Miami Nursing Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Miami, Oklahoma.
- Location
- 1100 East Street Northeast, Miami, Oklahoma 74354
- CMS Provider Number
- 375388
- Inspections on file
- 29
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 14 (2 serious)
Citation history
Health deficiencies cited at Miami Nursing Center, Llc during CMS and state inspections, most recent first.
The facility failed to accurately document and account for controlled medications, including Norco, Ativan, and tramadol, for several residents. For one resident receiving PRN Norco for pain, the narcotic count sheets repeatedly showed more doses signed out than were recorded as administered on the MAR, with no documentation that the extra tablets were destroyed. For another resident with a nightly Ativan order, the narcotic record often showed doses as given while the MAR documented refusals, and there were no destruction notations for the refused tablets; on one occasion the MAR showed a dose given with no corresponding narcotic sign-out. A third resident’s narcotic record showed tramadol doses administered on a day when the MAR showed none given and no destruction documented. CMAs and nursing staff acknowledged that the records were inaccurate and that refused controlled medications were not consistently brought to a nurse for joint destruction and co-signature as required.
A resident with cognitive impairment and behavioral challenges was physically restrained and verbally antagonized by an agency CNA during care, despite objections from other staff. The CNA pinned the resident's arms behind their back, dragged them to a chair, squeezed their wrist, and encouraged the resident to strike staff. The resident expressed pain and distress during the incident, which was witnessed and reported by other CNAs. The DON confirmed the abusive actions and noted missing orientation documentation for the agency CNA.
A resident with severe cognitive impairment, sharing a room with another resident in isolation for COVID-19, was observed without PPE or isolation signage and was allowed to move freely throughout the facility without a mask. Staff did not intervene or enforce infection control protocols, and no PPE supplies or isolation barriers were present in the room.
A resident with a history of behavioral disturbances and multiple medical conditions was required to eat meals alone in a separate room, after being told by the administrator that this was necessary to avoid disturbing others. The resident, who is cognitively intact, expressed feeling isolated and would have preferred to eat in the dining room. Staff interviews confirmed the decision was made due to repeated outbursts, resulting in involuntary seclusion.
A resident with severe cognitive impairment and multiple wounds was not assessed or treated for pain during repeated wound care procedures, despite exhibiting clear signs of distress and verbalizing significant pain. An LPN did not stop or address the pain during care, and staff interviews confirmed ongoing unaddressed pain. The DON was unaware of the lack of pain medication orders for the resident.
Surveyors found that opened beverage containers in the kitchen refrigerator were not labeled with the date they were opened, and the top of the oven and nearby walls were not kept clean as required by facility policy. A dietary aide confirmed the labeling requirement, while the dietary manager was unaware of it. Meals prepared in this kitchen were served to 65 residents.
A facility-wide assessment did not include information about residents with wounds or the training and competency required for staff to care for wounds, despite four residents with wounds being present. The administrator confirmed that these aspects were missing from the assessment.
The facility did not provide or document training and competency assessment for staff on wound care, even though several residents had wounds. The Facility-Wide Assessment omitted wound care training, and the DON could not confirm a process for verifying nurses' competency in wound identification and treatment.
A resident with neurogenic bladder and quadriplegia, who was cognitively intact, was not offered an advance directive as required. The clinical record lacked documentation or acknowledgement of this process, and the DON was unable to provide evidence that the opportunity to develop an advance directive had been offered.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room without prior notification to their representative, as required by facility policy. The move was made to accommodate another resident's request, and documentation of the notification was incomplete. The representative was only informed after the room change had already occurred.
A resident with dementia, anxiety disorder, and PTSD was administered both 1 mg and 0.5 mg doses of Risperdal after a dose reduction order was written but the original higher dose was not discontinued. The resident did not understand why the medication was being given and expressed a desire not to take it. The DON confirmed the unnecessary administration resulted from a failure to discontinue the previous order.
Nurses and nurse aides did not demonstrate competency in pain assessment and management during wound care for a resident. During a wound care procedure, a resident showed clear signs of pain, but the LPN did not stop or address the discomfort, and had not assessed for pain beforehand. There was no documentation of wound care training for staff, and the DON could not confirm a process to ensure nursing competency in wound care.
A resident with a suprapubic catheter did not consistently receive catheter care as ordered, with multiple missed care opportunities and incomplete documentation. The resident, who was cognitively intact, reported that only one nurse routinely provided catheter care, while others did not offer or perform it. An LPN admitted to documenting refusals without always offering care, and the DON confirmed that refusals should not be recorded if care was not offered.
Staff inaccurately documented catheter care for a resident with a suprapubic catheter, recording that care was provided on several occasions when it was not actually performed. Interviews revealed that CNAs documented the care without completing it, with one CNA assuming a nurse had done it. The DON confirmed that documentation should only reflect care actually provided.
A resident with severe cognitive impairment was moved to a different room without written notification being provided to the resident or their representative, as required by facility policy. The DON confirmed that no documentation of written notice was available.
A resident with an indwelling urinary catheter, who was cognitively intact, did not receive a chest x-ray as ordered due to a nurse failing to place the order. The x-ray, originally scheduled for one day, was delayed by two days until the order was completed and the imaging was performed, as confirmed by the DON.
