Leisure Village Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 2154 South 85th East Avenue, Tulsa, Oklahoma 74129
- CMS Provider Number
- 375230
- Inspections on file
- 32
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Leisure Village Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain comfortable water temperatures in all shower rooms, resulting in water that quickly became uncomfortably cold during use. Temperature checks by surveyors showed significant drops from initially warm or hot water to much cooler levels within minutes in multiple shower rooms. A resident reported that shower water became "ice cold" after a brief period and that they avoided showers, while others described the water as "freezing" and "frigid." CNAs reported that water turned very cold within a few minutes, forcing them to rush bathing and leading some residents to refuse showers. Staff stated they had reported the issue to maintenance several times, but the maintenance supervisor admitted there were no routine water temperature checks or logs, and the administrator acknowledged the water was too cold for them to take a shower.
Surveyors found that dietary staff lacked proper training and competency to operate the low-temperature dish machine. Two dietary aides relied on the presence of suds and visual checks of a temperature gauge instead of using required test strips or documented temperature checks, and one aide stopped the dish machine mid-cycle and walked away. One aide reported receiving informal training from another staff member and had not been taught how to check temperatures or use test strips, despite frequent use of the machine. The DM could not produce quarterly training records, 90-day nutrition services training, or annual competency documentation for dietary staff and acknowledged that, although procedures were reviewed in orientation, staff did not understand or follow the required dish machine testing process.
The facility failed to ensure proper sanitation and monitoring of dishware and cooking utensils for residents receiving meals from the kitchen. Surveyors observed a low-temp dishwasher stopped mid-cycle with suds in the reservoir and a temperature around 140°F, while the warewashing log lacked required daily documentation for multiple days. Staff reported hot water problems, use of three plastic tubs with heated water from the stove, and reliance on paper products, but the dietary manager and other dietary staff did not check or document water or sanitizer temperatures as required. One dietary aide relied only on the dishwasher gauge and visible suds and did not use test strips, while another had not been trained to test the machine. The administrator and dietary manager acknowledged uncertainty and lack of documentation regarding required daily dishmachine testing.
The facility did not consistently notify resident representatives of significant changes in condition for two residents, including new diagnoses, medication changes, and a fall. Documentation and interviews revealed that while physicians were informed, representatives were not always notified, and staff had inconsistent understanding of notification requirements.
A resident with hypertension and intact cognitive status frequently left the facility independently in a motorized wheelchair, sometimes signing out and sometimes requiring staff assistance. The care plan did not address the resident's ability to sign out, their preference for outdoor activities, or the need for staff involvement in the sign-out process, despite facility policy and observed behaviors. Staff confirmed these elements were not included in the care plan.
A resident in a long-term care facility was verbally abused by a staff member, as reported by the resident's roommate who overheard the staff member cursing. The facility's investigation substantiated the verbal abuse incident.
The facility experienced a 12% medication error rate due to errors in administering medications to two residents. One resident did not receive their prescribed medications for GERD and constipation, while another received the wrong ophthalmic solution at an incorrect time. The errors were attributed to CMAs forgetting to review the MAR and administering medication at the resident's request.
The facility failed to ensure medications were labeled and dated when opened, as observed in four medication and treatment carts. Staff acknowledged the requirement to date medications upon opening, yet several items, including insulin pens and inhalers, were found without dates. Additionally, some medications lacked proper labeling with the resident's name and dosage information.
A resident with multiple diagnoses, including multiple sclerosis and chronic pain, had a physician's order for a catheter privacy bag to be in place every shift. However, observations revealed the catheter bag was visible from the hallway without a privacy bag. The resident preferred the bag to be covered, but staff only did so upon request. A CNA admitted the oversight, and the DON expected privacy bags for all residents with indwelling catheters.
A resident with contractures did not receive recommended restorative services for contracture management, as indicated by a PT evaluation. Despite a physician's order for hand roll use and observations of positioning aids, there was no documentation of restorative services being provided. The DON and corporate RN could not locate records of the program's initiation or follow-up, and the former DON noted the resident was not agreeable to therapy.
A facility failed to properly position a urinary catheter bag for a resident, as it was observed on the floor on two occasions. A CNA confirmed the improper placement, and the DON acknowledged the absence of a policy regarding catheter bag positioning.
