Ignite Medical Resort Norman, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Norman, Oklahoma.
- Location
- 1050 Rambling Oaks Drive, Norman, Oklahoma 73072
- CMS Provider Number
- 375461
- Inspections on file
- 24
- Latest survey
- July 14, 2025
- Citations (last 12 mo.)
- 4 (2 serious)
Citation history
Health deficiencies cited at Ignite Medical Resort Norman, Llc during CMS and state inspections, most recent first.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident with frequent pain and physician orders for as-needed Tylenol and oxycodone did not receive pain medication when expressing pain during care. Staff delayed administration, incorrectly believing it was too soon for the next dose, resulting in unmanaged pain until the next scheduled medication was given. The DON confirmed that pain management orders were not followed.
Staff failed to follow infection control protocols by placing soiled linens and pads directly on the floor during incontinent care for a resident and by transporting dirty linens without gloves or proper bagging. Multiple CNAs acknowledged not adhering to facility procedures for handling contaminated linens, and the DON confirmed the expected process was not followed.
A resident with rectal cancer and an indwelling catheter did not receive tube feeding as ordered, and the facility failed to document physician notification of the resident's refusal. Additionally, the facility did not remove the Foley catheter for a trial of void as ordered by the physician. The resident was unaware of the voiding trial order, and the catheter remained in place. The LPN and DON confirmed the lack of documentation and adherence to physician orders.
A facility failed to provide a resident with scheduled showers, despite the resident's need for moderate assistance with hygiene due to conditions like spinal stenosis and dementia. The resident did not receive a shower over a five-day period, and the DON confirmed the lack of documentation for a scheduled shower.
A resident, admitted with chronic kidney disease and other conditions, did not receive scheduled showers or baths as required. Despite being cognitively intact and needing substantial assistance, there was no documentation of showers from admission to discharge. The DON confirmed that without documentation, there was no proof of showers being provided.
A resident with a history of femur fracture and dysphasia sustained repeated injuries during transfers due to inadequate documentation and lack of preventive measures. Despite being dependent on assistance, the resident's injuries were not documented in the health records, and no incident reports were completed by the staff, including LPNs and CNAs, as required by the facility's policy.
The facility failed to label and date oxygen tubing for three residents requiring respiratory care. A resident with acute kidney failure and heart failure, another with heart disease and spondylosis, and a third with COPD and a respiratory infection were all observed using oxygen without proper labeling. Staff confirmed the tubing should be changed and dated weekly.
The facility failed to conduct an entrapment risk assessment and obtain a physician order for bed rails for two residents. One resident, with epilepsy and morbid obesity, used bed rails without a documented risk assessment. Another resident, with muscle weakness, also lacked a physician order and risk assessment for bed rail use. The facility's policy required these steps, which were not followed.
The facility failed to administer medications according to physician-ordered parameters for three residents. Medications for hypertension were given despite blood pressure readings being outside the specified limits. Both the CMA and DON acknowledged the oversight, indicating a lapse in following the facility's Pharmacy Services policy.
The facility failed to document appropriate diagnoses for the use of antipsychotic medications in three residents. One resident was prescribed olanzapine without a psychotic disorder diagnosis, another was given aripiprazole without a documented indication, and a third received quetiapine for insomnia without an insomnia diagnosis. The facility's policy requires documented diagnoses for psychotropic drug use, which was not adhered to in these cases.
The facility failed to label food items with the date opened and maintain a clean kitchen, as observed during a survey. Items like cheeses and sour cream lacked proper labeling, and the kitchen had unsanitary conditions, including spilled coffee and food debris. The CDM acknowledged these issues and the potential for cross-contamination.
A facility failed to accurately assess a resident's need for oxygen therapy. Despite having a physician's order for supplemental oxygen and documented use of oxygen, the resident's comprehensive assessment incorrectly indicated no need for oxygen therapy. Interviews with staff revealed discrepancies in the care plan and MDS assessment, with the MDS Coordinator admitting to an error in coding.
A facility failed to follow physician orders for weekly weight monitoring of a resident with chronic kidney disease and fluid overload. Despite orders to report significant weight changes, a weight was missed, and a 28.7-pound gain over 23 days was not documented or reported. Staff interviews revealed a lack of documentation and clarity regarding the resident's weight monitoring.