A facility failed to ensure proper hand hygiene during catheter care for a resident with quadriplegia and neuromuscular dysfunction of the bladder. A CNA and an LPN were observed not changing gloves or performing hand hygiene when moving from soiled to clean areas during catheter care. Both staff members acknowledged their oversight, and the DON confirmed the requirement for glove changes during such procedures.
The facility failed to ensure privacy and dignity for residents, with issues such as missing privacy curtains in shared rooms and inadequate privacy measures for cognitively impaired residents. Additionally, meals were served in disposable containers due to insufficient dishware, impacting the residents' dining experience.
A facility improperly charged residents for services covered by Medicare/Medicaid and for administrative supplies. A resident was billed for room and board during periods covered by Medicaid and Medicare, and four residents were charged for checks drawn on the Residents' Trust account. The BOM attributed these errors to corporate instructions, acknowledging that the resident's account should have been credited for overpayments.
The facility failed to conduct timely skin assessments for two residents and did not obtain necessary orders for intravenous care for another resident. One resident with hypertension did not receive skin assessments as required, leading to untreated redness and odor under the breast. Another resident with a history of skin infections had open areas on the legs without dressings. Additionally, a resident with a PICC line returned from the hospital without orders for necessary care, and the dressing was not changed as per protocol.
A facility failed to provide routine catheter care for a resident with quadriplegia and neurogenic bladder. The resident reported inconsistent care, and interviews revealed confusion among staff about who was responsible for catheter care. The DON confirmed that both licensed nurses and CNAs were responsible for catheter care and documentation, but no records were found to support that care was provided.
The facility failed to monitor residents on psychotropic medications for behaviors and side effects, as shown by incomplete and inaccurate behavior flow sheets for three residents. One resident with schizophrenia had inconsistent monitoring for anxiety and agitation, while another with bipolar disorder lacked required AIMS assessments. A third resident's behavior documentation was inaccurate, as the resident regularly exhibited behaviors not reflected in the records. The DON admitted to insufficient monitoring of staff documentation practices.
The facility failed to secure medications properly, with carts left unlocked and unattended, and medications not dated when opened. Additionally, expired medications were found in the medication room. The DON admitted to not monitoring these practices effectively, relying on monthly pharmacist reviews.
The facility did not maintain a surety bond sufficient to cover the residents' personal funds in the facility trust. The bond was set at $90,000, but bank statements from April to June 2024 showed balances exceeding this amount, with a peak of $97,106.92. The administrator was unaware of the high balance, mistakenly believing it to be around $70,000.
Two residents in a facility were found to lack privacy curtains, compromising their visual privacy. One resident, sharing a room with two others, confirmed the absence of a curtain, which was corroborated by a CNA. Another resident, with dysphagia and incontinence, also lacked a curtain, as confirmed by staff. Maintenance noted the curtain track was inadequate, and the DON acknowledged the oversight.
A facility failed to update the care plan for a resident who returned from a hospital stay with a PICC line and an order for intravenous antibiotics. The care plan did not document the intravenous access, and the MDS coordinator admitted that the care plan had not been updated to reflect this change. The DON acknowledged the absence of a system to monitor care plan updates upon readmission or status changes.
A resident with dementia experienced significant weight loss due to the facility's failure to implement nutritional interventions. Despite a care plan requiring weight maintenance and meal consumption, the resident lost 11.65% of their weight over two months. The facility's policy mandated nutritional supplements if meals were less than 50% consumed, but records showed no supplements were offered. The DON acknowledged missing the weight loss and not notifying the physician or dietician.
A facility failed to conduct proper post-dialysis assessments for a resident with end-stage renal failure. The resident reported that while pre-dialysis checks were performed, post-dialysis assessments were not conducted unless requested. The resident had a recent port infection requiring antibiotics. A review of records showed missing documentation for post-dialysis assessments on several dates. Nursing staff confirmed the lack of a specific dialysis protocol, despite acknowledging the need for such assessments.
A resident experienced a significant weight loss of 11.65% over two months, dropping from 132.2 lbs to 116.8 lbs. Despite eating less than 50% of meals on several occasions, there was no documentation of supplemental nutrition being offered. The DON admitted to missing the weight loss and failing to notify the physician or dietician. The physician was informed during a monthly visit and ordered an appetite stimulant.
The facility did not comply with the requirement to post complete staffing information. Observations showed that the staffing schedule at the nurses' station was missing critical details like the resident census and nursing hours. The DON confirmed the presence of 73 residents, and the administrator admitted the omission of necessary information on the posted schedule.
A facility failed to administer clopridogrel as per physician orders for a resident with a history of transient ischemic attack. The resident was supposed to take clopridogrel daily, but the medication was not documented or administered upon admission. The DON was unaware of the oversight until reviewing the clinical record.
The facility failed to maintain a sanitary kitchen environment, with flies observed on food preparation areas and unsanitary conditions in the refrigerator, including undated and improperly stored food items. The ice machine was found to have algae, and the kitchen's open back door allowed flies to enter. Maintenance efforts to address these issues were inadequate.
The facility failed to implement enhanced barrier precautions during catheter and wound care for two residents, as required by their infection control program. One resident received catheter care without staff donning gowns, and another resident with multiple medical devices did not have appropriate signage or supplies for enhanced precautions. Additionally, a resident's urinary catheter dignity bag and tubing were observed dragging on the floor, contrary to facility protocol.
The facility failed to maintain the physical environment in good repair, as evidenced by a leaking roof in the dining area. A wet floor sign and a bucket containing water were observed, indicating the leak. Maintenance staff and the CDM confirmed the issue, and the Maintenance Supervisor noted the last roof repair was in September 2023. This affected the safety and comfort of 73 residents.
