Lawton Post Acute & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawton, Oklahoma.
- Location
- 1700 Northwest Fort Sill Blvd, Lawton, Oklahoma 73507
- CMS Provider Number
- 375510
- Inspections on file
- 21
- Latest survey
- July 15, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lawton Post Acute & Rehab during CMS and state inspections, most recent first.
Staff did not follow the facility's enhanced barrier precautions policy when providing care to a resident with a feeding tube and other risk factors for MDROs. During high-contact care activities, such as changing linens and performing feeding tube site care, staff wore only gloves instead of both gown and gloves as required, despite PPE supplies being available and clear policy guidance.
A facility failed to accurately code the MDS for a resident who was readmitted from the hospital with Legionella. Despite the hospital discharge summary indicating severe sepsis due to Legionella pneumonia, the Medicare-5 day assessment did not document this diagnosis. The resident, with a history of COPD, pneumonia, and chronic kidney disease, later switched to hospice care, but the Legionella diagnosis was omitted from the assessment.
A facility failed to update a care plan for a resident with a new diagnosis of Legionella. The resident, with a history of COPD and chronic kidney disease, was readmitted with severe sepsis due to Legionella pneumonia. The care plan did not reflect this new diagnosis, contrary to the facility's policy to update care plans with new diagnoses promptly.
The facility failed to follow consistent protocols for BiPAP therapy for two residents. The cleaning policy was not adhered to, as one resident's care plan lacked cleaning instructions, and the physician orders did not specify cleaning procedures. The RN/DON acknowledged the absence of cleaning orders, and the RT confirmed they were just entered. For another resident, the care plan also lacked cleaning instructions and frequency of use, with cleaning orders entered on the survey day. The RN/DON was unsure about cleaning supplies, indicating inconsistent implementation of BiPAP protocols.
A resident with dementia experienced multiple falls, including a serious injury, due to the facility's failure to develop and implement effective fall prevention interventions. Despite being at risk for falls, the care plan was not consistently updated, and necessary interventions were not documented or implemented.
The facility did not ensure that residents were offered the choice to formulate advance directives, as shown by incomplete documentation for three residents. Two residents, admitted with chronic pain and hypertension, had unsigned advance directive forms, despite being documented as full code. The business office manager acknowledged the oversight and the need for improvement in discussing and signing these forms during admission. Another resident also had an unsigned form, highlighting the need for better completion of admission packets.
A facility failed to ensure proper communication with a dialysis center and did not obtain a physician order for a resident requiring hemodialysis. The resident, with end-stage renal disease, had a care plan for dialysis but lacked a comprehensive physician order specifying the dialysis schedule. Communication forms were often incomplete, and the nursing staff did not consistently fulfill their responsibilities in documenting dialysis details.
The facility failed to administer medications according to physician's orders for two residents, leading to a deficiency. One resident had multiple medications for diabetes and hypertension held without documented parameters, and another had blood pressure medication held without parameters. Staff confirmed the absence of necessary documentation and physician contact.
A facility failed to develop a comprehensive care plan for a resident with cerebrovascular accident and chronic pain, who was on anticoagulant and opioid medications. The care plan lacked documentation for these therapies, despite a quarterly assessment noting their use and the resident's severely impaired cognition. The DON confirmed the omission.
The facility failed to follow infection control practices during wound care for a resident with diabetes and peripheral vascular disease, as a soiled dressing was improperly disposed of in regular trash instead of a biohazard bag. Additionally, infection surveillance and tracking were not conducted since January 2024, with pneumonia cases undocumented, due to uncertainty about new ownership procedures.
The facility failed to maintain an antibiotic stewardship program as required by its policy. The IP reported that antibiotic use and infection tracking had not been conducted since January 2024, and was unsure of the new owner's expectations for infection control. The DON was also unaware of the lapse in monitoring and tracking.
The facility failed to ensure residents were assessed for, offered, and received pneumococcal immunizations as per policy. Several residents had no documentation of receiving the vaccine, no consent or declination, or outdated records. The IP was unaware of these issues, indicating a lack of tracking and communication processes.
The facility did not respond in a timely manner to an MRR for a resident with schizoaffective disorder. The MRR requested a GDR on a specific date, but the physician's declination was documented over a month later, exceeding the 30-day response requirement stated by the DON.
The facility did not post daily staffing information with required details, such as the facility name, total staff number, actual hours worked, and resident census. Observations at both the north and south hall nurses stations showed clipboards with staff assignments but missing essential information. The DON was unaware of these posting requirements.
