Heritage Hills Living & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcalester, Oklahoma.
- Location
- 411 North West Street, Mcalester, Oklahoma 74502
- CMS Provider Number
- 375317
- Inspections on file
- 28
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Heritage Hills Living & Rehabilitation Center during CMS and state inspections, most recent first.
Protected health information, including clinical records and personal identifiers, was found unsecured in an unlocked room containing multiple file cabinets and loose documents. The DON confirmed that these records were not stored according to facility policy, which requires locked storage with restricted access.
A resident with incontinence was directed by an LPN to return inside for cleaning after soiling themselves but refused, leading to the LPN grabbing the resident's chair and causing them to slide to the ground. Witnesses reported that the LPN then poured water over the resident and made derogatory remarks, including showing photos of the incident to others. Multiple staff and residents described the LPN's actions as abusive and humiliating, resulting in the resident sustaining minor injuries and emotional distress.
Surveyors found that hazardous chemicals, including floor polish and sanitizer, were stored in an unsecured resident room that could not be locked. The chemicals were accessible to residents and not secured as required by facility policy, with the DON confirming that only housekeeping and maintenance should have access.
A computer displaying protected health information (PHI) was repeatedly left open and unattended on a medication cart in the East/West Hall, making confidential resident information visible and accessible. The administrator and DON confirmed that the computer should not have been left open in this manner.
Surveyors observed a significant fly infestation in common areas and a resident room, including flies in and around cups of liquid and on resident furnishings. The facility did not ensure a clean and comfortable environment for its 54 residents, as required.
Two residents with histories of substance use and mental health conditions were repeatedly found smoking illegal substances using soda cans, but their care plans did not address this behavior. Staff confirmed that care plans were not developed to manage or mitigate the ongoing substance use.
Two residents with histories of substance abuse and mental health diagnoses were repeatedly found using illegal substances within the facility. Staff responded by confiscating the substances and providing education, but no substance abuse program or additional services were offered, and the administrator was unfamiliar with the facility's policy regarding such incidents.
A CNA used unnecessary force while assisting a resident with hemiparesis and hearing impairment in a wheelchair, admitting to acting out of frustration. This action violated facility policy prohibiting abuse and was documented in an incident report.
The facility failed to maintain a clean, safe, and homelike environment, with observations of broken tiles, scuffed walls, and mold in bathrooms. Staff and family representatives noted the disrepair, and the DON acknowledged the facility's policy was not followed. The administrator admitted to lacking a specific policy and recognized the need for repairs, despite not viewing the condition as severely inadequate.
The facility failed to protect two residents from abuse, with one resident exhibiting a history of aggression that was not documented or addressed in their care plan. This resident pushed another, resulting in a head injury. Staff interviews revealed a lack of communication and documentation regarding supervision and interventions to prevent further abuse.
The facility did not have a water management program to prevent Legionella growth. The maintenance supervisor was unaware of the requirement, and the IP confirmed the absence of policies and procedures for managing waterborne pathogens.
The facility was found deficient in maintaining the kitchen's physical environment and ensuring proper hygiene practices. Observations revealed a broken paper towel dispenser, missing door trim, a broken light fixture cover, sticky substance buildup on walls, and rusted air vents. Additionally, a male employee with a partial beard was seen not wearing a beard guard on two occasions.
The facility failed to ensure accurate resident assessments for two residents, with incorrect documentation of a psychotic disorder diagnosis. Despite having other diagnoses, their assessments inaccurately recorded a psychotic disorder. The IP confirmed no residents had this diagnosis, and the MDS coordinator attributed the error to previous assessments.
The facility failed to change and label oxygen tubing weekly as per physician orders for four residents receiving respiratory treatments. Observations showed that the tubing was not changed on the specified date, and the Director of Nursing confirmed the oversight.
The facility failed to notify the OHCA of new serious mental disorder diagnoses for two residents, as required by the PASARR program. One resident was diagnosed with a persistent mood disorder, and another with delusional disorder, but there was no documentation of OHCA contact for either case.
The facility failed to enforce its smoking policy and ensure proper storage of oxygen tanks. A resident was observed vaping in their room, contrary to the policy allowing smoking only in designated areas, and quarterly smoking assessments were not completed. Another resident had an unsecured oxygen tank in their room, which should have been stored in the nurse's closet.
The facility failed to investigate an abuse incident where a resident with major depressive disorder pushed another resident with Alzheimer's, causing injury. Despite the incident's severity, there was no documentation of a thorough investigation. Staff interviews revealed inconsistencies in supervision and interventions for the aggressive resident, and the DON admitted to not completing the necessary reports. The administrator acknowledged the lack of documentation, indicating a deficiency in handling abuse allegations.