The facility failed to implement a comprehensive care plan for a resident with stage three pressure wounds, as required weekly wound care documentation was missing before a specified date. Interviews with staff confirmed the lack of documentation.
The facility failed to provide and document pressure ulcer care as ordered by the physician, complete weekly wound observations, and document refusals in the nursing notes for a resident with quadriplegia and chronic pain syndrome. Interviews with nursing staff and the DON revealed that care was provided but not documented correctly, leading to deficiencies in pressure ulcer care.
Inaccurate Documentation and Handling of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication administration records (MARs) and controlled drug count sheets accurately reflected the disposition of controlled medications for multiple residents. Facility policy required that each dose of medication be properly recorded on the MAR and that when a CMA was unable to administer a medication, the charge nurse be notified immediately. For one resident with an order for Norco 10-325 mg every four hours as needed for pain, comparisons between the February MAR and the individual narcotic record from late January to late February showed repeated discrepancies: on multiple dates, the narcotic record reflected more doses signed out than were documented as administered on the MAR, with no notation that the unaccounted tablets were destroyed. The resident reported they kept their own notes on pain pill use and, when compared to the facility’s narcotic records, found the records were not accurate. A second resident had an order for Ativan 1 mg at bedtime. Review of the February MAR and the corresponding narcotic record showed that on numerous dates the narcotic record indicated a dose was administered, while the MAR documented that the dose was refused. There was no documentation on the narcotic record that the refused tablets were destroyed. On another date, the MAR showed the medication was administered, but no dose was signed out on the narcotic record. An additional undated narcotic entry, located after a late-February entry, showed a dose as administered while the MAR documented a refusal for that same time frame, again without any destruction notation. A third resident had an order for tramadol 50 mg, two tablets every six hours as needed for pain. For this resident, the narcotic record showed two tablets administered on a specific February date, while the MAR showed no tramadol doses given that day and there was no documentation that the tablets were destroyed. During interviews, CMAs and nursing staff acknowledged that the MARs and narcotic records for these residents were inaccurate and showed pills signed out without documentation of administration or destruction. Staff described that refused controlled medications were supposed to be taken to the charge nurse and destroyed together with both parties initialing the count sheet, but one CMA reported they had been destroying refused medications alone without notifying the nurse, contrary to the described procedure. The DON stated that some CMAs had not been following the procedure to alert charge nurses of refused narcotics and to jointly destroy and document them.
Resident Subjected to Physical and Verbal Abuse by Agency CNA
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, non-Alzheimer's dementia, depression, and hoarding disorder was subjected to physical and verbal abuse by a certified nursing assistant (CNA) employed through an agency. The resident, who was known to display verbal and physical behaviors and to reject care, was being assisted by three CNAs to prepare for bed. During the interaction, the resident became combative and grabbed one CNA by the neck. In response, another CNA restrained the resident by pinning their arms behind their back and dragging them to a chair, despite objections from the other staff present. The same CNA also grabbed and squeezed the resident's wrist and verbally antagonized the resident by encouraging them to strike out at staff. Witness statements from the other CNAs present confirmed that the agency CNA repeatedly used physical force to restrain the resident, even after being told to stop by colleagues. The resident was heard yelling for help and expressing pain, and staff noted that the resident's behavior escalated while the agency CNA was present but calmed after the CNA left the room. The incident included both physical restraint and verbal provocation, with the resident being encouraged to hit staff members. The resident initially complained of arm pain but later denied discomfort and refused further assessment. Interviews with the involved CNAs and the Director of Nursing (DON) confirmed that the actions of the agency CNA were considered abusive. The DON stated that the agency CNA had worked at the facility for about a month and that the facility provided orientation materials and abuse prevention training to all staff, including agency personnel. However, the facility was unable to locate the completed orientation packet for the agency CNA involved in the incident.
Failure to Implement Infection Control Measures for COVID-19 Exposure
Penalty
Summary
The facility failed to minimize the risk of spreading infection by not implementing appropriate infection prevention and control measures for a resident exposed to COVID-19. Observation revealed that a resident who shared a room with another resident in isolation for COVID-19 was not provided with or observed using personal protective equipment (PPE) such as masks, gowns, or gloves. There were no isolation signs or PPE supplies at the entrance to the room, and no barriers were present between the two residents. The resident, who was severely cognitively impaired and required supervision for decision-making, was seen leaving the room and walking through common areas without a mask. Staff did not intervene or encourage the resident to wear a mask or return to their room, and staff themselves were not observed wearing isolation masks in the hallway. Record review indicated that the resident had a history of removing isolation signage and PPE supplies from their room, and staff were aware of this behavior. The resident had tested negative for COVID-19 but chose to remain in the room with the COVID-19 positive roommate. Despite being informed of the need to wear a mask when leaving the room, the resident was allowed to move freely throughout the facility without adherence to infection control protocols, and staff did not enforce or support these measures.