The facility failed to provide a SNF ABN to two residents discharged from Medicare Part A skilled services, as confirmed by the social services director. This oversight was identified among 23 residents discharged with benefit days remaining, indicating a potential pattern of non-compliance.
A facility failed to accurately complete a level 1 pre-screening assessment for a resident with schizoaffective disorder. The assessment incorrectly documented that the resident did not have a serious mental illness. An admissions RN later acknowledged the oversight, stating the diagnosis should have been documented.
A resident with a history of stroke experienced a dislodged PEG tube, and the facility failed to notify the physician as required by policy. The nurse managed to reinsert the tube after EMSA was unable to do so, but there was no documentation of physician contact or an order to replace the tube. Interviews revealed inconsistencies in staff understanding of the policy regarding PEG tube dislodgement.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident requiring enhanced barrier precautions. During observation, two CNAs were seen providing care and changing linens for a resident with a feeding tube, wearing only gloves and not gowns, despite PPE supplies being available at the door. Additionally, an LPN entered the same resident's room to perform feeding tube site care, using hand hygiene and gloves but not donning a gown as required by the facility's enhanced barrier precautions policy. The policy specifies that both gown and gloves are necessary for high-contact care activities, including feeding tube care, wound care, and changing linens for residents at increased risk of MDRO acquisition. Record review showed the resident had severely impaired cognition, a feeding tube, and physician orders for enhanced barrier precautions related to wound, colostomy, and indwelling catheter care. Interviews with staff revealed inconsistent understanding and implementation of the enhanced barrier precautions policy, with the LPN stating that only gloves were used for feeding tube care and gowns were reserved for other activities. The infection prevention nurse confirmed that both gown and gloves should be used for all high-contact care activities, including feeding tube site care, indicating a failure to follow established infection control protocols.
Inaccurate MDS Coding for Legionella Diagnosis
Penalty
Summary
The facility failed to ensure the minimum data set (MDS) was coded accurately for a resident who was discharged from the hospital with Legionella. The resident, who had diagnoses including COPD with acute exacerbation, pneumonia, and chronic kidney disease stage 4, was readmitted to the facility after testing positive for Legionella at the hospital. The hospital discharge summary indicated severe sepsis with acute organ dysfunction due to Legionella pneumonia. However, the Medicare-5 day assessment completed after the resident's return did not document the Legionella diagnosis. The MDS/QS coordinator confirmed that the assessment was completed for skilled services, but the resident later switched to hospice care with a diagnosis of malignant neoplasm, and the Legionella diagnosis was not included in the assessment.
Failure to Update Care Plan for New Legionella Diagnosis
Penalty
Summary
The facility failed to update the care plan for a resident who was readmitted with a new diagnosis of Legionella. The resident had a medical history that included COPD with acute exacerbation, pneumonia, and chronic kidney disease stage 4. Upon readmission from the hospital, the discharge summary indicated severe sepsis with acute organ dysfunction due to Legionella pneumonia, along with an acute COPD exacerbation and an improving urinary tract infection. However, the care plan, which was dated from 03/17/23 through 02/20/25, did not include the new diagnosis of Legionella. When questioned, the MDS/QS coordinator acknowledged that Legionella was not specifically listed in the care plan, despite the facility's policy to update care plans with new diagnoses as soon as they are identified.
Inconsistent BiPAP Therapy Protocols and Cleaning Procedures
Penalty
Summary
The facility failed to establish consistent protocols and follow its own policy for BiPAP therapy for two residents. The facility's CPAP/BiPAP Cleaning policy, dated May 2022, requires cleaning of the equipment in accordance with CDC guidelines and manufacturer recommendations to prevent infection. However, for one resident, the plan of care did not include BiPAP cleaning instructions, and the physician orders lacked details on cleaning procedures. The RN/DON acknowledged the absence of cleaning orders and mentioned plans to update them. The RT confirmed that cleaning orders were just entered and specified the use of Dawn soap. For the second resident, the plan of care also lacked BiPAP cleaning instructions and frequency of use. The physician orders to clean the BiPAP were entered on the day of the survey, specifying the use of mild soap and water for cleaning. The RN/DON admitted that the cleaning order was written and revised on the survey day and was unsure about the availability of cleaning wipes. Additionally, there was no specified frequency for using the BiPAP machine. These deficiencies indicate a lack of adherence to the facility's policy and inconsistent implementation of BiPAP therapy protocols.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement effective interventions to prevent falls for a resident with dementia, leading to multiple unwitnessed falls and a serious injury. The resident was admitted without a baseline care plan, and despite several falls documented in incident reports, interventions were either not documented or not implemented. The care plan was not updated following these incidents, and neuro checks were often not completed after falls. The resident experienced a series of falls, including one that resulted in a head injury and a broken hip, indicating a lack of adequate supervision and intervention. The resident was moderately to severely cognitively impaired and required varying levels of assistance with transfers. Despite being at risk for falls, as documented in fall risk assessments, the facility did not consistently update the care plan or implement necessary interventions. The Director of Nursing (DON) acknowledged the lack of documented interventions and stated that the only way to prevent the resident from falling would be to restrain them, which is illegal. The MDS coordinator, responsible for updating care plans, was unavailable for interview during the survey.
