Heritage Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 3804 North Barr Ave, Oklahoma City, Oklahoma 73122
- CMS Provider Number
- 375502
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Heritage Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a documented history of wandering was able to exit the facility unsupervised, despite being identified as high risk for elopement. Staff interviews revealed inconsistent awareness of the resident's elopement history and confusion about monitoring procedures. Documentation showed repeated exit-seeking behaviors, but there was no record of an elopement drill at the time of the incident, and not all staff had been educated on elopement protocols.
A facility failed to ensure privacy during personal care for a resident with severe cognitive impairment. A CNA provided incontinent care without using the privacy curtain, despite the presence of the resident's roommate. The facility's policy requires the use of a privacy curtain to ensure full visual privacy, which the CNA acknowledged but did not follow.
A resident with severe cognitive impairment and muscle weakness did not receive thorough incontinent care. A CNA partially removed the soiled brief and cleansed the buttocks but failed to clean the front peri-area, leaving fecal matter on the resident's labia. The CNA acknowledged the oversight when prompted.
A CNA failed to maintain infection control during incontinent care for a resident with severe cognitive impairment. The CNA did not change gloves appropriately while handling soiled materials and cleaning the resident, resulting in contamination of a new brief. The CNA acknowledged the need for more frequent glove changes and cited a lack of plastic bags for disposal as a contributing factor.
A facility failed to assess and update fall prevention interventions for residents at high risk for falls, resulting in repeated injuries. One resident with a history of falls and high fall risk experienced multiple falls with injuries, including a major head injury, without changes to their care plan. Another resident's room contained fall hazards, and specified interventions were not implemented. Staff confirmed the lack of intervention changes and presence of hazards.
The facility failed to submit accurate PBJ staffing data to CMS for FY quarter 1 2024, missing RN hours on several dates and lacking 24-hour licensed nursing coverage on specific days. A Corporate Nurse Consultant admitted the hours were available but not reported, and the Operations Manager later provided documentation of coverage.
The facility failed to provide a SNF ABN to a resident discharged from Medicare Part A services, despite having benefit days remaining. The Regional MDS Specialist identified 12 residents in similar situations over the past six months. Specifically, a resident admitted to Part A skilled services and later discharged did not receive the required notice, as confirmed by the Regional MDS Specialist.
A facility failed to maintain a clean environment in a resident's room, where a strong urine odor persisted despite daily cleaning and tile replacement. The issue was observed over several days, and staff confirmed the odor had been ongoing for months.
A facility failed to complete the cognitive pattern section of the MDS for a resident with multiple diagnoses, including schizophrenia and hypertension. The assessment was left with dashes, indicating it was not filled out, leading to an inaccurate assessment. The intern DON and Regional MDS coordinator confirmed the section should have been completed.
The facility failed to review care plans every three months for three residents, including those with complex medical conditions such as schizophrenia, diabetes, and acute kidney disease. The Regional MDS Coordinator, who has been managing care plans due to a staffing shortage, admitted that nearly all care plans were not current or updated, highlighting a systemic issue in maintaining timely reviews.
The facility failed to change a resident's soiled wound dressing for over six hours, despite visible dried blood and drainage. Additionally, the facility did not document behaviors justifying the administration of PRN antianxiety medication for another resident, as required by physician orders and facility policy.
A resident with significant weight loss and multiple health conditions did not receive timely intervention as recommended by a dietician. The facility delayed implementing an increase in nutritional shakes from twice to three times daily, as the recommendation was not signed by the DON and physician until much later. This delay was acknowledged by the dietary manager and interim DON.
The facility failed to provide adequate staffing and supervision, leading to multiple incidents involving residents. One resident, at high risk for falls, suffered several falls resulting in injuries due to insufficient supervision. Another resident with a non-pressure ulcer had a soiled dressing left unchanged for over six hours. Staff interviews and resident council feedback highlighted the lack of sufficient staff, particularly at night, impacting the quality of care.
