Meadowlake Estates
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 959 Southwest 107th Street, Oklahoma City, Oklahoma 73139
- CMS Provider Number
- 375256
- Inspections on file
- 38
- Latest survey
- March 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Meadowlake Estates during CMS and state inspections, most recent first.
A resident with quadriplegia and multiple sclerosis was not bathed as scheduled, with documentation showing only one bath in January and none in February. The resident expressed frustration over missed showers, and staff interviews revealed inconsistencies in documenting completed or refused baths. The DON confirmed the lack of documentation for the resident's scheduled baths.
The facility failed to prevent and manage pressure ulcers for two residents. One resident developed a Stage II pressure ulcer due to inadequate incontinent care, while another's heels were not floated as per physician orders, risking further skin damage. The DON acknowledged lapses in care and communication.
A resident with dysphagia was given a brownie not suitable for their minced and moist level 5 diet, leading to a choking incident. The oversight occurred due to a new cook's error and lack of verification by staff. The resident's care plan was updated, and dietary staff were in-serviced on the importance of adhering to diet sheets.
The facility failed to ensure proper food storage and handling, leading to deficiencies such as improper storage of raw meat, presence of dented cans, expired food items, and inadequate labeling. Observations revealed that raw meat was not stored to prevent cross-contamination, dented cans were found in storage, and expired items were not removed. Additionally, food items were not properly labeled or sealed, contributing to the deficiencies.
The facility failed to adhere to infection control protocols during incontinent care, handling of linens, and PPE usage for COVID-19 positive residents. CNAs did not change gloves or sanitize hands appropriately, and a CMA entered a COVID-19 room without proper PPE. Additionally, a nurse handled medication with bare hands, violating the facility's policy.
The facility did not complete the MDS entry tracking for a resident as required by RAI guidelines. The resident's MDS list showed a discharge with a return anticipated, but no entry tracking record was completed. The clinical reimbursement specialist confirmed the resident went to the hospital and needed an entry, indicating non-compliance with RAI guidelines.
A resident with a history of seizures and traumatic brain injury was incorrectly documented as having died in the facility, despite being transferred to the hospital where they later expired. The DON confirmed the assessment was inaccurately coded, and the staff member responsible was no longer employed at the facility.
A resident with a UTI and cognitive impairment did not receive proper incontinent care, as a CNA failed to fully clean the resident's peri area before applying a new brief. Despite multiple attempts, the CNA left a brown substance on the resident's skin and brief, contrary to facility policy requiring thorough cleaning. The DON and LPN confirmed the expectation for staff to ensure residents are clean before placing a new brief.
A resident with chronic obstructive pulmonary disease received incorrect oxygen therapy at 3 liters per minute instead of the prescribed 2 liters per minute. The oxygen concentrator had significant dust buildup, and the filter was missing. The DON identified 24 residents receiving oxygen therapy, and RN #1 confirmed the incorrect dosage, adjusting it accordingly. Maintenance personnel were responsible for the concentrator filters, but cleaning frequency was uncertain.
The facility failed to remove expired medications from stock, as observed during a medication storage inspection. An expired magnesium chloride with calcium bottle was found, and staff interviews revealed inconsistent adherence to medication rotation processes. The DON confirmed that medications were supposed to be rotated to prevent expiration, indicating a lapse in medication management practices.
The facility failed to maintain the walk-in freezer in safe operating condition, affecting services for 106 residents. Significant ice buildup prevented the freezer door from sealing properly, with light visible from inside when closed. The CDM noted the issue had persisted for at least a year, with intermittent maintenance attempts. The DON could not locate a maintenance policy for the kitchen equipment.
The facility failed to complete discharge summaries for several residents, as required by their policy. The DON confirmed that the summaries were not completed, impacting residents discharged to other facilities, hospitals, and home with home health services.
The facility failed to provide adequate staffing, resulting in a resident not receiving timely incontinence care. Multiple staff members confirmed insufficient staffing, and the DON acknowledged the issue.
The facility failed to follow physician orders to provide diabetic residents with bedtime snacks and ensure snacks were served in accordance with residents' needs and preferences. Four residents reported rarely or never receiving their prescribed snacks, with one resident observing staff eating the residents' snacks. Resident council meeting forms also documented ongoing complaints about the lack of snacks provided.