Unsecured Storage of Resident Health Information
Penalty
Summary
The facility failed to securely store protected health information for its residents. During an observation, an unsecured resident room at the end of the East hall was found to contain three 4-drawer and one 5-drawer tall file cabinets, all unlocked, with loose papers and files on top. These documents included residents' names, birthdates, social security numbers, insurance information, laboratory results, and physician's progress notes. Two of the file cabinets contained additional resident clinical records. The Director of Nursing (DON) confirmed the unsecured state of the storage room and records, and acknowledged that facility policy requires all resident records to be kept behind locked doors with keys stored in the administrator's office.
Failure to Maintain Abuse-Free Environment for Resident
Penalty
Summary
A resident with a history of incontinence and requiring supervised smoking was involved in an incident where they defecated in the hallway and proceeded outside to smoke, despite being directed by staff to return indoors for cleaning. Multiple staff and resident statements indicate that an LPN confronted the resident outside, and after the resident refused to return inside immediately, the LPN grabbed the resident's chair, resulting in the resident sliding to the ground. Witnesses reported that the LPN then went inside, returned with a pitcher of water, and poured it over the resident, who was still on the ground. Several staff and residents described the resident as being soaked with water in areas inconsistent with incontinence, and the resident reported feeling humiliated by the LPN's actions and comments, which included making fun of the resident and showing photos of the incident to others. The LPN's own account differed, stating that the water was used to clean feces from the concrete and the resident's feet, and that the chair was grabbed to prevent the resident from falling backward. However, multiple witness statements contradicted this, describing the LPN's actions as punitive and disrespectful, including pouring water over the resident and making derogatory remarks comparing the resident to a pet. Staff also reported that the LPN showed photos of the resident's feces to other residents and laughed about the incident, further contributing to the resident's distress and humiliation. The resident involved sustained scrapes on their elbow, hip, and knee as a result of the incident and expressed emotional distress, stating they had never been treated in such a manner before. Other residents and staff who witnessed the event described the LPN's behavior as uncalled for and abusive. The incident was reported to facility administration, and statements were collected from all involved parties, documenting the sequence of events and the actions taken by the LPN that led to the deficiency in maintaining an abuse-free environment.
Unsecured Hazardous Chemicals Found in Resident-Accessible Storage Room
Penalty
Summary
Surveyors observed that the facility failed to secure hazardous chemicals in a resident-accessible area. Specifically, an unsecured resident room at the end of the East hall was being used for storage and contained six 1-gallon bottles of chemicals, including ZEP Wet Look Floor Polish, Floor Front Floor Finish, and Betco Advanced Alcohol Gel Sanitizer. The storage room door could not be locked, and the chemicals were not secured, despite each bottle having warning labels to keep out of reach of children. The DON confirmed the chemicals were accessible and acknowledged that staff were aware of the requirement to keep such items locked and only accessible to housekeeping and maintenance. Review of the facility's policy indicated that all chemicals must be secured with locks and only accessible to authorized personnel. The MSDS for the chemicals present in the room detailed potential harms, including skin and eye irritation, respiratory irritation, and flammability. At the time of the observation, there were no wandering residents seen on the East hall, but the unsecured chemicals presented a potential hazard. The DON observed the unsecured chemicals and reiterated the facility's policy regarding chemical security.
Unattended Computer Displaying PHI on Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' protected health information (PHI) as required. On multiple occasions, a computer displaying PHI was observed left open and unattended on top of a medication cart in the East/West Hall. These observations occurred at various times over two consecutive days, with the computer screen visible and accessible while staff were not present. The administrator confirmed that the computer should have been closed and not displaying PHI when unattended. The facility had 54 residents at the time of the observations.
Failure to Maintain a Fly-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents by not ensuring the environment was free from flies. On observation, flies too numerous to count were present in the lobby, including in and around cups of liquid next to a resident resting in a recliner, with a dead fly observed floating in one of the cups. Further observation in a resident room revealed flies all over the room, bed, and bedside table. The presence of flies was directly observed by surveyors, and the facility had not yet implemented effective measures to address the infestation at the time of the survey. The administrator confirmed that 54 residents resided in the facility during the time of the deficiency. No specific medical history or conditions of the residents involved were mentioned in the report.
Failure to Address Illegal Substance Use in Resident Care Plans
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Summary
The facility failed to develop and implement care plans addressing the use of illegal substances for two residents with histories of substance use and mental health diagnoses. One resident with schizoaffective disorder, opioid dependence, and psychotic disorder was found smoking an illegal substance using a soda can, as documented in a nurse note, but their care plan did not address this behavior. Another resident with major depressive disorder, hypoxemia, and alcoholic hepatitis was also found smoking an illegal substance from a soda can, with no corresponding care plan intervention. Both residents had been caught multiple times engaging in this behavior, and staff interviews confirmed that care plans were not developed to address the issue.
