Memory Care Center At Emerald
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremore, Oklahoma.
- Location
- 2700 North Hickory Street, Claremore, Oklahoma 74017
- CMS Provider Number
- 375553
- Inspections on file
- 24
- Latest survey
- May 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Memory Care Center At Emerald during CMS and state inspections, most recent first.
A resident reported to an LPN that they were involved in a romantic relationship with a CNA, that an unidentified LPN had sexually assaulted a resident, and that a CNA was living at the resident's home and receiving monthly payments. The LPN documented informing the ADON and administrator, but the administrator did not report the allegations, and the DON was unaware of them and did not investigate or report to state authorities.
A resident with severe cognitive impairment made multiple allegations of sexual abuse and misappropriation involving staff, which were documented in progress notes and reported to supervisory staff. However, the DON and administrator either did not review the notes or failed to initiate an investigation, and the alleged staff member continued working without suspension. The facility did not follow its policy to immediately investigate and protect residents from alleged perpetrators.
A resident with severe dementia was found unresponsive on a courtyard patio, suffering from heat exhaustion due to inadequate supervision. Staff interviews revealed that the courtyard doors were improperly propped open, allowing the resident unsupervised access, and the resident was not appropriately monitored.
The facility failed to maintain proper food service sanitation and storage requirements. Observations included a cook without a beard guard, multiple food items without date labels, and various areas with visible debris and dirt. Additionally, the dishwasher and three-compartment sink did not reach required temperatures for proper sanitization, and black mold was identified around the sink area.
The facility failed to ensure that the code status was correctly completed and that two residents were offered the choice to formulate advanced directives. One resident's POA incorrectly initialed both full code and DNR, and another resident had no advanced directive on file.
The facility failed to ensure wheelchairs were clean and maintained in good repair for two residents. Observations revealed torn armrests with yellow padding showing and dirty wheelchairs. The ADON confirmed the need for cleaning and repair, noting that torn armrests could not be properly disinfected.
The facility failed to implement its abuse policy by not reporting or investigating allegations of abuse and neglect for three residents and did not provide abuse training upon hire for seven employees.
The facility failed to develop care plans for a resident receiving oxygen therapy and another with a hand contracture. The care plans lacked documentation and interventions for both conditions, as confirmed by staff and observations.
The facility failed to provide sufficient staff for resident care. One resident with neurocognitive disorder was left without incontinent care for hours due to no CNAs being assigned to their hall. Another resident with dementia was not properly supervised during meals, leading to inadequate food intake. Additionally, the facility was without a licensed nurse for 3.5 hours, leaving residents without adequate supervision.
The facility failed to ensure that an LPN and three CNAs received required competency and skills checks, as revealed by a review of employee files and confirmed by the ADON. This lapse is contrary to the facility's policy, which mandates that staff must have the appropriate competencies to ensure resident safety and well-being.
The facility failed to ensure RN coverage for at least 8 consecutive hours daily, seven days a week, and did not have a full-time DON. Time punch records and interviews revealed inconsistent RN presence and a vacant DON position for two weeks, leading to the deficiency.
The facility failed to follow the planned lunch menu, resulting in five residents not receiving buttered egg noodles and one resident not getting their requested meal. Additionally, the dessert was not prepared on time.
A resident with acute respiratory failure and hypoxia had their oxygen tubing improperly stored, leading to cross-contamination risks. The tubing was found lying on the floor and hanging from the regulator, both discolored and dirty. The humidifier bottle was also out of water and stained. The ADON confirmed these deficiencies.
The facility failed to ensure that emergency call cords in the bathrooms were long enough to be reached by residents if they were lying on the floor in the shower. This deficiency was observed in two residents who were able to independently shower, posing a potential risk to their safety.
The facility failed to ensure a resident with dementia was treated with dignity during dining. A nurse left the resident with food on their plate to assist another resident, and the resident indicated they were still hungry. Another CNA resumed feeding the resident after being informed.
A facility failed to investigate a resident's alleged abuse and subsequent STI diagnosis. Despite the resident's cognitive impairment and statements suggesting possible sexual assault, no investigation was initiated. The facility did not comply with its own policy or regulatory requirements.
The facility failed to ensure accurate MDS assessments for a resident with limited range of motion. The resident's annual assessment documented no impairment, but observations and interviews confirmed the resident's hand was contracted. The ADON acknowledged the assessment was filled out incorrectly.
