Midwest City Post Acute & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Midwest City, Oklahoma.
- Location
- 8200 National Avenue, Midwest City, Oklahoma 73110
- CMS Provider Number
- 375252
- Inspections on file
- 35
- Latest survey
- August 15, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Midwest City Post Acute & Rehab during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple medical conditions was observed sitting in a hallway in a wheelchair wearing only a t-shirt and a brief, without being covered by a towel or blanket. Staff and the DON confirmed this was not appropriate and did not align with facility policy on resident dignity.
A medication cart was found unlocked and unattended in a hallway, blocking a doorway, while an LPN was inside a resident's room and unable to supervise the cart. Facility policy requires medication carts to be locked unless in direct view of nursing staff, a standard that was not met in this instance.
The facility failed to ensure accurate resident assessments, leading to discrepancies in medical records for four residents. One resident with Alzheimer's was inaccurately documented regarding mobility and pressure ulcers. Another resident with chronic pain was incorrectly recorded as not receiving PRN pain medication. A resident receiving hospice care was documented without hospice services and a prognosis of more than six months. Lastly, a resident discharged home was inaccurately documented as discharged to the hospital. These inaccuracies were confirmed by facility staff.
A facility failed to report an abuse allegation involving a confused resident and an injury of unknown origin for another resident with dementia. The abuse allegation was investigated by a state representative, but no incident report was filed. The injury involved bruising, possibly from a sit-to-stand lift, but was not reported to the State Agency. The administrator acknowledged the reporting requirements but did not adhere to them.
A facility failed to investigate allegations of abuse and an injury of unknown origin involving two residents. One resident reported abuse by a CMA, but the DON and ADON were not informed. Another resident was found with bruising, but the origin was not identified, and the incident was not reported to the SA. The administrator later attributed the bruising to a lift, but lacked documentation. Staff were pressured to sign backdated statements, compromising the investigation.
A facility failed to complete a significant change assessment for a resident placed on hospice services. The resident, with diagnoses including dementia and heart disease, was admitted to hospice care, but no assessment was documented. Staff interviews confirmed the oversight, and the MDS consultant stated that such an assessment was required.
A resident with central cord syndrome and muscle wasting experienced a decline in range of motion due to the facility's failure to provide necessary equipment, including a wrist splint and adaptive eating tools. The resident was unable to use a specialized walker, which was crucial for their mobility, due to delays in ordering and confusion over insurance responsibilities.
A facility failed to ensure a resident receiving a psychotropic medication had an appropriate diagnosis. The resident, diagnosed with generalized anxiety disorder, was prescribed olanzapine, an antipsychotic, without any other psychiatric diagnoses to justify its use. The facility's policy requires psychotropic medications to be administered only for specific documented conditions. The resident's records and assessments confirmed the absence of additional psychiatric conditions, highlighting a deficiency in medication management.
A resident with chronic kidney disease and dementia was found with unexplained bruising, and the facility failed to maintain complete and accurate records. The administrator provided backdated witness statements for staff to sign, causing concern among staff members. The investigation into the incident was not conducted properly, leading to a deficiency in record-keeping.
A facility failed to ensure a call cord was within reach for a resident with mobility limitations. The resident, dependent on staff for daily activities due to cerebral infarction and hemiplegia, was observed with a touch pad call light out of reach. An LPN acknowledged the issue and repositioned the call light, noting the resident's inability to call for assistance without it. Facility policy requires call lights to be accessible, which was not followed in this case.
A resident with limited ROM due to cerebral infarction did not receive adequate restorative therapy after insurance changes led to the discontinuation of skilled services. Despite recommendations for restorative nursing programs, the facility's documentation showed inconsistent therapy provision. Interviews revealed confusion among staff regarding the resident's therapy needs and documentation, leading to a deficiency finding.
