Medical Park West Rehabilitation & Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Norman, Oklahoma.
- Location
- 3110 Healthplex Drive, Norman, Oklahoma 73072
- CMS Provider Number
- 375551
- Inspections on file
- 36
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Medical Park West Rehabilitation & Skilled Care during CMS and state inspections, most recent first.
Two residents experienced significant medication errors when a nurse incorrectly transcribed admission orders, resulting in each resident receiving the other’s medications for an extended period. One resident with atrial fibrillation and a moderately impaired BIMS score did not receive ordered Eliquis, Famotidine, Culturelle, and an antibiotic, but instead received antidepressant, antihypertensive, cholesterol, and thyroid medications intended for another resident. The second resident, with hypertension and intact cognition, did not receive prescribed antidepressant, multiple antihypertensives, thyroid, cholesterol, pain, and steroid medications, and instead received Eliquis, Famotidine, and Culturelle. The same nurse entered and reviewed both sets of orders, and the ADON and clinical team did not double-check the drug regimen review. Additionally, BP medication with ordered hold parameters was administered to one resident despite a BP reading below the specified threshold.
A resident with a seizure disorder and multiple comorbidities did not receive several ordered doses of Levetiracetam, resulting in seizure activity and hospitalization for emergency treatment. The DON was unaware of the medication error or the reason for the resident's ER visit at the time.
A resident dependent on dialysis did not have consistent pre- and post-dialysis monitoring documentation as required by facility policy, with only one pre-dialysis report found during a review period when multiple sessions occurred. The DON confirmed that documentation should have been completed for each dialysis session.
A resident with multiple chronic conditions experienced bladder pain and had a urinalysis performed, which was within normal limits. Although the patient and family were informed of the results, there was no documentation that the physician was notified as required by facility policy. The resident was later sent to the ER and diagnosed with a urinary tract infection. The DON confirmed the policy was not followed.
A facility failed to monitor a resident's bowel movements and conduct daily skilled nursing assessments. The resident, with a history of vertebrae fracture and pulmonary fibrosis, had a care plan for elimination issues but lacked documented interventions after three days without a bowel movement. Additionally, daily assessments were not completed on three occasions, contrary to facility expectations.
The facility failed to complete baseline care plans for several residents with significant medical conditions, including congestive heart failure and diabetes mellitus with chronic kidney disease. The absence of these care plans was confirmed through record reviews and an interview with the DON, highlighting a lapse in meeting residents' immediate needs upon admission.
The facility failed to monitor weights and meal intake as ordered for four residents, leading to inconsistent documentation and significant weight loss. A resident with cerebral infarction and underweight was not weighed weekly as ordered, and meal intake was poorly documented. Another resident with a femur fracture also had inconsistent meal intake records. A resident with diabetes and chronic kidney disease was weighed only once a month, and meal intake was sparsely recorded. A resident with cerebral infarction experienced significant weight loss due to inadequate monitoring. Staff interviews revealed a lack of supervision and adherence to facility policies.
The facility failed to label and store medications properly, leading to a mix-up of insulin pens for two residents and unsecured storage of liquid Ativan for a deceased resident. The ADON was unaware of the Ativan's presence due to a lack of narcotic count sheets from a hospice pharmacy, resulting in inadequate medication reconciliation.
The facility did not provide proper beneficiary notifications to two residents who remained in the facility as LTC residents after being discharged from skilled services. Both residents had skilled days remaining but were not given an ABN. The social services director admitted to not providing the ABNs, assuming the MDS coordinator had done so, and the administrator confirmed a lack of training on beneficiary notifications.
A facility failed to complete a quarterly assessment for a resident with hypertension, as required every three months. The last quarterly assessment was in June, followed by an annual assessment in September, with no further assessments documented. The MDS coordinator could not explain the oversight, and the DON confirmed the assessment should have been done.
