Magnolia Creek Skilled Nursing And Therapy
Inspection history, citations, penalties and survey trends for this long-term care facility in Altus, Oklahoma.
- Location
- 2610 Cedar Creek Drive, Altus, Oklahoma 73521
- CMS Provider Number
- 375505
- Inspections on file
- 24
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Magnolia Creek Skilled Nursing And Therapy during CMS and state inspections, most recent first.
A resident with diabetes, intact cognition, and partial to moderate ADL dependence had thick, overgrown toenails that had not been trimmed despite the resident repeatedly telling staff they needed cutting. Nursing notes over several months contained no indication that toenail care was needed or that a podiatry referral was made, and the facility lacked a nail care policy. The DON reported that LPNs were expected to assess toenails weekly as part of skin assessments and that nursing and social services enrolled residents for podiatry, but the podiatrist had not provided services in the facility for several months. The ADON stated staff tried to cut the resident’s toenails, yet no documentation of this attempt existed.
A facility failed to investigate an alleged resident-to-resident abuse incident where a resident with intact cognition and certain medical conditions reported feeling afraid after another resident entered their room, shook their bed, and made threatening gestures. Despite the incident being reported to the police and facility staff, no thorough investigation was conducted, and the facility's response was limited to staff education on preventing the second resident from wandering.
A facility failed to update a care plan for a resident with increased wandering and exit-seeking behaviors. Despite an elopement band and staff redirection, the care plan lacked documentation of these behaviors. Observations and reports confirmed the resident's continued wandering and intrusion into other residents' rooms, which was not reflected in the care plan. An LPN confirmed that such behaviors should be included in the care plan.
A facility failed to ensure a call light was within reach for a legally blind resident, who required moderate assistance with daily activities. The resident, a fall risk, expressed frustration at being unable to locate the call light while sitting in a recliner. A CMA confirmed the call light was out of reach, noting the resident sometimes yelled for help when needed.
A resident with legal blindness reported that their bed had not been made for several days, and there were pillows without pillowcases. An extra mattress was improperly stored in the room, which was confirmed by a CMA who noted the resident was a fall risk.
A resident with a surgical wound on the right hip did not receive wound care as per physician orders, which specified the use of a silver dressing. The facility staff used a different dressing, causing skin breakdown, due to a misunderstanding about the availability of the silver dressing. The resident reported that the staff cited cost as a reason for not using the prescribed dressing, despite it being provided by the hospital.
A resident was discharged with medications not prescribed to them, including those belonging to another resident. The facility lacked a policy for medication dispensing at discharge, leading to the error. The resident reported the issue, and the facility later retrieved the incorrect medications.
A resident with congestive heart failure and edema experienced a significant weight gain of 36 pounds over 15 days, but the facility failed to notify the physician as required by policy. Despite the resident's condition and documented edema, the physician was only informed after a nurse's progress note indicated severe edema. This represents a deficiency in the facility's communication and adherence to its policies.
Three residents with significant medical conditions, including dementia and Alzheimer's, were left without necessary care for extended periods, despite being dependent on staff for activities of daily living. Observations revealed that these residents were not checked on or provided with required care every two hours, as stipulated in their care plans. Staff interviews confirmed the lack of timely care, and the DON acknowledged the deficiency.
A resident with congestive heart failure experienced a significant weight gain of 36 pounds over 15 days, but the facility failed to notify the physician in a timely manner or conduct necessary assessments. Despite persistent edema and discomfort, the resident's condition was inadequately monitored, leading to a hospital admission for CHF exacerbation.
The facility failed to provide adequate staffing, resulting in delayed care for residents. Observations showed residents with dementia and incontinence were left without care for extended periods, and staff confirmed that insufficient aides made it impossible to meet care requirements. Residents and family members reported long wait times for assistance, and the DON admitted that the standard of quality care was not being met.
The facility failed to maintain infection control measures for several residents, including improper glove changes and lack of enhanced barrier precautions. An LPN did not sanitize hands between glove changes for a resident with pressure ulcers, and CNAs did not change gloves during peri care for another resident. Additionally, a resident with an indwelling catheter was not placed on enhanced barrier precautions upon returning from the hospital, and a CNA did not wear a gown during catheter care.
A resident with paraplegia and high blood pressure experienced a decline in their ability to perform ADLs, requiring more assistance over time. Despite this decline, the facility did not complete a significant change assessment, as confirmed by the ADON during a review.