The facility did not post required staffing information, as observed on multiple occasions. An operations manager admitted to being unaware of the requirement to post this information on a designated board near the nurses' station. The facility housed 51 residents during these observations.
The facility administered influenza vaccines to several residents before obtaining their consent. The consent forms for these residents were dated after the vaccines were given, contrary to facility policy. A Regional Nurse Consultant confirmed that vaccines should not be administered before education and consent are obtained, but documentation showed this was not adhered to.
The facility administered COVID-19 vaccines to three residents without providing education or obtaining consent. The Regional Nurse Consultant confirmed that no documentation of education or consent was found in the residents' records, indicating a failure to follow proper procedures.
A resident was discharged into the community without proper discharge planning, as the facility failed to arrange necessary medical and pharmacy services before the discharge. The resident left with medications, but scripts were transferred only afterward. Concerns about the resident's safety led to reports filed with adult protective services and the police. The social service director was responsible, but no documentation of pre-discharge planning was found.
Failure to Prevent Elopement for High-Risk Resident with Dementia
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent an elopement for a resident with a known history of wandering and severe cognitive impairment. The resident had been assessed as high risk for wandering and exit-seeking behaviors, with documentation showing repeated attempts to exit the facility and a BIMS score indicating severe cognitive impairment. Despite these known risks, the resident was able to leave the facility unsupervised, as confirmed by nurse notes and a state reportable incident, which indicated that the resident was found outside by neighbors and brought back into the facility. Staff interviews revealed inconsistent awareness and understanding of the resident's elopement history and the reasons for frequent monitoring. Several staff members were not aware that the resident had actually eloped, and there was confusion regarding the implementation and documentation of elopement drills. The facility's elopement policy required specific interventions and monitoring for high-risk residents, but there was no documentation to show that an elopement drill was conducted at the time of the incident, and not all staff had been educated on the procedures following the event. Observations and record reviews further indicated that the resident continued to exhibit wandering and exit-seeking behaviors both before and after the elopement incident. The facility had coded doors with alarms, but the resident was able to exit through a door that alarmed, and staff did not immediately locate the resident. The lack of consistent documentation, staff awareness, and immediate response contributed to the failure to prevent the resident's elopement, resulting in a deficiency related to supervision and accident prevention.
Removal Plan
- Educate all staff on the Elopement Policy on hire, annually, and periodically as a reminder.
- Complete in-service with all staff over the Elopement Policy, including interventions to prevent elopement: place any resident determined to be a wanderer on admission on Elopement Risk on their profile and conduct frequent Q 15 minute visual checks to monitor for exit seeking behaviors for 4 weeks and then re-evaluate. If no exit seeking behaviors have been noted, remove elopement risk status.
- Institute 1:1 monitoring or Frequent Visual Checks charting Q 15 minutes or as indicated if a resident with Dementia is having any exit-seeking behaviors or attempts to go out without supervision, until no longer deemed at risk.
- Re-evaluate at least quarterly for wandering and exit seeking and revise plan for monitoring according to resident's risk.
- Institute other interventions as needed for residents with exit seeking behaviors to re-direct or distract resident from exit seeking behaviors such as: camouflaging doors with wallpaper or curtains, stop signs on exit doors, encouraging family members to visit, and diversional activities during times of restlessness.
- Maintain location of the Elopement Risk book that has a list and information for all residents on Elopement Risk.
- Post a list of residents at risk for elopement in each charge nurse's report book.
- Provide agency staff with in-service materials.
- In-service any staff on vacation or unable to reach before working their next shift.
- Ensure all residents considered high risk for elopement have an identifier on the resident's profile to alert staff.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during the provision of personal care, as required by their policy. A certified nursing assistant (CNA) entered the room of a resident with severe cognitive impairment and diagnoses including generalized muscle weakness and cerebral infarction, to provide incontinent care. Although the CNA closed the door, they did not utilize the privacy curtain, despite the presence of the resident's roommate in the room. The facility's policy mandates the use of a privacy curtain to ensure full visual privacy during such care. The CNA acknowledged the policy but admitted to not pulling the privacy curtain during the care provided.
