Higher Call Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Quapaw, Oklahoma.
- Location
- 407 Whitebird Street, Quapaw, Oklahoma 74363
- CMS Provider Number
- 375579
- Inspections on file
- 14
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Higher Call Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its food labeling, storage, and monitoring policies. In the main kitchen refrigerator, several prepared food items, including pudding-type desserts and turkey sandwiches, lacked labels and dates, an opened container of Caesar dressing was kept past its manufacturer use-by date, and fresh produce such as zucchini and iceberg lettuce was wilted, soft, and discolored. In a south community refrigerator, opened mayonnaise and barbeque sauce were stored beyond their manufacturer expiration dates, and an opened carton of lactose-free reduced-fat milk had no open or use-by date. The temperature log for this community refrigerator had no entries for multiple consecutive days, despite facility policy requiring daily temperature checks and proper dating of all food items. A total of 41 residents were identified as receiving meals from the kitchen.
A resident experienced a documented fall from bed with reported shoulder and knee pain and observable knee swelling, and the fall was incorporated into the resident’s care plan with fall-prevention interventions. However, the subsequent annual MDS assessment incorrectly indicated that the resident had no falls since admission or the prior assessment. During later review, the MDS coordinator confirmed that the fall history on the annual MDS was inaccurately coded, resulting in a non-comprehensive and inaccurate assessment of the resident’s status.
A nurse failed to follow proper infection prevention practices during wound care for a resident with lower extremity wounds. While performing dressing changes, the RN placed gloved hands on the floor, then used the same gloves to touch the resident’s skin and apply dressings, exited the room wearing the same gown to use hand sanitizer, and handled wound dressings and a pen with partially donned gloves before completing the dressing change. Facility policy required wound care to be performed using clean or sterile technique, but the RN later admitted not changing gloves correctly and not feeling skilled or routine in performing dressing changes, while the DON noted the nurse was nervous and inadequately prepared.
The facility failed to ensure that residents did not receive unnecessary psychotropic medications. One resident receiving an antianxiety medication had no documented side-effect monitoring, and another resident with a PRN order for lorazepam did not have frequent evaluations of the PRN order. Staff interviews confirmed the lack of required documentation.
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Temperature logs for refrigerators, freezers, and dish machines were not recorded, and open food packages were undated. Bulk containers were left open with scoops inside, and trash cans were uncovered. Cook #1 confirmed these lapses in protocol.
The facility failed to complete a Skilled Nursing Facility Advance Notice of Beneficiary Notice of Non-coverage (SNFABN) form before having a resident sign it. The form lacked essential information such as the services to be charged, the reason Medicare may not pay, and the estimated costs. The resident's decision to continue or discontinue the services was also not indicated. The BOM confirmed the document should have been completed accurately before obtaining the resident's signature.
The facility failed to assess a resident for safe bed rail use and obtain informed consent before using bed rails. The resident required substantial assistance and had moderate cognitive impairment, but no documentation of assessment or consent was found. The DON confirmed the staff did not follow the proper procedure.
The facility failed to follow infection control protocols during wound care for a resident with MRSA and stage 3 pressure ulcers. An LPN did not perform hand hygiene between glove changes and supported the resident's uncovered heels on their uniform pants. Interviews confirmed these actions were against facility policy.
A resident with multiple health conditions repeatedly stated they did not feel well and did not want to go to the dining hall for a meal. Despite these refusals, an LPN physically removed the resident from their room and moved them to the dining room using a gait belt. Multiple staff members corroborated the incident, and the DON confirmed that the resident's rights were violated.
An Immediate Jeopardy situation was identified due to an LPN's failure to prevent mental and physical abuse of a resident. The LPN forcefully walked the resident using a gait belt despite the resident's complaints of feeling unwell, leading to multiple falls and the resident becoming unresponsive. Three staff members witnessed the abuse but did not intervene.
A resident with multiple diagnoses, including heart disease and Alzheimer's, became unresponsive after multiple falls. The LPN failed to assess the resident immediately and did not initiate CPR, mistakenly believing the resident was a DNR. CPR was eventually performed improperly, leading to a deficiency identified by surveyors.