The facility failed to label, date, and store food items according to policy, affecting 77 residents. Surveyors found unlabeled and undated frozen biscuits and cookies, as well as an unsecured bag of lettuce without a label or date. The DM confirmed that all leftover food should be securely closed and labeled with a date.
A facility failed to implement enhanced barrier precautions during peg tube care for a resident with dysphasia. Despite signage and supplies being present, an LPN administered medication without wearing a gown, and stated the resident was not on infection control precautions. The infection preventionist and DON confirmed that such precautions should be used, but a policy had not been implemented.
A facility failed to ensure the required two-person assist during a mechanical lift transfer for a resident with a femur fracture and dementia, resulting in the resident falling. Despite training, only one CNA was present during the transfer, contrary to the care plan and safety protocols.
A resident with cognitive decline and dementia was left upset and partially clothed after a CNA improperly performed perineal care by picking off dry material with their hands instead of using wipes and cleanser. The CNA did not inform other staff of the resident's condition, leaving the resident without proper assistance and with the door open. The DON confirmed the CNA did not follow facility policy.
A CNA failed to provide perineal care according to accepted standards for a resident. The CNA found the resident with vaginal discharge and, instead of using a cleanser and wipes, attempted to pick the dry discharge off with their hands, causing discomfort. The DON confirmed this was substandard care.
The facility failed to provide showers for two residents who required assistance with activities of daily living. One resident, with COPD and Parkinson's, reported not having a shower in over a week due to staffing issues. Another resident stated they only received showers when they had a doctor's appointment. CNAs confirmed time constraints and inconsistent documentation of showers. The DON acknowledged the issue and mentioned plans to hire bath aides.
The facility failed to answer call lights promptly, as documented in resident council minutes and grievance logs. Residents reported waiting up to an hour, with one experiencing a colostomy bag burst due to delays. Staff acknowledged call lights should be answered within 5-10 minutes, but no written policy existed to enforce this standard.
A CMA was observed using bare fingers to break a potassium pill before giving it to a resident, acknowledging that gloves and a pill cutter should have been used, indicating a breach in infection control practices.
Failure to Maintain Comfortable Shower Water Temperatures
Penalty
Summary
The facility failed to maintain comfortable water temperatures in all five shower rooms, affecting residents' right to a safe, clean, comfortable, and homelike environment. Surveyors measured water temperatures in multiple shower rooms over two days and found that while initial temperatures were within or near a comfortable range, they dropped significantly within minutes. In the large South shower, water started at 100.4°F and fell to 77.4°F within 11 minutes. In the small East shower, water began at 107.4°F and dropped to 85.2°F within eight minutes. The large East shower showed a relatively stable temperature (97.6°F to 98.4°F within one minute), but the North shower dropped from 81.3°F to 70.5°F within two minutes, and the small South shower decreased from 104.6°F to 85.8°F within five minutes. Facility policy on ADL bathing required ensuring the bathing area was at a comfortable temperature, and a maintenance document dated 11/17/25 noted that hot water was not working on the north hall. Residents and staff reported ongoing problems with shower water becoming uncomfortably cold. One resident stated the shower water was warm for about two minutes and then became "ice cold," leading them to avoid taking many showers. Another resident reported that within five minutes the water became "freezing" and described it as "frigid," while another said the water on the north hall became freezing within a minute. CNAs reported that when they started showers, the water turned very cold within about three minutes, forcing them to hurry to rinse soap off residents and resulting in residents feeling their showers were cut short or refusing showers because they knew the water would get cold quickly. Staff also stated they had reported the cold water issue in the shower rooms to the maintenance supervisor several times. The maintenance supervisor acknowledged they did not perform routine water temperature checks and had no temperature logs, and the administrator stated that after feeling the water from the north hall shower, they personally would not take a shower in that water because it was too cold.