Failure to Provide Thorough Incontinent Care
Penalty
Summary
The facility failed to provide thorough incontinent care for a resident with severe cognitive impairment and diagnoses including generalized muscle weakness and cerebral infarction. The resident's care plan required total assistance with toileting. During an observation, a CNA entered the resident's room to provide incontinent care, partially removed the soiled brief, and cleansed the resident's buttocks. However, fecal matter was observed on the resident's labia, and the CNA did not clean the front peri-area. When asked to observe the area, the CNA acknowledged not seeing the fecal matter and confirmed that they were supposed to clean the front peri-area.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the provision of incontinent care for a resident with severe cognitive impairment and diagnoses including generalized muscle weakness and cerebral infarction. During the care, a CNA did not change gloves appropriately while handling soiled materials and cleaning the resident. The CNA initially removed the resident's soiled brief and placed a soiled pad on the floor mat without changing gloves. They then put a new brief on the resident without noticing fecal matter in the peri-area, which resulted in the new brief being soiled. The CNA continued to use the same gloves to search for wipes and a new brief in the resident's drawers, and only changed gloves after leaving the room to locate the necessary supplies. Upon returning, the CNA donned new gloves, cleansed the resident's peri-area, and put on another new brief, but again did not change gloves before completing the care and handling other items in the room. The CNA acknowledged they were supposed to change gloves three times during the care but only did so twice, citing a lack of plastic bags for disposing of soiled materials as a contributing factor.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adequately assess and implement interventions to prevent falls for a resident with a history of falls and high fall risk. The resident, diagnosed with schizophrenia, dementia, and other conditions, experienced multiple falls resulting in injuries, including a major head injury in December 2023. Despite the resident's care plan indicating a high risk for falls, the facility did not evaluate the causes of these falls or update the care plan with new interventions after each incident. Observations noted the resident ambulating unsteadily without assistive devices, contrary to care plan recommendations. Another resident experienced falls with injuries, and the facility failed to implement care plan interventions designed to mitigate fall risks. Observations revealed that the resident's room contained fall hazards, such as throw rugs, and lacked a fall mat at the bedside, which were specified interventions in the care plan. The operations manager acknowledged these deficiencies upon inspection of the resident's room. The facility's failure to evaluate falls and update care plans for residents at high risk for falls resulted in repeated incidents and injuries. Staff interviews confirmed the lack of intervention changes and the presence of environmental hazards in residents' rooms, indicating a systemic issue in addressing fall risks and implementing preventive measures.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate payroll-based journal (PBJ) staffing data to CMS for the first quarter of fiscal year 2024. The PBJ Staffing Data Report for the period from October 1, 2024, to December 31, 2024, indicated that the facility lacked registered nurse (RN) hours on multiple dates, including October 22, 23, November 3, 10, 17, 30, December 1, 4, 7, 8, 9, 10, 22, 23, 24, 25, and 30, 2024. Additionally, the report documented that the facility did not have licensed nursing coverage for 24 hours a day on December 9, 10, 23, and 24, 2024. During an interview on May 23, 2024, a Corporate Nurse Consultant acknowledged that the hours were available but were not included in the report. Later that day, the Operations Manager provided documentation of coverage for the specified dates.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who was discharged from Medicare Part A covered services. The Regional MDS Specialist identified that 12 residents had been discharged from a Medicare Part A covered stay with benefit days remaining in the past six months. Specifically, Resident #206 was admitted to Part A skilled services on November 16, 2023, and discharged on December 5, 2024. However, there was no documentation indicating that a SNF ABN was provided to this resident. On May 20, 2024, the Regional MDS Specialist confirmed that they had completed the SNF benefit review and acknowledged that Resident #206 did not receive the required notice.
