Marlow Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Marlow, Oklahoma.
- Location
- 702 South 9th, Marlow, Oklahoma 73055
- CMS Provider Number
- 375490
- Inspections on file
- 27
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Marlow Nursing & Rehab during CMS and state inspections, most recent first.
Two cognitively intact residents with chronic medical conditions reported being inappropriately touched by the same CNA, one during a shower and the other during lotion application in their room. Both incidents involved unwanted physical contact, with one resident also reporting exposure to the CNA's breasts. The CNA denied the allegations when interviewed.
Staff failed to administer medication according to physician orders by giving midodrine despite blood pressure readings above the ordered threshold, and did not provide required supervision or assessment for a resident with a history of illicit substance use. Incident documentation, care planning, and resident assessment were incomplete or missing, and administration was not promptly informed of the events.
A resident with moderately impaired cognition and a history of cirrhosis was found with drug paraphernalia in their room, but the facility did not update the care plan to address substance use. Staff confirmed that the care plan should have included interventions for substance abuse, but no such measures were implemented.
A resident with multiple medical conditions reported their room was too cold, despite a thermostat reading 74 degrees. The resident had covered the air vent with a blanket due to it not closing, and staff suggested using more blankets, which was uncomfortable. The administrator, new to the facility, was unaware of previous actions taken. Maintenance replaced the air vent, and the resident had refused offers to change rooms.
A facility failed to update care plans and include a resident in care plan meetings. Despite the resident's request for restorative therapy, their care plan was not revised to reflect this need. The facility's administrator acknowledged that care plan meetings had not been conducted and that a restorative program was unavailable.
Two residents did not receive showers as scheduled or requested, leading to a deficiency in care. One resident was unsure of their last shower, and another reported inconsistent shower schedules due to staffing issues. Documentation gaps were noted, with missing Shower Sheets for specific periods. CNAs confirmed the process of documentation, but the administrator highlighted the need for adherence to care plans and EMR documentation.
The facility did not ensure that three residents were offered the choice to formulate advance directives, as required by federal law. The residents, diagnosed with conditions such as dementia, anxiety disorder, and chronic kidney disease, had incomplete advance directive acknowledgment forms. The corporate RN consultant confirmed the absence of these forms.
The facility failed to implement comprehensive care plans for three residents, omitting essential care areas such as dialysis and hospice services. A resident with end-stage renal failure lacked a dialysis care plan, another with dementia and diabetes had no hospice care plan, and a third resident's care plan omitted dialysis and suprapubic catheter care. These omissions were acknowledged by the facility's RN consultant and MDS coordinator.
The facility failed to act on pharmacist recommendations for medication regimen reviews for two residents. One resident, with depression and psychotic disorder, had no documented response to a suggested dose reduction of psychotropic medications. Another resident, with anxiety and depression, also had no response to a similar recommendation. Both residents' assessments showed intact cognition and no mood behaviors, yet their medication use continued unchanged.
The facility failed to ensure a psychotropic medication was necessary for a resident and did not limit the PRN use to 14 days. A physician order for Lorazepam was documented without a diagnosis of anxiety, which was confirmed by the MDS coordinator. The Corporate RN consultant acknowledged the PRN order had been in place since March and was aware of the 14-day limit.
The facility exceeded the acceptable medication error rate, reaching 8% due to two errors in 25 opportunities. A resident received Clonidine without a required blood pressure check, and there was a discrepancy in Glipizide administration timing. The corporate RN consultant acknowledged these issues, noting a transcription error omitted the timing instruction.
The facility failed to obtain required lab work for two residents with complex medical conditions, including diabetes and renal failure. Despite physician orders for specific lab tests at designated intervals, the facility did not order the necessary tests, as confirmed by the Corporate RN consultant. Both residents were dependent on staff for daily activities.