Inadequate Training and Competency of Dietary Staff in Dish Machine Operation
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure dietary staff were properly qualified and competent to operate the dishwashing equipment and carry out food and nutrition services. The DON reported that 81 residents received nutrition from the kitchen, and the DM reported there were 11 dietary staff members. During observation, two dietary aides were seen operating a low-temperature dish machine when one aide stopped the machine mid-wash cycle and walked away. One aide stated they determined the water was not hot enough by observing suds in the side tank and would wait and then try running the dishwasher again, rather than using the temperature gauge or test strips. The same aide reported working at the facility for about a month and stated they had been trained by another staff member but had not been instructed on checking the dish machine temperature or using test strips, despite using the machine several times a day. The other aide stated they checked the temperature gauge to ensure it was between two green lines and knew there were strips to check the machine but did not know where they were kept and did not usually worry about testing or documentation, instead relying on the presence of suds to judge water temperature. The DM later stated they were unable to locate quarterly training documents, 90-day nutrition services training, or annual competencies for dietary staff, and although they reported reviewing dish machine temperature and sanitation strip procedures during orientation, they acknowledged staff were not following or understanding the required testing process or frequency.
Failure to Ensure Proper Dishwashing Sanitation and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper sanitation of dishware and cooking utensils in accordance with professional standards and its own warewashing policy. Surveyors observed a low-temperature dishwasher being stopped mid-cycle by a dietary aide, with visible suds in the reservoir and a gauge reading around 140°F. The facility’s warewashing policy required dishware to be washed in a three-sink unit with sanitizer or disposable dishware to be used if the dish machine was not working or not meeting regulatory requirements, and required daily checks and documentation of sanitizer test strip results. The warewashing log for the dishmachine showed entries marked through one date with a note that hot water was being installed, and no documentation of testing or results for several subsequent days, despite the Director of Nursing identifying that 81 residents received nutrition from the kitchen. Staff interviews revealed that hot water had been an issue and a new hot water tank was being installed, during which time staff reported washing dishes in tubs, heating water on the stove for pots, pans, and utensils, and using paper plates and containers for resident meals. The dietary manager and cook stated they were using three plastic tubs and sanitizer but did not know they needed to check or document water or sanitizer temperatures in the tubs. One dietary aide stated they only checked that the dishwasher gauge was between two green lines, knew test strips existed but did not know their location, and did not usually worry about testing or documentation, instead relying on the presence of suds to judge water temperature. Another dietary aide reported not being shown how to check water temperature or use test strips and had been trained only by another staff member. The administrator acknowledged being unsure whether staff were completing dish machine testing due to lack of documentation, and the dietary manager later confirmed that temperature and sanitizer checks and documentation had not been completed for several days, attributing this to miscommunication among staff.
Failure to Notify Resident Representatives of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure that resident representatives were notified of significant changes in condition for two of four sampled residents. For one resident with diagnoses including congestive heart failure and obstructive sleep apnea, documentation showed that the physician was notified and new medications were ordered following complaints of nausea and an elevated A1C level, which led to a new diagnosis of type II diabetes mellitus. However, there was no documentation that the resident's representative was informed of the new medications, abnormal laboratory results, or the new diagnosis. The resident's representative confirmed limited contact from the facility since admission. For another resident with diabetes mellitus and muscle weakness, a nurse note indicated that after a fall from the bed, the physician, DON, and family member were reportedly notified. However, the family member stated they were not informed of the fall. Interviews with nursing staff revealed inconsistent understanding of when to notify resident representatives, particularly for cognitively intact residents, with some staff believing notification was not always necessary unless requested by the representative.
Failure to Develop Comprehensive Care Plan for Resident's Independent Outings
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident who was cognitively intact and had a diagnosis of hypertension. The resident was able to leave the facility independently in a motorized wheelchair and enjoyed spending time outside. Facility policy required residents to sign out when leaving the premises, but documentation showed that the resident sometimes signed themselves out, while at other times staff signed out on their behalf. There were instances where the resident left the facility without signing out or alerting staff, as noted in nurse documentation and staff interviews. Despite the resident's established pattern of independent outings and the need for adherence to the sign-out protocol, the care plan did not address the resident's ability to sign out, their enjoyment of outdoor activities, or the need for staff involvement in the sign-out process. Interviews with staff, including the DON and care plan coordinator, confirmed that these aspects were not included in the resident's care plan, and the care plan coordinator acknowledged the omission.
Verbal Abuse Incident in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from abuse, specifically in the case of a resident who was verbally abused by a staff member. The incident was reported by the resident's roommate, who overheard the staff member cursing while speaking to the resident. This verbal abuse was substantiated by the facility's investigation, which confirmed the occurrence of the incident.