The facility failed to include a care plan regarding isolation for a resident admitted with dementia, brain degeneration, and anxiety disorder. Despite an infection note ordering isolation precautions, the care plan did not document these precautions. The MDS coordinator confirmed the omission.
The facility failed to complete and document neurological checks after a resident with severe cognitive impairment experienced two falls with head injuries. Despite initiating neuro monitoring, the facility was unable to locate the neuro sheets for both incidents.
A resident with acute respiratory failure was found using undated and outdated oxygen tubing, and a discolored nasal cannula. The humidifier bottle was also out of water and stained. The ADON and RN confirmed that the equipment should be changed weekly and dated, but this was not done, compromising the resident's respiratory care.
The facility failed to ensure antipsychotic medications were ordered with an appropriate diagnosis for a resident. The resident was prescribed aripiprazole for unspecified dementia, which the ADON confirmed was not an appropriate diagnosis for this medication.
The facility failed to explain the arbitration agreement in a manner that a resident's family member could understand, leading to the family member unknowingly waiving their right to litigation in court. The Social Services Director did not provide sufficient information about the agreement, including the 30-day rescission period.
Failure to Report and Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and misappropriation of property to the Oklahoma State Department of Health as required by both facility policy and state law. According to a progress note, a resident reported to an LPN that they were involved in a romantic relationship with a CNA, that an unidentified LPN had sexually assaulted a resident on two occasions, and that an unidentified CNA was living at the resident's home and receiving monthly payments from the resident. The LPN documented that these allegations were communicated to the Assistant Director of Nursing (ADON) and the administrator. Upon interview, the administrator confirmed awareness of the allegations but stated they had not reported the incident or participated in the investigation, as those responsibilities were assigned to the Director of Nursing (DON). However, the DON stated she had not seen the progress note or been informed of the allegations prior to being shown the note by the surveyor, and therefore had not reported the allegations to the state or initiated an investigation. This sequence of events resulted in the facility's failure to report and investigate serious allegations as required.
Failure to Investigate and Respond to Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and misappropriation involving a resident with severe cognitive impairment, as indicated by a BIMS score of 03. Progress notes documented that the resident reported having a romantic relationship with a CNA, alleged sexual assault by an unidentified LPN, and claimed a CNA was living at their home and receiving monthly payments. These allegations were communicated to the ADON and administrator, but there was no evidence of an immediate or comprehensive investigation. Additionally, another progress note documented an allegation of stolen credit cards, but this was not reported to administration or investigated. Interviews revealed that the DON and administrator were either unaware of or did not act upon the documented allegations. The DON stated they had not seen the relevant progress notes or conducted any investigation, and the administrator indicated they had delegated the responsibility but did not follow up. The alleged perpetrator, CNA, was not suspended and continued working scheduled shifts. Staff interviews confirmed that allegations were either not communicated to the appropriate personnel or not acted upon, resulting in a lack of protective measures for the resident and failure to follow facility policy requiring immediate investigation of abuse, neglect, or exploitation.
Resident Neglect Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by an incident involving a resident with severe unspecified dementia and anxiety. The resident was found unresponsive on a concrete patio in the courtyard, having suffered from heat exhaustion and volume depletion. The resident was discovered by a CMA and was unresponsive to a sternal rub, prompting staff to call 911. The hospital discharge paperwork confirmed the diagnoses related to the incident. Interviews with various staff members, including CNAs, LPNs, and the ADON, revealed that the courtyard doors should have been locked, and residents should not have been outside without supervision. It was noted that the door between the courtyard and the 600-hall was propped open with a chair, allowing the resident to access the area unsupervised. The ADON admitted that the resident was not being adequately supervised, and the Administrator confirmed the lack of appropriate supervision at the time of the incident.