A facility failed to follow infection control practices by not covering a resident's nebulizer mask when not in use. A resident with a cognitive communication deficit had their nebulizer mask left uncovered on a paper towel in the window sill next to food and drinks. A CNA and an LPN confirmed that the mask should have been bagged according to facility policy, which was not followed in this instance.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Timely Pain Management as Ordered
Penalty
Summary
A deficiency occurred when a resident who was frequently in pain and had physician orders for as-needed pain medications did not receive pain management as ordered. During incontinent care, the resident expressed pain, was observed groaning, and reported discomfort to the CNAs. The resident's orders included Tylenol 325 mg two tablets by mouth every six hours as needed and oxycodone HCl 5 mg, with specific dosing based on pain level. The medication administration record showed the last dose of oxycodone was given at 5:06 a.m., and the next dose was not administered until 1:07 p.m., despite the resident expressing pain around noon. Tylenol was not administered during this period. CNA staff reported the resident's pain to the CMA, who stated it was too early to administer additional pain medication and that the resident had already received all available pain relief. However, upon review, the CMA acknowledged a miscalculation and that the resident should have received pain medication when they complained. The DON confirmed that the CMA did not follow the resident's pain management orders. The failure to provide timely pain medication as ordered resulted in the resident experiencing unmanaged pain during the observed period.
Improper Handling of Dirty Linens During Care and Transport
Penalty
Summary
The facility failed to ensure proper handling of dirty linens to prevent cross-contamination during incontinent care and general linen management. During an observation of incontinent care provided to a resident, two CNAs were seen placing soiled pads and a pillowcase directly on the floor instead of immediately bagging them as required by facility protocol. The soiled items remained on the floor next to other linens before being bagged and removed from the room. Both CNAs later acknowledged in interviews that they did not follow the facility's process for handling dirty linens during the care episode. In a separate observation, another CNA was seen picking up dirty linens and a pad from the floor near a resident's room without wearing gloves and holding the items close to their upper body while transporting them to the designated environment room. This CNA also confirmed in an interview that the linens were dirty and that the facility's process was to bag dirty linens before transport, which was not followed. The Director of Nursing confirmed that staff are expected to bag dirty linens during care and transportation.
Failure to Follow Physician Orders for Tube Feeding and Catheter Management
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with rectal cancer and had an indwelling catheter and a feeding tube. The physician had ordered catheter care every shift and the administration of Jevity 1.5 Cal at 65 ml/hr via g-tube every night shift for feeding. However, the facility did not administer the tube feeding as ordered on 11/27/24, and the resident refused the feeding on subsequent days without proper documentation of physician notification. Additionally, the resident was observed with a full bag of tube feeding formula that was not labeled or dated, and the connection end had dried and crusted formula, indicating neglect in tube feeding management. Furthermore, the facility did not follow the physician's order for a trial of void by removing the Foley catheter. The resident was unaware of the order for the voiding trial, and the catheter remained in place without any attempt to remove it for the trial. The LPN confirmed that there was no documentation of physician notification regarding the refusal of tube feeding, and the DON acknowledged that the blank on the MAR/TAR indicated the tube feeding was not done. The failure to follow physician orders for both tube feeding and catheter management resulted in a deficiency in the care provided to the resident.
Failure to Provide Scheduled Showers to a Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received the necessary assistance with activities of daily living, specifically showering. The resident, who was admitted with diagnoses including spinal stenosis, back pain, and dementia, was documented as cognitively intact and requiring moderate assistance with hygiene and bathing. Despite the facility's schedule indicating that the resident was to receive showers on Tuesdays, Thursdays, and Saturdays, records showed that the resident did not receive a shower from September 12 to September 17, 2024. The Director of Nursing (DON) confirmed the absence of documentation for a shower on September 14, 2024, acknowledging that the resident should have received their shower on that date.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide scheduled baths or showers for a resident who was unable to perform activities of daily living independently. The resident, who was cognitively intact and required substantial to maximal assistance with bathing, was admitted with diagnoses including chronic kidney disease, pleural effusion, and fluid overload. Despite being scheduled to receive showers every Tuesday and Friday, there was no documentation in the medical record indicating that the resident received any showers or baths from admission until discharge. A grievance form dated July 7, 2024, documented the resident's request for a shower over several days. The Director of Nursing (DON) confirmed that completed baths should have been documented in the electronic health record (EHR) or under tasks in the resident's medical record, and acknowledged that without such documentation, there was no proof that the resident received a shower during their stay.
