Mcmahon-tomlinson Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawton, Oklahoma.
- Location
- 2007 Nw 52nd Street, Lawton, Oklahoma 73505
- CMS Provider Number
- 375562
- Inspections on file
- 23
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mcmahon-tomlinson Nursing Center during CMS and state inspections, most recent first.
The facility failed to report an allegation of abuse to the state agency within the required 2-hour timeframe after a cognitively intact resident with CHF was found on admission to have bruises on the thighs and near the rib cage. APS arrived to investigate an abuse allegation involving this resident and informed facility staff of the investigation. The Administrator, DON, ADON, and Skilled Nurse Manager met, concluded the bruising was caused by a lift sling and not abuse, and decided not to report the allegation, believing that APS involvement as a state agency meant no separate report to OSDH was required.
A resident with congestive heart failure and intact cognition was found on admission to have multiple bruises on the thighs and near the rib cage. APS notified facility staff that they were present to investigate an abuse allegation involving this resident. The Administrator, DON, ADON, and skilled nurse manager met, determined the bruising was caused by a lift sling, and decided not to report or further investigate the abuse allegation, believing that APS involvement as a state agency meant the allegation did not need to be reported to the state health department as required by facility policy.
A facility failed to accurately code the MDS for a resident who had pneumonia from Legionella. Despite the hospital discharge report indicating the Legionella diagnosis, the Medicare-5 day MDS assessment did not include it. The MDS coordinator admitted the oversight, stating it was not seen on the discharge report, contrary to facility policy.
The facility failed to update the care plan for a resident diagnosed with Legionella. The DON/IP believed the issue was resolved and did not update the care plan, despite the facility's policy requiring updates after hospital readmission.
A facility failed to implement effective infection control practices, leading to a resident contracting pneumonia from Legionella. The Water Management Program lacked documentation of preventative measures, and housekeeping staff were not consistently instructed to run water in sinks and showers. Water testing for Legionella was only conducted after the case was identified.
The facility failed to ensure accurate assessments for two residents. One resident's fall with injury was documented as non-injury, and another resident's discharge to a private home was incorrectly documented as a hospital discharge. The errors were confirmed by the DON and MDS Coordinator upon review.
The facility failed to update care plans with appropriate interventions after multiple falls for two residents. Despite several unwitnessed falls, the care plans for both residents were not revised to include new interventions, as confirmed by the DON.
The facility failed to ensure neurological checks were completed after unwitnessed falls for a resident with altered mental status, dementia, and anxiety. Despite being at high risk for falls, the resident experienced multiple unwitnessed falls where neurological checks were either not started, incomplete, or not restarted after subsequent falls. The DON confirmed these deficiencies, indicating a significant lapse in care.
The facility failed to ensure proper respiratory care for three residents by not labeling and dating oxygen tubing and not administering respiratory medications per standard practice. One resident was observed using outdated oxygen tubing, another received a breathing treatment without a nurse present and had unlabeled tubing, and a third had unlabeled and undated oxygen tubing.
The facility failed to ensure proper communication and assessment for a resident requiring dialysis services. The Hemodialysis Communication Record was found to be incomplete or missing information for multiple dialysis events, affecting the resident's care. The DON acknowledged the lapses in documentation and communication.
The facility failed to ensure RN coverage for 8 hours per day, 7 days a week, on nine specific dates within a 92-day period. The Administrator confirmed the lack of RN coverage, affecting the care of 97 residents and contributing to a one-star rating.
The facility failed to ensure that extended release medications were not crushed for two residents, leading to a medication error rate of 6.94%. The errors involved the administration of crushed Metoprolol Succinate and Potassium Chloride extended release medications, contrary to physician orders.
The facility failed to maintain proper infection control measures, including not changing gloves during perineal care, not sanitizing medical equipment between residents, and not sanitizing hands between resident interactions during medication administration.
A resident with a history of falls and multiple diagnoses was observed without the required fall mats, despite the care plan specifying their use. Both a CNA and an LPN confirmed the absence of fall mats, and the DON stated that staff had discontinued their use, believing the resident was no longer a fall risk. This failure to follow the care plan and facility policy resulted in a deficiency.
The facility failed to specify time frames for medication regimen reviews, resulting in a delayed response to a review for a resident prescribed venlafaxine for depression. The physician's response to a February 2024 review was not received until April 2024, as confirmed by the DON.
