Latimer Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilburton, Oklahoma.
- Location
- 103 Southwest 9th Street, Wilburton, Oklahoma 74578
- CMS Provider Number
- 375535
- Inspections on file
- 19
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Latimer Nursing Home during CMS and state inspections, most recent first.
Staff did not follow enhanced barrier precautions during urinary catheter care for a resident with an indwelling catheter. Observations showed that PPE such as gowns and masks were not used, soiled items were handled improperly, and the catheter was not secured. Staff interviews revealed a lack of knowledge about EBP requirements, and the facility's infection preventionist confirmed inconsistent implementation of infection control policies.
A strong urine odor was repeatedly present on one hall, affecting 14 residents. Staff, including an LPN and a CNA, confirmed the persistent smell, which was traced to specific rooms and mattresses. Despite changing linens and cleaning mattresses, the odor remained, indicating a failure to maintain a clean and comfortable environment.
A resident with chronic pain and multiple sclerosis did not receive their prescribed hydrocodone/acetaminophen at several scheduled times because the facility was waiting for insurance prior authorization. The resident reported severe pain and distress during this period, and nursing documentation confirmed the missed doses and the resident's pain levels.
A resident's admission assessment was not completed within the required fourteen-day timeframe, with documentation showing it was finalized nearly three months after admission. The MDS coordinator confirmed the delay in completing the assessment.
A resident who was totally dependent on staff for ADLs and had urinary incontinence was not provided with timely incontinent care, as evidenced by observation of a saturated brief and strong urine odor. The resident reported infrequent changes, and a CNA confirmed that care was not provided every two hours as required by facility policy, citing being too busy as the reason.
The facility failed to develop and implement a policy and procedure for a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems. The maintenance man confirmed the absence of such a policy, although efforts were being made to create one. The administrator identified 23 residents in the facility.
The facility failed to ensure residents were offered the choice to formulate advanced directives for three of six sampled residents. Two residents had no documentation of an advance directive or acknowledgment in their records, and another resident had incomplete documentation regarding the assistance provided by the durable power of attorney.
The facility failed to ensure accurate resident assessments for three residents, including errors in medication documentation, weight records, and omission of significant diagnoses. These inaccuracies were confirmed by the ADON/MDS Coordinator.
The facility failed to implement comprehensive care plans for several residents, including those with bedrails, hospice care, respiratory care, and unnecessary medications. Observations and interviews revealed that assessments and care plans were either missing or incomplete, leading to multiple deficiencies.
The facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side-rails for eight residents reviewed for accident hazards. Observations revealed that bedrails were in use without documented assessments or care plan updates, and staff interviews confirmed the lack of assessments and alternative attempts.
The facility failed to ensure a consultant pharmacist reviewed the medications of each resident monthly, leading to unnecessary medications for four residents. The acting DON did not follow through with the pharmacist's recommendations for gradual dose reductions during several months.
The facility failed to ensure medication cards were labeled with an expiration date for 49 of 55 sampled medication cards. During an inspection, it was observed that many medication card labels had no readable expiration date. A CMA confirmed the inability to read the expiration dates, and the consultant pharmacist was unaware of the issue.
The facility failed to serve food under sanitary conditions for 23 residents. The dietary manager was observed serving lunch trays while wearing the same set of gloves and without proper hand washing between residents. The dietary manager believed that wearing gloves allowed them to avoid hand washing when exiting and entering the kitchen.
The facility failed to ensure regular inspections and proper assessments of bedrails for eight residents, leading to potential safety risks. Observations and interviews revealed that bedrails were in use without proper documentation or inclusion in care plans, and maintenance checks were only conducted when issues were reported or beds were moved.
A resident with cerebral brain stem hemorrhage, anxiety disorder, and depression disorder, requiring total assistance with ADLs, was transported from the shower room to their room by a CNA. During the transfer, the resident's body was exposed to those in the hallway. The CNA admitted they should have used two sheets to cover the resident and did not notice the exposure.