Medication Administration Errors Lead to 12% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 12% error rate during medication administration. This was observed over 25 opportunities, with three medication errors identified. One incident involved a resident with diagnoses of GERD and constipation, who did not receive their prescribed medications, docusate sodium and famotidine, during a medication pass. The Certified Medication Aide (CMA) responsible for administering the medications admitted to forgetting to review the Medication Administration Record (MAR) to obtain the medications from the house stock supply. Another incident involved a resident with glaucoma, who was prescribed bimataprost ophthalmic solution to be administered at bedtime. Instead, the CMA administered latanoprost ophthalmic solution earlier than the prescribed time, at the resident's request. The Director of Nursing (DON) confirmed that the medication was administered at the wrong time, despite the medications being considered interchangeable. The Assistant Director of Nursing (ADON) stated that they monitored medication administration three times a week but had not observed these specific errors.
Medication Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated when opened, as observed in four medication and treatment carts. During the survey, it was noted that medications on the north hall medication cart, east hall treatment cart, south hall medication cart, and south hall treatment cart were opened but not dated. Staff members, including CMAs and LPNs, acknowledged that medications should be dated upon opening, yet several items were found without dates. These included a bottle of milk of magnesia, glucometer check strips, insulin pens, inhalers, and nasal sprays. Additionally, some medications lacked proper labeling with the resident's name and dosage information, as required. The DON confirmed that medications should be dated when opened and should have a pharmacy label with the resident's name and dosage. The failure to adhere to these protocols was observed across multiple carts, indicating a systemic issue in the facility's medication management practices.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to maintain a resident's dignity by not using a privacy bag over an indwelling catheter bag for one of the residents reviewed for dignity. The resident, who was admitted with multiple diagnoses including multiple sclerosis, anxiety, depression, urogenital implants, and chronic pain, had a physician's order to verify the dignity bag was in place every shift. Despite this order, observations on multiple occasions revealed that the resident's catheter bag was visible from the hallway without a privacy bag in place. The resident expressed a preference for the catheter bag to be covered, indicating that staff only covered it upon request. A CNA acknowledged that the resident should have a catheter privacy bag in place at all times but admitted it was missed because the resident had not been getting out of bed as much. The Director of Nursing also stated that they would expect any resident with an indwelling catheter to have a privacy bag in place, highlighting a lapse in adherence to the facility's dignity policy.
Failure to Provide Recommended Restorative Services for Contracture Management
Penalty
Summary
The facility failed to provide range of motion (ROM) services to a resident with contractures, as recommended by a physical therapist (PT). The resident had diagnoses including contracture to the right elbow, wrist, and hand. A PT evaluation dated 03/30/24 indicated that the resident was not a candidate for skilled PT but would benefit from a restorative program for geri chair positioning and contracture management. Despite this recommendation, there was no documentation in the clinical record that the resident received restorative services. A physician's order dated 07/19/24 instructed the use of a hand roll for the left hand daily, and the resident was observed with hand rolls and positioning pillows. However, the Director of Nursing (DON) and corporate RN could not find documentation that the restorative program was initiated or followed up on, and the former DON indicated the resident was not agreeable to restorative therapy at that time.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure proper positioning of a urinary drainage bag for a resident with a urinary catheter. On two separate occasions, the resident was observed in bed with the urinary catheter bag placed on the floor. A Certified Nursing Assistant (CNA) acknowledged that the urinary catheter bag should not be on the floor. Additionally, the Director of Nursing (DON) confirmed that the facility did not have a policy regarding the positioning of urinary catheter bags, but agreed that the bag should not have been on the floor.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were labeled, dated, and stored according to its policy, which affected 77 residents receiving services from the kitchen. During an observation, surveyors found an unlabeled and undated zip lock freezer bag containing frozen biscuits and another with frozen cookies in the freezer. Additionally, an opened and unsecured bag of lettuce was observed without a label or date. The facility's policy, revised on 08/21/24, requires all leftovers to be labeled and dated with an expiration date. The Dietary Manager (DM) confirmed that all leftover food should be securely closed and labeled with a date.
Failure to Implement Enhanced Barrier Precautions for Peg Tube Care
Penalty
Summary
The facility failed to ensure the use of enhanced barrier precautions during peg tube care for a resident diagnosed with dysphasia. On August 20, 2024, enhanced barrier precautions signage and supplies were observed on the resident's door. However, an LPN was observed administering medication via the peg tube without wearing a gown. The LPN stated that the resident was not on infection control precautions. On August 23, 2024, the infection preventionist confirmed that enhanced barrier precautions should be used for peg tube care, among other procedures. The Director of Nursing also acknowledged that enhanced barrier precautions should be used for peg tube care and admitted that an enhanced barrier precaution policy had not yet been implemented.