The facility failed to encode and transmit assessments for two residents. A resident with hypertension was discharged without a completed discharge return not anticipated assessment. Another resident with paraplegia had discharge return anticipated assessments but lacked re-entry assessments upon returning to the facility. The DON and MDS coordinator acknowledged the oversight, noting the previous MDS coordinator's failure to complete required assessments.
A facility failed to complete a discharge summary for a resident with hypertension, who was discharged to home. The discharge summary was missing a recapitulation of the resident's stay, with only dietary and activities sections filled out. The DON acknowledged the incomplete summaries and the responsibility of each department to complete their sections.
A facility failed to consistently assess a resident's dialysis access site after dialysis sessions, as required by policy. The resident, with end-stage renal disease, was scheduled for dialysis three times a week. Despite the policy and physician's orders, documentation showed that post-dialysis assessments were not consistently performed. Interviews with staff revealed that staffing changes contributed to the inconsistency in completing the required assessments.
A facility failed to conduct monthly medication reviews and address pharmacist recommendations for a resident with chronic pain. The consultant pharmacist's recommendation to adjust gabapentin dosage was not addressed for several months, and the December 2024 medication review was missing. The DON acknowledged the oversight in addressing the pharmacist's recommendation.
A resident with diabetes mellitus did not receive scheduled laboratory tests as ordered by their physician. The facility was supposed to conduct a CBC every six months and a hemoglobin A1C every three months, but these tests were not completed as required. The DON indicated that the ADON was responsible for ensuring the completion of these tests, but they were not entered into the lab company's ordering system.
A facility failed to implement Enhanced Barrier Precautions (EBP) during the treatment of a resident's stage 2 pressure ulcer. The wound care nurse did not wear a gown as required by the facility's policy, which mandates EBP for residents with wounds. Misunderstandings about the policy led to inadequate infection control measures.
Transcription Errors and Failure to Follow BP Parameters Lead to Significant Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and administration of admission medication orders for two residents, resulting in significant medication errors. For one resident admitted from the hospital with discharge orders for Eliquis, Famotidine, Culturelle, and Linezolid, the facility’s medication record shows these ordered medications were not administered for multiple days following admission. Instead, this resident received Duloxetine, Amlodipine, Atorvastatin, Levothyroxine, and Valsartan over the same period, which were not part of the hospital discharge medication list for that resident. The resident had diagnoses including atrial fibrillation and wound infection, and an admission assessment documented moderately impaired cognition with a BIMS score of 11. The second resident’s hospital discharge medication list included Duloxetine, Amlodipine with specific blood pressure hold parameters, Atorvastatin, Levothyroxine, Valsartan, Celecoxib, and Prednisone. However, the medication record shows this resident did not receive these ordered medications for an extended period after admission. Instead, the resident received Eliquis, Famotidine, and Culturelle, which were not on this resident’s hospital discharge list but were ordered for the first resident. An admission assessment documented that this resident had diagnoses including hypertension and osteoporosis and had intact cognition with a BIMS score of 13. Record review and interviews revealed that both residents were admitted on the same day and that the same nurse entered the medication orders for both residents and completed the drug regimen review. The facility’s root cause analysis documented that the medications intended for the second resident were entered on the first resident’s orders, and vice versa, and that the ADON and clinical team did not double-check the orders or recheck the drug regimen review. Additionally, the medication administration record for the first resident showed that Amlodipine was not held when the blood pressure reading was 105/69, despite physician-ordered parameters to hold the medication for systolic blood pressure below 110, diastolic below 60, or pulse below 60. Staff interviews confirmed that the orders were switched during entry, that another nurse did not double-check the orders, and that blood pressure medications with hold parameters should be held when readings are below those parameters.