The facility failed to update a care plan for a resident with peripheral vascular disease and a right above-the-knee amputation when the resident developed a right stump wound. Despite a physician's order for wound care treatment, the care plan was not revised, as acknowledged by the new MDS Coordinator.
The facility failed to document a recapitulation of a resident's stay on the discharge summary. The resident was admitted and later discharged to another facility, but the discharge summary lacked a recap of the stay. The MDS Coordinator/ADON acknowledged the issue and indicated future compliance.
The facility failed to develop and implement physician's orders for oxygen tubing care maintenance for two residents on oxygen therapy, despite their medical conditions and assessments indicating the need for such orders. The ADON/MDS Coordinator confirmed the absence of these necessary orders.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Facility staff failed to implement enhanced barrier precautions (EBP) during urinary catheter care for a resident with an indwelling catheter. Observations revealed that staff did not utilize required personal protective equipment (PPE) such as gowns and masks, as outlined in the facility's own EBP policy for residents with devices like urinary catheters. Specifically, a CNA was seen draining a urinary catheter without wearing an isolation gown or mask, using a towel and washcloth that had been on the floor, and carrying soiled items out of the resident's room while still wearing contaminated gloves. The CNA also demonstrated a lack of knowledge regarding EBP requirements. Similarly, an LPN performed catheter care without securing the catheter to the resident's leg and did not use an isolation gown or mask, also indicating unawareness of EBP protocols. Interviews with staff and the infection preventionist (IP) confirmed that the expectation was to use gloves and clean technique, but there was no consistent understanding or implementation of EBP, despite the facility's policy requiring gloves, gowns, and face shields for care involving artificial openings or tubing. The resident involved was cognitively intact and had an indwelling catheter, and reported that staff only wore gloves during care. The lack of visible EBP signage or equipment in the resident's room further demonstrated the facility's failure to follow its own infection control policies.
Failure to Maintain Odor-Free Environment on Resident Hall
Penalty
Summary
A deficiency was identified when a strong urine odor was repeatedly observed on the South hall, which housed 14 residents. Surveyors noted the persistent odor on multiple occasions, and staff interviews confirmed the presence of the smell. An LPN reported that the odor was particularly strong in the morning and intensified when the hopper room door was opened, attributing the smell to residents' urine. A CNA indicated that the odor seemed to originate from specific rooms, and despite changing residents, linens, and cleaning mattresses, the strong urine smell persisted. The CNA also noted that another resident's mattress had a similar odor, and cleaning efforts did not eliminate it.
Failure to Administer Ordered Narcotic Pain Medication Due to Authorization Delay
Penalty
Summary
The facility failed to ensure that a resident received their prescribed narcotic pain medication as ordered by the physician. The resident, who was cognitively intact and had diagnoses including multiple sclerosis and chronic pain, was ordered to receive hydrocodone/acetaminophen every six hours, along with other pain management medications. According to the medication administration record, the resident did not receive the hydrocodone/acetaminophen at multiple scheduled times over a two-day period. Nursing notes indicated that the resident was given ibuprofen for a reported pain level of 7, and later had no complaints of pain, but the prescribed narcotic was not administered as ordered. The administrator confirmed that the facility was waiting for prior authorization from the resident's insurance for the hydrocodone/acetaminophen, resulting in a lapse in administration of the medication. The last dose of the narcotic pain medication was given the evening before the missed doses began. When asked about their pain, the resident expressed significant distress, stating they were "dying without their pain medication" and described their pain as severe. The failure to provide the ordered pain medication was directly related to the delay in obtaining insurance authorization.
Delayed Completion of Admission Assessment
Penalty
Summary
The facility failed to complete an admission assessment for a resident within the required timeframe. Record review showed that the resident was admitted on a specific date, but the admission assessment was not signed as completed until nearly three months later, well past the required fourteen-day period. The MDS coordinator confirmed in an interview that the assessment was not completed in a timely manner. This deficiency was identified for one of twelve sampled residents whose assessments were reviewed, out of a total of 27 residents in the facility.
