Ignite Medical Resort Edmond, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 1400 East Memorial Road, Oklahoma City, Oklahoma 73131
- CMS Provider Number
- 375583
- Inspections on file
- 15
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Ignite Medical Resort Edmond, Llc during CMS and state inspections, most recent first.
Multiple infection control deficiencies were identified, including failure to date and properly store oxygen and BIPAP equipment for two residents, lack of enhanced barrier precautions during supra-pubic catheter care, delivery of uncovered laundry to resident rooms, and absence of documented legionella surveillance and water management practices. Staff interviews confirmed lapses in following facility policies for infection prevention.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents experienced inappropriate behavior from a CNA, leading to anxiety and fear. One resident, with anxiety and depression, reported rough handling and an inappropriate comment. Another resident, with physical limitations, reported a threatening comment and unprofessional attitude. The CNA was suspended and later left the facility.
The facility was found to have multiple food safety and sanitation deficiencies, including improperly labeled and expired food items, unsanitary storage conditions, and inadequate dishwashing practices. Staff failed to follow established policies for food handling and storage, leading to potential health risks for residents.
The facility did not complete annual competency reviews for two CNAs as required by their policy. The DON and Executive Director acknowledged the oversight, noting that while reviews are scheduled annually, the previous year's reviews were missing.
The facility did not offer two residents the choice to formulate advanced directives, as required. One resident had a fracture of the right arm, and another was recovering from knee replacement surgery. The Admissions Coordinator stated that the offer would be made during the admission contract signing process, which had not yet been completed for these residents.
A resident with conversion disorder and seizures was discharged without a physician's order, contrary to the facility's policy. A progress note recorded the discharge date and time, but the DON confirmed the lack of a required physician's order.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with acute kidney failure and gastrointestinal hemorrhage. Despite the facility's policy requiring such a plan, it was not found in the resident's clinical record. This was confirmed by an MDS Coordinator during an interview.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan inaccurately documented their mobility needs, while another resident admitted with acute kidney failure and gastrointestinal hemorrhage had no care plan in their clinical record. These deficiencies were confirmed by staff observations and interviews.
A resident with conversion disorder and seizures was discharged without a complete discharge summary. The summary, dated in January, noted the resident's stability and follow-up instructions but lacked documentation of medication reconciliation. The DON confirmed the omission in April.
A resident with hypertension did not receive their prescribed medication, losartan potassium-HCTZ, due to an RN holding the medication for a low pulse, contrary to the physician's order to hold it for low blood pressure. This indicates a misinterpretation of the order, as the RN later mentioned the need to clarify the order with the physician.
The facility failed to document appropriate indications for medications for two residents. A resident with dementia and pain was prescribed Lorazepam for pain, which the DON confirmed was inappropriate. Another resident had orders for Torsemide and Apixaban without documented indications. The DON acknowledged the lack of documentation and planned to seek clarification.
The facility failed to disinfect a glucometer before or after its use on a resident. The Glucometer Disinfection policy requires cleaning after each use, but an RN was observed using the device without disinfecting it. The RN stated that cleaning is done by the night shift, but the log only documented the glucometer's range, not its cleaning.
Infection Control Failures in Respiratory Care, Catheter Care, Laundry Handling, and Water Management
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures in several areas related to respiratory care, urinary catheter care, laundry handling, and water system management. For one resident requiring supplemental oxygen, the oxygen tubing and nasal cannula were observed not labeled with the date of administration and not stored in a bag when not in use, as required by facility policy. The equipment was left exposed, wrapped around a bed bar, and connected to a humidifier, also undated. Staff interviews confirmed that the equipment should have been dated and bagged to prevent contamination, but these procedures were not followed. Another resident with a BIPAP machine and a supra-pubic catheter did not have a physician order or care plan focus for BIPAP therapy, and the BIPAP mask and hose were found with visible moisture, stored in an open drawer and not bagged. During catheter care, staff wore gloves but did not use an isolation gown as required by the resident's care plan and physician orders for enhanced barrier precautions (EBP). The resident confirmed that staff did not consistently use gowns during catheter care, and staff interviews revealed a lack of awareness regarding the EBP requirement for catheter care. Additionally, laundry was observed being delivered to resident rooms uncovered, contrary to facility practice of returning clean clothes in individual bags. The housekeeping supervisor acknowledged the incident. Regarding water management, the maintenance supervisor reported the absence of a facility water flow map, lack of documentation for maintenance activities, and unawareness of the water management or legionella prevention plans, despite facility policies requiring such programs and documentation.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, as evidenced by incidents involving two residents. One resident, diagnosed with anxiety disorder and depression, reported that a CNA was rough during care and made an inappropriate comment, suggesting the resident should be in a bubble. The CNA admitted to making the statement, and the incident caused anxiety for both the resident and the CNA, who was new to the unit. Another resident, with diagnoses including epileptic seizures and muscle wasting, reported that the same CNA had an unprofessional attitude and made a threatening comment about getting the resident kicked out. The resident was unable to comply with the CNA's care method due to physical limitations from a stroke. Other residents also reported feeling uncomfortable with the CNA's demeanor, leading to fear of using the call light for assistance. The CNA was placed on suspension pending investigation and eventually left the facility.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and handling protocols, as observed during a survey. Several deficiencies were noted, including improperly labeled and expired food items in the refrigerator, such as a jar of grape jelly opened and dated months prior, and various dairy products with expired use-by dates. Additionally, thawed chicken pieces and other food items lacked proper labeling and use-by dates. The facility's walk-in cooler and large refrigerator contained items that were either expired or not properly dated, indicating a lack of compliance with the facility's 'Date Marking for Food Safety' policy. Further observations revealed unsanitary conditions in the kitchen, such as the use of dirty and greasy bins for storing bulk foods and the absence of beard restraints for staff with facial hair. The dishwashing process was also found to be inadequate, with clean dishware exposed to splash from soiled dishes and a lack of routine testing for proper chemical sanitization in the dishwasher rinse cycles. The facility's 'Dishwashing Machine Use' policy was not followed, as there were no documented sanitizer levels for the dishwasher, and staff were unaware of how to check these levels. These findings were acknowledged by the Certified Dietary Manager, who confirmed that proper procedures for food handling and storage had not been followed.
