Homestead Of Hugo
Inspection history, citations, penalties and survey trends for this long-term care facility in Hugo, Oklahoma.
- Location
- 1001 Heritage Way, Hugo, Oklahoma 74743
- CMS Provider Number
- 375492
- Inspections on file
- 29
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Homestead Of Hugo during CMS and state inspections, most recent first.
The facility did not ensure or document consistent RN coverage for at least eight consecutive hours daily for its resident population. Review of RN time records over several months showed eight-hour RN coverage only on scattered dates, rather than every day. The interim DON, who was considered the primary RN coverage Monday through Friday, did not complete time sheets or otherwise record their hours in the building. The administrator confirmed reliance on the interim DON for daily RN coverage but was unable to provide documentation verifying that the required RN presence was maintained.
The facility failed over multiple consecutive months to provide sufficient nursing staff on a 24-hour basis to meet resident care needs, as shown by Quality of Care Monthly Reports documenting repeated shortfalls in required direct care staffing hours on day, evening, and night shifts. For each of three months reviewed, numerous specific days were identified where required staffing hours were not met on one or more shifts. The administrator acknowledged awareness of ongoing staffing shortages, reported relying on existing staff to cover open shifts, and confirmed that agency staff or other external staffing sources were not used to address these persistent gaps.
Hazardous chemicals, including disinfectants, cleaners, and personal care items labeled to be kept out of reach of children, were found unsecured in multiple unlocked rooms within the memory care unit. A resident with severe cognitive impairment and dementia was observed accessing an unlocked closet containing these chemicals. Staff interviews revealed that doors and cabinets meant to secure hazardous items were not consistently locked, keys were missing or left accessible, and there was no formal policy in place for chemical storage.
An allegation of financial abuse by a family member involving a resident with severe cognitive and behavioral impairments was not reported to the OSDH within the required two-hour window. The incident was reported several days late, and the administrator could not provide a reason for the delay.
Several MDS assessments for multiple residents were either not submitted or were submitted late to CMS, despite being completed on time or remaining incomplete past the required deadlines. The MDS coordinator confirmed the delays and late submissions during interviews, as verified by CMS Submission Reports.
The facility experienced significant staffing shortages from May through July, affecting both day and evening shifts. The Quality of Care Monthly Report highlighted multiple days with insufficient staffing hours, impacting the care of all residents. The administrator acknowledged the challenges and reported efforts to recruit more staff.
A facility failed to develop a diabetes care plan for a resident with diabetes, despite having physician's orders for insulin administration and documented high blood sugar levels. The resident's comprehensive care plan lacked a focus on diabetes management, which was acknowledged as an oversight by the DON and administrator.
A resident with Alzheimer's and muscle wasting received perineal care from two staff members who failed to change gloves or sanitize hands during the process. The staff handled soiled items and touched the resident and bedding with contaminated gloves, violating infection control procedures. The Regional RN confirmed the staff's failure to follow proper protocols.
The facility failed to implement infection control policies in the kitchen and ensure food was distributed in a sanitary manner. A staff member worked while sick, and during meal service, improper handling of utensils and wet serving trays were observed. The Dietary Manager acknowledged these lapses in protocol.
The facility failed to provide sufficient staff, resulting in inadequate care for two residents who did not receive scheduled showers. One resident with psoriasis and malnutrition missed multiple showers, while another with hemiplegia and muscle weakness also missed scheduled showers. Staffing shortages were acknowledged by the DON.
The facility failed to provide scheduled bathing to two residents, one with psoriasis and malnutrition and another with hemiplegia and muscle weakness. Documentation revealed missed showers and refusals, with CNAs citing rushed schedules and staffing issues. The DON confirmed the deficiency.
The facility failed to provide double portions for a resident with moderate protein calorie malnutrition, despite a physician's order. The resident reported feeling hungry, and observations confirmed that double portions were not served. The DON was unaware of the order.
Failure to Ensure and Document Consistent RN Coverage
Penalty
Summary
The facility failed to ensure an RN was present in the facility for at least eight consecutive hours a day, seven days a week, for a census of 55 residents. Review of RN time summary sheets from November 2025 through February 2026 showed that eight consecutive hours of RN coverage were documented only on specific, scattered dates within those months, and not consistently throughout the entire period. The interim DON/corporate RN reported they had been serving as the interim DON since the end of October 2025 and were considered the RN coverage for eight consecutive hours per day Monday through Friday, but acknowledged they did not complete time summary sheets or otherwise document their days and times worked in the facility as RN coverage. The administrator confirmed that the interim DON/corporate RN was considered the facility’s eight-hour-a-day RN coverage but stated they could not provide documentation to support that this required RN coverage was actually provided.