Involuntary Seclusion of Resident During Meals Due to Behavioral Issues
Penalty
Summary
A deficiency occurred when a resident was involuntarily secluded from other residents during meal times. The resident, who is cognitively intact with a BIMS score of 15 and has diagnoses including lymphedema, dementia with agitation, depression, epilepsy, type 2 diabetes, and asthma, was observed eating alone at a table facing the wall in the day room, away from other residents. The resident reported being told by the administrator that they had to eat alone in the day room to avoid disturbing others, and expressed feeling like a child being chastised, preferring to eat in the dining room instead. Staff interviews revealed that the resident had a history of outbursts and causing disturbances in the dining room, leading to the decision to move the resident to a separate room for meals. The administrator and nursing staff acknowledged that the resident was disruptive during meal times and stated that the move was intended to find a compromise for all involved. However, the action resulted in the resident being separated from others without their consent, constituting involuntary seclusion.
Removal Plan
- The DON and Care plan coordinator met with resident #1 and advised her that she would be offered 3 locations for her meals: main dining room, smaller dining room, or her room.
- An alert has been added to the EMR for resident #1 that she will be able to choose where she would like to take meals.
- Staff will ask resident #1 prior to each meal where she would like her meal served.
- Care plan will be updated to reflect that resident is able to choose her dining locations.
- Resident #1's dietary card has been updated to reflect that meals may be taken at the location of resident's choice.
- Facility will not ask any other resident to receive meals in the small dining room unless the resident requests to do so.
- The facility has reviewed all current residents and no other residents were identified as being secluded in any manner.
- In the future, the facility will not seclude a resident exhibiting behavior problems that may be detrimental to other residents.
- If resident #1 or any other resident exhibits disruptive behaviors, staff will attempt to de-escalate the situation.
- If a resident is removed from an area, a staff member will remain with them until behaviors have resolved.
- All nursing staff will receive in-service training on the above.
- If any nursing staff is unable to be present in person, they will receive in-service via phone.
Failure to Assess and Manage Pain During Wound Care
Penalty
Summary
The facility failed to assess, monitor, and intervene for pain management during wound care for one resident with multiple medical conditions, including type 2 diabetes, Alzheimer's disease, peripheral vascular disease, and hypertension. The resident, who was severely cognitively impaired, had wound care orders for multiple sites and was observed during a wound care procedure to be in visible pain, grimacing, stiffening, and verbally expressing discomfort. Despite these clear signs of pain, the LPN performing the wound care did not stop the procedure or address the resident's pain, and stated afterward that they had not assessed the resident for pain prior to the procedure and were unaware of any pain medication orders for the resident. Further review revealed that from the start of the wound care order through the date of the incident, there were 35 missed opportunities to assess the resident for pain during wound care. Interviews with CNAs confirmed that the resident regularly exhibited signs of pain during wound care, such as clenching teeth, moaning, tensing up, and verbalizing that the procedure was painful. The resident also reported experiencing significant pain, rating it as an 8 out of 10 during wound care. The DON acknowledged not knowing why pain medication had not been ordered for the resident.
Removal Plan
- A pain assessment was completed on Resident #27.
- Primary care physician for Resident #27 was contacted and a new order for Tramadol, an analgesic, was obtained.
- Staff will offer PRN pain medication prior to wound care.
- Care plan for Resident #27 will be updated accordingly.
- For all other residents a new pain assessment will be completed.
- All employees will be in-serviced on pain management including recognition of pain (verbal and non-verbal signs).
- If employee is unable to come in person for training they will receive training over the phone and then in person training prior to the beginning of their next shift.
Failure to Label Opened Food Containers and Maintain Kitchen Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to ensure that opened containers of beverages, including orange drink, grape juice, prune juice, and thickened lemon water, stored in the reach-in refrigerator were properly labeled with the date they were opened. Additionally, the top of the oven was found to be covered with debris, and the walls above the oven were coated with a sticky brown substance. Facility policies required that opened packaged foods be dated and that the oven and surrounding walls be cleaned weekly. During interviews, a dietary aide confirmed that opened items should be labeled, while the dietary manager, who was new, was unaware of the labeling requirement and acknowledged that the oven and its surrounding area should be thoroughly cleaned. The Director of Nursing identified that 65 residents received meals prepared in the kitchen where these deficiencies were observed.
Facility Assessment Lacked Wound Care and Staff Competency Evaluation
Penalty
Summary
The facility failed to ensure that its facility-wide assessment addressed the needs of residents with wounds and the necessary staff training and competency to care for these residents. Record review showed that four residents with wounds were present in the facility, but the assessment reviewed on 07/30/25 did not include information about these residents or the required wound care training and competency for staff. During an interview, the administrator acknowledged that the assessment did not address wounds or wound training.
Failure to Ensure Staff Training and Competency in Wound Care
Penalty
Summary
The facility failed to provide training and ensure competency for staff regarding wound care. Record review showed that the Facility-Wide Assessment did not address training or competency for wound care, despite the presence of four residents with wounds. Employee records lacked documentation of wound care training and competency. During an interview, the DON was unable to confirm whether there was a specific process to determine nurses' competency in identifying and treating wounds.
Failure to Offer Advance Directive to Cognitively Intact Resident
Penalty
Summary
The facility failed to ensure that an advance directive was offered to a resident who was cognitively intact, as evidenced by a BIMS score of 15 on a quarterly assessment. The resident had diagnoses including neurogenic bladder and quadriplegia. Review of the clinical record revealed there was no documentation or acknowledgement indicating the resident had been offered the opportunity to develop an advance directive. When requested, the Director of Nursing was unable to provide an advance directive acknowledgement for this resident, and none was provided by the end of the survey.