A resident with severe cognitive impairment and Parkinson's disease was transferred without a gait belt by two CNAs, contrary to the facility's policy requiring gait belt use during transfers. The CNAs used an improper method by placing arms under the resident's arms and holding the backside of the pants. Interviews revealed a misunderstanding of the policy, with staff acknowledging the requirement for gait belt use during all one to two-person assists. The facility is a no-lift facility, and the use of gait belts is mandated for residents who can stand and pivot.
An IJ situation was identified due to a facility's failure to prevent significant medication errors for a resident. An LPN administered additional doses of Morphine outside the prescribed schedule without physician authorization, leading to the resident's death. The facility's Medication Error policy and Guidelines for Physician Orders policy were not followed, resulting in significant medication errors.
The facility failed to maintain comfortable water temperatures in two shower rooms, causing residents to experience either too hot or too cold water. Observations confirmed fluctuating temperatures, and staff acknowledged the issue, suggesting that mixing valves might need replacement.
The facility failed to ensure that licensed nurses received competency/skills checks. One LPN administered morphine outside of physician orders to a hospice resident, who subsequently expired. Another LPN's file also lacked documentation of a competency/skills check. The DON confirmed that these checks should be documented but were not for these two LPNs.
The facility failed to ensure accurate medical records for a resident with nontraumatic intracerebral hemorrhage. Discrepancies were found in the documentation of lorazepam and morphine administration, including incorrect dates and post-mortem entries. The DON confirmed these issues and noted inconsistencies in pain level documentation.
The facility failed to reconcile controlled medications upon delivery for a resident with a physician order for morphine. The pharmacy delivered 20mls of morphine, but the Controlled Drug Receipt/Record/Disposition Form indicated only 15mls were received. The discrepancy was not identified or reconciled by the staff, highlighting a lapse in the facility's medication management process.
Resident Not Properly Covered in Public Area
Penalty
Summary
A deficiency was identified when a resident with anoxic brain damage, cognitive impairment, and other medical conditions was observed sitting in a hallway in a wheelchair wearing only a t-shirt and a brief, without being covered by a towel or blanket. Facility policy requires that residents be treated with respect and dignity, and the resident's care plan indicated assistance was needed with dressing. Staff interviews confirmed that it was not appropriate for the resident to be uncovered in a public area, and the DON acknowledged that the resident should have been covered.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart on hall 300 was observed to be unlocked and unattended, blocking the doorway in front of a resident's room. At the time of the observation, the assigned LPN was inside the room behind a closed curtain and could not see the medication cart. Facility policy requires that medication carts remain locked unless in direct view of the unit nurse, and that no medications should be left unattended. The LPN confirmed that the cart was not visible from their location and acknowledged that it should have been locked when unattended. The Director of Nursing also stated that medication carts should be locked and supervised at all times. This incident involved one of three medication carts used for dispensing medications in a facility housing 72 residents. The report does not mention any specific residents being directly affected or provide details about their medical history or condition at the time of the deficiency.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for four residents, leading to discrepancies in their medical records. One resident with Alzheimer's was documented as not applicable for walking 50 feet or more, despite being constantly mobile around the facility. Additionally, this resident's assessment inaccurately recorded only one stage 3 pressure ulcer, omitting a stage 4 pressure ulcer on the sacrum. Another resident, admitted with chronic pain, was documented as not having received PRN pain medication during the assessment's look-back period, despite records showing daily administration of such medication. Further discrepancies were noted for a resident with dementia and other conditions, who was receiving hospice care. Their assessment incorrectly indicated no hospice services and a prognosis of more than six months, contrary to their medical records. Lastly, a resident discharged home was inaccurately documented as discharged to the hospital. These inaccuracies were acknowledged by the facility's staff, including the DON and MDS consultant, who confirmed the assessments were not correctly coded.