Ongoing Failure to Meet Required Direct Care Staffing Hours Across All Shifts
Penalty
Summary
The facility failed to ensure sufficient nursing staff were provided on a 24-hour basis to meet the needs of all 55 residents in accordance with their plans of care. Quality of Care Monthly Reports for three consecutive months documented repeated failures to meet required direct care staffing hours across all shifts. In November 2025, the facility did not meet required direct care staffing hours on 18 of 30 days for the day shift, 12 of 30 days for the evening shift, and 6 of 30 days for the night shift, with specific dates identified for each shift. In December 2025, the facility again failed to meet required direct care staffing hours on 22 of 31 days for the day shift, 12 of 31 days for the evening shift, and 5 of 31 days for the night shift, with multiple clusters of consecutive days where staffing requirements were not met. In January 2026, the Quality of Care Monthly Report showed continued noncompliance, with required direct care staffing hours not met on 14 of 31 days for the day shift, 13 of 31 days for the evening shift, and 17 of 31 days for the night shift, again with specific dates listed for each shift. During an interview on 02/18/26 at 10:30 a.m., the administrator acknowledged awareness of staffing shortages on various shifts over the prior three months. The administrator stated they attempted to address staffing needs by calling current staff for coverage but were not always able to secure sufficient staff, and further stated that the facility did not use agency staff or any other external source to fill staffing gaps.
Unsecured Hazardous Chemicals Accessible to Wandering Residents in Memory Care Unit
Penalty
Summary
The facility failed to ensure that hazardous chemicals were secured and inaccessible to residents who wander, particularly in the memory care unit. Surveyors observed three rooms— a clean linen closet, a soiled linen closet, and a whirlpool/shower room— all found unlocked and containing unsecured hazardous chemicals such as disinfectant cleaner, all-purpose cleaner, degreaser, bleach, hand sanitizer, and personal care items labeled to be kept out of reach of children. Keys to these storage areas were found hanging nearby or missing, and staff interviews confirmed that the doors were supposed to be locked but were not, with one LPN noting that a resident had previously taken the key and that keys could not be located. Staff also reported that the cabinet in the shower room had not been locked for approximately one month. A resident with severe cognitive impairment and a diagnosis of dementia was observed wandering and opening the unlocked clean linen closet containing hazardous chemicals. The administrator acknowledged that there was no formal policy regarding chemical storage and assumed it was understood that doors should be locked. The deficiency was identified for 10 of 26 wandering residents in the memory care unit, with 12 rooms in the facility identified as storing hazardous chemicals.
Removal Plan
- Locks on the clean linen room and dirty room have been locked.
- Padlock on the shower cabinet has been replaced.
- Facility has been checked for chemicals.
- Keys to these rooms will be on a separate key chain locked in the Medication Cart.
- In person and telephone in-services were begun on all employees about chemical storage.
- Monitoring will be conducted.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of abuse, neglect, exploitation, or mistreatment was reported immediately to the Oklahoma State Department of Health (OSDH), as required by regulation. Specifically, an allegation of financial abuse by a family member involving a resident with major depressive disorder, psychotic features, dementia, and behavioral disturbances was not reported to the OSDH within the mandated two-hour timeframe. Documentation showed the incident was reported several days after the initial allegation. The administrator acknowledged that all allegations should be reported within two hours but was unable to explain the delay in this case.
Failure to Timely Transmit MDS Assessment Data
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for several residents. Specifically, quarterly and annual assessments for three residents were completed but not submitted by the required deadlines, as confirmed by both record review and staff interview. Additionally, one resident's assessment remained incomplete past the due date and was subsequently submitted late. CMS Submission Reports confirmed the late submissions for all affected residents. The MDS coordinator acknowledged the missed deadlines for each case during interviews.
Staffing Shortages Affect Resident Care
Penalty
Summary
The facility failed to maintain sufficient direct care staffing levels from May through July, which had the potential to affect all residents. The Quality of Care Monthly Report documented multiple days where staffing levels were below the required amount. In May, the day shift was short on several days, with shortages ranging from 3.85 to 11.44 hours, and the evening shift was short on three occasions, with shortages ranging from 7.12 to 9.21 hours. In June, the day shift experienced shortages on six days, with the most significant being 25.16 hours short, while the evening shift was short on eight days, with the largest shortage being 15.33 hours. In July, the day shift was short on five days, with the most significant shortage being 19.84 hours, and the evening shift was short on three days, with the largest shortage being 14.14 hours. The administrator acknowledged the staffing challenges and reported ongoing efforts to acquire more staff.
Failure to Develop Diabetes Care Plan
Penalty
Summary
The facility failed to develop a diabetes care plan for a resident with a diagnosis of diabetes. The resident had physician's orders for Novolin R insulin on a sliding scale, with specific instructions for insulin administration based on blood sugar levels. The resident's blood sugar log documented blood sugars above 400 on 14 occasions. Despite these documented instances, the resident's comprehensive care plan did not include a focus on diabetes management. The Director of Nursing (DON) and the administrator acknowledged the absence of a diabetes care plan for the resident, stating it must have been overlooked.