A resident with multiple diagnoses, including Alzheimer's Disease and generalized muscle weakness, was forced by an LPN to walk to the dining room using a gait belt, despite the resident's repeated statements of feeling unwell and not wanting to leave their room. Multiple staff members observed the resident's distress and instability, and the Director of Nursing confirmed that the gait belt was used as a physical restraint.
A resident with multiple diagnoses was forced by an LPN to walk to the dining room despite feeling unwell, leading to repeated falls and eventual death. The facility delayed investigating the incident and did not immediately suspend the LPN, potentially exposing other residents to further risk.
A facility failed to notify a resident's family of a significant weight loss, as required by policy. The resident experienced a 22.28% decline in body weight over one month, and the family only learned of the change through a family friend. The DON confirmed the lack of documentation and acknowledged that staff did not follow the notification policy.
The facility failed to conduct and document skin and wound assessments as ordered by a physician for a resident with pressure ulcers and quadriplegia. Multiple daily skin assessments and weekly wound assessments were missing from the resident's electronic medical record. Both an LPN and the DON confirmed the assessments were not completed as required.
Failure to Label, Discard, and Monitor Food Items and Refrigerator Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to follow its own food labeling, storage, and monitoring policies for food served to residents. Surveyors observed in the main kitchen refrigerator multiple prepared food items without required labels, preparation dates, or use-by dates, including five covered containers with a white pudding-type substance and two prepared turkey sandwiches wrapped in plastic. They also found an opened one-gallon container of Caesar dressing with a manufacturer use-by date that had already passed, as well as fresh produce (zucchini squash and iceberg lettuce) that was wilted, soft to the touch, and discolored. The facility’s policy required all food containers to be labeled with the common name of the food, date prepared or opened, discard date, and staff initials, and the dietary manager acknowledged that staff had not consistently labeled and dated items and that fresh food should be checked and discarded if not fresh. In a south community refrigerator, surveyors observed additional failures to manage food items and temperature monitoring as required. They found an opened container of mayonnaise and an opened container of barbeque sauce, both past the manufacturer’s expiration dates, and an opened carton of lactose-free reduced-fat milk without an open or use-by date. The refrigerator temperature log posted on this community refrigerator had no dates or temperatures recorded for three consecutive days. Facility policy for LTC resident refrigerators required staff to document the date received, date opened, expiration date, and resident name on each food item, and to maintain the refrigerator at or below 40°F. The administrator stated that housekeeping was responsible for checking community refrigerator temperatures daily and outdated food weekly, and acknowledged that the temperature checks for the south community refrigerator had not been completed as required. A total of 41 residents were identified as receiving meals from the kitchen during this period.
Inaccurate MDS Coding of Resident Fall History
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment of a resident’s fall history. A progress note dated 07/30/25 at 3:45 a.m. documented that Resident #36 reported rolling out of bed onto the floor, with complaints of left shoulder pain and right knee pain, and observation that the right knee appeared slightly larger than the left. A care plan initiated the same day documented that the resident had a fall on 07/30/25 and included interventions such as use of a fall mat next to the bed and education not to sleep on the edge of the bed. Despite this documented fall and related care plan, the resident’s annual MDS assessment dated 10/15/25 indicated that the resident had not had any falls since admission, entry, reentry, or the prior assessment. On 01/08/26, during review of the annual assessment, the MDS coordinator acknowledged that the annual assessment was not accurately coded regarding the resident’s fall history, demonstrating that the facility did not complete a comprehensive and accurate assessment as required by its MDS 3.0 Completion policy and federal regulations.
Inadequate Infection Control During Wound Care Procedure
Penalty
Summary
The deficiency involves the facility’s failure to maintain infection control practices during wound care for one resident receiving treatment to multiple lower extremity wounds. During observation of a wound dressing change, an RN providing care knelt on the tiled floor and placed both gloved hands on the floor, then used the same contaminated gloves to touch the resident’s bare skin and apply a gauze dressing to the left shin. The RN then exited the room while still wearing the gown to use hand sanitizer from a container outside the room, partially donned new gloves, reached into a pocket to retrieve a pen, and with those partially donned gloves handled gauze soaked in Dakin’s solution and placed it onto a wound on the right heel. The RN then fully donned the gloves and used the same gloved hands to write the date on the dressing, insert iodoform gauze soaked in Dakin’s solution into the right heel wound, and apply a border gauze dressing. Facility policy required that wound care be performed by licensed nursing staff using clean or sterile technique as ordered. The RN later acknowledged not realizing they had not changed gloves correctly and stated they were not very skilled at dressing changes and did not feel they had an established routine, while the DON reported the RN was nervous and should have better prepared for the wound care. The Director of Nursing identified that a total of 15 residents in the facility were receiving wound care, and the cited deficient practice was observed in one of two sampled residents reviewed for wound care during the survey.