Failure to Report Abuse Allegation and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with cognitive communication deficit and generalized anxiety. The resident was reportedly confused, and an incident was investigated by a state representative who advised the facility not to report it. The administrator and ADON were aware of the situation, but no incident report was filed, and there was no documentation in the progress notes. The only records were statements from the administrator and a CNA, indicating a lack of proper documentation and reporting. Another deficiency involved a resident with stage three chronic kidney disease and dementia, who was found with bruising of unknown origin. The facility did not report this injury to the State Agency (SA). The resident required substantial assistance for daily activities and was noted with purple discoloration under the left breast, ribs, and arm. Despite notifying the ADON, administrator, and NP, and obtaining x-rays, the origin of the bruising was not identified, and the incident was not reported as required. The administrator acknowledged the need to report injuries of unknown origin but failed to do so in this case. The investigation into the bruising suggested it might have been caused by the use of a sit-to-stand lift, but there was no documentation to support this conclusion. The administrator's statements and the lack of a formal report highlight a failure to adhere to the facility's abuse prevention policy and state reporting requirements.
Failure to Investigate Allegations of Abuse and Injury
Penalty
Summary
The facility failed to fully investigate an allegation of abuse involving a resident with cognitive communication deficit and generalized anxiety. The resident reported that a weekend CMA threw pills at them and used curse words, which was allegedly reported to the weekend charge nurse. However, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were not made aware of this allegation. The administrator stated that a state representative had previously investigated a separate allegation involving the same resident, but no incident report was filed, and the only documentation was a written statement by the administrator and a CNA. Another deficiency involved a resident with stage three chronic kidney disease and dementia, who was found with purple discoloration under the left breast/ribs and left upper and forearm. The facility's incident report documented the bruising but did not identify its origin. The administrator and ADON were notified, and x-rays were ordered, but the incident was not reported to the State Agency (SA). The administrator later stated that the bruising was likely caused by the sit-to-stand lift, but there was no documentation to support this conclusion. The investigation into the bruising incident was further compromised when it was revealed that the administrator had staff fill out witness statements after the fact, instructing them to backdate the forms. Several staff members expressed discomfort with this process, feeling pressured to sign statements that were not in their handwriting. The administrator's actions in handling the investigation and documentation were inadequate, leading to a failure to properly report and investigate the incidents as required by the facility's abuse prevention policy.
Failure to Complete Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change resident assessment for a resident who was placed on hospice services. The resident, who had diagnoses including dementia, generalized anxiety disorder, and atherosclerotic heart disease, was admitted to hospice care services with a physician order dated 10/30/25. However, there was no documentation of a significant change resident assessment in the resident's clinical record following the initiation of hospice services. Interviews with facility staff, including a CNA and an LPN, confirmed that the resident was receiving hospice services. The Director of Nursing (DON) acknowledged the oversight and attempted to contact regional staff for assistance. The MDS consultant, contacted by the DON, confirmed that a significant change resident assessment should have been completed when the resident began hospice services, as it is required when a resident experiences a change in their baseline condition.