Failure to Notify Representative of Room Change for Cognitively Impaired Resident
Penalty
Summary
The facility failed to notify a resident's representative of a room change, as required by its own policy and procedure for notification of change. On observation, a resident with severe cognitive impairment, as indicated by a BIMS score of 00 and diagnoses including heart failure, hypertension, cerebrovascular accident, and seizure disorder, was found to have been moved to another room. Review of clinical progress notes showed no documentation that the resident's representative was notified prior to the move. The facility's form for room or roommate change was incomplete, lacking a documented reason for the move and containing only a scribble mark for the resident's signature, with the nurse's printed name below it. The Director of Nursing confirmed that the resident was moved over the weekend to accommodate another resident's request due to a roommate issue, and acknowledged that notification should have been made and documented before the move. The resident's representative reported not being informed of the room change until after it had occurred, stating that the facility called them after the move had already taken place and did not seek their input beforehand.
Failure to Discontinue Unnecessary Psychotropic Medication Order
Penalty
Summary
The facility failed to prevent the administration of unnecessary psychotropic medication to a resident who was admitted with diagnoses including dementia, anxiety disorder, and post-traumatic stress disorder. Upon admission, the resident was prescribed Risperdal 1 mg at bedtime for dementia with behavioral disturbance. Subsequently, a new order was written to decrease the Risperdal dose to 0.5 mg at bedtime for 14 days, with an end date specified. However, the original 1 mg order was not discontinued, resulting in the resident receiving both the 1 mg and 0.5 mg doses over a weekend. The resident expressed a lack of understanding regarding the reason for taking Risperdal and indicated a desire not to receive the medication. The DON confirmed that the resident had come from a geriatric psychiatric hospital and that the facility intended to discontinue Risperdal due to an inaccurate diagnosis. The DON acknowledged that the continued administration of Risperdal 1 mg was unnecessary and resulted from a failure to discontinue the previous order when the dose was reduced.
Failure to Assess and Address Pain During Wound Care
Penalty
Summary
Nurses and nurse aides failed to demonstrate appropriate competencies in pain assessment and management during wound care for a resident with wounds. During an observed wound care procedure, the resident exhibited clear signs of pain, including grimacing, body stiffening, and verbal expressions of discomfort, yet the LPN performing the care did not stop the procedure or address the resident's pain. The LPN admitted to not assessing the resident for pain prior to the procedure and was unaware of any pain medication orders for the resident. Review of employee files revealed no documentation of completed wound care training. The Director of Nursing was unable to confirm any specific process in place to ensure nursing staff competency in identifying and treating wounds.
Failure to Provide Ordered Catheter Care and Inaccurate Documentation
Penalty
Summary
The facility failed to provide catheter care as ordered for one resident with a suprapubic catheter. A physician's order required staff to cleanse the area around the catheter and tubing every shift, but review of the treatment administration record showed that catheter care was not completed as ordered, with 20 missed opportunities out of 51 in the first 17 days of May. Documentation indicated that the resident refused care 16 times, but there were also shifts with no documentation of care or refusal. The resident, who was cognitively intact, reported that CNAs never performed catheter care and that only one nurse routinely provided it, while others did not even ask if care was wanted. An LPN stated they documented refusals without always offering care, and the DON confirmed that refusals should not be documented if care was not offered.
Inaccurate Documentation of Catheter Care
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one resident who had a suprapubic catheter. Physician orders required catheter care to be performed every shift, and documentation indicated that two CNAs had recorded providing this care on multiple dates. However, both CNAs later stated in interviews that they did not perform the catheter care as documented, with one CNA admitting to assuming the nurse had completed the care and documenting it as done. The resident involved was cognitively intact and had an indwelling urinary catheter at the time of the deficiency. The Director of Nursing confirmed that staff should not document care that was not performed.
Failure to Provide Written Notice of Room Change
Penalty
Summary
The facility failed to provide written notice of a room change for one resident with severe cognitive impairment, as required by facility policy. The policy states that residents and their legal representatives or interested family members must be notified in writing within 48 hours of a change in room or roommate assignment. Record review showed that the resident was moved to a different room, but there was no documentation in the medical record indicating that the resident or their representative received written notification of this change. During an interview, the DON confirmed that there was no documentation of written notice being given.
Delay in Providing Ordered Chest X-ray
Penalty
Summary
The facility failed to provide timely imaging services as ordered for one resident. A physician's order dated 12/29/24 indicated that the resident was to have a chest x-ray on 12/29/24. However, nurse documentation from 12/29/24 revealed that the resident reported not receiving a chest x-ray that was supposed to be performed on 12/27/24. The administrator confirmed that the x-ray was indeed scheduled for 12/27/24. The resident, who was cognitively intact with a BIMS score of 15 and had an indwelling urinary catheter, stated on 05/20/25 that the chest x-ray was not performed until 12/29/24. The DON confirmed that the x-ray order was not placed by the nurse, resulting in a two-day delay in obtaining the imaging service.
Inadequate Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during catheter care for one of the three residents reviewed. The resident involved had diagnoses including quadriplegia and neuromuscular dysfunction of the bladder. During an observation, a CNA donned gloves, cleansed around the catheter area, and then touched the resident's table and computer keyboard without changing gloves or performing hand hygiene. Similarly, an LPN was observed to cleanse the catheter area, dispose of a soiled dressing, and then apply a clean dressing without changing gloves or performing hand hygiene. Both staff members acknowledged their failure to change gloves and perform hand hygiene when moving from soiled to clean areas. The DON confirmed that gloves should be changed during catheter care when transitioning from dirty to clean tasks.