Failure to Provide Timely Incontinent Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely incontinent care and assistance with activities of daily living (ADLs) for a resident who was totally dependent on staff. Observation revealed that the resident's brief was very saturated with a dark yellow substance and there was a strong urine odor in the room. The resident, who was cognitively intact and had diagnoses including multiple sclerosis and urinary incontinence, reported that bed checks were not performed every two hours and that they were typically changed only once a day. Staff interview confirmed that the resident had not been changed between 6:45 a.m. and a bit after 10:00 a.m., and that the facility policy required changing residents every two hours. The CNA stated they were unable to follow the policy due to being too busy. These findings demonstrate that the facility did not adhere to its own policy for regular incontinent care, resulting in the resident remaining in a saturated brief for an extended period.
Lack of Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to develop and implement a policy and procedure for a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems. This deficiency was identified through observation, record review, and interview. The maintenance man confirmed that the facility did not have a policy and procedure for Legionella at the time of the survey, although they were working on writing one. The administrator identified 23 residents who resided in the facility.
Failure to Offer Advanced Directives to Residents
Penalty
Summary
The facility failed to ensure residents were offered the choice to formulate advanced directives for three of six sampled residents. Resident #17, admitted with hypertension and diabetes, had no advance directive or acknowledgment in their electronic health record or paper chart. Similarly, Resident #20, admitted with diabetes, also lacked any documentation of an advance directive or acknowledgment in their records. The Assistant Director of Nursing (ADON) was unable to provide documentation that these residents had been offered the choice to formulate an advance directive. Resident #25, admitted with diagnoses including convulsions, peripheral vascular disease, anemia, and anxiety disorder, had an admission assessment indicating cognitive intactness and various levels of assistance required for daily activities. Although a document titled 'Acknowledgement of Receipt Advanced Directive/Medical Treatment Decisions' was marked that the resident had chosen to formulate an advance directive by the durable power of attorney, the ADON reported that there was no documentation that the durable power of attorney had assisted the resident in filling out the advance directive. The ADON acknowledged that Resident #17 and #20 should have had an advance directive or acknowledgment in their medical records.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure resident assessments were accurate for three of the 14 sampled residents. Resident #2 was admitted with multiple diagnoses including diabetes mellitus type II and depressive disorder. A quarterly assessment inaccurately documented that the resident was taking both anti-anxiety and anti-depressive medications, whereas the resident was only on anti-depressive medication. The ADON/MDS Coordinator confirmed this was a mistake. Resident #5, who had diagnoses including transient cerebral ischemic attack and depressive disorder, had a quarterly assessment that incorrectly recorded the resident's weight as 131 pounds instead of the accurate 121 pounds. The ADON/MDS Coordinator acknowledged this as a typographical error. Resident #16, admitted with a diagnosis of malignant neoplasm of the bone among other conditions, had a significant change assessment that failed to document the malignant neoplasm cancer. The ADON/MDS Coordinator confirmed that this diagnosis should have been included in the assessment. These inaccuracies in resident assessments were identified through record reviews and interviews, highlighting a failure in the facility's process to ensure accurate documentation. The errors included incorrect medication documentation, typographical errors in weight records, and omissions of significant diagnoses. These deficiencies were confirmed by the ADON/MDS Coordinator during interviews, indicating lapses in the accuracy of resident assessments, which are critical for providing appropriate care and treatment plans for the residents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a comprehensive care plan for several residents, leading to multiple deficiencies. For instance, five residents with bedrails did not have proper assessments or care plans documenting the use of bedrails. These residents had various diagnoses, including cerebral palsy, multiple fractures, hip fracture, malignant neoplasm, and convulsions. Observations revealed that these residents were either unable to remove or lower the bedrails themselves or used them to prevent falls, yet no assessments were conducted, and the bedrails were not included in their care plans. The ADON/MDS Coordinator admitted to the lack of assessments and care plans for bedrails and was unaware of the requirement for such assessments until recently discovering it in the EHR system. Additionally, the facility failed to include hospice care in the care plan for a resident with dementia, depressive disorder, encephalopathy, and Parkinson's disease, despite a physician's order to admit the resident to hospice. The ADON/MDS Coordinator acknowledged that hospice care should have been included in the care plan. Furthermore, two residents on oxygen therapy did not have their respiratory care documented in their care plans. One resident with diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure, and another with dementia, depressive disorder, encephalopathy, and Parkinson's disease, were both on oxygen, but this was not reflected in their care plans. The facility also failed to document the use of unnecessary medications in the care plans of three residents. One resident with dementia, depressive disorder, encephalopathy, and Parkinson's disease was on anti-psychotics, another with malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, and HTN was on Lasix, and a third resident with congestive heart failure, ischemic cardiomyopathy, and atrial fibrillation was on Brilinta. The ADON/MDS Coordinator admitted that these medications should have been included in the care plans but were not. The MDS Coordinator, who was new to the position, acknowledged still learning about care plans and what should be included.