The facility failed to ensure that residents' call lights were within reach for five residents, despite their varying levels of cognitive impairment and assistance needs. Observations showed call lights were often placed out of reach, and residents confirmed they could not access them until assisted by a CNA. Both RN and CNA staff acknowledged that call lights should be within reach, but this was not consistently ensured.
The facility failed to obtain signatures from the responsible party on the admissions agreements for a resident admitted with multiple diagnoses. The responsible party confirmed they were never asked to sign any admission paperwork, and the admission coordinator admitted that no signed consent to treat was available.
The facility failed to post nurse staffing information in a prominent area on halls 200, 300, 400, and 500 over several days. The DON confirmed that the information should have been posted daily. The facility had 114 residents at the time.
Failure to Adhere to Bathing Schedule for Resident
Penalty
Summary
The facility failed to ensure that a resident was bathed as scheduled, which was identified during a survey. The resident, who was admitted with quadriplegia, multiple sclerosis, and muscle wasting, was dependent on staff for bathing and mobility. The resident's care plan indicated a preference for morning baths twice a week, on Wednesdays and Saturdays. However, documentation showed that the resident was bathed only once in January 2025, and there was no documentation for February 2025. The resident expressed frustration over missed showers and stated that staff did not offer to reschedule missed baths. Interviews with staff revealed inconsistencies in documenting completed or refused showers. A CNA acknowledged that all showers should be documented, and refusals should be recorded, but noted that the resident often refused baths. An LPN confirmed that refusals were not always documented as required. The DON admitted the absence of documentation for the resident's scheduled baths in January and February 2025, indicating a failure to adhere to the facility's bathing policy.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate incontinent care and adhere to physician orders, leading to the development and worsening of pressure ulcers in two residents. Resident #5, who was admitted with diagnoses including muscle wasting and major depressive disorder, was found to be soaking wet and developed a Stage II pressure ulcer on the sacrum due to moisture-associated skin damage. Despite a physician's order for hydrocolloid treatment three times weekly, the resident's condition was not adequately managed, resulting in a pressure wound. The Director of Nursing (DON) acknowledged that the resident should have been checked every two hours, and a Certified Nursing Assistant (CNA) was terminated as a result of this oversight. Resident #6, diagnosed with dementia and anxiety disorder, was observed multiple times with heels resting directly on the mattress, contrary to a physician's order to float the heels while in bed. This order, dated several months prior, was not followed, as the Licensed Practical Nurse (LPN) was unaware of it. The DON confirmed that physician orders should always be followed, indicating a lapse in communication and adherence to care protocols within the facility.
Failure to Follow Prescribed Diet Leads to Choking Incident
Penalty
Summary
The facility failed to adhere to the prescribed minced and moist level 5 diet for a resident, which resulted in a choking incident. The resident, who had a physician's order for a minced and moist diet due to dysphagia and other medical conditions, was given a brownie that was not suitable for their dietary needs. This incident occurred while the resident was eating lunch in their room, and a medication aide noticed the resident choking, prompting a nurse to perform the Heimlich maneuver to expel the brownie. The incident report revealed that the dietary manager was notified, and it was determined that a new cook on the line had overlooked the resident's dietary restrictions. The dietary staff, including cooks and aides, were subsequently in-serviced on the importance of following diet sheets and ensuring residents receive the correct diet. The resident's care plan and plan of care were updated following the incident. Interviews with staff indicated a lack of awareness and verification of the resident's dietary needs at the time of the incident. The Assistant Director of Nursing (ADON) and other staff members acknowledged the oversight and emphasized the need for staff to check diet cards and ensure the correct diet is provided. The Director of Nursing (DON) also noted that speech therapy had not evaluated the resident, and there was reliance on hospital discharge reports for diet orders, which may have contributed to the oversight.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, leading to multiple deficiencies in the kitchen. Observations revealed that raw meat items were not stored in a manner to prevent cross-contamination, as different types of meat were placed together on a tray, and some pieces were hanging over the edges. Additionally, dented cans were found in the dry storage area, with some dents located in the seams, which could compromise the integrity of the cans. Expired food items, such as a container of salad dressing past its best-by date, were not removed from circulation, and leftover food items were not discarded within the appropriate timeframe, as evidenced by tartar sauce that should have been thrown away but was still present. Further issues included improper labeling and sealing of food items in the refrigerator, with grated Parmesan cheese left open to air and unlabeled cups of a dark material in the walk-in cooler. The facility's staff, including the CDM, acknowledged these lapses, noting that some staff members could not write English, which contributed to the labeling issues. The facility's policies on food storage, use of leftovers, and general food preparation were not consistently followed, as evidenced by the lack of proper dating and labeling of food items, and the failure to use a First In, First Out system effectively.
