Kingwood Skilled Nursing And Therapy
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 1921 Northeast 21st Street, Oklahoma City, Oklahoma 73111
- CMS Provider Number
- 375155
- Inspections on file
- 25
- Latest survey
- December 11, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Kingwood Skilled Nursing And Therapy during CMS and state inspections, most recent first.
A facility failed to report and address allegations of sexual abuse involving two residents, one of whom had severe cognitive impairment and was unable to communicate. Despite staff observations of inappropriate behavior, the facility did not follow mandated reporting procedures, leading to an Immediate Jeopardy situation. Staff members expressed fear of retaliation, contributing to the lack of reporting, and the administration was not informed in a timely manner.
The facility failed to accurately code assessments for two residents. One resident with significant weight changes had assessments inaccurately documenting no weight loss or gain. Another resident with a colostomy was incorrectly assessed as not having one. These discrepancies were confirmed by MDS Coordinators.
A resident with essential hypertension did not receive their prescribed losartan potassium as ordered, with multiple doses held without physician authorization. The facility's MAR indicated the medication was withheld due to vital signs outside parameters, but no holding parameters or standing orders were documented. Interviews with staff confirmed the lack of proper documentation and notification to the physician.
The facility failed to obtain physician-ordered labs for two residents, one with major depressive disorder and liver disease, and another with seizures. The required lab tests, including CBC, CMP, and Keppra levels, were not documented or conducted as ordered, indicating a deficiency in the facility's process for managing lab orders.
CNA #10 failed to perform hand hygiene between resident interactions during an ice pass, contrary to the facility's Hand Hygiene policy. The CNA admitted to sanitizing hands every other room due to the distance between rooms, which was confirmed as non-compliant by the DON. This lapse in protocol could lead to cross-contamination among the 67 residents in the facility.
A facility failed to notify a physician when holding a resident's medication, losartan potassium, due to vital signs being outside parameters. The resident, diagnosed with essential hypertension, had their medication held multiple times without documented physician notification, contrary to facility policy. Interviews revealed no holding parameters for the medication, and standing orders were not provided to surveyors.
The facility failed to report an incident of resident-to-resident abuse to the OSDH, as required by their policy. A resident with schizophrenia was involved in an incident with another resident with Alzheimer's, resulting in a skin tear. Despite the policy mandating reporting to state authorities, the incident was only documented internally, and the Administrator confirmed no state report was filed.
The facility failed to investigate an incident where a resident with schizophrenia allegedly hit another resident with Alzheimer's, causing a skin tear. Despite the facility's policy requiring thorough investigations of abuse allegations, only an incident report was completed, and no further investigation was conducted.
A resident with major depressive disorder and liver disease required specific lab tests ordered by a third-party provider, but the facility failed to conduct these tests. Despite having a contract that outlined responsibilities, the facility did not document or collect the necessary samples, leading to a communication breakdown between the facility and the provider. Both parties acknowledged the lapse, and the facility had previously terminated contracts with the provider for other residents due to similar issues.
A resident with Alzheimer's and muscle weakness fell during a mechanical lift transfer when the lift's feet got caught under a geri chair, causing it to flip. Staff interviews revealed inconsistencies in understanding the facility's lift use policy, which requires two persons to assist. The resident was sent to the ER for evaluation.
A facility failed to coordinate care with a dialysis provider for a resident with end-stage renal disease and hypertension. Despite instructions from the dialysis center to withhold hypertension medications before dialysis, the facility continued administering them, potentially affecting fluid removal. The DON and LPN were unaware of the dialysis center's communication, and there was no evidence that the physician was informed. The medical records department could not find additional provider visits, indicating poor documentation and follow-up.
Failure to Report and Address Allegations of Abuse
Penalty
Summary
The facility failed to implement its abuse reporting policy, resulting in an Immediate Jeopardy situation. The deficiency involved a failure to report and address allegations of sexual abuse involving two residents. One resident, who had severe cognitive impairment and was unable to communicate effectively, was allegedly subjected to inappropriate behavior by another resident. This resident, who had a history of wandering and inappropriate gestures, was observed entering the room of the non-verbal resident multiple times, raising concerns among staff members. Despite these observations, the facility staff did not follow the mandated reporting procedures. Several staff members, including CNAs and RNs, were aware of the situation but did not report it to the appropriate authorities or document the incidents as required by the facility's abuse policy. The staff expressed fear of retaliation and job loss, which contributed to the lack of reporting. The facility's administration was not informed of the allegations in a timely manner, and the police were not notified until much later. The facility's failure to act promptly and follow its abuse policy resulted in a delay in addressing the potential abuse and ensuring the safety of the residents involved. The lack of documentation and communication among staff members further exacerbated the situation, leaving the residents vulnerable to harm. The deficiency highlights a significant breakdown in the facility's abuse prevention and reporting protocols, which are critical to protecting residents from harm.
