter inch long with dark debris underneath, despite the resident's preference for shorter nails. Interviews with facility staff, including a CNA and an LPN, confirmed that the resident was dependent on staff for nail care and that refusals were sometimes documented. The Director of Nursing (DON) acknowledged the lack of documentation and stated that nail care should have been provided on scheduled shower days and as needed. Upon reviewing the records and observing the resident's nails, the DON admitted that the facility had failed to adequately monitor and document nail care, indicating a lapse in the facility's adherence to its own care policies.
Failure to Monitor and Document Resident's Bruising
Penalty
Summary
The facility failed to monitor and evaluate a resident's response to an intervention, specifically regarding the presence of bruising on the neck of a resident diagnosed with vascular dementia, Alzheimer's disease, and delusions. The care plan for the resident included monitoring for skin alterations due to incontinence and notifying the physician of changes such as bruising. However, there was no documentation of concern regarding bruising in the care plan, and no records of the bruise on the resident's neck were found in the priority charting or physician progress notes. Staff members, including LPNs and CNAs, were unaware of the bruise or had previously reported it without follow-up. The DON acknowledged that the bruising had been addressed over a year ago but had not been re-evaluated since it resolved without intervention. Despite the DON's claim that the medical director had addressed the issue by discontinuing aspirin, no documentation was found to support this. The facility's protocol for reporting and assessing such incidents was not followed, as evidenced by the lack of documentation and communication with the physician regarding the resident's condition.
Failure to Properly Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the use of bed rails, as required by their policy. The policy mandates that side rails should only be used to treat a resident's medical symptoms or assist with mobility and transfer, and requires a comprehensive assessment including the resident's bed mobility, risk of entrapment, and appropriateness of bed dimensions. Additionally, documentation should indicate if less restrictive approaches were unsuccessful, and informed consent should be obtained after discussing the risks and benefits with the resident or their representative. However, for the resident in question, the assessment was incomplete, and there was no documentation indicating that the side rails treated a medical condition, that alternative interventions had been attempted, or that informed consent had been obtained. The resident, who had unspecified dementia and hemiparesis of the left side, was observed with half bed rails in the up position, yet they stated they did not use them and assumed they were for safety. The LPN and DON were unaware of the necessity for bilateral side rails, given the resident's inability to utilize their left side. The DON admitted that the resident preferred the rails but did not require them, and acknowledged that the assessment was not completed. Furthermore, the care plan did not document the use of bed rails, and the care plan coordinator was unaware of their presence, indicating a lack of communication and documentation within the facility regarding the resident's care needs and the use of bed rails.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted for public view, which is a requirement. During a review of the Quality of Care (QOC) reports for October, November, and December 2024, it was noted that staffing numbers were generally adequate, except for one day shift in December. On January 14, 2025, the administrator acknowledged that while they had the staff names and positions for each shift on each hall, they did not have the total number of nursing hours posted. Additionally, the Director of Nursing (DON) mentioned that there was a book containing the daily schedule at the nurses' desk, but during the survey, the book was in their office, and it did not include the total nursing hours.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident did not receive unnecessary medications, specifically psychotropic drugs, without proper monitoring and documentation. The resident, who had diagnoses including Alzheimer's/dementia, anxiety, and depression, was receiving multiple psychotropic medications such as Nuedexta, trazodone, Ativan, and Risperdal. However, the clinical record lacked documentation of side effect monitoring or evidence that the physician was provided with a medication regimen review (MRR) or a gradual dose reduction (GDR) for Risperdal. Additionally, the care plan for the resident was not updated to include Risperdal, despite documenting concerns for psychotropic drug use and approaches to evaluate the effectiveness and side effects of medications. The Director of Nursing (DON) was unable to provide a clear policy regarding gradual dose reductions and cited issues with medical records as the reason for the lack of documentation. Furthermore, the pharmacist reported not having seen an order for Risperdal since they started in April 2023 and had no notes about the resident being on Risperdal recently. This indicates a failure in communication and documentation within the facility, leading to the resident potentially receiving unnecessary medication without proper oversight.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as ordered by the physician for two residents. One resident, diagnosed with schizoaffective disorder, bipolar type, had a physician's order to obtain a valproic acid level every three months in July, October, January, and April. However, the clinical record and labs provided did not show that the valproic acid level was obtained in July or October 2024. Another resident, diagnosed with vascular dementia, had a physician's order to obtain a comprehensive metabolic panel (CMP) every six months. The last CMP was obtained in May 2024, but there was no record of a CMP for November 2024. The Director of Nursing (DON) acknowledged responsibility for ensuring labs were obtained as ordered and mentioned issues with medical records obtaining and filing lab reports. Despite this, no additional lab reports were provided by the end of the survey.
Failure to Document Regular Bed Safety Inspections
Penalty
Summary
The facility failed to ensure regular safety inspections of resident beds, specifically for a resident with unspecified dementia and hemiparesis of the left side, who was using bed rails. The facility's Bed Safety policy, dated June 2024, mandates regular inspections by maintenance staff to identify risks, including potential entrapment risks, and to ensure proper installation of bedrails. However, a review of the clinical record and maintenance logs revealed no documentation of regular safety inspections for the resident's bed. Observations confirmed the resident was using half bedrails in the up position. Interviews with the DON and a maintenance worker indicated that while maintenance staff were responsible for bed safety inspections, they did not document these checks, relying instead on addressing issues as they were brought to their attention or during routine rounds. The administrator confirmed the lack of documentation for these inspections.
Failure to Ensure RN Licensing Compliance
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was licensed in accordance with applicable state laws. An RN was observed working as the charge nurse at the nurse station, and their employee record showed a valid RN license for the state of Texas but not for Oklahoma. Upon review, the administrator found that the RN's Oklahoma license had expired, as confirmed by documentation from the Oklahoma Board of Nursing. The Director of Nursing (DON) stated that the RN had been working full-time at the facility since a specified date, with only one break in full-time status, and was unaware of the expired Oklahoma license.
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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