Infection Control and PPE Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide proper infection prevention and control measures during incontinent care and handling of linens for two residents. One resident was observed with a CNA whose hair fell into the brief and touched the resident during care. The CNA did not change gloves after handling soiled items and before touching clean items, such as the resident's pillow and quilt. Another resident was cared for by a CNA who did not change gloves or sanitize hands when transitioning from dirty to clean tasks, resulting in potential cross-contamination. Soiled linens were improperly handled, being placed on the floor instead of being bagged immediately. In the case of COVID-19 positive residents, the facility failed to ensure proper PPE usage. A CMA entered a COVID-19 positive resident's room without the required gown, gloves, face shield, or N95 mask, only wearing a standard face mask. Another CNA was observed wearing inadequate PPE while caring for two COVID-19 positive residents in the same room, failing to change PPE between residents. This CNA also did not wear a face shield or N95 mask, contrary to the facility's COVID-19 policy. Additionally, a nurse was observed handling medication with bare hands, contrary to the facility's medication administration policy, which requires gloves to be worn. The nurse admitted to not following the policy, acknowledging that gloves are a safety precaution meant to be used for all medication handling. These deficiencies highlight lapses in adherence to established infection control protocols, potentially compromising resident safety.
Failure to Complete MDS Entry Tracking per RAI Guidelines
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) entry tracking was completed according to the Resident Assessment Instrument (RAI) guidelines for a resident who was reviewed for assessments. The facility's Resident Assessment policy, revised in January 2020, mandates that assessment data be entered into a computerized format and transmitted to the Centers for Medicare & Medicaid Services (CMS) in a specified format. However, for one resident, the MDS list documented a discharge with a return anticipated, but there was no entry tracking record completed. On December 31, 2024, the clinical reimbursement specialist confirmed that the resident had gone to the hospital and required an entry, indicating that the RAI guidelines were not followed.
Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to ensure accurate coding of resident assessments, specifically for a resident with a history of seizures and traumatic brain injury. The deficiency was identified when a resident coded and was transferred to the hospital, where they eventually expired. However, the resident assessment inaccurately documented that the resident had died in the facility. This discrepancy was noted during a review of the resident's records, which included a nurse note and a transfer form indicating the resident was transferred to the hospital after emergency personnel restored their pulse. The Director of Nursing (DON) acknowledged the error, stating that the assessment was incorrectly coded as the resident did not die at the facility. The DON also mentioned that the staff member responsible for the incorrect assessment no longer worked at the facility. The facility's Resident Assessment policy requires each individual completing a portion of the assessment to certify its accuracy, which was not adhered to in this case, leading to the inaccurate documentation of the resident's status.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide proper incontinent care for a resident, leading to a deficiency in preventing urinary tract infections (UTIs). The resident, who had a diagnosis of UTI and moderate cognitive impairment, required substantial assistance for toilet hygiene and was always incontinent of bowel and bladder. During an observation, a CNA was seen providing peri care to the resident but failed to completely clean the resident's peri area, leaving a brown substance on the resident's skin and the new brief. Despite multiple attempts to clean the resident, the CNA did not ensure the resident was fully clean before placing a new brief. The facility's policy required staff to perform perineal care with each bath and after each incontinent episode, using a different wipe for each stroke and ensuring all urine and feces were removed before placing a clean brief. However, the CNA did not adhere to these guidelines, as evidenced by the incomplete cleaning observed. The DON and LPN confirmed that staff were expected to visually ensure residents were clean before applying a new brief, and acknowledged that there had been instances where staff needed reminders to complete incontinent care properly.