The facility failed to implement enhanced barrier precautions for three residents, leading to a deficiency in infection prevention and control. A resident with a PEG tube and another with an indwelling catheter were observed without proper PPE or signage. Staff were not initially trained on EBP, resulting in improper sanitization and infection control practices.
A facility failed to accurately code an MDS assessment for a resident who was discharged to the hospital after a fall resulting in a femoral neck fracture. The quarterly assessment inaccurately documented the resident's condition and independence with transfers. A nurse's note later confirmed the fall and fracture, and the MDS coordinator acknowledged errors in the discharge and return dates.
A resident with diagnoses of dementia, anxiety, depression, psychotic disorder, and schizoaffective disorder was not referred for a level II PASRR evaluation despite these conditions. The initial PASRR did not document evidence of a serious mental illness, and subsequent assessments and physician's orders indicated active diagnoses that were not included in the PASARR. The corporate RN consultant confirmed the oversight in reevaluating the resident's PASARR.
A resident with depression, seizure disorder, and psychotic disorder had an outdated care plan that was not revised following a psychiatric hospital admission and a comprehensive assessment documenting medication use. The RN consultant noted that care plans were an issue and a new MDS nurse was addressing updates.
A facility failed to provide bathing assistance as per the care plan for a resident with significant ADL dependence. Despite the resident's report of receiving showers, there was a noticeable body odor, and the shower records were incomplete. The resident was scheduled for showers three times a week, but records showed only five showers, one refusal, and 21 days marked as non-bath days in June.
A facility failed to assess a resident's blood pressure and pulse immediately after dialysis, as ordered by a physician. Despite the resident's end-stage renal failure, the required assessments were not documented on several occasions, as confirmed by an LPN and a Corporate RN consultant.
The facility failed to offer the pneumonia vaccination to three residents as per policy, which requires assessment within five days of admission. The residents, with conditions like hemiplegia, diabetes, coronary artery disease, and dementia, had no documented proof of vaccination offers or assessments. The corporate RN consultant noted that new staff had not been obtaining vaccine consent or declination, and the business office was responsible for screening during admission.
The facility failed to notify the designated DPOA for a resident transferred to the hospital and did not inform a physician about another resident's abnormal temperature at admission. The corporate RN confirmed these lapses were against the facility's policies.
The facility failed to maintain an accurate clinical record for a resident, as the face sheet did not correctly identify the responsible party and contained incomplete contact information. The corporate RN confirmed the need for an update.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by two separate allegations involving the same CNA. One resident, who was cognitively intact and had multiple medical diagnoses including COPD, diabetes, and heart failure, reported that the CNA touched their private area over their shorts and exposed their breasts to the resident after assisting with lotion application. The resident stated that the contact was not accidental and made them uncomfortable, prompting them to ask the CNA to leave their room. The incident was reported to the administrator, who confirmed that the resident had initially approached a nurse but only disclosed the details to the administrator. During the investigation of the first allegation, another cognitively intact resident with chronic medical conditions, including COPD and kidney cancer, reported that the same CNA had groped them while assisting with a shower. This resident had not previously reported the incident and only disclosed it when questioned by the administrator. Both residents described inappropriate physical contact by the CNA, with one incident occurring in a resident's room and the other in the shower. The CNA denied all allegations when interviewed.
Failure to Follow Medication Orders and Supervise Substance Use
Penalty
Summary
The facility failed to administer medications according to physician orders and did not provide appropriate supervision and assessment for a resident with a history of illicit substance use. For one resident, staff repeatedly administered midodrine despite blood pressure readings above the physician-ordered threshold for holding the medication. Documentation showed multiple instances over two months where the medication was given when the systolic blood pressure exceeded 120 mmHg, contrary to the order and facility policy requiring vital sign monitoring and adherence to parameters before administration. In a separate incident, another resident with a diagnosis of cirrhosis and moderate cognitive impairment was found to have drug paraphernalia in their room, including a broken glass pipe with a white substance, foil, scissors, and a burned light bulb. Staff did not complete an incident report, notify the police, or document how the paraphernalia was discarded. The resident's care plan did not include goals or interventions related to substance use, and there was no documentation of assessment upon the resident's return to the facility after outings, despite a policy requiring such assessments for signs of substance use or overdose. Additionally, sign-out sheets for the resident were incomplete, lacking reasons for outings and times, and progress notes did not reflect required assessments upon return. The facility's administration was not made aware of the incident until prompted by surveyors, and the Director of Nursing confirmed that the required monitoring and documentation were not performed as per policy.