Failure to Conduct Annual CNA Competency Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for two certified nurse aides (CNAs) as required by their Competency Evaluation policy. The policy mandates that subsequent and/or annual competency evaluations be conducted based on the facility assessment, training program evaluation, and job performance evaluations. However, upon review, it was found that there were no annual competency reviews in the personnel files of two CNAs, one hired in November 2021 and the other in July 2022. The Director of Nursing (DON) and Executive Director confirmed that while competency reviews are supposed to be completed upon hire and annually, the reviews from the previous year could not be located, and skills checks were scheduled for May.
Failure to Offer Advanced Directives
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate advanced directives, as required. This deficiency was identified during a review of the clinical records and interviews with facility staff. Specifically, two residents, one with a diagnosis of a displaced comminuted fracture of the right arm and another following joint replacement surgery of the left knee, were not documented as having been offered the choice to formulate an advanced directive. The Admissions Coordinator confirmed that these residents had not been offered this choice because they had not yet completed the admission contract signing process.
Failure to Obtain Discharge Order
Penalty
Summary
The facility failed to obtain a discharge order for a resident diagnosed with conversion disorder with seizures. The facility's policy, revised in 2023, requires obtaining a physician's order for transfer or discharge. However, a progress note dated January 25, 2024, indicated the date and time of discharge without a corresponding physician's order. During an interview on April 23, 2024, the Director of Nursing confirmed the absence of a physician's order for the discharge of the resident.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was completed within 48 hours for a resident admitted with acute kidney failure and gastrointestinal hemorrhage. The facility's policy, dated 2023, mandates that a baseline care plan be developed within 48 hours of a resident's admission. However, upon review, there was no baseline care plan found in the clinical record of the resident in question. This deficiency was confirmed during an interview with MDS Coordinator #2, who acknowledged that the baseline care plan had not been developed.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their care needs. Resident #9's care plan, initiated in February 2024, inaccurately documented the resident's ability to walk with assistance, despite an admission assessment indicating the need for substantial assistance with bed mobility and no attempts to transfer or walk due to medical or safety concerns. This discrepancy was confirmed by a nurse and the MDS Coordinator, and a physical therapist was observed assisting the resident with a stand pivot transfer using a gait belt. Additionally, Resident #28, admitted with acute kidney failure and gastrointestinal hemorrhage, did not have a comprehensive care plan in their clinical record, as confirmed by the MDS Coordinator.
Incomplete Discharge Summary for a Resident
Penalty
Summary
The facility failed to ensure a complete discharge summary for a resident diagnosed with conversion disorder with seizures. The discharge summary, dated January 25, 2024, indicated that the resident received skilled nursing and therapy services and was stable at the time of discharge. It also noted that the resident and their representative were instructed to follow up with the primary care provider after discharge. However, the Clinical Discharge Instruction Form, which should have included a section for medications sent home, was found to be incomplete. On April 23, 2024, the Director of Nursing confirmed that medication reconciliation was not documented.
Medication Administration Error Due to Misinterpretation of Physician's Order
Penalty
Summary
The facility failed to administer medications as ordered for a resident diagnosed with hypertension. The resident had a physician's order for losartan potassium-HCTZ to be given daily, with instructions to hold the medication if the systolic blood pressure was less than 105 or the diastolic was less than 65, and to notify the physician. On the specified date, an RN documented holding the medication due to a low pulse, which was not in accordance with the physician's order. The RN later stated the order was to hold the medication if the blood pressure was low and to notify the physician, indicating a misunderstanding or miscommunication regarding the order.
Failure to Document Appropriate Indications for Medications
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary medications, as evidenced by the lack of proper indications for the use of certain medications for two residents. Resident #4, who had diagnoses including dementia and pain, was prescribed Lorazepam, an antianxiety medication, for pain management. However, the Director of Nursing (DON) confirmed that pain was not an appropriate indication for Lorazepam use. Additionally, Resident #262 had physician orders for Torsemide, a diuretic, and Apixaban, an anticoagulant, but neither medication had an appropriate indication for use documented. The DON acknowledged this oversight and indicated they would seek clarification from the physician.
Failure to Disinfect Glucometer
Penalty
Summary
The facility failed to disinfect a glucometer before or after its use on a resident, as observed during a survey. The facility's Glucometer Disinfection policy, dated 2023, mandates that blood glucometers be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use. On April 23, 2024, at 11:30 a.m., RN #2 was observed performing glucose monitoring with a glucometer without disinfecting it before or after use. RN #2 stated that the glucometer is cleaned by the night shift, but the provided Glucometer Control Log only documented that the glucometer was in range, with no record of any cleanings.
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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