Failure to Ensure Advance Directives Completion
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate advance directives, as evidenced by the incomplete documentation for three residents. Resident #42, admitted with chronic pain, and Resident #55, admitted with hypertension, both had their advance directive acknowledgment forms unsigned, despite their electronic medical records indicating a full code status. The business office manager acknowledged that these forms were not signed and admitted the need for improvement in ensuring the forms were discussed and signed during admission. Additionally, Resident #19, admitted in February 2022, also had an unsigned advance directive acknowledgment form, with the business office manager noting the omission and the need for better completion of admission packets.
Failure in Dialysis Communication and Physician Order
Penalty
Summary
The facility failed to ensure proper communication between the dialysis center and the facility and did not obtain a physician order for dialysis for a resident with end-stage renal disease. The resident was admitted with a diagnosis requiring hemodialysis, and a care plan was documented to reflect this need. However, the physician order only addressed post-dialysis care, such as bandage removal and bleeding checks, without specifying the dialysis schedule or location. Observations revealed that the resident was sent to dialysis with a notebook for communication, but the dialysis communication forms were missing or incomplete for the majority of the opportunities. The Assistant Director of Nursing (ADON) stated that it was the responsibility of the nursing staff to complete the communication form sections, but this was not consistently done, and a physician order for dialysis was not entered into the resident's chart.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications according to physician's orders for two residents, leading to a deficiency in pharmaceutical services. Resident #14, who had diagnoses including diabetes and hypertension, had multiple medications held without documented hold parameters. These medications included Carvedilol, Lisinopril, Hydralazine, Insulin Glargine, and Insulin Lispro. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April, May, and early June 2024 showed numerous instances where these medications were held without parameters. Licensed Practical Nurse (LPN) #2 confirmed that medications were sometimes held without physician orders and that there were no progress notes documenting physician contact or updated orders. Similarly, Resident #69, diagnosed with hypertension, had Amlodipine held without parameters on several occasions. The MAR for April and May 2024 documented instances where the medication was held without parameters, and some administrations were left blank. LPN #2 and Assistant Director of Nursing (ADON) #2 acknowledged that there were no progress notes documenting the nurse's assessment or physician contact when the blood pressure medication was held. The ADON confirmed that there should have been hold parameters and progress notes, but these were absent.
Failure to Develop Comprehensive Care Plan for Anticoagulant and Opioid Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a diagnosis of cerebrovascular accident and chronic pain, who was receiving anticoagulant and opioid medications. The care plan, dated May 20, 2024, did not include any care areas related to anticoagulant therapy, chronic pain, or opioid use. A quarterly assessment conducted on May 22, 2024, documented the resident's severely impaired cognition and the use of anticoagulant and opioid medications. However, the resident's order summary report from June 5, 2024, indicated the administration of Eliquis and Norco, which were not reflected in the care plan. On June 6, 2024, the Director of Nursing confirmed that these therapies and medications should have been included in the resident's care plan.
Infection Control Deficiencies in Wound Care and Surveillance
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident with diabetes and peripheral vascular disease. The resident had a physician's order for the application of Gentamycin ointment to a wound bed due to a skin infection. During an observation of wound care, the Infection Preventionist (IP) placed a soiled dressing, saturated with a green-tinged liquid, into a regular trash bag instead of a red biohazard bag. The IP acknowledged that the soiled dressing should have been treated as biohazardous waste and disposed of accordingly, despite the resident not being on isolation. Additionally, the facility did not conduct infection surveillance and tracking as per its policy. The IP reported that tracking and trending of infections had not been monitored since January 2024, due to uncertainty about the new owner's infection control procedures. The IP provided a list of four residents treated for pneumonia since January 2024, but these cases were not documented in the infection control book. The Director of Nursing (DON) was unaware that infection surveillance had not been conducted since the change in ownership, although it was expected to be done monthly.