Inaccurate Resident Assessments for Weight and Colostomy Status
Penalty
Summary
The facility failed to ensure accurate coding of resident assessments for two residents. Resident #23, who had diagnoses including edema and end-stage renal disease, experienced significant weight fluctuations over several months. Despite these changes, the resident's assessments on multiple occasions inaccurately documented no or unknown weight loss or gain. Specifically, the assessments on 05/02/24, 07/26/24, and 10/26/24 failed to reflect the resident's weight loss, as confirmed by the MDS Coordinators during interviews. Resident #16, who had a diagnosis that included colostomy status, was inaccurately assessed in their Annual Resident Assessment dated 11/22/24. The assessment incorrectly documented that the resident did not have an ostomy or colostomy, despite the resident having a colostomy. This discrepancy was acknowledged by the MDS Coordinators, who noted that the resident's bowel continence was not rated because it was not marked, further indicating an oversight in the assessment process.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident diagnosed with essential hypertension. The resident was prescribed losartan potassium 50 mg to be taken twice daily. However, the medication was held multiple times in October and November 2024 without obtaining an order to do so. The Medication Administration Record (MAR) documented that the medication was withheld due to vital signs being outside parameters, but there was no documentation of an order to hold the medication or any notification to the physician regarding the withheld doses. Interviews with the LPN and the Director of Nursing (DON) revealed that there were no holding parameters documented for the losartan potassium, and the facility did not have standing orders to hold the medication for low blood pressure. Despite this, the medication was repeatedly held without proper authorization or documentation. The Regional Nurse Consultant and the Administrator confirmed that the electronic record system showed medications due for each shift, and the physician should have been notified when a medication was held, but this procedure was not followed.
Failure to Obtain Physician-Ordered Labs for Residents
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for two residents, leading to a deficiency in care. Resident #37, who had diagnoses including major depressive disorder, liver disease, and unspecified viral hepatitis B, had a physician order for a CBC and CMP to be conducted every six months in October and April. However, there was no documentation that the October 2024 labs were collected. An LPN explained the process for ordering and documenting labs, but upon review, they were unable to locate the lab results in the electronic system. The Director of Nursing (DON) also confirmed that the labs were not on the monthly orders for the resident. Similarly, Resident #24, who had a diagnosis of seizures, had a physician order to draw Keppra levels every three months. The October 2024 Keppra level results were missing from the resident's record. The Regional Nurse Consultant confirmed the absence of these lab results. These lapses in obtaining and documenting necessary lab tests for residents indicate a failure in the facility's processes for managing physician orders and ensuring timely laboratory testing.
Inadequate Hand Hygiene During Ice Pass
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during an ice pass, as observed on multiple occasions. CNA #10 was seen entering several residents' rooms, handling personal cups, and distributing ice without performing hand hygiene between each resident interaction. This occurred despite the facility's Hand Hygiene policy, which emphasizes the importance of using alcohol-based hand rub after touching a resident or their immediate surroundings. During the ice pass, CNA #10 admitted to not sanitizing their hands between each resident due to the distance between rooms, opting instead to sanitize every other room. The Director of Nursing (DON) later confirmed that staff are required to sanitize their hands when moving from room to room while passing ice. The failure to adhere to these protocols was observed during the ice pass, potentially leading to cross-contamination among the 67 residents residing in the facility.