Oxygen Therapy Administration and Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered and that the oxygen concentrator was properly maintained for a resident with chronic obstructive pulmonary disease. The resident had a physician's order for oxygen at 2 liters per minute via nasal cannula, which could be removed for activities of daily living. However, observations revealed that the resident was receiving oxygen at 3 liters per minute, contrary to the physician's order. Additionally, the oxygen concentrator had significant dust buildup, and the filter was missing from the vent. The Director of Nursing (DON) identified 24 residents receiving oxygen therapy in the facility. During an interview, RN #1 confirmed that the resident was not receiving the correct oxygen dosage and adjusted it to the prescribed 2 liters per minute. The maintenance personnel were responsible for the concentrator filters, but there was uncertainty about the frequency of cleaning, which was suggested to be quarterly. The maintenance director and regional maintenance director confirmed the dust buildup and missing filter upon inspection of the concentrator.
Failure to Remove Expired Medications from Stock
Penalty
Summary
The facility failed to ensure that outdated medications were removed from stock, as observed during a medication storage inspection. A bottle of magnesium chloride with calcium was found to be expired, with a best by date that had already passed. The Assistant Director of Nursing (ADON) confirmed that all 111 residents in the facility were administered medications by the nursing staff. During the inspection, it was noted that the facility's medication storage policy required outdated, contaminated, discontinued, or deteriorated medications to be immediately removed from stock. However, this policy was not adhered to, as evidenced by the expired medication found. Interviews with the staff revealed a lack of consistent adherence to the medication rotation process. ACMA #2 acknowledged that someone was supposed to check expiration dates and rotate stock, but the expired medication was still present. CMA #3 expressed surprise at the expired medication, stating that they had last checked the medications on a previous date and had attempted to rotate stock by placing new medications at the back. However, they admitted that the expired magnesium might have been overlooked if it had fallen behind or under the cart. Additionally, a vitamin E bottle was found improperly rotated, with an older expiration date placed behind a newer one. The Director of Nursing (DON) confirmed that medications were supposed to be rotated to prevent expiration, indicating a lapse in the facility's medication management practices.
Walk-in Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to ensure the walk-in freezer was in safe operating condition, affecting the services provided to 106 residents. During an observation, the walk-in cooler's internal temperature was noted to be 34.7 degrees. The entrance to the walk-in freezer, located inside the cooler, exhibited significant ice buildup on the doorway, preventing the door from sealing properly. Light was visible from inside the freezer with the door closed, and icicles of varying sizes were observed on the shelving inside the freezer. A large clump of ice was found on the middle shelf, and ice covered the floor at the entrance. The Certified Dietary Manager (CDM) mentioned that the freezer door was supposed to have a heater, but due to its age, it had been malfunctioning for at least a year. The CDM stated that maintenance personnel had been addressing the issue intermittently by using a hammer to remove ice so the door could close properly. The last maintenance work on the freezer was reported to have occurred the previous month. The Director of Nursing (DON) was unable to locate a maintenance policy for the kitchen equipment.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure a discharge summary was completed for five residents reviewed for discharge summaries. The facility's policy, revised on 01/12/202, mandates that a recapitulation summary should be completed within 20 days of the date of discharge to ensure necessary information is communicated to the resident and the receiving health care provider. However, for residents #41, 44, 99, and #115, there was no documentation that a discharge summary had been completed. The Director of Nursing (DON) confirmed that if the discharge summary is blank in the Electronic Health Record (EHR), it indicates that a discharge summary was not completed. The MDS coordinator was identified as the person responsible for completing the discharge summaries. Resident #41, admitted with multiple diagnoses including diabetes mellitus and chronic pain, was discharged to another facility without a completed discharge summary. Resident #44, with diagnoses such as UTI and atrial fibrillation, was discharged to the hospital without a discharge summary. Resident #99, with chronic pain syndrome and diabetes, was discharged to home with home health services, and Resident #115, with CVA and diabetes, was also discharged to home with home health services, both without completed discharge summaries. The lack of discharge summaries for these residents indicates a failure to adhere to the facility's policy and ensure proper communication of necessary information at the time of discharge.