Inadequate Infection Control During Perineal Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the provision of perineal care to a resident diagnosed with Alzheimer's Disease and muscle wasting and atrophy. During an observation, two staff members, CNA #3 and Employee #1, were seen transferring the resident from a wheelchair to a bed while wearing gloves. They proceeded to provide perineal care without changing their gloves after removing the resident's pants and dirty briefs. Employee #1 cleaned the resident's vaginal and anal areas with the same gloves and then placed a new brief on the resident, touching various parts of the resident's body and rearranging the bedding, including the pillow, with the contaminated gloves. Employee #1 was also observed touching their face with the same gloved hand used for cleaning the resident's perineal area. The staff members did not change their gloves or sanitize their hands during the care process, and there were no spare gloves available in the room. When questioned, CNA #3 admitted to forgetting to bring a trash bag for the dirty items and acknowledged that they had not changed gloves after handling potentially soiled items. Employee #1 also admitted that they should have changed their gloves. RN #2, the Regional RN, confirmed that the staff members should have cleaned their hands before providing care and after handling dirty items, indicating a failure to follow infection control procedures.
Infection Control and Food Sanitation Deficiencies
Penalty
Summary
The facility failed to implement infection control policies in the kitchen and ensure food was distributed in a sanitary manner. An undated facility policy required employees to report symptoms of illness such as diarrhea and vomiting, and to be excluded or restricted from work if symptomatic. On 03/16/24, DA #1 worked while sick and was involved in passing meals to residents until DA #2 arrived to relieve them. Despite the policy, the Dietary Manager (DM) allowed DA #1 to continue working until relief arrived. Cook #2 confirmed that a sick staff member was present in the kitchen and was vomiting, but was eventually sent home after the DM was contacted. During meal service on 04/09/24, Cook #2 was observed touching the rims of glasses and the eating end of silverware with bare hands. Additionally, serving trays were wet, and Cook #1 was seen handling a can of tomato juice and returning to serve meals without changing gloves or washing hands. The DM acknowledged that kitchen staff should not touch eating areas of utensils or glasses, and should not handle dirty items and then serve food without changing gloves. The DM also stated that trays should be air-dried completely before use.
Staffing Deficiency Leading to Inadequate Resident Care
Penalty
Summary
The facility failed to provide a sufficient number of staff to ensure residents received the needed care and services. Resident #2, who had diagnoses including psoriasis, skin changes, and moderate protein calorie malnutrition, required assistance with bathing. Despite being scheduled for showers on specific days, the resident received only four showers out of 13 opportunities in March 2024, with multiple refusals and missing documentation. In April 2024, there was no documentation of the resident receiving a shower on their scheduled days. The resident reported not receiving a requested shower on April 7th, and the shower sheets lacked proper documentation for several days. Resident #4, diagnosed with hemiplegia, hemiparesis, muscle weakness, and lack of coordination, was dependent on assistance for bathing. The resident did not receive showers on their scheduled days in March 2024. Interviews with CNAs revealed that they often had to rush to complete showers and sometimes failed to document them. The facility's daily staffing hours sheets showed that staffing requirements were not met on multiple days in February and March 2024. The Director of Nursing acknowledged the staffing challenges, citing issues with CNAs not showing up for work or leaving the facility.
Failure to Provide Scheduled Bathing to Residents
Penalty
Summary
The facility failed to provide scheduled bathing to two residents, leading to a deficiency in care. Resident #2, who had diagnoses including psoriasis, skin changes, and moderate protein calorie malnutrition, required assistance with bathing. Despite being scheduled for showers on Mondays, Wednesdays, and Fridays, the resident only received four showers out of 13 opportunities in March 2024, with eight refusals documented and no documentation for the remaining days. In April 2024, there was no documentation of the resident receiving a shower on any of the scheduled days up to the 10th, including the day the resident specifically requested a shower. Resident #4, diagnosed with hemiplegia, hemiparesis, muscle weakness, and lack of coordination, was dependent on assistance for bathing. The resident did not receive showers on their scheduled days in March 2024. Interviews with CNAs revealed that showers were often rushed, sometimes not documented, and occasionally not completed due to staffing constraints. The DON confirmed that the showers were not completed as scheduled based on the documentation reviewed.
Failure to Provide Double Portions for Malnourished Resident
Penalty
Summary
The facility failed to ensure double portions were provided for a resident diagnosed with moderate protein calorie malnutrition. Despite a physician's order dated 08/02/23 for a regular diet with double portions, the resident's meal card did not reflect this requirement. On 04/09/24, the resident expressed dissatisfaction with the food quality and reported feeling hungry for a month. Observations during the lunch meal service revealed that the kitchen ran out of taco meat and did not serve double portions to any resident. Cook #1 confirmed that no residents received double portions, and the DON was unaware of the order for double portions for the resident.
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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