Failure to Provide Necessary Equipment for Resident's Range of Motion
Penalty
Summary
The facility failed to prevent a decrease in range of motion for a resident diagnosed with central cord syndrome of cervical spine paraplegia and muscle wasting. The resident was cognitively intact but had functional limitations in the range of motion in both upper extremities. Despite a physician's order for a right-hand wrist contracture splint and adaptive equipment for eating, these items were not provided in a timely manner. The resident expressed that the lack of a specialized platform walker, which was used during skilled care, hindered their ability to stand and perform daily activities effectively. The physical therapy assistant (PTA) acknowledged that the specialized walker was not ordered promptly, and the wrist splint ordered in October had not arrived by the end of January. The PTA also noted that the facility was responsible for providing necessary equipment, but there was confusion regarding insurance and payment for private pay residents. The dietary manager confirmed delays in ordering adaptive eating equipment, and the resident reported not having a bedside commode since admission. The administrator recognized the need for new procedures to ensure therapy orders are communicated to all relevant departments to prevent such oversights.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure that a resident receiving a psychotropic medication had an appropriate diagnosis or indication for its use. The facility's policy on psychotropic medications, dated June 5, 2023, mandates that such medications should only be administered if necessary to treat a specific condition documented in the medical record. Resident #9, who was diagnosed with generalized anxiety disorder, was prescribed olanzapine, an antipsychotic, without any other psychiatric or mood disorder diagnoses to justify its use. The resident's admission assessment confirmed cognitive intactness with a BIMS score of 15 and noted the use of an antipsychotic instead of an antianxiety medication. Progress notes from both an APRN and a medical doctor reiterated the diagnosis of anxiety disorder without additional psychiatric conditions. The Director of Nursing, upon reviewing the resident's clinical record, confirmed the presence of only a general anxiety diagnosis.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for a resident with diagnoses including stage three chronic kidney disease and dementia. On a specific date, a nurse's note documented that the resident was observed with purple discoloration under the left breast/ribs and left upper and forearm. Orders were obtained for a stat x-ray, and the family was notified. However, the origin of the bruising was not identified in the nurse's note. An incident report also documented the discoloration but failed to describe the injuries observed and did not identify the origin of the bruising. The investigation into the incident was incomplete and improperly documented. The administrator provided a sign-in sheet for an inservice related to transfer lifts, but no additional information was provided to the survey team. The administrator later found and provided forms, including a resident interview form that was undated and unsigned, and several confidential witness statements. These statements were signed by staff members but were reportedly filled out by the administrator after the fact, with staff members expressing discomfort and concern about signing them. Staff interviews revealed that the administrator had instructed them to sign backdated witness statements, which were not in their handwriting, and to report the date on the forms if questioned. Staff members expressed that they felt pressured to sign these forms and were concerned about the implications of doing so. The incident investigation was not conducted in a timely manner, and the documentation was not completed accurately, leading to a deficiency in maintaining complete and accurate resident records.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call cord was within reach for a resident with significant mobility limitations. The resident, who had a history of cerebral infarction and hemiplegia on the dominant side, was observed in a specialized mobile chair with a touch pad call light attached to a curtain against the wall, out of their reach. This resident's quarterly assessment indicated functional range of motion limitations in all four extremities, making them dependent on staff for all activities of daily living. During an observation, an LPN acknowledged that the call light was not positioned correctly and subsequently clipped it to the resident's blanket, noting that the resident would be unable to call for assistance without the call light within reach. The facility's policy stated that call lights should always be accessible to residents, but this was not adhered to in this instance.
Inadequate Restorative Therapy for Resident with Limited ROM
Penalty
Summary
The facility failed to provide adequate restorative therapy to a resident with limited range of motion (ROM), as identified in a survey. The resident, who had a history of cerebral infarction, hemiplegia, and hemiparesis, was initially receiving skilled services upon admission. However, due to a change in insurance coverage, the resident's therapy services were discontinued. Despite recommendations for restorative nursing programs to maintain the resident's current level of performance and prevent decline, the facility's documentation showed inconsistent and insufficient provision of restorative therapy. The resident received minimal rehabilitation sessions, which did not meet the recommended frequency and duration. Interviews with facility staff revealed a lack of clarity and consistency in the provision of restorative services. The Director of Nursing (DON) and other staff members indicated that the resident was on a restorative care program, but there were discrepancies in the documentation and execution of the therapy. The restorative aide mentioned that the resident required two-person assistance for transfers, yet the nursing rehab documentation did not consistently reflect this level of care. Additionally, there was confusion regarding whether the resident refused therapy or if it was not adequately documented. This lack of proper restorative therapy provision led to the deficiency identified in the survey.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the use of a gait belt during a two-person physical assist transfer for a resident with severe cognitive impairment and diagnoses including Parkinson's disease and tremor. The facility's policy on bed mobility and transfers requires the use of a gait belt during sit-to-stand transfers and transfers between a bed and a wheelchair. However, during an observation, two CNAs were seen transferring the resident without a gait belt, instead placing one arm under each of the resident's arms and holding the backside of the resident's pants to hoist them from a wheelchair to a bed. Interviews with the CNAs revealed a misunderstanding of the policy, with one CNA stating that gait belts were used for residents who were stronger and more able, while the other acknowledged that gait belts should be used for all one to two-person assists. Further interviews with an LPN and the DON confirmed that the facility is a no-lift facility and that gait belts should be used for residents who can stand and pivot, with lifts available for assistance.