Persistent Urine Odor in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in room [ROOM NUMBER], as evidenced by a persistent strong odor of urine. This issue was observed over several days, from May 19 to May 23, 2024, with the odor detectable down the hall approximately six feet from the room. Housekeeper #1 reported that the odor had been present since they began working at the facility in March 2024, despite the room being cleaned twice daily and the bathroom tile being replaced. The Housekeeping Supervisor confirmed that the room was cleaned twice a day using chemicals to eliminate odors, but the strong urine smell persisted. The operations manager acknowledged awareness of the ongoing issue, which had been present before their tenure at the facility.
Incomplete Cognitive Assessment in MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's cognitive pattern, as required by the minimum data set (MDS). The resident, who had multiple diagnoses including schizophrenia, angina, cerebral infarction, restlessness and agitation, hypertension, acute kidney disease, psychosis, and diabetes mellitus, had a quarterly assessment with section C, cognitive patterns, left incomplete. The assessment contained dashes in every box of section C, indicating that no answers were documented for the cognitive assessment questions. Interviews with the intern Director of Nursing (DON) and the Regional MDS coordinator confirmed that section C should have been completed and that the absence of this information rendered the assessment inaccurate.
Failure to Review Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans were reviewed every three months for three residents out of the 13 care plans reviewed. Resident #12, who had diagnoses including an unspecified skin condition, peripheral vascular disease, and non-pressure ulcers, had their care plan last reviewed on March 11, 2023. Resident #42, with diagnoses such as schizophrenia, angina, cerebral infarction, restlessness and agitation, hypertension, acute kidney disease, psychosis, and diabetes mellitus, had their care plan last reviewed on May 4, 2023. Resident #48, diagnosed with schizophrenia, diabetes mellitus, unspecified psychosis, abnormal coagulation, and acute kidney failure, had their care plan last reviewed on August 14, 2023. The Regional MDS Coordinator, who has been handling care plans for over a year due to the absence of a full-time care plan coordinator, acknowledged that care plans should be reviewed quarterly and annually comprehensively. However, they admitted that nearly all care plans were not current or updated, indicating a systemic issue in maintaining timely reviews.
Deficiencies in Wound Care and Medication Documentation
Penalty
Summary
The facility failed to ensure proper wound care for a resident with a trauma wound on the left second toe. The resident, diagnosed with an unspecified skin condition, peripheral vascular disease, and non-pressure ulcers, had specific physician orders for wound care, including cleansing and dressing changes. However, observations revealed that the resident's dressing was visibly soiled with dried blood and drainage for over six hours without being changed. Despite multiple observations throughout the day, the dressing remained unchanged until after 2:00 p.m., when an LPN finally addressed it. The LPN admitted that the dressing should have been changed earlier but was unaware of its condition. Additionally, the facility failed to accurately document behaviors to support the administration of as-needed antianxiety medication for another resident. The resident had a physician's order for Vistaril to be administered as needed for anxiety. However, the medication administration records and progress notes did not document any behaviors warranting the use of the medication on the dates it was given. Interviews with staff confirmed that the medication should only be administered after unsuccessful attempts to redirect or calm the resident, and such episodes should be documented to assess the need for continued medication use. The lack of documentation suggests that the medication may have been administered without proper justification.
Failure to Timely Implement Weight Loss Intervention
Penalty
Summary
The facility failed to implement a weight loss intervention for a resident who was at risk for weight loss and had a history of severe weight loss. The resident, who had diagnoses including Schizophrenia, Diabetes Mellitus, unspecified psychosis, abnormal coagulation, and acute kidney failure, experienced a severe weight loss of 32 pounds over 180 days and 11 pounds over 30 days. A care plan updated in May 2023 indicated the need for a registered dietician to evaluate and make dietary recommendations. On April 1, 2024, a consulting dietician recommended increasing the resident's intake of house shakes from twice a day to three times a day due to significant weight loss. However, the facility did not act on this recommendation in a timely manner. The recommendation was not signed by the facility's director of nursing and physician until May 14, 2024, and the resident did not begin receiving the shakes three times a day until that date. The dietary manager and the interim director of nursing acknowledged that the facility failed to implement the dietician's recommendations promptly, leading to a delay in addressing the resident's weight loss.