Failure to Develop Care Plan for Illicit Substance Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing illicit substance use for a resident after drug paraphernalia was discovered in the resident's room. Documentation showed that a housekeeper found a tissue box containing a broken glass pipe with a white substance, foil, scissors, and a burned light bulb. The incident was reported to administration, and the paraphernalia was collected, but no incident report was completed, and law enforcement was not contacted. The resident involved had moderately impaired cognition, a BIMS score of 09, was independent with activities of daily living, and had a diagnosis of cirrhosis of the liver. Despite the discovery of items suggestive of illicit drug use, the resident's care plan did not include any goals or interventions related to substance abuse. Staff interviews confirmed that the care plan should have addressed substance use following the incident, but no such updates were made. The facility's policy required care plans to identify problem areas and develop targeted interventions, which was not followed in this case.
Failure to Provide a Comfortable Environment for a Resident
Penalty
Summary
The facility failed to provide a warm and comfortable environment for a resident, who was one of three residents reviewed for a homelike environment. The resident, who had medical conditions including cellulitis, diabetes, chronic pain, osteoarthritis, polyneuropathy, and coronary artery disease, reported that their room was too cold and had been for a long time. Despite understanding that their medical conditions caused poor circulation, the resident expressed a desire for a warmer room. The resident had a digital thermostat that read 74 degrees and had covered the air vent with a blanket because it wouldn't close. Staff had encouraged the resident to use more blankets, which was uncomfortable for the resident's legs. The administrator, who was new to the facility, stated they would check what had been done to address the issue. The Ombudsman reported having discussed the cold room with the resident and the previous administrator multiple times, noting that the use of additional blankets was uncomfortable for the resident. Maintenance staff later replaced the air vent, which had been covered with a blanket and boxes, suggesting limited airflow. The administrator mentioned that the resident had been offered a different room several times but had refused to move.
Failure to Update and Include Resident in Care Plan Meetings
Penalty
Summary
The facility failed to review and revise care plans and include the resident or their representative in care plan meetings for one of the residents reviewed. The facility's policy, dated December 2016, requires a comprehensive, person-centered care plan to be developed and implemented for each resident, involving the resident and their legal representative in the planning process. However, for a resident with multiple diagnoses including cellulitis, diabetes, and coronary artery disease, the care plan was not updated to reflect the unavailability of restorative therapy. Despite the resident's request for restorative therapy, the care plan did not address this need. The resident reported not having an official care plan and could not recall the last time they were included in a care plan meeting. The facility administrator admitted that care plan meetings had not been conducted and was unaware of any being scheduled. The administrator also confirmed that the facility did not have a restorative program available to residents. This lack of communication and failure to update care plans led to the deficiency identified by the surveyors.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled and requested showers for two residents, leading to a deficiency in the care provided. Resident #1 was observed with facial hair and was unsure of their last shower or bath. The review of Resident #1's Shower Sheets from 09/11/24 to 10/17/24 showed multiple refusals and some completed showers, but there were no records for 10/18/24 to 10/22/24. This indicates a lack of consistent documentation and possibly a failure to provide the necessary hygiene care as per the resident's needs. Resident #3 reported not receiving showers as scheduled, which were supposed to occur on Monday, Wednesday, and Friday. The resident mentioned that sometimes an extra shower aide was available, but they were often reassigned to other duties. The review of Resident #3's Shower Sheets from 09/11/24 to 10/16/24 showed several completed showers and one refusal, but no records were available for 10/17/24 to 10/22/24. CNA #1 confirmed that Shower Sheets were filled out and reviewed by the charge nurse and DON, while CNA #2 stated that staffing was usually adequate. The administrator noted that showers should be documented in the EMR and given per the care plan or as requested, highlighting a gap in adherence to these protocols.