Failure to Prevent Significant Medication Errors
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified due to the facility's failure to prevent significant medication errors for a resident. The resident was ordered Morphine 20mg/ml to be administered 0.5ml every four hours as needed. However, the Controlled Drug Receipt/Record/Disposition Form documented that an LPN administered additional doses of Morphine outside the prescribed schedule, including at 10:15 a.m., 2:30 p.m., and 3:00 p.m., per family request, without contacting the physician for orders for these additional doses. The Medication Administration Record (MAR) also showed discrepancies in the administration times and doses, with the LPN admitting to documenting the wrong date and failing to follow the physician's orders. The resident expired later that day at 4:13 p.m. without the LPN having contacted the physician for the additional doses administered. The Oklahoma State Department of Health was notified and verified the existence of the IJ situation. The facility's Medication Error policy and Guidelines for Physician Orders policy were not followed, as the LPN administered medications outside the prescribed time frames and without physician authorization. The LPN admitted to using a 10ml syringe to draw up an unknown amount of Morphine and administering it to the resident in an attempt to appease the family. The LPN also admitted to making hasty and inaccurate entries on the narcotic record to justify the discrepancies and ensure the oncoming nurse would take the cart keys. The DON and other staff members confirmed that the LPN had not followed physician orders and had administered Morphine outside the prescribed schedule, leading to the resident's death. The DON and other staff members expressed concerns about the LPN's actions, stating that the LPN was a danger to the residents due to their failure to follow physician orders and accurately document medication administration. The medical director described the LPN's actions as gross negligence, and the regional nurse consultant confirmed that the LPN had administered Morphine outside the prescribed schedule based on family requests. The facility's failure to ensure medications were administered as ordered resulted in significant medication errors and the resident's death.
Removal Plan
- Nurse #1 was immediately interviewed and suspended pending investigation following the discovery of the potential medication error, thus removing the potential to affect other residents.
- Nurse #1 was terminated after not showing up for her scheduled meeting, competency validation, and continued employment evaluation.
- Narcotic count sheets were audited to verify accurate count recorded and matching count of medications.
- Physician's Orders were validated to match the Medication Administration Record and administration times were verified to be within acceptable range.
- Licensure verification for licensed nurses and CMA's were completed.
- Licensed Nurses and CMA's were inserviced on medication administration of routine and as needed medication, following physician's orders, physician notification, change of condition, medication orders/requests, additional medication doses, adverse reactions, and new admission process.
- Phone calls with a verbal inservice will be given if any staff are on vacation or unable to come to the facility for an in-person inservice.
- Competency validations began for all licensed nurses and CMA's to be successfully completed prior to administering medication and/or providing care.
- Newly hired nurses and CMA's will be educated upon hire and competence validated prior to administering medications to any resident.
- An Ad-Hoc QAPI Meeting was held by the Administrator, the Interdisciplinary Team, and Medical Director to review and approve the Plan of Removal and Allegation of Compliance.
- Audit Tools were created to include monitoring of medication delivery including following physician's orders, narcotic count, and accuracy of count compared to actual medication.
- The QAPI Committee will review the audit tools and will determine compliance. Any concerns will have been addressed. If indicated, additional Action Plans will be recommended and/or written by the QAPI Committee.
- All Action Plans will be monitored by the Administrator to ensure substantial compliance.