Privacy and Dignity Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide adequate privacy and dignity for several residents. Resident #55, who had dysphagia, was in a three-bed room without a privacy curtain for the middle bed, leaving them exposed to their roommates during episodes of incontinence. Similarly, Resident #4, diagnosed with PTSD and depression, also lacked a privacy curtain in their three-bed room, leading to a lack of privacy and distress due to roommates frequently yelling. Resident #50, with severe cognitive impairment due to anoxic brain damage, was observed with a sign on their door to keep it open at all times, and their privacy curtain was inadequately pinned, leaving them exposed. Resident #26, who had dementia and frequent falls, also had a sign to keep their door open, which the DON acknowledged could be a dignity issue. Additionally, the facility did not provide enough dishware, resulting in meals being served in disposable containers. Cook #1 noted that some residents received meals in styrofoam containers and used plasticware due to behavioral issues, such as marking up dishware or poking others with cutlery. The dietary manager confirmed the lack of sufficient bowls and the high cost of lids, leading to the use of styrofoam containers for side items. These actions and inactions contributed to the deficiencies observed during the survey.
Improper Billing for Covered Services and Administrative Supplies
Penalty
Summary
The facility failed to ensure that residents were not charged separately for services covered by Medicare or Medicaid. Specifically, Resident #174 was charged for room and board during periods that should have been covered by Medicaid and Medicare. The facility's billing statements and trust transaction history revealed that Resident #174 was charged $2015.00 for a Medicaid pending stay in January 2024, despite Medicaid covering all charges for that month. Additionally, the resident was charged for room and board in March 2024, even though Medicare covered the skilled nursing stay from February 2, 2024, to April 3, 2024. The Business Office Manager (BOM) and Administrator #2 acknowledged the billing errors, which were attributed to instructions from corporate. The BOM stated that the resident's account should have been credited for any overpayments once the actual amounts were determined. However, the billing errors persisted, and the resident was incorrectly charged for services during their skilled nursing stay. The BOM also mentioned that the billing errors were entered at the corporate level, and the facility's accounting of the resident's trust was correct based on the information received. Furthermore, the facility charged four residents, including Resident #174, for administrative supplies, specifically $3.25 for the purchase of checks drawn on the Residents' Trust account. The BOM explained that the cost of ordering checks was divided among all residents with monies in the trust. This practice resulted in residents being charged for administrative supplies, which should not have been billed to them.
Failure to Conduct Skin Assessments and Obtain IV Care Orders
Penalty
Summary
The facility failed to conduct timely skin assessments for two residents and did not obtain necessary orders for intravenous care for another resident. Resident #42, who had a diagnosis of hypertension, was supposed to have weekly skin assessments as per the care plan. However, no skin assessments were conducted between the admission date and a later date when redness with a foul odor was noted under the resident's left breast, leading to a new order for treatment. Similarly, Resident #3, with a history of erysipelas and cellulitis, was observed with superficial open areas on the lower legs without any dressings, despite the care plan requiring weekly skin inspections. The areas were not addressed until a later date when a treatment was finally ordered. Additionally, Resident #8, who had a diagnosis of atrial fibrillation, returned from a hospital stay with a PICC line in place. The facility did not have any orders for PICC line care, such as flushing or dressing changes, upon the resident's readmission. The dressing on the PICC line had not been changed since the resident's return from the hospital, and the facility's protocol for intravenous care was not followed. The DON acknowledged the lack of orders and the failure to perform necessary care for the PICC line.
Failure to Provide and Document Routine Catheter Care
Penalty
Summary
The facility failed to provide routine catheter care for a resident with quadriplegia and neurogenic bladder. The resident reported that only one nurse consistently provided catheter care, and when that nurse was off, they did not receive the care. Interviews with CNAs revealed that they did not provide catheter care, believing it was the responsibility of the nurses. Conversely, LPNs stated that catheter care was assigned to the CNAs. The Director of Nursing (DON) confirmed that catheter care was the responsibility of both licensed nurses and CNAs and should be documented every shift. However, upon reviewing the clinical records, the DON found no documentation of catheter care for the resident, indicating that even if care was provided, it was not recorded.
Inadequate Monitoring of Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor residents receiving psychotropic medications for behaviors and side effects, as evidenced by the incomplete and inaccurate documentation on behavior flow sheets for three residents. Resident #3, diagnosed with schizophrenia, had a care plan requiring monitoring for anxiety, tearfulness, and agitation every shift. However, the behavior flow sheets for May, June, and July 2024 showed that behaviors were monitored inconsistently, with no specific behaviors indicated on the sheets. Similarly, Resident #44, with a diagnosis of bipolar disorder, had a care plan that required AIMS assessments upon admission and quarterly, but no such assessments were found in the clinical record. The behavior flow sheets for this resident also lacked specific behavior indications and were inconsistently completed. Resident #28, also diagnosed with schizophrenia, had behavior flow sheets that were inconsistently filled out, with no specific behaviors indicated. The DON acknowledged that the behavior sheets used a code system to identify behaviors, but was unable to specify what behaviors were monitored for Resident #28. The DON admitted that the behavior monitoring sheets were not accurate, as the resident regularly exhibited behaviors contrary to the documentation. The DON also stated that there was a lack of monitoring to ensure staff were documenting behaviors and side effects properly, including the completion of AIMS assessments.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications across several areas, leading to multiple deficiencies. Observations revealed that medications were not secured on the North hall medication cart, which was left unlocked and unattended on multiple occasions. This was confirmed by CMA #1, who admitted to forgetting to lock the cart. Additionally, medications were found to be opened but not dated on the North hall, North Main, and treatment carts, despite policies requiring such dating. The DON acknowledged that medications should be secured and dated but admitted to not monitoring these practices effectively. Furthermore, the facility did not adequately monitor for expired medications. During an inspection of the medication room, expired medications, including an influenza vaccine and hydrocort, were found. The DON stated that the pharmacist reviewed the medication/treatment carts monthly but did not personally monitor for expired medications. This lack of oversight contributed to the presence of expired medications in the facility, further highlighting the deficiencies in medication management and storage practices.