Failure to Assess and Document Bedrail Use
Penalty
Summary
The facility failed to attempt appropriate alternatives and perform an entrapment risk assessment prior to installing bed or side-rails for eight residents reviewed for accident hazards. The residents involved had various diagnoses including cerebral palsy, chronic pain syndrome, anxiety disorders, cardiomegaly, multiple fractures, anorexia, dementia, osteoarthritis, hip fractures, multiple sclerosis, convulsions, atrial fibrillation, mood disorders, depressive disorder, encephalopathy, Parkinson's disease, malignant neoplasm of the bone, myocardial infarction, diabetes mellitus type II, hypertension, bilateral hip replacements, right knee replacement, peripheral vascular disease, and anemia. Observations revealed that bedrails were in use without documented assessments or care plan updates, and staff interviews confirmed the lack of assessments and alternative attempts. For instance, one resident with cerebral palsy and chronic pain syndrome was observed with bedrails on each side of the bed, but no assessment for bedrails was found, and the bedrails were not added to the care plan. Another resident with multiple fractures and dementia was observed with a half bedrail raised, but again, no assessment was documented. Similar deficiencies were noted for other residents, with staff members stating that bedrails were used to prevent falls or assist with mobility, yet no formal assessments or care plan updates were conducted. The ADON/MDS Coordinator admitted to being unaware of the requirement for bedrail assessments and alternative attempts prior to their use.
Failure to Ensure Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure a consultant pharmacist reviewed the medications of each resident in the facility monthly for four of five sampled residents reviewed for unnecessary medications. Resident #2, who was admitted with diagnoses including diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure, was documented as taking antianxiety, antidepressants, and diuretics. Resident #10, admitted with diagnoses such as fracture of hip, multiple sclerosis, and mood disorder, was taking antipsychotics and opioids. Resident #16, with diagnoses including malignant neoplasm of the bone and myocardial infarction, was taking opioids and diuretics. Resident #21, with Alzheimer's, diabetes, and anxiety, was taking an anti-anxiety, anti-coagulant, insulin, and an anti-depressant. The facility did not provide a policy and procedure for drug regimen review, and the acting DON did not follow through with the gradual dose reductions recommended by the pharmacist during the months of May, June, July, and August 2024. The deficiency was identified when the DON returned to the facility in September 2024 after a short leave of absence and discovered that the pharmacist had completed the monthly reviews, but the acting DON had not implemented the recommended gradual dose reductions. This failure to follow through with the pharmacist's recommendations led to the deficiency in ensuring that the medications of each resident were reviewed and adjusted as necessary to avoid unnecessary medications.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure medication cards were labeled appropriately with an expiration date for 49 of 55 sampled medication cards. During an inspection of the medication carts, it was observed that 30 of 34 medication card labels for female residents and 19 of 21 medication card labels for male residents had no readable expiration date. CMA #1 confirmed the inability to read the expiration dates and admitted they would have to guess the expiration dates. The consultant pharmacist was unaware of the missing expiration dates on the labels.
