Heritage At Brandon Place Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 13500 Brandon Place, Oklahoma City, Oklahoma 73142
- CMS Provider Number
- 375119
- Inspections on file
- 24
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Heritage At Brandon Place Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with a fractured humerus and cognitive impairment experienced severe pain, but the facility failed to administer prescribed pain medication in a timely manner. Despite having orders for Oxycodone and morphine, the resident's pain was not managed according to policy, leading to an allegation of mistreatment.
The facility failed to protect residents from misappropriation of their bank cards and funds. A resident with heart disease reported unauthorized withdrawals totaling $900, while another with heart failure found unauthorized charges on their account, linked to staff. A third resident with cerebral infarction reported their debit card missing from the facility's safe. The facility's policy on preventing misappropriation was not effectively implemented.
A resident with severe cognitive impairment and medical conditions was found with a call light inaccessible, tucked under the foot of the bed, contrary to the facility's policy. A CNA confirmed the policy requires call lights to be within reach, but the resident could not have reached it due to its placement.
A resident with hypertensive heart disease reported unauthorized withdrawals from their bank account, totaling $900. The facility's investigation was incomplete, lacking identification of the suspended staff member and necessary documentation. The VP of Clinical Services admitted that the investigation did not include all required steps, such as safe surveys and staff in-services.
A facility failed to ensure lab tests were collected with a physician's order for a resident with chronic peripheral venous insufficiency and nonrheumatic mitral valve insufficiency. A lab report documented that a CBC, CMP, HbA1c, and prothrombin time with INR were collected without an order. The VP of clinical services confirmed the absence of a lab order and described the facility's process for handling lab services.
The facility breached resident confidentiality by releasing protected health information to unauthorized individuals. The previous administrator sent medical records to the corporate office for approval, which directed the release of a resident's records to their daughter. However, the records included information from other residents, violating the facility's policy on confidentiality.
A resident with dementia and a history of unsafe smoking caught on fire in their room due to inadequate supervision and access to smoking materials. Despite the facility's policy requiring supervision and secure storage of smoking supplies, the resident accessed a cigarette and lighter, resulting in severe burns. Previous incidents of the resident smoking unsupervised and non-compliance with smoking policies were documented, but effective interventions were not implemented.
The facility failed to develop comprehensive care plans for two residents, one with sepsis and heart conditions requiring hospice care, and another with a knee prosthesis infection and osteomyelitis. The first resident's care plan was not initiated beyond a 48-hour baseline, while the second resident's plan was incomplete, only addressing fall risk and antibiotic therapy.
A resident with severe cognitive and functional impairments was left in a wet state overnight, despite the facility's policy to check and change every two hours. Staff inconsistencies in following the policy were noted, with the resident last changed at 2:00 a.m. and found wet at 5:31 a.m.
A resident with multiple medical conditions and pressure ulcers experienced a decline in wound condition, including gangrene, due to the facility's failure to notify the physician of changes and schedule a vascular surgeon consult. Despite documentation of the resident's worsening condition, timely communication and follow-up were lacking, leading to a deficiency in care.
The facility did not adequately explain arbitration agreements to residents, leading to confusion and unawareness among them. Several residents, upon interview, stated they were unaware of signing such agreements and would not have done so if they understood the implications, such as giving up the right to sue. The administrator admitted difficulty in conveying the residents' right to refuse the agreement.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who experienced severe pain. Resident #2, who was cognitively impaired and had a diagnosis of pain, dementia, and a fractured humerus, was admitted with a pain level of five on the PAINAD scale. Despite having physician orders for Oxycodone and morphine sulfate for pain management, the resident did not receive pain medication when their pain was assessed at a level of 10 on a numerical scale. There was no documented follow-up pain assessment as required by the facility's policy. The facility's narcotic count sheet indicated that morphine was available, yet it was not administered to the resident at the time of the initial high pain assessment. A subsequent pain assessment also recorded the resident's pain at a level of 10, and only then was morphine documented as given. The lack of timely pain management led to an allegation of abuse/mistreatment, which was reported and investigated. Interviews with staff revealed that the process for managing pain was not followed, as the resident was not offered pain medication despite a high pain rating.
