Hennessey Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Hennessey, Oklahoma.
- Location
- 705 East 3rd Street, Hennessey, Oklahoma 73742
- CMS Provider Number
- 375485
- Inspections on file
- 20
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hennessey Nursing & Rehab during CMS and state inspections, most recent first.
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.
The facility did not complete bed rail safety assessments, review risks and benefits with residents or their representatives, or obtain informed consent before installing bed rails for three residents. The DON acknowledged the lack of necessary documentation according to facility policy.
The facility did not ensure that influenza and pneumococcal vaccinations were offered to four residents. The DON confirmed that these immunizations should be offered during admission and annually, but there was no documentation in the clinical records showing that the residents or their representatives had been offered or received the vaccines.
A resident with psychiatric disorders was transferred to a VA hospital ER due to behaviors, but the facility failed to document follow-up or discharge. The DON stated the resident was a danger and the facility couldn't meet their needs, yet there was no documentation supporting this decision or a physician's discharge order.
A resident with multiple psychiatric diagnoses was transferred to the VA hospital ER due to behaviors and subsequently discharged from the facility without notification to the resident or their family. The DON acknowledged the lack of notification.
A facility failed to complete a discharge MDS assessment within the required timeframe for a resident discharged at the end of their skilled days. The EHR review showed the assessment was not completed, which was confirmed by a nurse consultant.
A facility failed to complete a baseline care plan within the required 48-hour timeframe for a resident. The resident was admitted, but the care plan was only documented as completed several days later. This issue was identified during a review and interview with a nurse consultant.
A facility failed to implement a comprehensive care plan for a resident with an indwelling urinary catheter, despite having a physician order for catheter changes and documentation of the catheter in the admission assessment. The baseline care plan did not include the catheter, and a nurse consultant confirmed the absence of a comprehensive care plan, stating it was still being completed.
A facility failed to complete a discharge summary and discharge instructions for a resident upon their discharge. The resident's clinical record contained an incomplete 'Discharge Summary' form and an undated, incomplete Discharge Instructions form. The DON acknowledged the oversight.
A facility failed to document a DNR consent form for a resident, despite having a physician's order and care plan indicating DNR status. The DON acknowledged the absence of the form, stating that residents should have both a physician's order and a DNR form upon admission or remain a full code until the form is obtained. An LPN confirmed that code statuses were found in health records and the resident roster.
A facility failed to administer oxygen as ordered by a physician and did not change oxygen tubing as per policy for a resident with COPD and respiratory failure. The resident was receiving oxygen at 3.5 LPM instead of the ordered 3 LPM, and the tubing had not been changed weekly as required.
The facility did not complete annual competency reviews for two CNAs, as required by policy. CNA #2, hired in 2022, and CNA #1, hired in 2023, both lacked these reviews in their files. The BOM confirmed the absence of these reviews.
The facility failed to implement a physician order for a GDR for a resident's trazodone medication, resulting in continued administration of a higher dose. Additionally, there was no physician response to GDR recommendations for another resident's psychotropic medications, including buspirone, Abilify, and duloxetine. The DON confirmed the lack of documentation for these GDRs.
A resident receiving IV antibiotic therapy via a PICC line experienced a breach in infection control practices. An LPN used unlabeled IV tubing, placed it on a pillow, and continued using it after it fell to the floor. The DON confirmed that facility policy was not followed, as IV tubing should be changed every 24 hours and labeled.
A resident experienced a significant change in condition, including weakness, irregular heart rate, and mental status decline. Despite being diagnosed with pneumonia and prescribed Augmentin, the facility failed to notify the physician, order the medication, and administer it. The resident's condition worsened, leading to hospital admission.
A facility failed to accurately assess a resident's risk for pressure ulcers and did not initiate necessary dietary measures, leading to the development of pressure ulcers. The RD's assessment contained discrepancies, and the care plan was not updated to reflect changes in the resident's condition, such as weight loss, decreased mobility, and incontinence. The DON acknowledged the inaccuracies and the need for dietary measures and care plan interventions.
The facility failed to ensure proper care of a PICC line for a resident, including timely dressing changes and obtaining physician orders for continued flushes and removal of the PICC line after antibiotic therapy completion. Interviews confirmed that facility policy and professional standards were not followed.
A resident with multiple diagnoses, including insomnia, was prescribed temazepam 15 mg to be taken nightly as needed for sleep. However, the medication was administered at 12 a.m. on multiple dates due to an incorrect transcription of the order by an LPN. The ADON confirmed the medication was not given as per the physician's order.