Failure to Administer Anticonvulsant as Ordered Leads to Seizure and Hospitalization
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one of seven sampled residents reviewed for significant medication errors. Specifically, a resident with a history of seizures, chronic kidney disease, dependence on dialysis, hypothyroidism, cardiomegaly, and atherosclerotic heart disease had a physician order for Levetiracetam 500 mg to be given every 12 hours for seizure control. The medication administration record showed that 9 out of 26 morning doses of Levetiracetam were missed over a period of less than a month. As a result of these missed doses, the resident experienced seizure activity and required emergency department intervention, where IV Levetiracetam was administered. Documentation indicated that the resident returned from the hospital after receiving treatment for seizures, and it was noted that future medication administration would be adjusted to occur prior to dialysis. The DON was not aware of the reason for the resident's emergency room visit or the significant medication error at the time of the incident.
Removal Plan
- Regional Nurse Consultant will educate the Director of Nursing on identification of significant medication errors and administration of medication per physician orders.
- Director of Nursing/Designee will educate all licensed nurses and certified medication aides regarding administering medication according to physician orders and identification of significant medication errors.
- Medication aides and Licensed nurses will document medication administration in the eMAR.
- Any licensed nurse or certified medication aide not educated will not be allowed to work until they have received education.
- An audit of current residents missing significant medications for the last 7 days was conducted and completed by nursing management to assure that significant medications are given as ordered by physician.
- Any significant medication errors found during the audit will be reviewed by the Director of Nursing.
- The medical director will be notified of the findings for any further recommendations.
Failure to Complete Required Pre- and Post-Dialysis Monitoring Documentation
Penalty
Summary
The facility failed to ensure that residents receiving dialysis had proper pre- and post-dialysis monitoring as required by policy. Specifically, for one resident with a diagnosis of dependence on dialysis and a physician's order for dialysis three times per week, the medical record review over a nearly one-month period revealed only one pre-dialysis communication report. The facility's policy required completion of pre- and post-dialysis forms for each dialysis session, but this was not consistently done. The Director of Nursing confirmed that the required documentation should have been present for every dialysis day, indicating a lapse in following established procedures for monitoring residents before and after dialysis sessions.
Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to ensure timely physician notification of laboratory results for a resident who complained of bladder pain and pressure. A urinalysis (UA) was ordered and obtained, with results reported as within normal limits (wnl). Although the patient and family were informed of the normal UA results, the medical record did not show documentation that the physician was notified of these results, as required by facility policy. The resident, who had a history of atrial fibrillation, heart failure, and hypertension, was subsequently sent to the emergency room at the insistence of the patient and family, and was later diagnosed with a Pseudomonas urinary tract infection. The Director of Nursing confirmed that the facility policy regarding physician notification was not followed and that there was no documentation of physician notification in the medical record.
Failure to Monitor Bowel Movements and Conduct Daily Assessments
Penalty
Summary
The facility failed to monitor and intervene for the absence of bowel movements and complete daily skilled nursing assessments for a resident receiving skilled services. The resident was admitted with diagnoses including a stable burst fracture of the vertebrae, pulmonary fibrosis, and anxiety. A care plan indicated the resident was at risk for elimination problems, with a goal to maintain or improve elimination status. However, documentation showed the resident had a bowel movement on one day, with no further bowel movements recorded for the remainder of their stay. Despite the facility's practice of implementing interventions if a resident goes three days without a bowel movement, no such intervention was documented. Additionally, the facility did not complete daily skilled nursing assessments for the resident on three separate days. The Director of Nursing (DON) and RN confirmed that skilled assessments should be conducted daily for all skilled residents, yet there was no documentation of these assessments on the specified dates. The DON acknowledged the absence of a written policy for bowel movement monitoring and skilled nursing assessment frequency, but stated that the facility followed best standard practices, which were not adhered to in this case.
Failure to Complete Baseline Care Plans for New Residents
Penalty
Summary
The facility failed to complete baseline care plans for four of the seven sampled residents reviewed for baseline care plans. These residents included individuals with significant medical conditions such as congestive heart failure, non-Alzheimer dementia, hemiplegia, and diabetes mellitus with chronic kidney disease. The absence of baseline care plans was confirmed through record reviews and an interview with the Director of Nursing (DON), who stated that they were unable to locate the necessary documentation for these residents. This deficiency indicates a lapse in the facility's process for meeting the residents' immediate needs within 48 hours of admission.