The facility failed to monitor side effects for a resident prescribed anticoagulant therapy, despite having a policy in place. The resident's records lacked documentation of side effect monitoring, and the DON confirmed the policy was not followed.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported to the state agency within the required 2-hour timeframe for one resident. The facility’s Abuse and Neglect policy dated 09/12/25 stated that the facility shall immediately report allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. Resident #1 was admitted on 12/05/25 with a diagnosis of congestive heart failure, and the admission assessment documented that the resident’s cognition was intact with a BIMs score of 15. A skilled assessment on the same date showed the resident had bruises on the right lateral thigh, left inner thigh, and near the rib cage. According to interview and record review, an APS investigator reported going to the facility on 12/05 and informing staff they were there to investigate an allegation of abuse for Resident #1. The DON stated that on 03/05/26 a meeting was held with the Administrator, DON, ADON, and Skilled Nurse Manager regarding the allegation of abuse and the bruising. They discussed and investigated the bruising and concluded it was caused by the lift sling and determined it was not abuse, deciding that an investigation into the allegation of abuse would not be reported. The Administrator later reported that APS had come to the facility and informed them they were there to investigate an allegation of abuse for Resident #1, and that the facility believed they did not have to report the allegation because APS is part of a state agency. The Administrator acknowledged that the abuse allegation should have been reported to OSDH and investigated.
Failure to Investigate and Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was investigated and reported as required for one resident. The facility’s Abuse and Neglect policy, dated 09/12/25, required immediate reporting of allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. Resident #1 was admitted on 12/05/25 with a diagnosis of congestive heart failure, and the admission assessment documented intact cognition with a BIMS score of 15. A skilled assessment on the same date identified bruises on the resident’s right lateral thigh, left inner thigh, and near the rib cage. On 12/05, an APS investigator came to the facility and informed staff they were there to investigate an allegation of abuse for Resident #1. The DON later reported that a meeting was held regarding this allegation, attended by the Administrator, DON, ADON, and Skilled Nurse Manager, during which they discussed and investigated the bruising and concluded it was caused by a lift sling and not abuse. Based on this internal conclusion, they decided not to report or further investigate the allegation of abuse. The Administrator reported that APS had informed them they were conducting an investigation concerning an allegation of abuse for the resident, and acknowledged they believed they did not have to report the allegation because APS is part of a state agency, despite the facility policy requiring immediate reporting and investigation.
Inaccurate MDS Coding for Legionella Diagnosis
Penalty
Summary
The facility failed to ensure the minimum data set (MDS) was coded accurately for a resident who was discharged from the hospital for skilled services. The resident had diagnoses including pneumonia from Legionella, high blood pressure, and non-Alzheimer's dementia. A hospital discharge report indicated the resident was admitted for altered mental status due to pneumonia from Legionella. However, the Medicare-5 day MDS assessment did not reflect the Legionella diagnosis. The MDS coordinator acknowledged that the resident was discharged to the hospital and returned, and the MDS assessment was completed for skilled services. They admitted that the Legionella diagnosis was not incorporated into the MDS as it was not seen on the hospital discharge report, which was against facility policy to list it under other diagnoses.
Failure to Update Care Plan for Legionella Diagnosis
Penalty
Summary
The facility failed to update the care plan for a resident who was diagnosed with Legionella. According to the facility's policy, the interdisciplinary team is required to review and update the care plan when a resident is readmitted from a hospital stay. However, in this case, the Director of Nursing/Infection Preventionist (DON/IP) reported that they believed the issue had been resolved and therefore did not update the care plan. This oversight occurred despite the policy requirement and the resident's recent diagnosis of Legionella.
Inadequate Water Management Leads to Legionella Case
Penalty
Summary
The facility failed to implement effective infection prevention and control practices, specifically in identifying high-risk areas and ensuring the flushing of unused water outlets to prevent the spread of waterborne illnesses such as Legionella. The facility's Water Management Program, dated 03/05/25, outlined the need for identifying risk factors, establishing control measures, and maintaining detailed records of testing and monitoring results. However, the maintenance director admitted to having only water and air temperature records, with no documentation of preventative measures or cleaning schedules. The housekeeping staff were supposed to run water while cleaning rooms, but this was not consistently done prior to the Legionella case. A resident was admitted to the hospital with altered mental status due to pneumonia from Legionella, highlighting the deficiency in the facility's water management practices. Interviews with housekeeping staff revealed that they were not routinely instructed to run water in sinks and showers while cleaning, and there was no prior in-service training related to this practice before the Legionella case. The maintenance director confirmed that water testing for Legionella was only conducted in the affected resident's room after the case was identified, indicating a lack of proactive measures to prevent such occurrences.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for two residents. One resident with a diagnosis of weakness had a fall resulting in a laceration, but the assessment inaccurately documented the fall as non-injury. The Director of Nursing confirmed the error upon review. Another resident with a diagnosis of sepsis was discharged to a private home, but the discharge assessment incorrectly documented the discharge as to a hospital. The MDS Coordinator confirmed the discrepancy upon review of the discharge notes.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that interventions were added to the care plans of two residents after multiple falls. Resident #38, who had diagnoses including type 2 diabetes mellitus, urinary incontinence, and hypertensive heart disease, experienced several unwitnessed falls on 04/15/23, 12/04/23, 03/30/24, and 03/31/24. Despite these incidents, no new interventions were documented in the resident's care plan since 01/12/22. The Director of Nursing (DON) confirmed that the care plan had not been updated with new fall interventions as required by the facility's policy on assessing falls and their causes, revised in 03/2018. Similarly, Resident #41, who had diagnoses including altered mental status, dementia, and anxiety, experienced multiple unwitnessed falls between 01/16/24 and 03/15/24. Although the resident's care plan was revised on 03/13/24, no specific interventions were updated to address the falls. The DON confirmed that the care plan had only been updated on 04/10/24, after the surveyor's inquiry. This failure to update care plans with appropriate interventions after falls is a clear deficiency in the facility's adherence to its own policies and procedures for fall prevention.