Failure to Offer Advance Directives to Residents
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate advance directives, as required by the Patient Self-Determination Act of 1990. This deficiency was identified for three of the twelve sampled residents. The facility's policy on Advance Directives and Do Not Resuscitate Orders, which was not dated, mandates that residents be informed of their rights to make medical decisions, including the formulation of advance directives. However, the facility did not complete the advance directive acknowledgment forms for these residents. Resident #20, who was admitted with unspecified dementia, had an incomplete advance directive acknowledgment form, and their electronic medical record indicated a full code status. Resident #29, diagnosed with generalized anxiety disorder, and Resident #37, with chronic kidney disease, also had incomplete advance directive acknowledgment forms. The corporate RN consultant confirmed the absence of these forms for the three residents during interviews conducted on the same day.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which was identified during a survey. Resident #11, who had end-stage renal failure and required dialysis, did not have a care plan addressing dialysis services, despite a physician's order to obtain the resident's weight on specific days before dialysis. The MDS coordinator acknowledged that dialysis services should have been included in the care plan. Resident #23, diagnosed with dementia, diabetes mellitus, and hypertension, was admitted to hospice care, but the care plan lacked any reference to hospice services. Similarly, Resident #37, with diagnoses including anemia, renal insufficiency, and diabetes mellitus, had no care plan for a suprapubic catheter or dialysis, despite physician orders for both. The corporate RN consultant and MDS coordinator confirmed these omissions and indicated that care plans should have been in place for these services.
Failure to Act on Pharmacist's Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that medication regimen reviews conducted by the pharmacist were acted upon for two residents. Resident #15, who had diagnoses including depression, seizure disorder, and psychotic disorder, was prescribed multiple psychotropic medications. A pharmacist's medication regimen review recommended a gradual dose reduction for some of these medications, as they had been in place for over 12 months. However, there was no documented response from the physician or facility to this recommendation. A comprehensive assessment later documented that the resident's cognition was intact and no mood behaviors were exhibited, yet the use of antipsychotic, antidepressant, and hypnotic medications continued. Similarly, Resident #21, diagnosed with anxiety and depression, was also subject to a pharmacist's recommendation for a dose reduction of certain medications. Despite this, there was no physician response or facility acknowledgment of the recommendation. The resident's medical record indicated a recent inpatient psychiatric hospital stay, and a subsequent comprehensive assessment noted intact cognition and no mood behaviors, while the use of antianxiety, antidepressant, and hypnotic medications persisted. The Corporate RN consultant confirmed that the medication regimen reviews for both residents were not acted upon and were not found in the residents' medical records.
Failure to Ensure Necessary Psychotropic Medication and Limit PRN Use
Penalty
Summary
The facility failed to ensure that a psychotropic medication was necessary to treat a specific condition indicated in the clinical record and did not limit an as-needed psychotropic medication to 14 days for one resident. The facility's Medication Regimen Reviews policy requires a thorough review of each resident's medical record to prevent and resolve medication-related issues. However, a physician order for Lorazepam, an anti-anxiety medication, was documented for a resident without a diagnosis of anxiety. The MDS coordinator confirmed that the resident's MDS did not include a diagnosis of anxiety, which would be expected if they were receiving anti-anxiety medication. The Corporate RN consultant acknowledged that the PRN order for Lorazepam had been in place since March 2024 and had not been administered in June 2024, but was aware that PRN orders should not exceed 14 days.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% during a survey. This deficiency was identified through the observation of 25 medication administration opportunities, where two errors were noted. One specific incident involved the administration of Clonidine to a resident without checking their blood pressure, despite physician orders to hold the medication if the blood pressure was below 100/60 or the pulse was less than 60. Additionally, there was a discrepancy between the pharmacy card instructions and the physician's orders for Glipizide administration, which was not given 30 minutes before breakfast as required. The corporate RN consultant acknowledged the need to check the blood pressure and noted that the transcription error led to the omission of the timing instruction for Glipizide administration.