Facility Fails to Maintain Adequate Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a surety bond in an amount sufficient to cover the residents' personal funds deposited in the facility trust. The business office manager identified that there were 38 residents with funds in the facility trust. The surety bond, dated October 7, 2022, was documented to cover a balance of $90,000. However, the bank statements from April to June 2024 showed that the daily balances exceeded this amount, reaching as high as $97,106.92. On July 19, 2024, the administrator admitted to being unaware of the high balance in the trust, mistakenly believing it to be around $70,000, and acknowledged the need to increase the bond to cover the higher balance.
Lack of Privacy Curtains for Residents
Penalty
Summary
The facility failed to provide adequate privacy curtains to ensure full visual privacy for two residents. Resident #4, who shared a room with two other roommates, did not have a privacy curtain, which was confirmed by both the resident and a CNA. The CNA mentioned that during incontinent care, they would pull the curtains around the two roommates and shut the door, but there was no curtain available to provide full visual privacy for Resident #4. This lack of privacy was acknowledged by the resident, who expressed a desire for a curtain. Similarly, Resident #55, who had a diagnosis of dysphagia and experienced episodes of incontinence, also lacked a privacy curtain. The resident reported that while the staff closed the door, there was no curtain to ensure visual privacy from the two roommates. A CNA confirmed that the curtains were pulled around the other beds but not for the middle bed, where Resident #55 was located. Maintenance staff noted that the ceiling track for the privacy curtain was insufficient, and the DON admitted to not noticing the absence of privacy curtains for the middle beds in rooms with three residents.
Failure to Update Care Plan for Resident with PICC Line
Penalty
Summary
The facility failed to revise the care plan for a resident who had returned from a hospital stay with a midline placed in the left arm and an order for an intravenous antibiotic. The care plan, updated shortly after the resident's return, did not document the presence of intravenous access. Observations later confirmed that the resident had a PICC line in the left upper arm. The MDS coordinator acknowledged that care plans were supposed to be updated quarterly, with significant changes, new orders, and upon readmission from the hospital, but admitted that the care plan for this resident had not been updated to reflect the PICC line. The DON stated there was no system in place to monitor care plans to ensure they were updated upon readmission or with a change in a resident's status.
Failure to Prevent Unnecessary Weight Loss
Penalty
Summary
The facility failed to implement interventions to prevent unnecessary weight loss for a resident diagnosed with dementia. The resident's care plan, dated May 2, 2024, indicated a nutritional problem or potential for one, with a goal to maintain weight within 5% of the current weight and consume at least 50% of three daily meals. However, between May 2, 2024, and July 3, 2024, the resident experienced a significant weight loss of 11.65%, dropping from 132.2 lbs to 116.8 lbs. Observations noted the resident appeared emaciated and was not consistently redirected to meals, as seen when the resident wandered the halls instead of eating. The facility's policy required that if a resident consumed less than 50% of a meal, a nutritional supplement, such as a house shake, should be provided and documented. Despite this, the resident's electronic medical record showed multiple instances where the resident ate less than 50% of their meals, with no documentation of a house shake being offered. Interviews with CNAs and the DON confirmed the protocol for providing supplements, yet there was no record of compliance. The DON admitted to missing the significant weight loss and failing to notify the physician or dietician in a timely manner.
Failure to Conduct Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure proper post-dialysis assessments for a resident with end-stage renal failure. The resident, who was cognitively intact, reported that while their blood pressure and temperature were checked before dialysis, they did not see a nurse upon returning unless they requested assistance. The resident also mentioned a recent infection in their port, which required antibiotics due to a blood infection. A review of the resident's electronic medical record revealed a lack of documentation for post-dialysis assessments, including vital signs, weight, and fistula/port assessments on multiple dates. Interviews with nursing staff confirmed the absence of a specific dialysis protocol, although they acknowledged the need for pre and post-dialysis assessments.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss for a resident, which was identified during a record review and interview. The resident's weight dropped from 132.2 lbs to 116.8 lbs over two months, marking an 11.65% weight loss. Despite the resident eating less than 50% of their meals on multiple occasions, there was no documentation of a house shake being offered as a supplement in the last 30 days. The LPN and CMA stated that a health shake should be offered if a resident eats less than 50% of a meal, and this should be reported to the charge nurse. However, the DON admitted to not noticing the significant weight loss and failing to notify the physician or dietician. The physician, who visits the facility monthly, was only informed of the weight loss on July 19, 2024, and subsequently ordered an appetite stimulant for the resident. The DON acknowledged the oversight and the lack of communication with the physician regarding the resident's condition. The physician confirmed that they were notified of the weight loss during their visit and reviewed the resident's chart and condition at that time.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to post the required staffing information as mandated. Observations on multiple dates revealed that the staffing schedule displayed at the nurses' station did not include the necessary details such as the resident census or the nursing hours. The Director of Nursing (DON) confirmed that there were 73 residents in the facility. On July 22, 2024, the administrator acknowledged that the posted schedule lacked the nursing hours and resident census.
