Hillcrest Manor Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Blackwell, Oklahoma.
- Location
- 1210 South 6th Street, Blackwell, Oklahoma 74631
- CMS Provider Number
- 375402
- Inspections on file
- 19
- Latest survey
- May 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hillcrest Manor Nursing Center during CMS and state inspections, most recent first.
A CMA failed to maintain physical support of a resident requiring assistance during a transfer, letting go of the resident to close a bathroom door, which resulted in the resident falling. The resident, who had intact cognition and required staff support for transfers, reported pain and was evaluated at a hospital. Facility policy and best practice were not followed, as confirmed by staff interviews.
A resident experienced multiple falls, primarily while attempting to use the bathroom independently during early morning hours, resulting in injuries including a hip fracture. Despite recognition of this pattern by both staff and the resident's POA, and a specific request for increased monitoring during high-risk times, the care plan was not updated to include targeted interventions such as scheduled checks. The lack of communication and failure to revise the care plan contributed to ongoing incidents.
A resident with a history of falls while attempting to use the bathroom during early morning hours suffered multiple incidents, including a hip fracture requiring surgery, due to staff not providing targeted supervision or updating the care plan despite repeated requests from the POA and awareness of the risk. Communication lapses between staff and management contributed to the deficiency.
A resident was allowed to self-administer insulin without a documented assessment to determine their ability to do so safely, despite facility policy requiring such an evaluation. Nursing staff routinely set up the insulin injector and permitted the resident to inject themselves, but neither an order nor an assessment for self-administration was found in the medical record. Facility leadership and staff were unaware of the need for or existence of the required documentation.
A comprehensive assessment for a resident contained conflicting information regarding antipsychotic medication use, with the MDS indicating both use and non-use, despite the MAR confirming administration of Latuda. The DON and Corporate VP acknowledged the inaccuracy, noting that only spot checks of the MDS coordinator's work were performed.
A resident was discharged from the facility, but instead of completing and submitting the required discharge assessment, staff mistakenly completed a quarterly assessment. This error was confirmed by facility leadership during review of the electronic health record.
A resident requiring moderate assistance with bathing did not consistently receive scheduled showers, with documentation missing for several occasions. The resident reported not always receiving baths as scheduled, and staff interviews revealed that showers and refusals should be documented, but lack of documentation made it unclear if care was provided.
A resident with heart failure and hypertension who complained of cough and congestion did not receive a physician-ordered RSV test. The order was not entered into the computer, and the facility was out of necessary swabs. The facility did not follow up to ensure the sample was collected.
A resident with neuromuscular dysfunction of the bladder and a stage IV pressure ulcer, who was totally dependent on staff, did not consistently receive care with required enhanced barrier precautions. During wound and incontinent care, a CNA was observed not wearing a gown as required, despite staff acknowledging that gowns should be used for residents on enhanced barrier precautions.
A resident with dementia, identified as an elopement risk, was found outside the facility due to non-functioning Wander Guard alarms on two doors. Staff interviews revealed that residents at risk for wandering wore Wander Guard bracelets, and alarms were supposed to be tested weekly. However, monitoring of the system had not been initiated until the incident occurred.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Fall
Penalty
Summary
A certified medication aide (CMA) failed to provide adequate supervision to prevent a fall for one resident who required staff assistance for transfers. According to facility policy, staff are expected to implement interventions based on residents' specific risks to prevent falls. The resident involved had intact cognition and required physical support from staff for transfers, as documented in their assessment. On the day of the incident, the CMA was assisting the resident back from the bathroom but turned away to close the bathroom door, completely letting go of the resident. During this moment, the resident fell to the floor, as confirmed by both the CMA and a witness. Following the fall, the resident complained of hip pain and was transferred to a local hospital for evaluation, though no injuries were ultimately found. The resident's transfer status was subsequently elevated from a one-person to a two-person transfer, and pain medication was prescribed for reported pain. Interviews with the CMA and the ADON confirmed that the CMA should not have let go of the resident during the transfer and that this action was not in accordance with facility policy or best practice.
Failure to Update Care Plan for Recurrent Falls
Penalty
Summary
The facility failed to update a resident's care plan to include specific interventions to prevent a recurring pattern of falls, despite multiple documented incidents. The resident experienced several falls, most of which occurred between 3:00 a.m. and 5:00 a.m. while attempting to go to the bathroom independently. These falls resulted in injuries, including a laceration, skin tear, abrasion, and ultimately a hip fracture that required surgical intervention. The care plan was revised after some of these incidents, but did not include targeted interventions such as scheduled checks during the high-risk time frame. Progress notes and interviews revealed that both staff and the resident's power of attorney (POA) recognized the pattern of falls occurring during early morning hours. The POA specifically requested that staff check on the resident during these times to help prevent further incidents. An LPN confirmed having this conversation with the POA but did not communicate the request to the night shift or management, and the intervention was not added to the care plan. The Director of Nursing (DON) acknowledged that information about the resident's fall pattern and the POA's request should have been communicated to management and incorporated into the care plan. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan, but this was not followed in the case of this resident, resulting in a lack of appropriate interventions to address the identified risk.