Failure to Monitor Weights and Meal Intake
Penalty
Summary
The facility failed to ensure that weights were obtained and meal percentages were monitored as ordered by the physician for four residents. Resident #11, diagnosed with cerebral infarction and underweight, had a physician order for weekly weights and nutritional supplements, but weights were recorded monthly, and meal intake was inconsistently documented. Resident #56, with a femur fracture, also had a physician order for weekly weights, but meal intake was not consistently recorded. Resident #60, with diabetes mellitus and chronic kidney disease, had a similar order for weekly weights, but only one weight was recorded each month, and meal intake documentation was sparse. Resident #63, diagnosed with cerebral infarction, was to be weighed weekly for four weeks, but only two weights were recorded, showing a significant weight loss. The facility's policy required changes in diet, weight, and appetite to be reviewed during morning meetings, but this was not adhered to. Interviews with staff revealed that meal intake documentation was inconsistent due to a lack of supervision, and weight loss interventions were only implemented after a significant loss was noted. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the inconsistencies in documentation and monitoring, attributing them to inadequate supervision and failure to follow the facility's policy of weighing residents upon admission or the next day.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications according to accepted standards of practice. During an observation, an LPN discovered that a multi-use insulin pen labeled for one resident was mistakenly placed in a bag labeled for another resident. This error led to the need to order additional insulin for the affected resident. Additionally, the facility's medication storage practices were found to be inadequate, as a refrigerator intended for medication storage was not properly secured with a padlock, and an unlocked metal lock box inside contained 30 syringes of liquid Ativan labeled for a resident who had expired weeks prior. The Assistant Director of Nursing (ADON) acknowledged that they were unaware of the presence of the Ativan in the facility and that there was no narcotic count sheet associated with it. The ADON explained that medications from the primary pharmacy typically came with narcotic count sheets, but the Ativan was from a hospice pharmacy and lacked such documentation. This oversight meant that the medication was not routinely reconciled, and the nurses were unaware of its presence. The ADON also confirmed that all stored medications required proper labeling, highlighting a lapse in the facility's medication management practices.
Failure to Provide Beneficiary Notifications
Penalty
Summary
The facility failed to provide proper beneficiary notifications to two residents who were discharged from skilled services but remained in the facility as long-term care residents. Resident #54 was discharged from skilled services on September 29, 2024, and Resident #66 on August 28, 2024. Both residents had skilled days remaining, yet neither they nor their representatives were provided with an Advance Beneficiary Notice (ABN). The social services director acknowledged that the ABNs were not provided, mistakenly believing that the MDS coordinator had taken care of it. The administrator confirmed that the social services director had not been trained on beneficiary notifications.
Failure to Complete Quarterly Assessment for a Resident
Penalty
Summary
The facility failed to ensure that quarterly assessments were completed for a resident at least once every three months. Specifically, a resident with a diagnosis of hypertension had their last quarterly assessment completed on June 27, 2024, and an annual assessment on September 25, 2024. However, no subsequent quarterly assessment was documented after the annual assessment. On January 30, 2025, the MDS coordinator confirmed that the last assessment was the annual one from September 2024 and was unable to explain why a quarterly assessment was not completed in December 2024. The Director of Nursing acknowledged that a quarterly assessment should have been conducted in December for the resident.