The facility failed to allow a resident to return after hospitalization, lacking a written policy on post-hospitalization returns. The resident, with multiple diagnoses, was emergency discharged due to harmful behaviors. The facility did not provide a signed discharge notice or physician summary, and the hospital was unaware of the discharge status.
Failure to Provide and Document Necessary Toenail Care
Penalty
Summary
The facility failed to provide appropriate toenail care for one resident when surveyors observed the resident’s toenails to be thick, overgrown, and approximately half an inch long. The resident, who had intact cognition with a BIMS score of 13, had been admitted with diagnoses including diabetes mellitus and required partial to moderate assistance with most ADLs. A significant change assessment documented these needs, yet nurse’s notes from late August through January contained no indication that the resident’s toenails required cutting or that a podiatry referral was needed. The resident reported that their toenails had needed cutting since admission and that they had informed staff on multiple occasions. The facility had no policy related to nail care, and although the DON stated that LPNs were expected to assess toenails weekly as part of skin assessments and that nursing and social services were responsible for signing residents up for podiatry services, there was no documentation that this occurred for this resident. The podiatrist reported that services were last provided in the facility several months earlier, and the ADON stated staff had attempted to cut the resident’s toenails but this was not documented. These combined observations and record reviews showed that the facility did not ensure toenail care was provided or documented for this resident in accordance with their needs and stated practices.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an incident of alleged resident-to-resident abuse involving a resident with intact cognition and diagnoses including cerebral infarction, insomnia, and depressive disorder. The incident involved another resident entering the first resident's room, shaking their bed, and making threatening gestures, which caused the first resident to feel afraid. Despite the incident being reported to the police and the facility's Director of Nursing (DON) and administrator, the facility did not conduct a thorough investigation as required by their policy. The police advised keeping the residents separated, but the facility's response was limited to educating staff about preventing the second resident from wandering into the first resident's room. The facility's policy mandates a thorough investigation of any alleged abuse, including completing an incident report and obtaining information about the incident. However, the facility did not interview other residents or staff related to the incident, and the administrator and DON did not consider the incident as abuse. The lack of a comprehensive investigation and failure to follow the facility's policy on abuse allegations led to the deficiency identified in the report.
Failure to Update Care Plan for Wandering Behavior
Penalty
Summary
The facility failed to update a resident's care plan to address wandering behavior, which was identified as a deficiency. Resident #2, who had diagnoses including depression, exhibited increased wandering and exit-seeking behaviors as noted in a behavior note dated 08/06/24. Despite the presence of an elopement band and staff redirection, the care plan dated 09/06/24 did not document any care areas related to wandering or elopement behaviors. A comprehensive assessment on 09/23/24 inaccurately documented the resident as having severely impaired cognition and no behaviors. Subsequent observations and reports on 11/04/24 and 11/05/24 confirmed the resident's continued wandering and intrusion into other residents' rooms, which was not reflected in the care plan. An LPN confirmed that wandering and elopement behaviors should be included in a resident's care plan.
Failure to Ensure Call Light Accessibility for Blind Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident with legal blindness, leading to a deficiency in accommodating the resident's needs and preferences. The resident, who had a diagnosis of severe vision impairment and required moderate assistance with activities of daily living, was observed sitting in a recliner with the call light placed by the side of their drawer, out of reach. The resident expressed frustration at being unable to locate the call light when they needed assistance. A Certified Medication Aide (CMA) confirmed that the resident, who is a fall risk, sometimes used the call light or yelled for help when assistance was needed. The CMA also observed that the call light was indeed out of the resident's reach.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to maintain a homelike environment for a resident diagnosed with legal blindness. On September 5th, the resident reported that their bed had not been made for several days, and there were two pillows without pillowcases along with two personal pillows. Additionally, an extra mattress was improperly stored in the resident's room by a wall table. A Certified Medication Aide (CMA) confirmed the resident's bed was unmade and expressed uncertainty about the presence of the extra mattress, noting that the resident was a fall risk.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to perform wound care according to physician orders for a resident with a right femur fracture, who was admitted with a surgical wound on the right hip. The physician had ordered the use of a silver dressing every five days or as needed until healed. However, the treatment administration record showed that the silver dressing was applied only once, and there was no documentation for its use on a subsequent date. The resident's medical record lacked any new wound care orders or reasons for not using the silver dressing as prescribed. During a physician visit, it was noted that the resident had a saturated gauze dressing instead of the ordered silver dressing, which was causing skin breakdown. The resident reported that the facility staff did not use the silver dressing due to its cost, despite having been provided with it by the hospital. An LPN confirmed that the facility typically used the silver dressing when ordered and that any deviation from the prescribed treatment should have been documented. The DON later reported that the nurse responsible for the resident's care was unaware of the availability of the silver dressings and used a different dressing until the resident's doctor's appointment.