Insufficient Staffing and Supervision in LTC Facility
Penalty
Summary
The facility failed to provide sufficient staffing and supervision to meet the needs of its residents, as evidenced by multiple incidents involving two residents. One resident, diagnosed with schizophrenia, dementia, and other conditions, was at high risk for falls. Despite a care plan that included regular checks and reminders to use a walker, the resident experienced several falls, resulting in injuries such as a subdural hematoma and head lacerations. Staff interviews revealed that the facility was understaffed, with only two aides and one nurse on duty at night, making it difficult to supervise residents adequately and provide necessary care. Another resident, with a diagnosis including peripheral vascular disease and non-pressure ulcers, was observed with a soiled dressing on their left toe for over six hours without it being changed, despite visible dried blood and drainage. The dressing was not changed until after 2:00 p.m. due to staffing constraints. During a resident council interview, multiple residents reported that there were not enough staff to provide timely care, particularly at night.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted with the required components and was accessible to all residents. Observations on multiple occasions revealed that no staff information was posted in the facility. Specifically, on May 19, 2024, at 8:00 a.m., and on May 20, 2024, from 8:00 a.m. through 2:30 p.m., no staffing information was observed. Additionally, on May 21, 2024, at 6:15 a.m., the absence of posted staff information was again noted. An operations manager acknowledged that the staffing information should have been posted on a large white dry erase board near the nurses' station but admitted they were unaware of the requirement to post this information. The facility housed 51 residents at the time of these observations.
Failure to Obtain Consent Before Vaccination
Penalty
Summary
The facility failed to provide education and obtain consent before administering the influenza vaccine to four residents. Specifically, the signed consent forms for these residents were dated after the vaccines were administered. For example, Resident #12 received the influenza vaccine on 10/03/23, but their consent form was dated 10/04/23. Similarly, Resident #15's consent form was dated 04/19/24, while the vaccine was administered on 10/03/23. This pattern was consistent for Residents #23 and #32 as well. During an interview, the Regional Nurse Consultant confirmed that, according to facility policy, vaccines should not be administered before education and consent are obtained. However, the documentation reviewed indicated that this policy was not followed, as the vaccines were given prior to obtaining the necessary consents.
Failure to Obtain Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to provide necessary education and obtain consent before administering the COVID-19 vaccine to three residents. Specifically, the immunization records for these residents showed that they received the vaccine, but there was no documentation of signed consent or evidence that education on the risks and benefits of the vaccine had been provided to them or their representatives. This deficiency was identified during a review of the clinical records for these residents. During an interview, the Regional Nurse Consultant confirmed that the standard procedure is to educate residents or their representatives about the vaccine upon admission or when boosters are available. However, upon reviewing the records, the consultant acknowledged that no education or consent forms were found for the residents in question, indicating that the vaccines were administered without proper consent.
Failure in Discharge Planning for a Resident
Penalty
Summary
The facility failed to ensure proper discharge planning for a resident who was discharged into the community. The resident expressed a desire to leave the facility and live with a friend, but there was no documentation in the clinical record indicating that the facility arranged for necessary medical services, pharmacy services, or follow-up appointments prior to the discharge. The resident was discharged with all belongings and medications, but the facility only transferred medication scripts to a local pharmacy after the discharge. Following the discharge, the facility filed a report with adult protective services and the local police department due to concerns about the safety of the resident's new living situation. The social service director was responsible for discharge planning, but there was no evidence that services were set up before the resident left the facility. The corporate human resource specialist confirmed that there was no documentation of discharge planning prior to the resident's departure, and efforts to complete necessary arrangements were made only after the discharge.
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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