Failure to Maintain Comfortable Water Temperatures in Shower Rooms
Penalty
Summary
The facility failed to ensure a homelike environment by maintaining comfortable water temperatures in two shower rooms (300 hall and 400 hall). Residents reported that the water in the shower rooms was either too hot or too cold, making it difficult to adjust to a comfortable temperature. Observations confirmed that the water temperatures in the 300 hall shower room ranged from 84 to 87 degrees Fahrenheit, while the 400 hall shower room had temperatures fluctuating between 55 and 122 degrees Fahrenheit. The maintenance supervisor acknowledged the issue and noted that they only monitored the water temperature for one shower in each room, suggesting that the mixing valves might need replacement. Residents expressed their dissatisfaction with the water temperature, with some opting for bed baths instead of showers due to the inconsistency. Certified Nursing Assistants (CNAs) also reported the difficulty in maintaining a comfortable water temperature for residents, indicating that both showers had to be turned on simultaneously to achieve a warm temperature. Despite the maintenance supervisor's awareness of the issue, the problem persisted, affecting the residents' comfort and daily living activities.
Failure to Ensure Competency/Skills Checks for Licensed Nurses
Penalty
Summary
The facility failed to ensure that licensed nurses received competency/skills checks, as evidenced by the review of employee files for two LPNs. One LPN administered morphine outside of physician orders and time regulations to a hospice resident, who subsequently expired. This LPN filled a 10ml syringe with 3ml of morphine and used it to administer several doses within their shift. The LPN was suspended pending investigation, and it was noted that no competency/skills check had been completed for this LPN. Another LPN's file also lacked documentation of a competency/skills check. The DON confirmed that competency/skills checks should be documented in the employee files but were not for these two LPNs.
Inaccurate Medical Records for Resident
Penalty
Summary
The facility failed to ensure accurate medical records for one of the five sampled residents. Resident #2, who had a diagnosis of nontraumatic intracerebral hemorrhage, had discrepancies in their medication administration records. A physician's order indicated that Resident #2 was to receive lorazepam for anxiety and morphine for pain/shortness of breath. However, the Controlled Drug Receipt/Record/Disposition Form and the Medication Administration Record (MAR) contained conflicting documentation regarding the administration times and dosages of morphine. Additionally, the MAR did not document the administration of morphine on a specific date, despite the Controlled Drug Receipt/Record/Disposition Form indicating otherwise. Furthermore, the MAR documented the administration of lorazepam after the resident had expired, which was later explained as a late entry by the LPN involved. The DON confirmed these discrepancies and noted that the electronic health record system required pain levels to be documented when pain medication was administered, which was not consistently done in this case. LPN #1 admitted to incorrectly dating the entries on the Controlled Drug Receipt/Record/Disposition Form and failing to document the administration of morphine doses on the correct date. The DON acknowledged that the electronic health record system would not allow documentation of medication administration unless it was due, and expressed uncertainty about how pain ratings were determined for Resident #2 when the resident was reportedly unresponsive. The DON also mentioned that they reviewed a 24-hour report to monitor for complete and accurate clinical records and would seek clarification from nurses if needed.
Failure to Reconcile Controlled Medications Upon Delivery
Penalty
Summary
The facility failed to ensure controlled medications were properly reconciled upon delivery from the pharmacy for one of the three sampled residents. Specifically, Resident #2, who had a diagnosis of nontraumatic intracerebral hemorrhage, had a physician order for morphine 20ml/mg every four hours as needed for pain/shortness of breath. The pharmacy delivered 20mls of morphine for Resident #2, as documented on the packing slip and signed for by an LPN. However, the Controlled Drug Receipt/Record/Disposition Form indicated that only 15mls of morphine were received, and this discrepancy was not identified or reconciled by the staff at the time of delivery. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the facility did not have a protocol in place to compare the pharmacy's documentation with the actual amount received. The ADON assumed the hospice nurse had delivered the medication, and the LPN admitted to signing for the medication without verifying the quantity. This lack of verification and reconciliation led to a failure in ensuring the correct amount of controlled medication was received and documented, highlighting a significant lapse in the facility's medication management process.
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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