Failure to Maintain Proper Food Service Sanitation and Storage
Penalty
Summary
The facility failed to ensure proper food service sanitation, cleaning, and storage requirements were followed. During a tour of the kitchen, several deficiencies were observed, including a cook not wearing a beard guard, multiple food items without date labels, and various areas with visible debris and dirt. Specifically, opened bags of cheese, boiled eggs, butter, milk, liquid eggs, bacon, and ranch dressing were found without date labels. Additionally, a red/pink drinking cup was found on a bottom shelf next to plastic ware, and multiple shelves and toasters were covered with black, brown, and white debris. The cook admitted to not being sure about the hair net policy and acknowledged the lack of cleanliness and proper labeling in the kitchen. The kitchen was reportedly swept and mopped every night, and shelves were cleaned every Wednesday, but these measures were insufficient to maintain proper sanitation standards. Further observations revealed black substance splattered on the wall around the sink area, which was identified as black mold by a dietary aide. The low-temperature dishwasher never reached above 100 degrees, and the three-compartment sink sanitizer compartment never reached above 10 ppm. Despite these issues, the dishwasher continued to be used, and the three-compartment sink was set up for usage after lunch. The hot water from the faucet was only 88 degrees when the dishwasher was running, and the sanitization level remained too low at 10 ppm. The blender used for preparing mechanical soft and puree food was washed in the dishwasher that had not reached the required temperature. The maintenance supervisor was observed in the kitchen dishwasher area during the follow-up observation.
Failure to Ensure Correct Code Status and Offer Advanced Directives
Penalty
Summary
The facility failed to ensure that the resident's representative completed the resident's code status correctly and offered the choice to formulate an advanced directive for two residents. For Resident #6, the Power of Attorney (POA) incorrectly initialed both full code and Do Not Resuscitate (DNR) on the code status document. Additionally, there was no documentation that Resident #6 had been offered or declined the opportunity to formulate an advanced directive. The office assistant confirmed that they did not ask any residents with dementia diagnoses if they wanted information to formulate an advanced directive. For Resident #48, who was admitted with diagnoses including Huntington's disease and unspecified dementia, there was no advanced directive on file. The Business Office Manager (BOM) confirmed that Resident #48 had not been offered the choice to formulate advanced directives. This indicates a failure in the facility's admission process to review and incorporate the resident's wishes regarding advanced care planning into their plan of care.
Failure to Maintain Clean and Repaired Wheelchairs
Penalty
Summary
The facility failed to ensure wheelchairs were clean and maintained in good repair for two residents. Resident #1's quarterly assessment documented that they ambulated with a manual wheelchair and walker. On observation, the wheelchair armrests were torn with yellow padding showing, and the wheelchair was dirty. Similarly, Resident #25's significant change assessment documented that they ambulated with a manual wheelchair. On observation, the wheelchair armrests were also torn with yellow padding showing, and the wheelchair was dirty. The ADON confirmed that the CNAs were responsible for notifying the nurse of the need for wheelchair maintenance, and the nurse would then notify maintenance. The ADON acknowledged that the wheelchairs needed cleaning and the armrests required repair, noting that torn armrests could not be properly disinfected or cleaned.
Failure to Implement Abuse Policy and Provide Training
Penalty
Summary
The facility failed to implement its abuse policy in several instances. For Resident #6, who had dementia and late-onset Alzheimer's Disease, a grievance was logged stating that night shift staff tried to smother the resident and pulled their call light out of reach. Despite this being considered an allegation of abuse by the SSD and the administrator, no investigation was conducted, nor was the incident reported to the OSDH. Similarly, for Resident #9, who had frontotemporal neurocognitive disorder and required substantial assistance with daily activities, a grievance was logged indicating neglect due to the absence of a CNA to provide care, resulting in the resident being found with dried urine. This incident was also not reported to the OSDH, and no investigation was conducted despite the SSD and administrator acknowledging it as an allegation of neglect. Additionally, Resident #41, who had Alzheimer's Disease and bipolar disorder, was involved in an incident where another resident pushed them, causing a fall and a minor injury. This incident was documented but not reported to the state. Furthermore, the facility failed to provide abuse training upon hire for seven employees, as their personnel files lacked documentation of such training. The HR department confirmed the absence of abuse training records for these employees.