Failure to Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an antibiotic stewardship program to monitor antibiotic use for its residents. The Infection Prevention and Control Program policy indicated that an antibiotic stewardship program should be part of the overall infection prevention and control program, with protocols and a system to monitor antibiotic use. The Infection Preventionist (IP), with oversight from the Director of Nursing (DON), was designated as the leader of the antibiotic stewardship program. However, during an interview, the IP reported that antibiotic use and infection tracking and trending had not been conducted since January 2024, contrary to the facility's policy. The IP also expressed uncertainty about how the new owner wanted infection control to be conducted. Additionally, the DON was unaware that antibiotic monitoring and infection tracking and trending had not been conducted since January 2024.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were assessed for, offered, and received pneumococcal immunizations upon admission or when needed. This deficiency was identified for seven out of eight residents reviewed for immunizations. The facility's Infection Prevention and Control Program policy stated that residents would be offered pneumococcal vaccines recommended by the CDC upon admission, with education provided regarding the benefits and potential side effects. However, documentation was lacking for several residents, indicating a failure to adhere to this policy. Specific instances included residents who either had no documentation of receiving the pneumonia vaccine, no consent or declination for the vaccine, or outdated immunization records. For example, one resident had a documented consent for the vaccine but had not received it, and another had not been assessed for additional vaccines despite not having received one in over five years. The Infection Preventionist (IP) reported being unaware of these issues, indicating a lack of a process to track when additional vaccines were due and a failure to receive vaccine consents or refusals from the admissions nurse.
Delayed Response to Medication Regimen Review
Penalty
Summary
The facility failed to ensure a timely response to a Medication Regimen Review (MRR) for a resident diagnosed with schizoaffective disorder. The MRR, dated March 11, 2024, included a request for a Gradual Dose Reduction (GDR), which the physician declined on April 16, 2024. However, the Director of Nursing (DON) stated that MRRs must be responded to within 30 days as designated on the form, indicating a delay in the response to the MRR for this resident.
Failure to Post Required Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted with the required details. Observations on multiple occasions revealed that the north and south hall nurses stations had clipboards with daily assignments, including staff names and hall assignments. However, these documents did not include the facility name, the total number of staff, the actual hours worked, or the resident census. This information was not posted elsewhere on the unit. The Director of Nursing (DON) later stated they were unaware of the requirements for posting daily nursing staff information.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents who were discharged from Medicare Part A skilled services. Resident #226 was admitted to Part A skilled services on March 6, 2024, and discharged on March 26, 2024, without documentation of a SNF ABN being provided to the resident or their representative. Similarly, Resident #227 was admitted on January 4, 2024, and discharged on January 22, 2024, also without documentation of a SNF ABN being provided. The Business Office Manager identified 23 residents who had been discharged from a Medicare Part A covered stay with benefit days remaining in the past six months, indicating a potential pattern of non-compliance. The social services director confirmed that the SNF ABNs for these residents were not completed.
Inaccurate PASARR Screening for Mental Disorders
Penalty
Summary
The facility failed to accurately complete a level 1 pre-screening assessment for a resident with a diagnosis of schizoaffective disorder. The resident was admitted to the facility with this diagnosis, but the level 1 pre-screening assessment, dated June 8, 2023, incorrectly documented that the resident did not have a serious mental illness. On June 7, 2024, an admissions RN acknowledged that the documentation on the resident's level 1 screening was an oversight and that the diagnosis should have been documented on the form.
Failure to Notify Physician of PEG Tube Dislodgement
Penalty
Summary
The facility failed to notify the physician of the dislodgement of a PEG tube for a resident with a history of stroke, as required by their policy. The incident was documented in a progress note, which stated that the PEG tube became dislodged and EMSA was called to replace the tube or take the resident to the hospital. However, the paramedics were unable to replace the tube, and the nurse managed to reinsert it. The progress note did not document any contact with the physician or an order to replace the tube, which is a requirement according to the facility's policy. Interviews with staff revealed inconsistencies in the understanding and execution of the facility's policy regarding PEG tube dislodgement. An LPN stated that they would notify the ADON and physician and would only attempt to replace the tube under a physician's order. The DON acknowledged that some nurses were trained to replace the tube but was unaware of the specific policy details without reviewing them. The DON also stated that the nurse should have documented the contact with the physician in the progress notes, indicating a lapse in following the established protocol.
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.
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.
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 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.
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 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.
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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