Failure to Complete Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure neurological checks were completed after unwitnessed falls for one resident reviewed for falls. The resident had multiple diagnoses, including altered mental status, dementia, and anxiety, and was identified as being at high risk for falls. Despite this, the facility did not consistently perform or document the required neurological checks following several unwitnessed falls. For instance, on 01/16/24, there was no documentation that neurological checks were started after an unwitnessed fall. On 01/24/24, neurological checks were started but were incomplete, and they were not restarted after a second fall on the same day. Similar issues were noted on 02/02/24, where checks were only partially completed, and on 02/22/24, where checks were inconsistently documented. Additionally, on 03/15/24, following a witnessed fall, the neurological assessment was incomplete. The Director of Nursing (DON) confirmed these deficiencies, acknowledging that neurological checks were either not started, not restarted after subsequent falls, or not accurately completed. The facility's policies on neurological assessments and fall assessments were not adhered to, leading to incomplete or missing documentation of neurological checks. This failure to follow protocol and ensure proper monitoring after falls represents a significant lapse in the care provided to the resident, who was already at high risk for falls and had a complex medical history.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents by not adhering to the policy of labeling and dating oxygen tubing and not administering respiratory medications per standard practice. Resident #14, who had diagnoses including macular degeneration and osteoporosis, was observed using oxygen tubing dated 02/26, which was not changed as per the physician's order to change it every two weeks. LPN #1 confirmed the tubing was outdated and did not follow the physician's orders. Resident #64, who required oxygen therapy and had a diagnosis of dependence on supplemental oxygen, was observed receiving a breathing treatment without a nurse present, and there was no assessment for self-administration of medication. Additionally, the oxygen tubing was not labeled with a date. LPN #1 confirmed the tubing was not labeled and that the resident did not have an order to self-administer medication. Resident #143, diagnosed with chronic respiratory failure and dependence on supplemental oxygen, was observed with oxygen tubing that was not labeled or dated, contrary to the physician's orders and facility protocol. LPN #3 confirmed the tubing should be changed and dated every Sunday and placed in a plastic bag when not in use.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper communication and assessment for a resident requiring dialysis services. Specifically, the facility did not maintain adequate communication between the dialysis center and the nursing staff, and pre- and post-dialysis assessments were not consistently completed. The facility's Hemodialysis Communication Record, which is divided into pre-dialysis, dialysis center, and return to facility assessments, was found to be incomplete or missing information for multiple dialysis events. For instance, pre-dialysis assessments lacked information for two out of 14 events and only contained vital signs without a physical assessment for six out of 14 events. Similarly, dialysis center assessments were missing for three out of 14 events and lacked physical assessments for 11 out of 14 events. Return to facility assessments were incomplete for eight out of 14 events and only contained vital signs and weights without a physical assessment for four out of 14 events. Resident #63, who had diagnoses including end-stage renal disease and dependence on renal dialysis, was directly affected by these deficiencies. The resident received dialysis three times per week but reported being unaware of any monitoring being conducted. The Director of Nursing (DON) acknowledged that the communication forms were not being fully completed and should be maintained in the resident's hard chart. The DON also stated that staff only documented in a progress note if the resident did not return from dialysis, further indicating lapses in the required documentation and communication processes.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage was provided for 8 hours per day, 7 days a week, for nine specific dates within a 92-day period. The facility's policy, revised in August 2022, mandates that an RN provides services for at least eight consecutive hours every 24 hours, seven days a week. However, a review of time documents revealed that there was no RN coverage for the required duration on the dates of 10/01/23, 10/07/23, 10/15/23, 10/22/23, 11/11/23, 11/19/23, 12/03/23, 12/09/23, and 12/17/23. The Administrator confirmed the lack of RN coverage on these dates, affecting the care of 97 residents residing in the facility. This deficiency contributed to the facility receiving a one-star rating.