Failure to Obtain Required Lab Work for Residents
Penalty
Summary
The facility failed to ensure that blood work was obtained according to physician orders for two residents. Resident #7, who had diagnoses including diabetes mellitus, anemia, and non-traumatic brain dysfunction, had physician orders for lab work to be conducted at specific intervals. However, the clinical record showed no lab results for February 2024, and the Corporate RN consultant confirmed that the lab work had not been ordered by the facility. Similarly, Resident #11, diagnosed with end-stage renal failure, diabetes mellitus, anemia, and hypothyroidism, had physician orders for lab work to be conducted in April 2024. The clinical record for this resident also lacked the required lab results, and the Corporate RN consultant reported that the facility failed to order the necessary lab work. Both residents were dependent on staff for activities of daily living, and the oversight in obtaining lab work was identified during a review by the Corporate RN consultant.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for three residents, leading to a deficiency in infection prevention and control. Resident #7, who had a non-traumatic brain dysfunction and was dependent on staff for activities of daily living, was observed without PPE supplies or EBP signage in place. Despite a physician's order for tube feeding, EBP was not implemented until after the survey began. Similarly, Resident #20, who was on a PEG tube for nutrition and fluids, did not have EBP signage or PPE available until the second day of the survey. The Corporate RN acknowledged the absence of EBP in the facility, indicating a lack of initial implementation. Resident #37, who had anemia, renal insufficiency, diabetes mellitus, and an indwelling catheter, also lacked EBP measures. The resident's room was not marked for EBP, and staff were observed not following proper sanitization protocols. A CMA used the same blood pressure cuff on multiple residents without sanitizing it, and a CNA was unaware of the need for a gown when emptying the catheter. The CNA reported not receiving training on EBP until after the survey began, highlighting a gap in staff education and adherence to infection control protocols.
Inaccurate MDS Assessment Coding After Resident Fall
Penalty
Summary
The facility failed to ensure accurate coding of a Minimum Data Set (MDS) assessment for a resident who was discharged to the hospital following a reportable fall. The quarterly assessment documented no upper or lower impairment and indicated the resident was independent with transfers. However, a nurse's note later documented that the resident fell in the bathroom, resulting in a left femur femoral neck fracture, and was subsequently transferred to the hospital. Upon review, the MDS coordinator confirmed that the MDS assessment contained errors regarding the discharge and return dates of the resident, which were incorrectly entered.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly evident or possible serious mental illness to the OHCA for a level II PASRR evaluation. Resident #23, who was one of two sampled residents reviewed for PASARR, had diagnoses including dementia, anxiety, depression, psychotic disorder, and schizoaffective disorder. A level I PASRR dated 07/14/22 documented the resident with a primary diagnosis of dementia with behavioral disturbances and no evidence of a serious mental illness. However, subsequent assessments and physician's orders indicated active diagnoses of anxiety, depression, and schizoaffective disorder, which were not included in the initial PASARR. Despite these diagnoses, there was no documentation of a referral for a level II PASRR evaluation. On 06/26/24, the corporate RN consultant confirmed that the resident's PASARR had not been reevaluated to include the diagnoses of anxiety, depression, or schizoaffective disorder, which should have prompted a rescreening for level II services.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised in a timely manner. The resident, who had diagnoses including depression, seizure disorder, and psychotic disorder, had a care plan dated May 18, 2023, which was last revised on June 13, 2023, and reviewed on August 18, 2023. However, the resident had an inpatient psychiatric hospital admission from April 3, 2024, through May 2, 2024, and a comprehensive assessment dated May 9, 2024, documented the use of antipsychotic, antidepressant, and hypnotic medications. Despite these significant changes, the care plan was not updated to reflect the new comprehensive assessment. The RN consultant acknowledged that care plans were an issue and that a new MDS nurse was working on updating them.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance as outlined in their care plan for a resident diagnosed with debility, cardiorespiratory conditions, heart failure, and depression. An assessment indicated that the resident required substantial maximum dependence for activities of daily living (ADLs). Despite the resident reporting that they received showers, there was a noticeable smell of body odor in their room. The corporate RN consultant acknowledged that the shower records for the resident were incomplete, with blanks on days when the resident was supposed to be showered. The shower schedule indicated that the resident was to be showered on Monday, Wednesday, and Friday, but the records showed that out of 27 opportunities in June, only five days were marked as showered, one day as refused, and 21 days as not a bath day.