Failure to Monitor Psychotropic Medication Side Effects and PRN Orders
Penalty
Summary
The facility failed to ensure that residents did not receive unnecessary psychotropic medications. Resident #5, who had diagnoses including depressive episodes and hip pain, was receiving an antidepressant and an antianxiety medication. However, there was no documentation of side-effect monitoring for the antianxiety medication in the resident's health record. Similarly, Resident #19, who had diagnoses including anxiety and depression, had a PRN order for lorazepam. The facility did not document frequent evaluations of the PRN order for this psychotropic medication. Interviews with RN #1 and the DON confirmed that side-effect monitoring and frequent evaluations of PRN orders for psychotropic medications were not consistently documented as required.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. During an observation on 05/13/24, it was noted that the refrigerator and freezer temperature logs had not been recorded since 05/06/24. Additionally, open packages of sliced ham, shredded cheese, and chicken noodle soup were found in a reach-in cooler without any dates. Bulk containers of sugar and flour were left open with scoops inside, and all four trash cans in the kitchen were uncovered. The dish machine temperature log also lacked documentation of temperature and sanitizer concentration for the first 13 days of May. Furthermore, the food temperature log had not recorded any meal temperatures since the noon meal on 05/06/24. Cook #1 confirmed that the temperature logs for the freezers and coolers should be recorded by the cook on duty and that open containers of food should be closed and dated. They also stated that scoops should not be left in bulk containers and that meal temperatures should be recorded prior to serving. The person washing dishes was responsible for monitoring the dish machine, and the temperature and chemical concentration should be recorded three times a day. The DON identified 37 residents who received meals from the kitchen, indicating a widespread impact of these deficiencies.
Incomplete SNFABN Form
Penalty
Summary
The facility failed to properly complete a Skilled Nursing Facility Advance Notice of Beneficiary Notice of Non-coverage (SNFABN) form before having a resident sign it. Specifically, the form for Resident #20, who was admitted and later discharged, was signed on 05/01/24 but lacked essential information. The sections where the services to be charged, the reason Medicare may not pay, and the estimated costs were supposed to be listed were left blank. Additionally, the area where the resident was to indicate whether they wanted to continue or discontinue the services was also not filled out. The Business Office Manager (BOM) confirmed that the document should have been completed with accurate information before obtaining the resident's signature.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was assessed for their ability to safely use bed rails and that informed consent was obtained from the resident or their representative prior to the use of bed rails. The facility's policy required an assessment and informed consent before bed rails could be used. A quarterly assessment documented that the resident required substantial assistance to reposition themselves in bed and had moderate cognitive impairment. However, a review of the resident's medical record did not find documentation of an assessment or informed consent for bed rail use. Observations confirmed that the resident's bed had half rails in the up position, and the resident stated they needed the rails for support. The DON confirmed that the staff had not followed the proper procedure as per the facility's policy.
Infection Control Protocols Not Followed During Wound Care
Penalty
Summary
The facility failed to ensure infection control protocols were followed during wound care for one resident with MRSA and stage 3 pressure ulcers on both heels. During an observation, an LPN was seen changing the resident's wound dressings without performing hand hygiene between glove changes on three occasions. Additionally, the LPN supported the resident's uncovered heels directly on their uniform pants while changing the dressings. Interviews with a CNA and the DON confirmed that hand hygiene should be performed when changing gloves and that it was unacceptable to rest an uncovered wound on a uniform.