Failure to Notify Physician When Holding Medication
Penalty
Summary
The facility failed to notify the physician when holding a medication without holding parameters for a resident diagnosed with essential hypertension. The resident was prescribed losartan potassium 50 mg to be taken twice daily. However, the medication was held multiple times in October and November 2024 due to vital signs being outside parameters, as indicated by the chart code '11'. Despite this, there was no documentation that the physician was notified prior to holding the medication, which is a requirement according to the facility's policy on notifying a resident's family or physician of significant treatment changes. Interviews with LPN #6 and the Director of Nursing (DON) revealed that there were no holding parameters for the medication, and the physician was not contacted when the medication was held. The Regional Nurse Consultant and the Administrator stated that the physician would be notified when a medication was held, but standing orders to hold the medication for low blood pressure were not provided to the survey team. This lack of communication and documentation led to the deficiency identified by the surveyors.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the Oklahoma State Department of Health (OSDH) for two residents. The facility's policy mandates that all employees report any incidents of abuse, neglect, or misappropriation of property to the appropriate authorities, including the OSDH. However, in this case, an incident involving two residents was not reported as required. Resident #25, who has a diagnosis of schizophrenia, was involved in an incident with Resident #39, who has Alzheimer's disease and an unspecified mood disorder. The incident report documented that Resident #39 was found bleeding from the left cheekbone and stated that someone had hit them, with another resident identifying Resident #25 as the perpetrator. Despite the facility's policy requiring such incidents to be reported to the OSDH, there was no documentation that an incident report was sent. The Administrator confirmed that there was no state report done, only an internal incident report. This oversight indicates a failure to adhere to the facility's policy and regulatory requirements for reporting abuse, which is crucial for ensuring resident safety and compliance with state regulations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving two residents. The facility's policy on Resident Abuse, Neglect, and Misappropriation of Property requires a member of the administrative staff to conduct a thorough investigation and report all allegations to the QAPI committee and appropriate Federal and State agencies. However, in this case, the facility did not adhere to its policy, as no investigation was conducted beyond the initial incident report. The incident involved a resident with schizophrenia, who was reported to have hit another resident with Alzheimer's disease, resulting in a skin tear on the latter's left cheekbone. The incident report noted that the resident with Alzheimer's was found bleeding and claimed to have been hit, but could not identify the perpetrator. Another resident identified the aggressor, who admitted to the act. Despite these details, the facility's Administrator confirmed that no further investigation was conducted, highlighting a failure to comply with the facility's own procedures for handling abuse allegations.
Failure to Coordinate Care with Third-Party Provider
Penalty
Summary
The facility failed to coordinate care with a third-party provider for a resident diagnosed with major depressive disorder, liver disease, and unspecified viral hepatitis B. The resident required specific laboratory tests as ordered by the third-party provider, but these tests were not conducted. The facility had a contract with the third-party provider that required written authorization for medically necessary services, including lab tests. Despite receiving a communication form from the third-party provider detailing the necessary labs, the facility did not document or collect the required samples. Interviews with facility staff, including an LPN and the Administrator, revealed a lack of communication and coordination between the facility and the third-party provider. The LPN acknowledged that the lab orders were not noted, and the Administrator confirmed that the third-party provider managed the resident's labs. The third-party representative stated that the facility was responsible for completing the labs and sending the results back. Both the facility and the third-party provider admitted to a communication breakdown, resulting in the labs not being drawn. The facility had terminated contracts with the third-party provider for other residents due to ongoing issues, but the contract for this resident remained active.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, resulting in an accident. The incident involved a resident with Alzheimer's disease and muscle weakness, who was dependent on staff for all transfers. During a transfer attempt, the feet of the lift became entangled with a geri chair, causing the lift to flip over and the resident to fall to the floor. The incident note documented that the resident was found lying on their back by the sink, with no immediate injuries observed, but was sent to the ER for further evaluation. Interviews with staff revealed inconsistencies in the understanding and implementation of the facility's policy regarding lift use. While some staff members stated that the policy required two persons to assist with the lift, others mentioned the need for a third person. The incident highlighted a lack of adherence to the established policy, as the lift was not operated with the required number of staff members, leading to the accident involving the resident.
Failure to Coordinate Dialysis Care for a Resident
Penalty
Summary
The facility failed to coordinate care with a dialysis provider for a resident with end-stage renal disease and essential hypertension. The resident had physician orders to attend dialysis sessions on Tuesday, Thursday, and Saturday. However, there was a lack of communication and coordination regarding the administration of hypertension medications. A communication form from the dialysis center indicated that the resident should not receive hypertension drugs prior to dialysis, as it could prevent the removal of excess fluids due to hypotension. Despite this, the facility continued to administer medications such as losartan potassium, minoxidil, and nifedipine during the morning timeframe, which included the dialysis days. The facility's Director of Nursing (DON) and LPN were unaware of the undated communication form from the dialysis center, and there was no evidence that the physician was informed of the dialysis center's recommendation. The DON and LPN stated that the facility coordinated care by sending a dialysis communication sheet with the resident, but they did not know when or how the note from the dialysis center was added to the resident's chart. The medical records department was unable to locate any additional provider visits for the resident, indicating a lack of proper documentation and follow-up on the dialysis center's instructions.
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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