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 Complete Bed Rail Safety Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to adhere to its policy regarding the use of bed rails, resulting in a deficiency. Specifically, the facility did not complete necessary bed rail safety assessments, nor did it review the risks and benefits of bed rails with the residents or their representatives. Additionally, informed consent was not obtained prior to the installation of bed rails for three residents. Observations revealed that these residents were using bed rails without the required documentation in their clinical records. The Director of Nursing acknowledged that the necessary paperwork had not been completed according to the facility's policy.
Failure to Offer Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were offered to four of the five residents reviewed for immunizations. The Director of Nursing (DON) confirmed that immunizations should be offered during the admission process and annually. However, there was no documentation in the clinical records of Residents #15, #18, #22, and #82 indicating that they or their representatives had been offered or received these vaccines. This deficiency was identified during a record review and interview with the DON, who acknowledged the lack of documentation for these residents.
Inadequate Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that a resident was not involuntarily discharged without adequate reason and proper documentation. A resident with multiple psychiatric diagnoses, including anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD, was transferred to a VA hospital ER due to behaviors. However, there was no documentation in the clinical record indicating follow-up on the resident's status after the transfer or stating that the resident had been discharged. The Director of Nursing (DON) later stated that the resident did not return because they were a danger to themselves and others, and the facility could not meet their needs. Additionally, there was no documentation in the clinical record indicating that the facility would not be able to meet the resident's needs upon their return, nor was there a physician's order to discharge the resident.
Failure to Notify Resident and Family of Discharge
Penalty
Summary
The facility failed to provide timely notification of a facility-initiated discharge for a resident diagnosed with anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. The resident was admitted on an unspecified date and was transferred to the VA hospital emergency room due to behaviors on June 25, 2024, as documented in a nurse's note. A discharge summary dated June 26, 2024, indicated that the resident had been discharged from the facility on June 25, 2024. However, there was no documentation in the clinical record that the facility notified or attempted to notify the resident or their family about the discharge. On August 6, 2024, the Director of Nursing acknowledged that neither the resident nor their family had been informed of the discharge.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge MDS assessment within the required timeframe for a resident who was discharged at the end of their skilled days. The resident was admitted to the facility and discharged on April 12, 2024. A review of the electronic health record (EHR) revealed that the discharge MDS assessment had not been completed. This was confirmed during an interview with Nurse Consultant #1 on August 6, 2024, who acknowledged the oversight.
Failure to Timely Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan in a timely manner for a resident. The resident was admitted on an unspecified date, and the baseline care plan was documented as completed on 07/27/24. However, it was noted during an interview with a nurse consultant on 08/06/24 that the baseline care plan was not completed within the required 48-hour timeframe following the resident's admission. This deficiency was identified during a review of records and interviews conducted by the surveyors.
Failure to Implement Comprehensive Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was admitted with diagnoses including neuromuscular dysfunction of the bladder and hydronephrosis. The resident had a physician order to change the Foley catheter every 30 days, specifically on the 1st of the month during the night shift. Despite the resident's admission assessment documenting the presence of an indwelling catheter, the baseline care plan did not include this information. Furthermore, there was no record of a comprehensive care plan being completed for the resident. During an interview, a nurse consultant confirmed that the resident did not have a comprehensive care plan and stated that they were in the process of completing one.
Incomplete Discharge Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a discharge summary and discharge instructions were completed for a resident upon their discharge. The resident was admitted to the facility and discharged at the end of their skilled days. A 'Discharge Summary' form was found in the resident's clinical record, dated prior to the discharge, but it was not completed. Additionally, a Discharge Instructions form was also found in the clinical record, undated and not completed. The Director of Nursing (DON) acknowledged that these documents had not been completed for the resident.
Failure to Document DNR Consent Form for a Resident
Penalty
Summary
The facility failed to have a process in place to identify a resident's code status, specifically for one resident reviewed for advanced directives. The resident was admitted with a physician's order indicating Do Not Resuscitate (DNR) status, dated 07/23/24, and a care plan dated 07/27/24, also documented the resident's preference for DNR. However, there was no documentation of a completed Oklahoma DNR consent form in the resident's record. On 08/05/24, the Director of Nursing (DON) acknowledged the absence of the DNR consent form in the health record, stating that residents should have both a physician's order and a DNR form upon admission or remain a full code until the form is obtained. Additionally, an LPN confirmed that residents' code statuses were found in their health records and the resident roster at the nurse's station.