Inadequate Staffing Leads to Neglect of Resident Care
Penalty
Summary
The facility failed to provide adequate staffing on a 24-hour basis to meet the needs of its residents, as evidenced by the case of one resident who required substantial assistance with most activities of daily living (ADLs) and was always incontinent of bowel and bladder. The resident reported that no one had changed their brief since 9:00 p.m. the previous night, and when they turned on their call light, CNAs would turn it off and say they would return but often did not. The resident had to call the Director of Nursing (DON) at home to receive care. Daily staffing sheets from 01/26/24 to 02/13/24 documented that 27 of 57 shifts did not meet the staffing ratio requirements for the facility census. Multiple CNAs confirmed that they had not checked on the resident that day, despite the facility's policy requiring checks every one to two hours. Additionally, both an RN and an LPN reported that they did not always have adequate staff on the 11 p.m. to 7 a.m. shift, and a CNA reported insufficient staffing on the 7 a.m. to 3 p.m. shift. The DON acknowledged the issue of insufficient staffing and stated that it was the staffing coordinator's responsibility to ensure adequate staffing to meet residents' needs.
Failure to Provide Prescribed Bedtime Snacks to Diabetic Residents
Penalty
Summary
The facility failed to follow physician orders to provide diabetic residents with a bedtime (HS) snack and ensure snacks were served to all residents at times in accordance with their needs, preferences, and requests. This deficiency was observed in four residents diagnosed with diabetes mellitus. Resident #18, #26, #32, and #38 all reported that they rarely or never received their prescribed bedtime snacks. Resident #26 additionally reported having to go into the hall to ask for a snack, often finding none left, and observed staff eating the residents' snacks. The facility's policy, dated 08/01/2018, required that snacks and supplements be prepared and available to residents three times daily, including a variety of foods for HS snacks, but this was not adhered to in practice. The deficiency was further corroborated by resident council meeting forms from August, September, and December 2023, which documented complaints about the lack of snacks being provided, particularly to diabetic residents. The Dietary Manager (DM) confirmed that snacks were prepared at 10 a.m., 2 p.m., and around 7 p.m., but did not specify any particular provisions for diabetic residents beyond offering fruit, sandwiches, and cake without icing. The Director of Nursing (DON) was unaware that residents were not being offered bedtime snacks until informed during the survey.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach for five sampled residents. Resident #3, who had severe cognitive impairment and required substantial assistance with most ADLs, was observed multiple times with their call light hanging from the wall at the end of their bed, out of reach. Similarly, Resident #5, with moderate cognitive impairment and requiring substantial assistance with ADLs, was also observed with their call light hanging from the wall between the wall and the end of their bed, making it inaccessible. Both residents confirmed they could not reach their call lights until a CNA handed them the device, after which they demonstrated how to use it. Resident #21, with severe cognitive impairment and limited assistance needs for ADLs, was observed multiple times with their call light hanging from the wall at the end of their bed, out of reach. The resident confirmed they could not reach their call light and demonstrated its use once it was handed to them. Resident #50, with intact cognition and moderate assistance needs for ADLs, was observed with their call light hanging from the wall and later underneath the bed, making it inaccessible. The resident confirmed they could not reach their call light until it was handed to them by a CNA. Resident #64, with moderate cognitive impairment and requiring moderate assistance with ADLs, was observed with their call light in the top drawer of their bedside table, which was closed on the call light, making it inaccessible. The resident confirmed they could not reach their call light until it was handed to them by a CNA. Both the RN and CNA interviewed stated that call lights should be within residents' reach, but observations showed this was not consistently ensured. The DON was made aware of these findings and acknowledged that call lights should be within residents' reach at all times.
Failure to Obtain Signatures on Admission Agreements
Penalty
Summary
The facility failed to obtain signatures from the responsible party on the admissions agreements for a resident. The resident was admitted with diagnoses including atrial fibrillation, UTI, hyponatremia, CVA, and bulimia. The facility's admission packet included various forms such as patient information, consent forms, and the resident admission agreement. However, the responsible party for the resident stated during a phone interview that they were never asked to sign any admission paperwork at the time of admission or afterward. No admission paperwork was found in the clinical record for this resident. The admission coordinator confirmed that their procedure involved conducting admission paperwork either in the facility or by emailing the packet to the resident's responsible party. When asked specifically about the signed consent to treat for the resident, the admission coordinator admitted that they did not have it. This failure to obtain the necessary signatures on the admission agreements was identified during the survey, highlighting a deficiency in the facility's admission process.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. This deficiency was observed on halls 200, 300, 400, and 500 from 02/13/23 through 02/16/23. The Director of Nursing (DON) confirmed that the nurse staffing information should have been posted in a prominent area daily. The facility had 114 residents at the time of the survey.
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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