Failure to Administer Medication Per Physician Orders
Penalty
Summary
The facility failed to ensure medications were administered per physician orders for a resident who was reviewed for unnecessary medications. The resident had a diagnosis of transient ischemic attack and was supposed to continue taking clopridogrel 75 mg daily as per the hospital discharge summary. However, the Order Recap Report did not document that clopridogrel had been started upon the resident's admission to the facility. The resident, who was cognitively intact, reported not receiving the medication while at the facility. The Director of Nursing (DON) stated that admission orders were obtained from the hospital discharge orders but was unaware that clopridogrel had not been ordered upon admission. Upon reviewing the clinical record, the DON acknowledged failing to continue the clopridogrel order.
Sanitation Deficiencies in Kitchen and Ice Machine
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by multiple observations of unsanitary conditions. Flies were seen landing on food preparation tables, cookware, and dishware, and two ceiling vents over food preparation areas were covered with grease, dust, and debris. Additionally, the kitchen refrigerator contained several open food items, such as apple juice, Pepsi, Coke, sliced luncheon meat, omelettes, waffles, shredded lettuce, cheese slices, chicken noodle soup, cranberry juice, and canned pineapple, all without open or preparation dates. The kitchen staff acknowledged the requirement to label and date foods and stated that leftovers should be discarded within 48 hours. Personal drinks were also found in the refrigerator, which staff knew was against policy. The facility also failed to maintain a clean ice machine, as a slimy black substance identified as algae was found in and around the water reservoir. The maintenance supervisor admitted to not knowing how often the ice machine was cleaned and was not qualified to determine its cleanliness. A technician from the contracted cleaning company confirmed the presence of algae and noted difficulty in keeping the machine clean. Furthermore, the kitchen's back door was left open to improve airflow, allowing flies to enter, which had been a persistent issue for months. Maintenance efforts to address the fly problem, such as caulking around the kitchen window, were ineffective. Additionally, maintenance staff acknowledged the dirtiness of the ceiling vents and planned to clean and paint them.
Inadequate Infection Control and Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program by not implementing enhanced barrier precautions during catheter and wound care for two residents. One resident with neuromuscular dysfunction of the bladder received catheter care from CNAs who did not don gowns, contrary to the facility's policy for transmission-based precautions. The Director of Nursing (DON) acknowledged that enhanced barrier precautions had not been initiated, despite new guidelines indicating their necessity during high-contact care activities. Another resident with quadriplegia, open wounds, a urinary catheter, and a colostomy did not have signage or supplies for enhanced barrier precautions in their room. The resident reported that only an LPN provided wound and catheter care, using gloves but not a mask or gown. Observations confirmed that the LPN did not use enhanced barrier precautions during wound care. Additionally, the facility failed to prevent cross-contamination by allowing the urinary catheter dignity bag and tubing of a resident to drag on the floor, which was against the facility's protocol.
Failure to Maintain Physical Environment in Good Repair
Penalty
Summary
The facility failed to ensure the physical environment was maintained in good repair. A yellow wet floor sign and a blue bucket containing approximately one half cup of water were observed on the floor in the middle of the dining area near the serving window. Maintenance staff indicated that the bucket was placed to prevent people from slipping and falling, and it appeared that the water was coming from the ceiling. The Certified Dietary Manager (CDM) confirmed that the roof leaks when it rains. The Maintenance Supervisor stated that the roof had last been repaired in September 2023. This deficiency affected the safety and comfort of the 73 residents residing in the facility.
Failure to Implement Comprehensive Care Plan for Pressure Wounds
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with stage three pressure wounds. The care plan, dated 02/16/24, required weekly treatment documentation, including measurements and observations of the wounds. However, there was no documentation of wound care being provided before 03/17/24. Interviews with an LPN and the DON confirmed the lack of documented wound observations prior to this date, despite the care plan's requirements.
Failure to Document and Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care as ordered by the physician, complete weekly wound observations and measurements, and document refusals in the nursing notes. The policy and procedure for the prevention and treatment of pressure ulcers required the facility to provide care and services necessary to promote healing, prevent infection, and document any refusals in the resident's clinical record. However, the facility did not adhere to these guidelines for Resident #1, who had diagnoses including quadriplegia and chronic pain syndrome. The treatment administration records (TAR) for February, March, and April 2024 showed multiple instances where the prescribed treatments were either not documented or marked as refused without proper documentation in the clinical record. Additionally, there were no documented wound observations prior to March 17, 2024, despite the requirement for weekly evaluations. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the care was being provided but not documented correctly. LPN #2 confirmed that refusals should be charted in the clinical record, and LPN #1 explained that a blank on the TAR meant the treatment was not provided, while specific numbers indicated refusal or other reasons, which should have been accompanied by a progress note. The DON acknowledged the lack of weekly wound documentation and admitted that the admit screener's documentation was insufficient. This lack of proper documentation and adherence to the care plan led to the identified deficiencies in pressure ulcer care for Resident #1.
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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