Failure to Serve Food Under Sanitary Conditions
Penalty
Summary
The facility failed to serve food under sanitary conditions for 23 residents who ate meals prepared by the kitchen. On 05/02/24 at 12:12 p.m., the dietary manager was observed serving lunch trays to the residents in the dining room while wearing gloves. The dietary manager exited the kitchen with a food tray, placed the food tray on the table for the resident in the dining area, and then re-entered the kitchen to collect another food tray for another resident, all while wearing the same set of gloves and without proper hand washing in between residents. At 12:23 p.m., the dietary manager stated they believed that wearing gloves allowed them to exit and enter the kitchen without washing their hands to serve the residents in the dining area. They also mentioned they would start handing the food trays to the aides without leaving the kitchen to avoid cross-contamination.
Failure to Conduct Regular Bedrail Inspections and Assessments
Penalty
Summary
The facility failed to ensure regular inspections of resident beds equipped with side rails for eight residents. Observations revealed that bedrails were present and in use without proper assessments or documentation in the care plans. For instance, one resident with cerebral palsy and chronic pain syndrome was observed using bedrails without an assessment or inclusion in the care plan. Another resident with multiple fractures and dementia was also found using bedrails without proper assessment or documentation. Similar deficiencies were noted for other residents with various diagnoses, including dementia, osteoarthritis, hip fractures, and malignant neoplasm of the bone, among others. Additionally, the facility's maintenance practices were found lacking, as the maintenance personnel stated that bedrails were only checked when a problem was reported or when beds were moved. This lack of regular inspection and documentation poses a significant risk to resident safety, as evidenced by the observations and interviews conducted during the survey. The absence of documented alternatives and risk assessments for side rail use further underscores the facility's failure to adhere to safety protocols and regulatory requirements.
Failure to Ensure Resident Dignity During Transfer
Penalty
Summary
The facility failed to ensure a resident was treated with dignity during a transfer. A resident with cerebral brain stem hemorrhage, anxiety disorder, and depression disorder, who required total assistance with most ADLs, was observed being transported from the shower room to their room by a CNA. During this transfer, the resident's body was exposed to those in the hallway. The CNA acknowledged that they should have used two sheets to cover the resident's lower body and admitted they did not notice the exposure while transporting the resident.
Failure to Revise Care Plan for Resident with Stump Wound
Penalty
Summary
The facility failed to revise the care plan for a resident with peripheral vascular disease and a right above-the-knee amputation. The resident's care plan, dated 02/23/24, noted a potential for skin issues but was not updated when the resident developed a right stump wound. A physician's order dated 03/26/24 documented a wound care treatment of silvadene cream to the right stump daily. On 05/02/24, the resident's wound care treatment was observed, and on 05/03/24, the MDS Coordinator acknowledged that the care plan should have been revised to include the new wound. The MDS Coordinator mentioned being new to the position and still learning about care plans.
Failure to Document Recapitulation on Discharge Summary
Penalty
Summary
The facility failed to document a recapitulation of a resident's stay on a discharge summary for one of two sampled residents whose closed records were reviewed. The resident was admitted on an unspecified date and discharged to another facility on February 5, 2024. Upon review, it was found that there was no recapitulation of the resident's stay in the facility on the discharge summary. The MDS Coordinator/ADON reported on May 3, 2024, that they had recently received an example of how a discharge summary should be documented and stated that they would be documenting a recap of the resident's stay going forward.
Failure to Implement Oxygen Tubing Care Maintenance Orders
Penalty
Summary
The facility failed to develop and implement physician's orders for oxygen tubing care maintenance for two residents who were on oxygen therapy. Resident #2, who was admitted with diagnoses including diabetes mellitus type II, atrial fibrillation, cerebral infarction, depressive disorder, and heart failure, had a quarterly assessment indicating cognitive intactness and dependency on most ADLs, but lacked physician orders for oxygen equipment maintenance. Similarly, Resident #13, admitted with diagnoses of dementia, depressive disorder, encephalopathy, and Parkinson's disease, had a significant change assessment documenting memory problems and moderate assistance required for all ADLs, but also lacked physician orders for oxygen equipment maintenance. The ADON/MDS Coordinator confirmed that there were no orders guiding the nursing staff on when to change the oxygen equipment, which should have been in place according to the facility's procedures.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