Failure to Provide Supervision to Prevent Repeated Resident Falls
Penalty
Summary
Staff failed to provide adequate supervision to prevent repeated falls for a resident with a known history of attempting to go to the bathroom independently during early morning hours. The resident experienced multiple falls between 3:00 a.m. and 5:00 a.m., as documented in several progress notes, with incidents resulting in injuries including a head laceration and, ultimately, a left hip fracture that required surgical intervention. The facility's fall management policy required staff to identify and implement interventions based on the resident's specific risks, but this was not effectively carried out. Despite the resident's power of attorney (POA) repeatedly notifying staff and requesting that the resident be checked during the high-risk time frame, this information was not formally communicated to management or incorporated into the resident's care plan. The LPN who received the POA's request did not ensure the intervention was relayed to the night shift or documented for agency staff, resulting in a lack of targeted supervision during the times when the resident was most at risk for falls.
Failure to Assess Resident for Safe Self-Administration of Insulin
Penalty
Summary
The facility failed to ensure that a resident who self-administered insulin was properly assessed for the ability to safely self-administer medication, as required by facility policy. During an observation, a nurse was seen handing an insulin injector to a resident, who then administered the injection without checking the dose. The resident had a physician's order for insulin and had been self-administering for approximately one year, with staff routinely setting up the injector and allowing the resident to inject themselves. However, there was no documented assessment in the medical record to determine if the resident was clinically appropriate or safe to self-administer their medication. Interviews with nursing staff and administration revealed a lack of awareness regarding the need for an assessment or a specific order for self-administration. The DON and ADON were not initially aware of any residents self-administering medications and could not locate an assessment or order for the resident in question. The facility's policy required an evaluation of the resident's mental and physical abilities before permitting self-administration, but this process had not been followed for the resident observed.
Inaccurate MDS Assessment for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of a comprehensive assessment for one resident, as required by policy. Specifically, the annual Minimum Data Set (MDS) assessment for the resident contained conflicting information in Section N, indicating both that the resident was and was not receiving antipsychotic medications. Review of the resident's medication administration record (MAR) confirmed that the resident had been administered the antipsychotic medication Latuda during the week prior to the assessment. Interviews with the Corporate Vice President and the Director of Nursing (DON) confirmed the inconsistency in the MDS and acknowledged that the resident was indeed taking an antipsychotic at the time of the assessment. The DON stated that while the Corporate VP spot-checked the MDS coordinator's work, they themselves did not review each assessment, and the MDS was found to be inaccurate.
Failure to Complete and Submit Required Discharge Assessment
Penalty
Summary
The facility failed to ensure that a required discharge assessment was completed and submitted to the Centers for Medicare and Medicaid Services for one resident. According to the records, the resident was discharged on 10/25/24, but the electronic health record only showed a quarterly assessment completed on that date, with no evidence of a discharge assessment. During an interview, the Corporate Vice-President of Operations confirmed that a quarterly assessment was completed instead of the required discharge assessment due to an error.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident who required moderate assistance with bathing received scheduled showers as required. According to the facility's policy, residents unable to perform activities of daily living independently should receive necessary services to maintain personal hygiene. Record review showed that, out of 18 scheduled opportunities, the resident did not have showers documented on seven occasions. The resident reported that they were supposed to receive baths twice weekly but sometimes did not, and when they requested a shower, staff would sometimes promise to return but did not always follow through. Staff interviews confirmed that showers should be documented and refusals noted, but if there was no documentation, staff could not confirm whether a shower was provided.
Failure to Complete Physician-Ordered Laboratory Test
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as ordered by the physician for one resident. The resident, who had diagnoses including heart failure and hypertension and was assessed as having no cognitive impairment, complained of cough and congestion. The physician was notified and ordered guaifenesin and an RSV test. However, there was no physician order for the RSV test documented in the health record, nor were there any results for an RSV test collected on the date in question. Interviews revealed that the order for the RSV test was not entered into the computer, and the facility was out of swabs needed for the test. The lab company was scheduled to bring more swabs, but the facility did not follow up to ensure the sample was collected.
Failure to Consistently Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were consistently implemented for a resident requiring such measures. During wound care and incontinent care provided to a resident with neuromuscular dysfunction of the bladder and a stage IV pressure ulcer, a CNA was observed not wearing a gown as required, while the RN did wear a gown during wound care. The resident was assessed as severely impaired for daily decision making and totally dependent on staff for care. Staff interviews confirmed that gowns should have been worn during direct care for residents on enhanced barrier precautions, but this protocol was not followed during the observed care activities.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm System
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with dementia, who was identified as being at risk for wandering. The resident's care plan documented a history of attempts to leave the facility unattended. An incident occurred where the resident was found walking beside the street in front of the facility, indicating a lapse in supervision and security measures. Upon investigation, it was discovered that the Wander Guard alarms on the southwest and northwest doors were not functioning, as they were not installed. Interviews with staff revealed that residents who wandered were supposed to wear a Wander Guard bracelet, and the alarms were expected to sound if a resident approached within 10-15 feet of a door. The maintenance supervisor was responsible for testing the Wander Guard system weekly, but the monitoring of the system had not been initiated until the date of the incident. This lack of monitoring and testing contributed to the failure in preventing the resident's elopement.
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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