Medication Dispensing Error at Discharge
Penalty
Summary
The facility failed to accurately dispense medication to a resident being discharged, leading to a significant medication error. The resident, who had undergone a right artificial hip replacement and had intact cognition, was discharged with medications that were not prescribed to them. The discharge summary indicated that the resident and their husband were given medications and educated on administration times. However, the medications sent home included several that were not ordered for the resident, such as Eliquis, Levothyroxine, Hydralazine, Loperamide, and Atarax. This error was discovered when the resident reported receiving another resident's medication along with their own. The facility lacked a policy related to medication dispensing at discharge, which contributed to the oversight. The Certified Medication Aide (CMA) involved admitted that the resident was discharged with medications left in stock, and another resident's medication was mistakenly included in the same bin. The CMA acknowledged that each package should have been checked against the resident's discharge orders. The Director of Nursing (DON) confirmed that the error was reported by the resident and that the medication was eventually picked up by the facility. The DON also noted that the discharge nurse should have reconciled the medications before the resident left the facility.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant weight gain in a resident diagnosed with congestive heart failure and edema. The resident experienced a severe weight gain of 36 pounds, or 17.24%, over a 15-day period. Despite the facility's policy requiring physician notification for significant weight changes, there was no documentation that the physician was informed of this weight gain. The resident's weight was recorded as 208.8 pounds on May 23 and increased to 244.8 pounds by June 7. A subsequent weight check on June 12 showed a slight decrease to 240.2 pounds, but the weight gain remained significant at 31.4 pounds, or 15.04%, since May 23. The Director of Nursing (DON) acknowledged that the physician had not been notified in a timely manner, despite the resident's condition of heart failure and documented edema. The DON stated that the physician was only asked to see the resident on June 13, following a nurse's progress note indicating 4+ pitting edema and edema to the forearm. The DON confirmed that the physician had not been notified earlier, even when the resident exhibited 3+ edema to the lower legs and arms. This lack of timely communication with the physician represents a deficiency in the facility's adherence to its own policies and procedures regarding significant changes in a resident's condition.
Failure to Provide Timely Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely assistance with care for three residents who were dependent on staff for activities of daily living. Resident #12, diagnosed with dementia, anxiety, major depression, hypertension, and hyperlipidemia, was observed from 5:00 a.m. to 9:10 a.m. without receiving any care, despite being incontinent and requiring assistance for toileting and hygiene. The care plan indicated that incontinent care should be provided every two hours, but Resident #12 was left in a geri-chair for over four hours without care. Resident #18, with Alzheimer's, a history of falling, osteoarthritis, chronic atrial fibrillation, and dysphagia, was also observed from 5:00 a.m. to 9:27 a.m. without receiving care. The resident was dependent on staff for toileting and hygiene, requiring two staff members for assistance. Despite the care plan's requirement for care every two hours, Resident #18 was left in a geri-chair for over four hours without any staff intervention. Resident #36, diagnosed with anemia, congestive heart failure, depression, anxiety, and dementia, was observed from 5:00 a.m. to 10:10 a.m. without receiving care. The resident was dependent on staff for toileting and hygiene, requiring two staff members for assistance. Despite the care plan's requirement for care every two hours, Resident #36 was left in a geri-chair for over five hours, resulting in dried feces on their buttocks. Staff interviews confirmed that care was not provided as required, and the Director of Nursing acknowledged the deficiency.