Failure to Provide Substance Abuse Services and Supervision
Penalty
Summary
The facility failed to provide appropriate services for residents with substance abuse issues, as evidenced by two residents repeatedly found using illegal substances on the premises. Facility records and nurse notes documented multiple incidents where these residents were found smoking illegal substances, often using improvised devices such as soda cans. In each instance, staff provided education about the risks of recreational drug use and reminded residents of the facility's policy prohibiting such substances. Despite these interventions, the residents continued to use illegal substances, and the facility's response was limited to confiscating the substances and re-educating the residents. The facility's policy stated that marijuana was not allowed due to federal funding, and outlined steps for staff to take when residents were found with marijuana, including notifying authorities and conducting an investigation. However, the administrator acknowledged that no substance abuse program or additional services were offered to residents with substance abuse diagnoses. The administrator also indicated a lack of familiarity with the facility's policy, and confirmed that the facility's approach was limited to confiscation of substances when discovered.
Unnecessary Force Used by CNA During Resident Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) used unnecessary force while assisting a resident in a wheelchair in the facility lobby. The resident had a medical history of left-sided hemiparesis/hemiplegia and bilateral hearing impairment. According to an incident report, the CNA admitted to acting out of frustration, stating the resident was 'getting on my last nerve.' This action was observed and documented, and it was found to be in violation of the facility's policy prohibiting mistreatment, neglect, or abuse of residents. The incident was reported to the Oklahoma State Department of Health, and the facility's records confirmed the occurrence of the event.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its 59 residents, as observed during two separate inspections. Observations included broken and cracked tiles in the main hallway and resident rooms, creating trip hazards, and sharp edges on the double doors leading from the front commons. The walls in the main center hallway and commons area were scuffed and damaged, and the tiled floors on the East hall were chipped, stained, and damaged. Additionally, there was brown stained residue on the tiles, and the baseboards and corners were damaged. The halls had missing paint, damaged sheetrock, and resident doors were scuffed with marks. There were also cracked tiles and black mold around the toilet and shower area on the North hall. Interviews with staff and family representatives revealed a consensus that the facility was in disrepair. Housekeeping staff noted that the tiles needed replacement and that the walls were scuffed from residents' wheelchairs. A family representative commented that the facility could use some help, and CNAs described the floors as stained and cracked, with walls soiled from spilled drinks and scuffed from carts and wheelchairs. The Director of Nursing (DON) acknowledged the disrepair, noting concerns about the fire doors, damaged corners, and baseboards, and stated that the facility's policy for maintaining a clean, safe, and sanitary environment was not being followed. The facility administrator admitted that the maintenance staff had quit and that the facility lacked a specific policy regarding maintaining a clean, safe, and homelike environment, relying instead on resident rights. The administrator acknowledged the need for repairs, including redoing the floors, replacing corners, and fixing the fire doors. Despite these acknowledgments, the administrator did not believe the facility's condition was severely inadequate, citing the challenges of caring for the residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving two residents, one with major depressive disorder and another with Alzheimer's disease. The first resident exhibited a history of verbal and physical aggression, including incidents of yelling, cursing, and physically threatening staff and peers. Despite these behaviors, there was no documentation of interventions or care plans addressing these aggressive tendencies. The second resident, who was severely cognitively impaired, was pushed by the first resident, resulting in a head injury and hospitalization. The incident was witnessed by another resident, who confirmed that the aggression was unprovoked. The facility's documentation lacked evidence of an investigation into the incident, and there was no record of any preventive measures being implemented to address the aggressive behavior of the first resident. Interviews with staff revealed a lack of communication and documentation regarding the supervision and care of the first resident. Staff members were not instructed to provide one-on-one supervision, and there was no clear documentation of any interventions to prevent further abuse. The Director of Nursing and other staff members acknowledged the absence of a documented care plan for the resident's aggressive behaviors, highlighting a significant oversight in the facility's management of resident safety.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to implement a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. During a record review and interview, it was found that there was no documentation of water management policies and procedures. The maintenance supervisor was unaware of the requirement for a water management program, stating that the facility did not need one because they never had any standing water. Additionally, the Infection Preventionist (IP) confirmed that the facility did not have policies and procedures to reduce the risk of growth and spread of Legionella.