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that extended release medications were not crushed for two residents, leading to a medication error rate of 6.94%. Resident #6, who had diagnoses including high blood pressure, edema, and atrial fibrillation, was administered crushed Metoprolol Succinate extended release 12.5 mg and Potassium Chloride extended release 20 milliequivalents, despite a physician order indicating that extended release medications should not be crushed. Similarly, Resident #23, who had a diagnosis of high blood pressure, was administered crushed Metoprolol Succinate extended release 25 mg, contrary to the physician's order that extended release medications should not be crushed and that alternatives should be sought from the pharmacy if necessary. During the medication pass observation, CMA #1 was seen crushing and administering these extended release medications to both residents. When questioned, CMA #1 confirmed that they had crushed the extended release medications for both residents. The Director of Nursing (DON) also confirmed that extended release medications should not be crushed unless the physician is aware, but acknowledged that Potassium extended release and Metoprolol extended release should not be crushed. This failure to adhere to medication administration protocols resulted in a medication error rate exceeding the acceptable threshold.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff maintained proper infection control measures during the provision of perineal care and personal hygiene for a resident. A CNA was observed not changing gloves while providing perineal care, cleaning the resident's eyes and mouth, and performing other hygiene tasks. The CNA admitted to not changing gloves during the entire process, which was confirmed as a violation of the facility's infection control policy by the DON. Additionally, a CMA was observed not sanitizing a blood pressure cuff and pulse oximeter between uses on multiple residents. The CMA admitted to not sanitizing the equipment after each use, which was against the facility's policy. The DON confirmed that staff should sanitize equipment between residents to prevent cross-contamination. Furthermore, another CMA was observed not sanitizing their hands between residents during medication administration. The CMA handled various medical tasks and equipment without washing or sanitizing their hands, which was against the facility's hand hygiene policy. The CMA acknowledged the lapse and cited the absence of hand sanitizer on the medication cart as a reason. The DON confirmed that hand hygiene should be maintained between resident interactions to prevent the spread of infections.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions were implemented for a resident with a history of falls. Resident #14, who had diagnoses including macular degeneration, lesion of the plantar nerve, and osteoporosis, was observed in bed without the required fall mats on each side. The care plan dated 11/22/23 specified the use of fall mats, but these were not in place during the observation on 04/09/24. Both a CNA and an LPN confirmed that the fall mats should have been in place according to the care plan, but they were not. The Director of Nursing (DON) stated that staff felt Resident #14 was no longer a fall risk, which led to the discontinuation of the fall mats without proper documentation or care plan update. The facility's policy on assessing falls and their causes, revised in 03/18, mandates that appropriate interventions be recorded in the resident's medical record to prevent future falls. However, this policy was not followed for Resident #14. The comprehensive assessment dated 03/25/24 indicated that the resident was dependent for transferring from bed to chair and had moderately impaired cognition, further emphasizing the need for fall prevention measures. The failure to implement and maintain these interventions as per the care plan and facility policy resulted in a deficiency in ensuring a safe environment for the resident.
Failure to Specify Time Frames for Medication Regimen Review
Penalty
Summary
The facility failed to identify specific time frames for the steps regarding the medication regimen review (MRR) in their policy, leading to a delay in addressing a medication review for a resident diagnosed with depression. The resident was prescribed venlafaxine for depression, and a medication regimen review conducted in February 2024 requested the physician to consider a dose reduction or provide a rationale for not doing so. However, the physician's response was not received until April 5, 2024. The Director of Nursing (DON) confirmed that the policy did not specify time frames for non-urgent MRRs and acknowledged the delay in addressing the February 2024 MRR. The deficiency was identified during a review of the facility's records and interviews with the DON.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure side effect monitoring was in place for a resident prescribed anticoagulant therapy. The resident had diagnoses including pulmonary embolism, hypertensive heart disease, and peripheral vascular disease, and was prescribed Apixaban. Despite the facility's Anticoagulation-Clinical Protocol policy requiring monitoring for adverse drug reactions, the Treatment Administration Record and Active Order Summary did not document any side effect monitoring for the resident. The Director of Nursing confirmed that the policy was not followed, as there was no side effect monitoring in the orders or the Treatment Administration Record.
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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