Failure to Administer Oxygen as Ordered and Change Tubing
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician and that oxygen tubing was changed as per facility policy for a resident receiving respiratory care. The resident, who had diagnoses including COPD and acute and chronic respiratory failure with hypoxia, had a physician's order for oxygen at 3 liters per nasal cannula to maintain oxygen saturation at 90% or above. However, during an observation, the resident was found to be receiving oxygen at 3.5 liters per minute, contrary to the physician's order. Additionally, the oxygen tubing was dated from 07/22, indicating it had not been changed weekly on Sundays as required by the facility's policy. RN #1 confirmed that the physician's order was not followed and that the tubing should have been changed according to the policy.
Failure to Conduct Annual CNA Competency Reviews
Penalty
Summary
The facility failed to conduct a nurse aide performance review every 12 months for two certified nurse aides (CNAs) out of five employee files reviewed. The facility's policy, revised in October 2017, requires all nursing staff to meet specific competency requirements as defined by state law. CNA #2, hired on April 28, 2022, did not have an annual competency review in their file. Similarly, CNA #1, hired on May 12, 2023, also lacked an annual competency review in their file. On August 6, 2024, the Business Office Manager (BOM) confirmed the absence of these reviews for both CNAs.
Failure to Implement and Document GDRs for Psychotropic Medications
Penalty
Summary
The facility failed to implement a physician order for a gradual dose reduction (GDR) for a resident diagnosed with insomnia and anxiety. A medication regimen review (MRR) recommended reducing trazodone from 150 mg to 100 mg at bedtime. Although the physician agreed to the reduction, and a nurse acknowledged the recommendation, there was no corresponding physician's order until a week later. Consequently, the resident continued receiving the higher dose until the order was implemented, and the reduced dose was first administered the following day. Additionally, the facility did not have a physician's response to GDR recommendations for another resident diagnosed with schizophrenia, anxiety, insomnia, and depression. The MRRs recommended dose reductions for buspirone, Abilify, and duloxetine, but there was no documentation of a physician's response to these recommendations. The Director of Nursing (DON) confirmed the absence of a physician's response to the GDRs upon review of the MRRs.
Infection Control Breach During IV Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during the administration of medication for a resident receiving intravenous antibiotic therapy via a PICC line. During an observation, an LPN was seen using IV tubing that was not labeled with the date, time, and initials as required by the facility's policy. The LPN used the unlabeled tubing to spike a new IV bag and laid the end of the tubing on the resident's pillow. During the process of flushing the PICC line lumens, the end of the tubing fell to the floor. Despite this, the LPN picked up the tubing from the floor, removed the cap, connected it to the PICC line lumen, and started the IV. The Director of Nursing (DON) confirmed that the facility's policy required IV tubing to be changed every 24 hours and labeled accordingly. The DON acknowledged that the proper infection control practices were not followed, and the facility policy was not adhered to. The LPN's actions, including using unlabeled tubing and failing to replace the tubing after it fell to the floor, contributed to the deficiency in infection control practices.
Failure to Monitor and Administer Prescribed Antibiotic Therapy
Penalty
Summary
The facility failed to assess, monitor, and intervene for a resident experiencing a significant change in condition and did not ensure the resident received prescribed antibiotic therapy to treat pneumonia. On 03/08/24, the resident exhibited acute changes such as weakness, inability to stand or sit, irregular heart rate, low oxygen saturation, incontinence, and mental status decline. Despite notifying the MD, the resident was not sent to the ER, and no further MD notifications were documented as the resident's condition continued to deteriorate over the following days. On 03/19/24, the resident requested to be sent to the ER and was diagnosed with pneumonia, receiving an order for Augmentin. However, the facility failed to notify the resident's physician of the new order, did not submit the medication order to the pharmacy, and did not place the medication on the MAR. Consequently, there was no documentation that the prescribed antibiotic was ever ordered, received, or administered to the resident between 03/19/24 and 04/08/24. The resident's condition continued to decline, and on 04/08/24, they were sent to the ER with low blood pressure, labored breathing, erratic pulse, and altered mental status, leading to their hospital admission. The DON acknowledged that the resident had not been properly assessed, monitored, or received necessary interventions according to facility policy after experiencing a significant change in condition. Additionally, the resident did not receive the prescribed antibiotic therapy for pneumonia, as documented in the clinical records and MARs.