Kitchen Hygiene and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the physical environment of the kitchen and ensure proper hygiene practices among kitchen staff. During observations, several issues were noted: a broken paper towel dispenser at the handwashing sink, missing trim on the exterior door, a broken cover on a fluorescent light fixture, a buildup of a brown sticky substance on the walls around the grill area, and rusted air vents on the ceiling. Additionally, a male employee with a partial beard was observed on two separate occasions not wearing a beard guard while in the kitchen. These deficiencies were identified during a survey involving 58 residents residing in the facility.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents out of a sample of 15. One resident had diagnoses including depression, anxiety, mood disorder, and intermittent explosive disorder, but their annual assessment inaccurately documented a diagnosis of psychotic disorder. Another resident with an impulse disorder also had a quarterly assessment inaccurately documenting a psychotic disorder. The Infection Preventionist (IP) confirmed that no resident in the facility had a diagnosis of psychotic disorder and was unsure why the assessments contained this error. The MDS coordinator, who started their position in December, reported that they documented the psychotic disorder diagnosis based on previous assessments, leading to the inaccuracies.
Failure to Change and Label Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the changing and labeling of oxygen tubing for four residents receiving respiratory treatments. The facility's policy required oxygen tubing to be changed weekly and labeled with the date and initials. However, observations revealed that the oxygen tubing for all four residents was not changed as per the physician's orders. The tubing for each resident was labeled with a date that was not consistent with the weekly change requirement, indicating that the tubing had not been changed on the specified date. Resident #17, diagnosed with COPD and chronic respiratory failure with hypercapnia, was observed with oxygen tubing labeled with a date that was not in compliance with the weekly change order. Similarly, Resident #28, also diagnosed with COPD and chronic respiratory failure, had tubing labeled with an outdated date. Resident #31, who had shortness of breath, and Resident #50, with multiple respiratory and cardiac conditions, were both found with tubing labeled with the same outdated date. The Director of Nursing acknowledged that the tubing had not been changed according to the physician's orders.
Failure to Notify OHCA of New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to notify the Oklahoma Health Care Authority (OHCA) of new possible serious mental disorder diagnoses for two residents, which is a requirement for the Pre-Admission Screening and Resident Review (PASARR) program. Resident #37, who initially had no serious mental illness documented in a Level I PASARR dated 07/19/21, was diagnosed with a specified persistent mood disorder on 10/06/21. However, there was no documentation indicating that the OHCA had been contacted to determine if a Level II PASARR was necessary. Similarly, Resident #20, who had diagnoses including diabetes mellitus and adjustment disorder with depressed mood, was diagnosed with delusional disorder on 01/06/23. The facility did not document any contact with the OHCA regarding this new diagnosis, as confirmed by the administrator's statement and the absence of documentation in the resident's medical record.
Failure to Enforce Smoking Policy and Secure Oxygen Tanks
Penalty
Summary
The facility failed to ensure compliance with its smoking policy and proper storage of oxygen tanks, leading to potential safety hazards. A resident with a diagnosis of nicotine dependence was observed vaping inside their room, contrary to the facility's policy that restricts smoking and vaping to designated areas. The resident's care plan indicated they were an unsupervised smoker and were expected to adhere to the facility's smoking policy. However, the resident believed it was permissible to vape in their room if their roommate did not object. Additionally, the facility did not complete quarterly smoking assessments for this resident, as required by their policy. Another resident, who had diagnoses of COPD and respiratory failure, was found with an unsecured oxygen tank standing upright in their room. The facility's policy requires oxygen tanks to be locked in the nurse's closet, but this was not adhered to, posing a potential safety risk. The Director of Nursing acknowledged that the oxygen tanks should not have been left unsecured in the resident's room.
Failure to Investigate Resident Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident of abuse involving two residents. Resident #33, who had diagnoses including major depressive disorder and suicidal ideations, was reported to have physically assaulted Resident #59, who had Alzheimer's disease and was severely cognitively impaired. The incident occurred when Resident #33 pushed Resident #59, resulting in a fall and head injury for Resident #59. Despite the severity of the incident, there was no documentation of a comprehensive investigation into the abuse. Interviews with staff revealed inconsistencies and a lack of clarity regarding the supervision and interventions implemented for Resident #33 following the incident. CNA #1 and CNA #2 both stated they were not instructed to provide one-on-one supervision of Resident #33, contradicting the DON's statement that such supervision was in place. Additionally, LPN #1 confirmed that no interventions were implemented to prevent further abuse, despite Resident #33's history of verbal and physical aggression. The DON admitted to not completing the incident report or investigation, and the IP nurse and ADON, who were responsible for these tasks, could not locate any documentation of the investigation. The administrator acknowledged the absence of documentation and stated that an investigation should have been conducted. This lack of documentation and follow-through on the investigation process highlights a significant deficiency in the facility's handling of abuse allegations.
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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