Violation of Resident's Right to Refuse Care
Penalty
Summary
The facility failed to ensure a resident's right to remain in their bed and to decline a meal. Resident #1, who had diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness, repeatedly stated they did not feel well and did not want to go to the dining hall for a meal. Despite these refusals, LPN #1 physically removed Resident #1 from their room and moved them to the dining room using a gait belt. This incident was captured on a facility video recording dated 11/02/23, showing LPN #1 walking Resident #1 from their room to the dining room at 8:22 a.m. Multiple staff members corroborated the incident. CNA #2 stated that Resident #1 had informed them and LPN #1 that they did not want to get out of bed as they did not feel well. CNA #1 observed LPN #1 walking behind Resident #1 in the hallway and heard the resident state they were out of breath and did not want to continue. CMA #1 observed LPN #1 bringing Resident #1 into the dining room using a gait belt and stated that LPN #1 was basically dragging the resident through the dining room. The Director of Nursing (DON) confirmed that by not allowing Resident #1 to remain in bed, LPN #1 had violated the resident's rights.
Removal Plan
- Grievance book has been established to ensure issues are being taken care of in a timely manner.
- Discussed policy on the residents' right to refuse any care, activities, or anything they want to refuse.
- In-service staff on Self Determination.
- Risk management will monitor the facility issues weekly during regularly scheduled meetings.
- QAPI will monitor quarterly.
Failure to Prevent Resident Abuse and Neglect
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified at the facility due to the failure to prevent mental and physical abuse of a resident. The incident involved a Licensed Practical Nurse (LPN) who used a gait belt to forcefully walk a resident from their room to the dining hall despite the resident's repeated statements of feeling unwell and not wanting to leave their room. The resident, who had diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness, fell multiple times during the incident and ultimately became unresponsive. The LPN did not perform CPR, mistakenly believing the resident was a Do Not Resuscitate (DNR) order, when in fact the resident was a full code. Three staff members witnessed the abuse but did not intervene to stop it. The facility's video recording documented the LPN walking the resident using a gait belt, the resident falling multiple times, and being picked up by the LPN before finally being placed in a wheelchair by three staff members and removed from the dining room. Progress notes and staff interviews revealed that the resident had informed staff of feeling dizzy, cold, and unwell, but the LPN dismissed these complaints and insisted on moving the resident to the dining room. The LPN's actions included physically lifting the resident multiple times despite their protests and visible instability, and making derogatory comments towards the resident. Staff interviews further corroborated the events, with witnesses describing the resident's unstable condition and the LPN's forceful handling of the resident. The Director of Nursing (DON) confirmed that the LPN's conduct was abusive and violated the facility's abuse prevention policy. The incident highlights a severe lapse in protecting the resident's right to be free from abuse and neglect, as well as a failure in staff intervention and adherence to proper care protocols.
Removal Plan
- Grievance book has been established to ensure issues are being taken care of.
- Discussed policy on not allowing abuse or neglect in the facility.
- In-service staff on abuse and neglect.
- Monitoring will happen in Risk management and in QAPI through regularly scheduled meetings.
Failure to Provide Timely CPR to Unresponsive Resident
Penalty
Summary
The facility failed to ensure that a resident who had become unresponsive was immediately assessed by a licensed nurse and received cardio-pulmonary resuscitation (CPR) according to standards of practice. The resident, who had diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness, was documented as a full code. Despite this, the resident did not receive timely CPR when they became unresponsive after multiple falls while being walked to the dining room by an LPN. The LPN, along with other staff members, transferred the unresponsive resident to a wheelchair and then to their bed without performing an immediate assessment or initiating CPR. The LPN incorrectly believed the resident was a do-not-resuscitate (DNR) and did not perform CPR until much later, after being informed by the Director of Nursing (DON) that the resident was a full code. By the time CPR was initiated, it was performed improperly, with the resident in a bed without a backboard and compressions being too deep, as observed by the DON. The incident was captured on a facility video recording, which showed the resident falling multiple times and being transferred to a wheelchair by the LPN, a physical therapist (PT), and a certified medication aide (CMA). The video also recorded the LPN and other staff members standing over the resident without performing an assessment or initiating CPR. Witnesses, including CNAs and the PT, confirmed that the resident appeared unresponsive and had blue lips, indicating a lack of oxygen. Despite these signs, the LPN did not perform CPR immediately and instead moved the resident to their room, where they were placed in bed and left unattended for a period. Interviews with staff members revealed that the LPN had a mistaken belief about the resident's code status, which led to a delay in initiating CPR. The DON confirmed that the LPN did not follow facility policy during the incident and that the CPR performed was inadequate. The LPN's actions and inactions, including the failure to assess the resident immediately and the improper execution of CPR, contributed to the deficiency identified by the surveyors.