Failure to Monitor and Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to adequately assess and monitor a resident who experienced a significant weight gain of 36 pounds, equating to a 17.24% increase over 15 days. The resident, who had a diagnosis of congestive heart failure and edema, was not re-weighed or had their physician notified in a timely manner as per the facility's policy. The resident's weight increased from 208.8 pounds to 244.8 pounds, and there was no documentation of the physician being informed of this severe weight gain. Despite the resident's condition, including persistent bilateral leg pain and significant peripheral edema, the facility did not conduct necessary assessments such as vital signs, lung sounds, or edema evaluations. The physician was eventually notified and ordered an increase in Lasix dosage, but the nursing staff failed to document assessments for worsening symptoms on several occasions. The resident continued to experience severe edema and discomfort, with no timely intervention or monitoring documented. The deficiency was further highlighted when the resident was eventually sent to the emergency room for evaluation and treatment after the physician was notified of the continued weight gain. The resident was admitted to the hospital for a congestive heart failure exacerbation. The facility's lack of timely notification to the physician and inadequate monitoring of the resident's condition contributed to the deficiency identified in the report.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, as evidenced by observations, record reviews, and interviews. The staffing sheets from June 7 to June 21, 2024, indicated that during the 6:00 p.m. to 6:00 a.m. shift, there was only one nurse and two aides available for the long-term care side on several dates. This staffing level was inadequate to provide the necessary care for the facility's census of 77 residents. Several residents were observed to have gone without care for extended periods. Resident #12, who had diagnoses including dementia and incontinence, was left without care for over four hours. Similarly, Resident #18, with Alzheimer's and a history of falls, was not attended to for over four hours. Resident #36, who required extensive assistance due to dementia and decreased mobility, was left without care for over five hours, resulting in dried feces on their buttocks. Staff interviews confirmed that the lack of sufficient aides made it impossible to provide care every two hours as required. Additional interviews with residents and family members highlighted the impact of inadequate staffing. Residents reported long wait times for call lights to be answered and delays in receiving assistance, such as repositioning or receiving water. A resident group meeting further confirmed that the majority of residents experienced delays in care, particularly during night shifts. The Director of Nursing acknowledged that the facility only followed state guidelines for staffing and admitted that the standard of quality care was not being met.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control measures during the provision of care for several residents. For Resident #4, who had severe cognitive impairment and was dependent on staff for activities of daily living, the facility did not adhere to enhanced barrier precautions during wound care. An LPN was observed not sanitizing their hands between glove changes and not changing gloves after providing incontinent care, despite the resident being incontinent of bowel during the procedure. Additionally, there were no gowns or gloves available behind the resident's door for enhanced barrier precautions. Resident #9, who had a recent urinary tract infection and an indwelling catheter, was not placed on enhanced barrier precautions upon returning from the hospital. The door to the resident's room was not marked to alert staff to use enhanced barrier precautions, and no gowns or gloves were supplied. The IP nurse acknowledged a breakdown in the process for enhanced barrier precautions, as the signs were not put back up after the resident's return from the hospital. For Resident #32, who was frequently incontinent of bowel and urine, CNAs were observed not changing gloves during the provision of peri care. One CNA used a wipe to clean their gloves after applying ointment, and another did not change gloves after cleaning the resident's buttocks. Additionally, Resident #42, who had an indwelling catheter, was not provided with proper PPE during catheter care. A CNA was observed emptying the resident's catheter without donning a gown, despite enhanced barrier precautions being in place.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who experienced a decline in their ability to perform activities of daily living (ADLs). The resident, who had diagnoses including paraplegia and high blood pressure, was initially assessed as being independent with oral hygiene and requiring varying levels of assistance with other ADLs. However, a subsequent quarterly assessment showed a decline, with the resident needing more assistance in multiple areas, including substantial maximal assistance with lower body dressing. Despite this decline in two or more areas, the facility did not complete a significant change assessment, as confirmed by the Assistant Director of Nursing (ADON) during a review of the assessments.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating the requirement to permit residents to return post-hospitalization or therapeutic leave. The resident, admitted with diagnoses including peripheral vascular disease and depressive disorder, was cognitively intact and exhibited no behaviors until an incident on 12/26/23. On that date, the resident displayed harmful behaviors, including combative actions, lighting fires, and making false emergency calls, leading to an emergency discharge to the hospital by police. The facility did not have a written policy on permitting residents to return after hospitalization or therapeutic leave, and the discharge notice was not signed by the resident. Additionally, the facility did not provide a discharge summary signed by a physician in the resident's medical record. The facility's administrator confirmed the emergency discharge due to the resident being a danger to himself and others, and acknowledged the lack of a policy on involuntary discharges. The hospital case manager reported being unaware of the resident's discharge status and was informed by the facility that the resident could not return due to unmet needs. The case manager also noted the resident's desire to return to the facility and the difficulty in finding alternative placement. The Administrative Law Judge overruled the involuntary discharge, citing non-compliance with federal regulations regarding written notice.
Latest citations in Oklahoma
A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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