Failure to Develop Care Plans for Oxygen Therapy and Contracture
Penalty
Summary
The facility failed to develop a care plan for oxygen therapy for one resident who received oxygen therapy and for another resident with limited range of motion and contracture. Resident #6, diagnosed with acute respiratory failure with hypoxia, had physician's orders for continuous oxygen therapy via nasal cannula. However, the care plan did not document the use of oxygen therapy, the frequency of changing the nasal cannula, oxygen safety, or any interventions. Observations confirmed the presence of oxygen equipment in the resident's room, and the MDS coordinator acknowledged the omission in the care plan. Resident #20's care plan did not document the resident's limited range of motion or contracture in the left hand, nor did it include interventions to prevent the contracture from worsening. The resident's family member and a CNA confirmed the contracture, and observations noted the absence of a splint or brace. The ADON also confirmed the lack of documentation and interventions in the care plan for the resident's contracted hand.
Staffing Deficiencies in Resident Care and Supervision
Penalty
Summary
The facility failed to ensure sufficient staff was available to provide necessary care for residents. Resident #9, diagnosed with frontotemporal neurocognitive disorder, required substantial assistance with toileting and was frequently incontinent. On 01/04/24, there were no CNAs assigned to the Burgundy hall during the night shift, resulting in Resident #9 not receiving incontinent care until 5:00 a.m., as documented in a grievance log. The ADON confirmed that the schedule did not reflect a staff member assigned to the Burgundy hall and that the CNA from the Green hall should have assisted but refused to do so. This led to Resident #9 being left in soiled conditions for an extended period. Resident #46, diagnosed with extrapyramidal and movement disorder, anxiety, and dementia, required supervision and cuing during meals. On 05/09/24, during breakfast, staff members were observed assisting other residents, but no one was seated with Resident #46 to ensure they stayed in the dining area and ate their meal. The resident was seen wandering and only ate sporadically. The MDS coordinator and ADON confirmed that staff should have been seated next to Resident #46 to provide the necessary supervision. Additionally, on 05/12/24, the facility was without a licensed nurse for 3.5 hours due to a call-in, leaving residents without adequate supervision and care during that period. A family member of another resident reported that their call light was not answered for over 40 minutes, indicating insufficient staffing levels.
Failure to Conduct Competency and Skills Checks for Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses and certified nurse aides received competency and skills checks, as required by their policy. The review of employee files revealed that four staff members, including one LPN and three CNAs, did not have documented competency or skills checks. Specifically, the LPN was hired in December, and the three CNAs were hired between September and November, yet none had completed the necessary evaluations to confirm their competencies in caring for residents as per the facility's policy. During an interview, the Assistant Director of Nursing (ADON) confirmed the absence of skills check-offs for the identified staff members and acknowledged that annual skills check-offs should be conducted. This deficiency indicates a lapse in the facility's adherence to its own policy, which mandates that staff must have the appropriate competencies and skill sets to ensure resident safety and well-being, as identified through resident assessments and care plans.
Failure to Ensure RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to ensure the services of a registered nurse (RN) were available for at least 8 consecutive hours daily, seven days a week, and did not have a full-time Director of Nursing (DON). The review of time punches from April 1st, 2024 through May 5th, 2024 revealed that RN #1 and RN #2 did not provide consistent daily coverage, with several days lacking any RN presence. Additionally, the previous DON had taken paid time off (PTO) for multiple days, and the position had been vacant for two weeks at the time of the survey. The facility had been without a designated DON for 37 days and lacked RN coverage for 14 days within the specified period. Interviews with the Administrator and Assistant Director of Nursing (ADON) confirmed the absence of a full-time DON and the inconsistent RN coverage. The Administrator acknowledged the vacancy in the DON position and the insufficient RN staffing, stating that they only had one part-time and one PRN RN. The ADON verified the lack of daily RN coverage and the absence of a full-time DON, further confirming the findings from the time punch records. The facility's failure to maintain the required RN coverage and a full-time DON led to the identified deficiency.
Failure to Follow Menus and Meet Nutritional Needs
Penalty
Summary
The facility failed to ensure menus were followed for one meal preparation and service observed. The policy required that menus meet residents' nutritional, religious, cultural, and ethnic needs and be followed. On the observed date, the lunch menu was supposed to include chicken paprikash, buttered egg noodles, squash medley, melon cubes, and a beverage. However, the actual meal served did not include the buttered egg noodles for five residents, as the remaining noodles were stuck to the pan. Additionally, the dessert was not prepared on time, and one resident did not receive their requested meal of sandwich meat and cheese roll-up because Cook #1 stated they did not have time to make it. This resulted in deviations from the planned menu and unmet dietary needs for the residents.