Removal Plan
- All Licensed RN/LPN staff educated on how to recognize acute changes in resident baseline condition, orientation, and/or change in vital signs with documentation of notification to the physician and family.
- All newly hired Licensed RN/LPN staff will be educated on how to recognize change in resident baseline condition, orientation, and/or change in vital signs with documentation of notification to the physician and family.
- All direct care nursing staff educated on how to recognize acute changes in resident baseline condition, orientation, and/or change in vital signs and report to charge nurse immediately.
- DON/Designee will review all new hire packets to ensure all training is completed.
- DON/Designee will report any negative findings to the QAPI team.
- All licensed RN/LPN In-serviced on Facility Policy and Procedure properly assessing, monitoring, and intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed.
- All licensed new hires will be educated on Facility Policy and Procedure on properly assessing, monitoring, intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed.
- DON/designee will review all new hire packets to ensure all training is completed.
- DON/designee will report any negative findings to QAPI.
- DON/Designee will compare physician orders on all new admissions to MAR and verify all medications are on hand.
- Any staff that are on leave will be educated prior to being placed on the schedule.
- DON/ADON in-serviced on reviewing all physicians' orders to include hospital discharges/doctor's appointment during clinical meeting to ensure orders are not missed.
- DON/ADON will review all physicians' orders to include hospital discharges/doctor's appointment during clinical meeting to ensure orders are not missed. Any negative findings will be corrected immediately.
- All Licensed nurses educated on comparing new orders/hospital discharge orders with the MAR and updating MAR to reflect any new orders.
Failure to Prevent Pressure Ulcers Due to Inaccurate Assessment
Penalty
Summary
The facility failed to accurately assess a resident's risk for pressure ulcers and did not initiate necessary dietary measures to prevent avoidable pressure ulcers. The resident had a history of left toe amputation and a PICC line in the upper right arm. Despite significant weight loss and a decline in nutritional intake, the Registered Dietitian (RD) assessed the resident as being at no/low risk for pressure ulcers. The RD's assessment contained several discrepancies, including incorrect documentation of weight loss, oral intake, mobility, and lab values. Additionally, the resident's care plan was not updated to reflect the changes in their condition, such as decreased mobility and incontinence, which increased the risk of skin breakdown. Physician's orders indicated the presence of open areas on the resident's coccyx, but there were no documented assessments or care plan updates addressing the risk of skin breakdown following the resident's change in condition. The Director of Nursing (DON) acknowledged that the RD's assessment was inaccurate and that dietary measures and care plan interventions should have been implemented to prevent the development of pressure ulcers. The lack of accurate assessment and timely intervention led to the resident developing pressure ulcers, which were not properly documented or addressed in the care plan.
Failure to Ensure Proper Care of PICC Line
Penalty
Summary
The facility failed to ensure the proper care of a peripheral intravenous central catheter (PICC) for a resident who had a PICC line in the upper right arm and was receiving intravenous antibiotics. The facility's policy required dressing changes every 3-7 days or as needed if the dressing became damp, loosened, or visibly soiled. However, there was no documentation that the PICC line dressing was changed between 03/11/24 and 04/08/24, despite a note on 03/11/24 indicating that the dressing was coming loose and was only reinforced with gauze. Additionally, the resident continued to receive PICC line flushes twice a day from 03/12/24 through 04/06/24 without a physician's order, and there was no documentation that the physician was contacted to obtain orders for these flushes or for the removal of the PICC line after the completion of the IV antibiotic therapy on 03/11/24. Interviews with the LPN and the Director of Nursing (DON) confirmed that the physician was not notified for an order to continue PICC line flushes or to remove the PICC line when the antibiotic therapy was completed. The DON also acknowledged that the facility policy and professional standards of practice were not followed, as there were no documented dressing changes or physician orders for the continued care of the PICC line during the specified period.
Medication Administration Error
Penalty
Summary
The facility failed to ensure medication was administered as ordered for one resident reviewed for medications. The resident had diagnoses including multiple sclerosis, insomnia, and abnormal weight loss. According to the hospital discharge summary, the resident was prescribed temazepam 15 mg to be taken nightly as needed for sleep. However, the April 2024 Medication Administration Record (MAR) showed that the medication was given at 12 a.m. on multiple dates. Upon review, an LPN acknowledged that the order had been transcribed incorrectly, and the Assistant Director of Nursing (ADON) confirmed that the medication had not been administered according to the physician's order.
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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