Removal Plan
- LPN #1 was terminated.
- The DON or designee educating all licensed nurses on the facility's policy and procedure for initiating CPR and location of code status for each resident.
- RN shift supervisor given responsibility to direct/assign staff roles during code/initiation of code.
- A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented. DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Compliance checks will be conducted.
- DON or designee will audit new admissions to compare the resident's advance directives to the physician orders for accuracy.
- DON or designee performed a Code Blue drill and was performed with licensed nursing staff on all shifts until every nurse had participated at least once. Code Blue drills will continue to be held.
Improper Use of Gait Belt as Physical Restraint
Penalty
Summary
The facility failed to prevent the use of a gait belt as a physical restraint for a resident diagnosed with atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness. On the specified date, a video recording showed an LPN walking behind the resident, who was hunched over a walker, while holding a gait belt secured around the resident's lower chest. Despite the resident's repeated statements of not wanting to leave their room and feeling unwell, the LPN used the gait belt to force the resident to the dining room. The progress note written by the LPN confirmed that the resident had declined to leave their room, but the LPN ignored the resident's statements and used the gait belt to remove them from their room and take them to the dining room. Multiple staff members, including two CNAs and a CMA, observed the incident and reported that the resident expressed feeling dizzy, out of breath, and unstable. The LPN continued to force the resident to walk using the gait belt, despite the resident's visible distress and statements of being unable to walk. The Director of Nursing later confirmed that the way the LPN used the gait belt on the resident constituted a physical restraint.
Delayed Investigation of Potential Abuse
Penalty
Summary
The facility failed to protect residents from potential abuse by delaying an investigation of possible abuse for one resident. The resident had diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, Alzheimer's Disease, and generalized muscle weakness. A video recording showed an LPN walking the resident to the dining room using a gait belt, despite the resident's complaints of not feeling well, being cold, having tremors, and being dizzy. The resident fell repeatedly and was eventually placed in a wheelchair and removed from the dining room. The resident later died, and the LPN was found performing chest compressions alone without a crash cart or backboard. The DON was informed of the incident but did not start an investigation until several days later, despite receiving information from CNAs and a family member about the resident being forced to walk to the dining room against their will. The DON and ADON were informed by CNAs that the LPN had made the resident get up from bed against their will and that the resident had died in the dining room. The DON did not start the investigation over the weekend because the weekend staff was not on duty when the resident died. The LPN was not instructed to stay away from the facility until the investigation began on Monday, allowing the LPN to have access to residents before being suspended. The delay in starting the investigation and the failure to immediately suspend the LPN potentially exposed other residents to further risk of abuse.
Failure to Notify Family of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's family of a significant weight loss. A review of records and interviews revealed that one resident experienced a 22.28% decline in total body weight from January 2024 to February 2024, dropping from 124.8 pounds to 97.0 pounds. Despite the facility's policy requiring notification of significant changes in a resident's condition, the family was not informed. A family member only became aware of the weight loss through a family friend who visited the resident. The Director of Nursing (DON) confirmed the lack of documentation indicating that the family had been informed and acknowledged that staff did not follow the policy in this situation.
Failure to Conduct and Document Required Skin and Wound Assessments
Penalty
Summary
The facility failed to conduct and document skin and wound assessments as ordered by a physician for a resident diagnosed with pressure ulcers and quadriplegia. The physician's orders required daily skin assessments starting on 01/23/24 and weekly wound assessments on Thursdays starting on 01/25/24. However, a review of the resident's electronic medical record revealed missing daily skin assessments on multiple dates and missing weekly wound assessments on several Thursdays. Both an LPN and the Director of Nursing confirmed that the assessments were not documented and likely not completed as required.
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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