Improper Storage of Oxygen Tubing
Penalty
Summary
The facility failed to ensure proper storage of oxygen tubing to prevent cross-contamination for a resident diagnosed with acute respiratory failure with hypoxia. The resident's monthly physician's orders included continuous oxygen therapy via nasal cannula. On multiple occasions, the resident's oxygen tubing was observed lying on the floor and hanging from the regulator, both of which were discolored and dirty. Additionally, the humidifier bottle attached to the oxygen concentrator was found to be out of water and had visible water stains. The Assistant Director of Nursing (ADON) confirmed that the nasal cannula was dirty and improperly stored, and that the humidifier bottle needed to be changed.
Inaccessible Emergency Call Cords in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that emergency call cords in the bathrooms were long enough to be reached by residents if they were lying on the floor in the shower. This deficiency was observed in two residents who were able to independently shower. For Resident #44, the emergency call cord was located next to the toilet and not within reach of the shower. The Assistant Director of Nursing (ADON) confirmed that Resident #44 would not be able to reach the call light if they fell in the shower. Resident #44 was aware of the purpose of the call cord and had the cognitive ability to use it, but the placement rendered it ineffective in the shower area. Similarly, for Resident #56, the emergency call cord was also located next to the toilet and not within reach of the shower. The Certified Nursing Assistant (CNA) stated that Resident #56 preferred to shower independently without supervision, and the ADON confirmed that staff should stay in the resident's room to provide privacy while the resident showered. However, the placement of the call cord did not allow Resident #56 to reach it in case of an emergency while in the shower. The ADON identified 12 residents in total who had the cognitive ability to utilize the call light, indicating a broader issue with the placement of emergency call cords in the facility. The observations and interviews revealed that the facility did not ensure the emergency call cords were accessible to residents in the shower, posing a potential risk to their safety. The deficiency was identified through direct observation and staff interviews, highlighting a failure in the facility's emergency preparedness for residents who shower independently.
Failure to Ensure Resident Dignity During Dining
Penalty
Summary
The facility failed to ensure a resident was treated with dignity during dining. Resident #20, who had a diagnosis of dementia and was dependent on staff for eating, was observed during a meal where RN #1 left the resident with food on their plate to assist another resident across the room. During this time, another resident encouraged Resident #20 to eat, but no staff were present to assist. When asked if they were hungry, Resident #20 nodded yes, indicating they still wanted to eat. CNA #7, upon being informed of this, resumed feeding Resident #20, who then ate the food provided by the CNA. The ADON acknowledged that staff should not have stopped feeding one resident to assist another across the room. The facility's policy on Activities of Daily Living (ADLs) states that residents who are unable to carry out ADLs will receive the necessary services to maintain good nutrition. The ADON stated that during meal times, the nurse, CMA, CNA, and float CNA should be present to assist residents with eating, indicating a failure to adhere to this policy during the observed meal times.
Failure to Investigate Alleged Abuse and STI
Penalty
Summary
The facility failed to ensure an investigation was initiated for a resident who was suspected of being abused. The resident, who had moderately impaired cognition due to dementia, was found to have a small amount of blood in the rectal-vaginal area. Despite the resident's statement that 'the boys touched me' and the nurse practitioner's concern about possible sexual assault, the facility did not initiate an investigation as required by their Abuse, Neglect, and Exploitation policy. The resident was transported to the hospital, where a small external labial laceration was noted, but no active bleeding was present at the time of examination. Subsequently, the resident tested positive for Chlamydia, a sexually transmitted infection (STI). The nurse practitioner expressed concern that the resident, who was not known to be sexually active, could have been manipulated by someone. Despite this, the facility did not conduct an investigation into the source of the STI. The Assistant Director of Nursing (ADON) and the Administrator both confirmed that no investigation was conducted for the recent STI or the previous incident of bleeding. The Administrator stated that it would be difficult for someone to assault the resident without being noticed, given the hall's layout and staffing. However, they acknowledged that male employees worked at night and could be alone on the hall. Despite these circumstances, the facility did not take steps to test other residents for potential infection or to investigate the source of the STI, thereby failing to comply with their own policy and regulatory requirements.