Failure to Ensure Adequate Staffing During Mechanical Lift Use
Penalty
Summary
The facility failed to ensure the required number of staff were present when operating a mechanical lift for a resident with a history of a left femur fracture and dementia. The resident's care plan specified the need for a two-person assist during transfers using a mechanical lift. However, an incident occurred where the resident was found on the floor next to the Hoyer Lift with the sling still under her, indicating that the lift was operated by only one staff member at the time of the incident. Interviews with multiple CNAs confirmed that they had been trained and inserviced on the proper use of the Hoyer Lift, which requires two staff members to operate. Despite this training, the incident report and the resident's account revealed that only one CNA was present during the transfer when the resident fell. This deficiency highlights a failure in adhering to the care plan and established protocols for safe mechanical lift operation, leading to the resident's fall.
Failure to Maintain Resident Dignity During Perineal Care
Penalty
Summary
The facility failed to maintain the dignity of a resident during and after perineal care. A CNA attempted to clean a resident's vaginal area by picking off dry material with their hands instead of using wipes and cleanser, which upset the resident and caused them to cry. The CNA did not complete the care properly, as they left the resident partially clothed and did not close the door upon leaving the room. Furthermore, the CNA did not inform other staff members of the resident's condition, leaving the resident without proper assistance. The incident involved a resident with age-related cognitive decline and dementia, highlighting their vulnerability. Other CNAs observed the resident's condition after the initial CNA left, noting that the resident was only partially dressed and the door to their room was open. The Director of Nursing confirmed that the CNA did not follow the facility's policy, which requires informing other staff members of a resident's condition and using appropriate cleaning methods during perineal care.
Inadequate Perineal Care by CNA
Penalty
Summary
The facility failed to ensure that a CNA provided perineal care in accordance with accepted standards for one resident. During an inspection, CNA #1 was asked to supervise the memory care unit and found a resident lying on their bed fully clothed. Upon detecting a foul smell, CNA #1 removed the resident's jeans and instructed them to remove their briefs, finding the resident dry but with visible vaginal discharge. Instead of using a cleanser and wipes as per the facility's Incontinent Care policy, CNA #1 attempted to pick the dry discharge off the resident's vaginal area with their hands, causing discomfort to the resident. The Director of Nursing later confirmed that CNA #1's actions were substandard and indicated a need for further training.
Failure to Provide Showers for Residents
Penalty
Summary
The facility failed to provide showers for two residents who required assistance with activities of daily living. Resident #5, diagnosed with COPD and Parkinson's disease, reported not having had a shower in over a week and feeling dirty. The resident mentioned that staff cited insufficient staffing as the reason for not receiving showers. Similarly, Resident #6 stated they had not received a shower in over a week and only received one when they had a doctor's appointment. Interviews with CNAs revealed that they often ran out of time to complete baths and that documentation for showers was inconsistent, with showers being documented as completed when they were not. The Director of Nursing acknowledged the issue and mentioned they were in the process of hiring bath aides to address the problem.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents, as documented in various reports and interviews. The Resident Council Minutes from January and February 2024 highlighted concerns about call lights not being answered or taking too long to be addressed. Additionally, the Grievance/Missing Property Monthly Tracking Log from March 2024 noted similar issues. A Device Activity Report from early June 2024 recorded multiple instances where call lights were activated for extended periods, ranging from 23 to 60 minutes, indicating a pattern of delayed responses. Interviews with residents and staff further corroborated these findings. Residents reported waiting times of up to an hour for call lights to be answered, with one resident experiencing a colostomy bag burst due to the delay. Staff members, including CNAs and LPNs, acknowledged that call lights should be answered within 5 to 10 minutes, yet there was no written policy in place to enforce this standard. The Director of Nursing confirmed the absence of a formal policy, stating that it is everyone's responsibility to answer call lights promptly.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration. On June 19, 2024, at 10:20 a.m., a Certified Medication Aide (CMA) was observed using bare fingers to break a potassium pill in half before administering it to a resident. The CMA acknowledged that gloves and a pill cutter should have been used during this process.
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A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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