Failure to Document and Prevent Repeated Resident Injuries During Transfers
Penalty
Summary
The facility failed to prevent an injury to a resident during transfers, as evidenced by multiple incidents involving Resident #29. The resident, who was admitted with a fracture of the right femur and dysphasia, was dependent on assistance for transfers. Despite this, the resident sustained a laceration on the left leg during transfers from the bed to a wheelchair on multiple occasions. The resident reported these injuries to staff, but there was no documentation of the incidents or any interventions to prevent further injuries in the electronic health records. The facility's staff, including LPNs and CNAs, were aware of the injuries but failed to document them or complete incident reports as required by the facility's policy. The Director of Nursing and the Corporate Administrator acknowledged the lack of documentation and investigation into the incidents. The facility's policy mandates a full investigation and documentation of any accidents, but this was not followed, leading to repeated injuries to the resident without any preventive measures being implemented.
Failure to Label and Date Oxygen Tubing
Penalty
Summary
The facility failed to ensure that oxygen tubing was labeled and dated according to professional standards of care for three residents who required respiratory care. Resident #4, admitted with acute kidney failure and systolic heart failure, was observed using oxygen via a nasal cannula without any date on the tubing or humidifier to indicate when it was last changed. Both a CNA and an RN confirmed the absence of labeling, with the RN acknowledging that the tubing should be changed and dated every seven days. Similarly, Resident #26, with diagnoses including atherosclerotic heart disease and spondylosis, was found using oxygen without the tubing or humidifier being labeled with a date. An RN confirmed the lack of labeling and stated the tubing should be changed weekly. Resident #93, who had chronic obstructive pulmonary disease and a lower respiratory infection, was also observed using oxygen without any date on the tubing or humidifier. The ADON confirmed the absence of labeling and reiterated that it is a nursing standard to change and label the tubing weekly.
Failure to Conduct Entrapment Risk Assessment and Obtain Physician Order for Bed Rails
Penalty
Summary
The facility failed to perform an entrapment risk assessment prior to installing bed or side rails for two residents and did not obtain a physician order for the medical rationale and use of bed rails for one of these residents. Resident #2, who had diagnoses including epilepsy, muscle wasting, and morbid obesity, had a physician order for quarter bed rails for turning and positioning. However, there was no documentation of an entrapment risk assessment in the medical record. The resident was observed using the bed rails for turning and positioning, and the facility administrator confirmed that the required assessment was not completed. Resident #86, admitted with diagnoses such as muscle weakness and peripheral vascular disease, also lacked documentation of a physician order and an entrapment risk assessment for the use of bed rails. The resident was observed using the rails to assist in turning, and the facility administrator acknowledged the absence of the necessary physician order and assessment. The facility's admission packet indicated that bed rails should only be implemented after a licensed nursing assessment and with a physician's written order, which was not adhered to in these cases.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that medications were administered according to physician-ordered parameters for three residents. Resident #12, who was admitted with dementia and hypertension, had orders for amlodipine and losartan to be held if the diastolic blood pressure was less than 70. However, the July and August 2024 Medication Administration Records (MAR) documented that these medications were administered on multiple occasions when the diastolic blood pressure was below the specified threshold. Resident #88, with diagnoses including dementia and chronic kidney disease, had an order for carvedilol to be held under similar blood pressure conditions, yet it was administered twice when the diastolic blood pressure was below 70. Resident #89, with chronic respiratory failure and hypertension, had an order for metoprolol to be held if the systolic blood pressure was less than 110 or diastolic less than 60, but it was administered twice under these conditions. The Certified Medication Aide (CMA) #1 and the Director of Nursing (DON) were informed of these discrepancies. CMA #1 acknowledged that the medications should have been held according to the physician's parameters. The DON also recognized that the medication staff should have been more attentive and not administered the medications when the blood pressure readings were outside the ordered parameters. This oversight in medication administration indicates a failure to adhere to the facility's Pharmacy Services policy, which emphasizes the importance of monitoring specific parameters related to medications to avoid unnecessary interruptions.