Failure to Complete and Transmit Resident Assessments
Penalty
Summary
The facility failed to ensure timely encoding and transmission of assessments for two residents. Resident #70, diagnosed with hypertension, was discharged from the facility on 10/31/24, but a discharge return not anticipated assessment was not completed. The MDS coordinator was unaware of the reason for this omission. Resident #184, diagnosed with paraplegia, had discharge return anticipated assessments on 12/07/24 and 12/24/24, but no re-entry assessments were completed upon their return to the facility. The DON and MDS coordinator acknowledged that re-entry assessments should have been completed on 12/08/24 and 12/25/24, but the previous MDS coordinator had not been fulfilling this requirement.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a complete discharge summary for a resident who was discharged to home. The resident, who had a diagnosis of hypertension, was discharged on 10/31/24. The Interdisciplinary Discharge Summary form in the electronic clinical record was incomplete, with only the dietary and activities sections filled out, and lacked a recapitulation of the resident's stay. The Director of Nursing (DON) acknowledged that each department was responsible for completing their section of the discharge summary and admitted that the summaries were not being completed to include a recapitulation of the residents' stays.
Failure to Consistently Assess Dialysis Access Site Post-Dialysis
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis was properly assessed after each dialysis session. The facility's policy required that a community nurse complete a post-dialysis assessment and document it on the Dialysis Pre/Post Communication Report forms. However, the treatment records and communication forms for specific dates in December 2024 and January 2025 did not show that the resident's fistula was assessed after dialysis. This lack of documentation indicates that the required post-dialysis assessments were not consistently performed. The resident involved had end-stage renal disease and was scheduled to receive dialysis three times a week. Despite the facility's policy and the physician's order, the resident reported that their dialysis access site was not assessed every time they returned from dialysis. Interviews with facility staff, including an LPN and the DON, revealed that while assessments were supposed to be conducted and documented, staffing changes had led to inconsistencies in completing the dialysis communication forms. The DON acknowledged that the administrative staff monitored documentation weekly, but the post-dialysis assessments had not been consistently completed due to these staffing changes.
Failure to Conduct Monthly Medication Reviews and Address Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that medications were reviewed monthly by the consultant pharmacist and that pharmacy recommendations were addressed by the physician for a resident reviewed for unnecessary medications. The facility's policy required the consultant pharmacist to review the medication regimen and medical chart of each resident at least monthly, with recommendations to be acted upon within 30 calendar days or per facility-specific protocols. However, the clinical record and monthly medication regimen reviews did not show a medication regimen review by the consultant pharmacist for December 2024. A resident with a diagnosis of chronic pain was involved in this deficiency. The consultant pharmacist had made a recommendation on May 31, 2024, regarding the titration of gabapentin for the resident, suggesting a dose reduction. This recommendation was not addressed by the physician until January 29, 2025. The Director of Nursing (DON) stated they could not locate the medication regimen review for December 2024 and acknowledged that the pharmacist's recommendation from May 31, 2024, had not been previously addressed, indicating a lapse in the facility's medication review process.
Failure to Conduct Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were conducted as ordered by the physician for a resident with diabetes mellitus. The physician had ordered a complete blood count (CBC) to be performed every six months in March and September, and a hemoglobin A1C test every three months in March, June, September, and December. However, a review of the clinical records revealed that the CBC was not completed in September, and the hemoglobin A1C tests were not completed in June, September, or December. The Director of Nursing (DON) stated that the Assistant Director of Nursing (ADON) was responsible for ensuring that labs were completed as ordered, but the tests were not conducted because they were not entered into the lab company's ordering system.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain infection control and adhere to Enhanced Barrier Precautions (EBP) during the treatment of a pressure ulcer for one of the residents reviewed for wound care. The facility's policy, revised in April 2024, mandates the use of EBP, which includes donning gowns and gloves during high-contact care activities, especially for residents with wounds or indwelling medical devices. Despite this policy, the wound care nurse did not wear a gown while treating a resident with a stage 2 pressure ulcer, which was identified as requiring EBP according to the facility's policy. During the wound care procedure, the nurse only donned gloves and did not follow the EBP protocol of wearing a gown. The nurse and the Director of Nursing (DON) both misunderstood the policy, believing that EBP precautions were only necessary for more severe wounds or those with drainage or catheters. This misunderstanding led to the failure to implement the required infection control measures for the resident with a stage 2 pressure ulcer, as confirmed by the facility's policy and the statements from the Registered Nurse Consultant (RNC).
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