Failure to Assess Resident Post-Dialysis
Penalty
Summary
The facility failed to ensure proper assessment of a resident after dialysis treatments as per the physician's order. The resident, who had end-stage renal failure and intact cognition, was supposed to have their blood pressure and pulse checked immediately after returning from dialysis appointments. However, the dialysis communication forms for specific dates did not document these vital signs as required. The oversight was confirmed by both an LPN and a Corporate RN consultant, who acknowledged that the assessments were not conducted immediately after the resident's return from dialysis on several occasions.
Failure to Offer Pneumonia Vaccination
Penalty
Summary
The facility failed to ensure that residents were offered the pneumonia vaccination according to its policy. Specifically, three residents were not assessed for their vaccination status within five days of admission, as required by the facility's Pneumococcal Vaccine policy. The policy mandates that residents be assessed for eligibility to receive the pneumococcal vaccine series upon or prior to admission and be offered the vaccine within thirty days unless contraindicated or previously vaccinated. However, the medical records for these residents showed no documentation of vaccination offers or assessments. The deficiency involved three residents with various medical conditions, including hemiplegia, diabetes mellitus, coronary artery disease, dementia, and atrial fibrillation. Despite the facility's policy, there was no proof in the medical records that these residents were screened for vaccination status or offered the pneumonia vaccine. The corporate RN consultant acknowledged the lack of documentation and attributed it to new staff not obtaining vaccine consent or declination and failing to document vaccination status. The responsibility for screening residents during admission and obtaining vaccine consent or declination was assigned to the business office, which had not been tracking the documentation of resident vaccination status.
Failure to Notify DPOA and Physician
Penalty
Summary
The facility failed to notify the designated Durable Power of Attorney (DPOA) for a resident who was transferred to the hospital. The resident, who had diagnoses including high blood pressure, diabetes, and bradycardia, was found lethargic with an oxygen saturation of 88%, a heart rate of 51, and a blood pressure of 117/72. Despite the facility's policy to notify the family or representative when a resident is transferred to the hospital, the DPOA was not contacted. Instead, a message was left for a secondary contact listed in the resident's file. The corporate RN confirmed that the DPOA should have been notified as per the facility's policy. Additionally, the facility failed to notify a physician about an abnormal temperature for another resident at the time of admission. The resident, who had diagnoses including high blood pressure, diabetes, and anxiety, had a recorded temperature of 101.1°F. The clinical record did not document any notification to the physician, rechecking of the temperature, or administration of a fever-reducing medication. The RN responsible for the admission could not recall why the physician was not notified, and the corporate RN confirmed that there was no order for a fever-reducing drug in the resident's records.
Inaccurate Clinical Record for Resident
Penalty
Summary
The facility failed to maintain an accurate clinical record for a resident, specifically regarding the responsible party contact information. The face sheet in the resident's clinical record did not identify the responsible party and listed a second contact person with a phone number and a third contact person without a phone number. During an interview, the corporate RN identified the third contact person as the resident's DPOA and acknowledged that the face sheet needed to be updated.
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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