Inaccurate MDS Assessment for Limited Range of Motion
Penalty
Summary
The facility failed to ensure that MDS assessments were accurate for a resident reviewed for limited range of motion. Specifically, Resident #20's annual assessment documented no impairment in the range of motion for the shoulder, elbow, wrist, or hand. However, observations and interviews revealed that the resident's left hand was contracted. On multiple occasions, the resident's family member, a CNA, and the ADON confirmed the contracture. The ADON reviewed the MDS assessment and acknowledged that it was filled out incorrectly, documenting no impairment in the upper extremities despite the resident's hand being contracted.
Failure to Include Isolation in Care Plan
Penalty
Summary
The facility failed to include a care plan regarding isolation for one of the 19 sampled residents reviewed for care planning. The resident was admitted with diagnoses including unspecified dementia, senile degeneration of the brain, and anxiety disorder. An infection note documented that a nurse practitioner ordered isolation precautions until the completion of antibiotic treatment. However, there was no documentation on the care plan regarding isolation precautions. The MDS coordinator confirmed that isolation was not included in the resident's care plan.
Failure to Complete Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure neurological checks were completed after a fall with head injury for one of the sampled residents. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's Disease and bipolar disorder, experienced two incidents. In the first incident, the resident was pushed by another resident, resulting in a fall and a laceration on the nose. Neuro checks were initiated and found to be within normal limits, but no neuro sheets were located in the resident's chart for this incident. In the second incident, the resident was found lying on the concrete patio with a laceration above the right eye and significant bleeding. Neuro monitoring was initiated, and the resident was sent to the hospital for further evaluation. However, the facility was unable to locate neuro sheets for this incident as well. The Assistant Director of Nursing (ADON) confirmed that neuro checks should have been started for both incidents but were not documented properly.
Failure to Adhere to Oxygen Therapy Protocols
Penalty
Summary
The facility failed to ensure that oxygen tubing was labeled, dated, and changed per facility policy for a resident receiving oxygen therapy. The resident had a diagnosis of acute respiratory failure with hypoxia and required continuous oxygen via nasal cannula. During observations, it was noted that the oxygen tubing connected to the oxygen concentrator was not dated, and the nasal cannula connected to the portable oxygen tank was dated over a month prior. Additionally, the nasal cannula was found to be discolored and the humidifier bottle was out of water and stained. The ADON confirmed that the tubing and humidifier bottle should be changed weekly and dated, and that the humidifier bottle should not run out of water. The nurse responsible for the resident's care was unaware of these requirements and failed to adhere to the facility's policy. The ADON and RN acknowledged the deficiencies upon review of the observations and photographs. The ADON stated that it was the nurse's responsibility to change the tubing and humidifier bottle and ensure they were properly dated and maintained. The failure to follow the facility's policy for oxygen therapy resulted in the resident using outdated and potentially contaminated equipment, which could compromise the resident's respiratory care and overall health.
Inappropriate Antipsychotic Medication Prescription
Penalty
Summary
The facility failed to ensure antipsychotic medications were ordered with an appropriate diagnosis for one of five sampled residents reviewed for unnecessary medications. Resident #5 was admitted with diagnoses including unspecified dementia and general anxiety disorder. A physician's order dated 09/20/22 documented aripiprazole 5 mg daily for unspecified dementia with behavioral disturbance. On 05/14/24, the ADON stated that schizophrenia, bipolar disorder, and depression were appropriate diagnoses for aripiprazole, but dementia was not. This indicates that the medication was prescribed without an appropriate diagnosis, contrary to regulatory requirements for psychotropic medications.
Failure to Adequately Explain Arbitration Agreement
Penalty
Summary
The facility failed to explain the arbitration agreement in a manner that the resident representative could understand. Specifically, a family member of a resident signed a Voluntary Arbitration Agreement without fully understanding its implications. The family member later stated that they did not realize they were giving up their right to litigation in court and were not informed that they could withdraw from the agreement within 30 days. The family member mentioned that the paperwork was presented quickly and under stressful conditions, which contributed to their lack of understanding. Further interviews revealed that the Social Services Director (SSD) did not adequately explain the arbitration agreement to residents or their representatives. The SSD admitted to keeping explanations short and simple, allowing the families to read the paperwork and ask questions but failing to inform them about the 30-day rescission period and the waiver of the right to go to court. The administrator acknowledged that the facility should consider the stress families are under when signing admission paperwork.
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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