Inadequate Documentation for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had appropriate diagnoses or indications for their use. Specifically, three residents were identified as receiving antipsychotic medications without documented diagnoses to justify their use. Resident #12 was admitted with dementia, anxiety, and depression, and was prescribed olanzapine for a psychotic disorder, yet no diagnosis of a psychotic disorder was found in their medical record. Similarly, Resident #88, who was severely cognitively impaired and had moderate depression symptoms, was prescribed aripiprazole without a documented diagnosis in the physician order to support its use. Additionally, Resident #89, who had chronic respiratory failure, chronic kidney disease, and hypertension, was prescribed quetiapine for insomnia, but there was no documentation of an insomnia diagnosis in their medical record. The facility's Medication Monitoring policy requires that psychotropic drugs are only given when necessary to treat a specific condition as diagnosed and documented in the clinical record. The administrator acknowledged the lack of appropriate diagnoses for the use of antipsychotic medications for these residents.
Deficiencies in Food Labeling and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to its Food & Nutrition Services Sanitation & Food Safety policy by not labeling food items with the date they were opened in the kitchen refrigerators. During observations, several food items, including cubed pears, various cheeses, sour cream, and watermelon cups, were found without labels indicating when they were opened. Staff members acknowledged the lack of labeling and sealing of food items, which is against the facility's policy that requires all refrigerated potentially hazardous foods to be labeled with the date received and opened. Additionally, the facility did not maintain a clean and sanitary kitchen environment. Observations revealed spilled coffee on the ice and coffee machines, watermelon juice on various surfaces, and food debris on shelf liners and clean containers. Clean pans and coffee thermos servers were improperly stored, and some items in the freezer were not labeled or sealed. The Certified Dietary Manager (CDM) admitted to being unsure of the policy for maintaining a clean kitchen and acknowledged the potential for cross-contamination due to the unsanitary conditions. The CDM also noted that the cleaning schedule was not being properly followed.
Inaccurate Resident Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate resident assessments for one of the sampled residents, specifically regarding the use of oxygen therapy. Resident #4, who was admitted with diagnoses including systolic heart failure and depression, had a physician's order for supplemental oxygen as needed. However, the comprehensive assessment dated 08/11/24 incorrectly documented that the resident did not require oxygen therapy, despite evidence from an O2 Sats Summary document indicating that the resident received oxygen on that date. Interviews with facility staff revealed discrepancies in the documentation of Resident #4's care plan and MDS assessment. LPN #1 confirmed that the resident was on oxygen and had an order for supplemental oxygen as needed, while the DON acknowledged that the resident's care plan did not reflect their oxygen care needs, even though the resident wore oxygen at night. The MDS Coordinator admitted to incorrectly coding the MDS assessment by selecting 'no' for oxygen therapy, despite the resident's use of oxygen on 08/11/24, resulting in an inaccurate assessment.
Failure to Follow Physician Orders for Resident Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders for obtaining weekly weights for a resident with chronic kidney disease, pleural effusion, and fluid overload. The physician had ordered weekly weights every Thursday, with specific instructions to report any weight differences of greater than 3 pounds in two days or 5 pounds in one week. Despite these orders, the resident's medical record showed weights were not consistently documented, with a missing weight entry on June 20, 2024. Additionally, there was no documentation that the significant weight gain of 28.7 pounds over 23 days was reported to the physician, nor were any interventions implemented to address this weight gain. Interviews with facility staff revealed a lack of clarity and documentation regarding the resident's weight monitoring. An LPN stated uncertainty about why the weight was not obtained on the specified date and believed they had notified the physician about the weight gain but failed to document it. The DON confirmed the absence of documentation for the weight on June 20, 2024, and acknowledged the resident was supposed to be weighed weekly. The physician did not recall being notified of the significant weight gain, although they noted the resident was in good spirits upon discharge and had voiced no concerns.
Infection Control Deficiency: Uncovered Nebulizer Mask
Penalty
Summary
The facility failed to adhere to infection prevention and control practices by not covering a resident's nebulizer mask when not in use. Resident #35, who was admitted with a fracture of the right lower leg and cognitive communication deficit, had a physician's order for Ipratropium Bromide Inhalation Solution to be used as needed for shortness of breath. On observation, the resident's nebulizer mask was found uncovered and placed on a paper towel in the window sill next to food and drinks. A CNA confirmed that the mask was not bagged as required, and an LPN stated that the facility's policy mandates that nebulizer masks should be bagged and changed weekly. However, the mask was observed to be improperly stored, indicating a lapse in following the facility's infection control policy.
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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