Failure to Protect Residents' Financial Assets
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically their bank cards and funds. Three residents were affected by this deficiency. One resident, diagnosed with hypertensive heart disease with heart failure, reported unauthorized withdrawals from their bank account totaling $900. The resident had memory problems, and it was documented that they were advised not to give their bank card or cash to staff. Another resident, with combined systolic and diastolic heart failure and intact cognition, discovered unauthorized charges on their bank account. An investigation revealed that large amounts of money had been taken by current and previous employees over the past two years. A third resident, with cerebral infarction and moderate cognitive impairment, reported their debit card missing from the facility's safe. The staff member responsible for the card was terminated due to previous misappropriation incidents. The facility's policy on abuse, neglect, exploitation, and misappropriation of property was not effectively implemented, as evidenced by these incidents. The facility's failure to secure residents' financial assets and prevent unauthorized access by staff led to the misappropriation of funds.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach of a resident, which is a violation of their policy on call light accessibility and timely response. The policy mandates that all staff be educated on the proper use of the resident call system and that each resident's unique needs and preferences be evaluated to ensure access to the call light. During an observation, it was noted that the call light for a resident with severe cognitive impairment and diagnoses including weakness and congestive heart failure was tucked under the foot of the bed, making it inaccessible. A Certified Nursing Assistant (CNA) confirmed that the policy requires call lights to be close to residents at all times and acknowledged that the resident was able to use the call light. However, the call light was found clipped to the bottom of the blanket at the foot of the bed, which the CNA admitted the resident could not have reached. The CNA attempted to explain the situation by stating that someone had put the blanket on upside down, but could not provide a verbal response when asked how the resident would reach the call light in that position.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of misappropriation of resident property involving a resident diagnosed with hypertensive heart disease with heart failure. The resident reported that their bank card had been compromised, resulting in two unauthorized withdrawals totaling $900. An initial state reportable incident form was completed, documenting the allegation and indicating further information would follow. However, the final report did not identify the staff member who was suspended, nor did it include supplemental documentation regarding the investigation. The VP of Clinical Services acknowledged that they could not determine all the steps taken during the investigation or identify the suspended staff member. They also stated that the investigation should have included safe surveys and staff in-services, indicating that these steps were not completed. The resident's discharge assessment noted memory problems, which may have impacted their ability to manage their financial affairs independently. The lack of a thorough investigation and documentation highlights a deficiency in the facility's response to the alleged misappropriation.
Lab Tests Conducted Without Physician Order
Penalty
Summary
The facility failed to ensure that laboratory tests were collected with a physician's order for one of the three sampled residents reviewed for lab services. The facility's policy, revised in September 2012, required that a physician identify and order diagnostic and lab testing based on diagnostic and monitoring needs. However, a lab report dated October 13, 2024, documented that a CBC, CMP, HbA1c, and prothrombin time with INR were collected for a resident without a physician's order. The resident had diagnoses including chronic peripheral venous insufficiency and nonrheumatic mitral valve insufficiency. On December 5, 2024, the VP of clinical services confirmed that they could not locate a lab order for the tests collected on October 13, 2024, and described the facility's process for laboratory services, which includes receiving an order from the provider, contacting the lab, verifying completion, retrieving results, notifying the physician, and following up on new orders if indicated.
Breach of Resident Confidentiality in Record Release
Penalty
Summary
The facility failed to ensure the confidentiality of resident-identifiable records, resulting in the release of protected health information to unauthorized individuals. The deficiency occurred when the previous administrator followed a process where medical records requests were sent to the corporate office for approval. The corporate office directed the release of records for a resident to their daughter via email. However, the previous administrator did not review the records before sending them, leading to the inclusion of other residents' records mixed with the intended records. This action was against the facility's policy, which required staff to have appropriate in-service training on resident rights, including confidentiality of protected health information.
Failure to Supervise Resident with Unsafe Smoking History
Penalty
Summary
An Immediate Jeopardy situation was identified at a facility due to the failure to supervise a resident with a known history of unsafe smoking. The resident, who had dementia and required supervision while smoking, was admitted to the hospital with second and third-degree burns after catching on fire while smoking a lit cigarette in their room. The facility's policy required that residents who needed supervision with smoking have their smoking materials maintained by nursing staff, but this was not adhered to in the case of the resident. The resident's care plan documented that they required supervision while smoking and that their smoking supplies were to be stored on the nurse's cart. Despite this, the resident was able to access a cigarette and lighter, leading to the incident. Prior to the incident, there were multiple documented instances where the resident attempted to smoke unsupervised, refused to wear a smoking apron, and was non-compliant with the facility's smoking policy. Staff frequently reminded the resident about safety and requested assistance as needed, but these measures were insufficient to prevent the incident. Interviews with staff and other residents revealed that the resident had previously attempted to smoke inside the building and had been seen smoking unsupervised. Staff reported that the resident was non-compliant with care and smoking policies, and there were no effective interventions in place to prevent the resident from accessing smoking materials. The facility's failure to ensure the resident did not have access to smoking materials and was supervised during smoking led to the resident sustaining severe burns.
Removal Plan
- Social Services conducted a 100% audit of residents who smoke on the Smoking Safety Screen and updated resident's screen to reflect the current status.
- Social Services conducted a 100% audit on BIMS assessments for residents who smoke and updated them to reflect the current status.
- Wound Care nurse conducted a 100% skin sweep of all residents who smoke and updated the skin assessment to reflect the current status.
- The Housekeeping Supervisor conducted an inspection of resident clothing for all residents who smoke to identify need for assessment or supervision.
- The Maintenance Director inspected the facility grounds for smoking materials, smoking aprons, ashtrays, and fire extinguishers.
- The MDS Coordinator conducted a 100% audit on residents' care plans and updated them to reflect the current status.
- The Administrator attended the Resident Council to review the smoking policy with the residents.
- The Housekeeping Supervisor and Social Services conducted a room sweep of residents who are supervised smokers for lighters and smoking materials.
- The DON and the Administrator conducted a smoking in-service for all employees. Ongoing education will be provided to new staff and as needed.
- The Administrator conducted QAPI to discuss the smoking policy and procedure.
- Delegated staff are assigned specific smoking times according to the smoking schedule for supervised smokers.
- The DON and/or designee will review smoking safety screening for each admission during clinical meeting and implement the appropriate interventions.
- Admissions and Social Service will review the smoking times and policy with each new admission.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their care needs. Resident #47, who was admitted with diagnoses including sepsis, atrial fibrillation, and congestive heart failure, was on hospice services and required significant assistance with daily activities. Despite a 48-hour baseline care plan being initiated, no comprehensive care plan was developed for this resident. Similarly, Resident #73, admitted with conditions such as infection due to a left knee prosthesis and acute osteomyelitis, required moderate assistance with daily activities. The care plan for this resident was incomplete, only addressing fall risk and antibiotic therapy, without a fully developed comprehensive care plan. These deficiencies were identified through observations, record reviews, and interviews with facility staff.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for all care. The resident, who was admitted with severe cognitive and functional impairments following a cerebral infarction, was observed to have been left in a wet state overnight. Despite the facility's policy to check and change residents every two hours, the resident was found wet at 5:31 a.m., with the last change documented at 2:00 a.m. Staff interviews revealed inconsistencies in following the policy, with CNAs stating that briefs were not to be used at night unless requested by the resident, and that checks were supposed to occur every couple of hours. The resident was unable to use the call light, further necessitating regular checks by the staff.
Failure to Notify Physician and Schedule Consult for Wound Care
Penalty
Summary
The facility failed to ensure proper notification of a change in condition for a resident with multiple wounds, including pressure ulcers. The resident, who had a medical history of atrial fibrillation, heart failure, hypertension, diabetes mellitus II, Alzheimer's disease, malnutrition, depression, COPD, CAD, and pressure ulcers, was readmitted to the facility with unstageable wounds on both heels, a non-pressure wound on the abdomen, and a Stage III pressure ulcer on the left buttock. Despite the presence of these wounds, there was a lack of timely communication and documentation regarding the changes in the resident's condition, as required by the facility's policy. The facility's staff, including LPNs and the DON, documented various observations and treatments for the resident's wounds over several months. However, there were significant lapses in communication and follow-up, particularly concerning the scheduling of a vascular surgeon consult. The resident's condition worsened, with the development of gangrenous wounds and a fracture in the left third toe, which were not promptly addressed. The wound physician noted the presence of gangrene and purulent drainage, indicating a severe deterioration in the resident's condition. The facility's failure to adhere to its policies for notifying physicians of significant changes in a resident's condition and ensuring timely consultations with specialists contributed to the deficiency. The lack of a scheduled vascular surgeon consult, despite recommendations, further exemplifies the facility's inadequate response to the resident's worsening condition. This deficiency highlights the need for improved communication and adherence to established protocols to ensure timely and appropriate care for residents with complex medical needs.
Failure to Explain Arbitration Agreements
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to residents or their representatives in a manner they could understand. This deficiency was identified through record reviews and interviews, revealing that four sampled residents who entered into a binding arbitration agreement were not informed of their choice or right to refuse. During a resident council interview, nine residents, including the four sampled, expressed unawareness of what an arbitration agreement was or whether they had signed one. The ombudsman noted that digital documents often required signatures to proceed, potentially pressuring residents into signing. Two residents specifically stated they would not have signed the agreement had they known they were relinquishing their right to sue and questioned the rationale behind voluntarily giving up such rights. The administrator acknowledged the challenge in ensuring residents understood their right not to agree to arbitration.
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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