Montereau, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 6800 South Granite Avenue, Tulsa, Oklahoma 74136
- CMS Provider Number
- 375460
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Montereau, Inc. during CMS and state inspections, most recent first.
A resident who required significant assistance with daily activities and was at risk for falls experienced multiple prolonged waits for call light responses, including one instance where the call light was active for over three hours. The resident, who was cognitively intact and had several medical conditions, reported having to call out for help and being left unattended on the toilet, leading them to slide to the floor. Staff interviews revealed inconsistent expectations and practices regarding call light response times, with some staff acknowledging delays during busy periods and issues with accurately recording response times.
Surveyors found that two treatment carts containing medications and biologicals were left unlocked and unattended in the facility. Staff admitted to leaving keys in accessible locations and not following protocol to keep carts locked when out of sight. The DON confirmed that facility policy requires carts to be locked and keys to be kept on the nurse.
A resident with a history of heart failure and recurrent nosebleeds was discharged from the hospital with instructions to follow up with an ENT physician, but the facility failed to schedule the required appointment. The ADON, responsible for scheduling, did not identify the need for the ENT referral, and there was no documentation or monitoring process in place to ensure the appointment was made. The resident confirmed they were not notified of or sent to the ENT appointment during their stay.
A resident with severe cognitive impairment and a stage three pressure ulcer did not consistently receive a physician-ordered liquid protein supplement, with eight missed doses documented due to issues such as unavailability and lack of staff awareness. Staff interviews revealed confusion about ordering and administration responsibilities, resulting in the resident not receiving the prescribed nutritional support for wound healing.
A resident with heart failure, hypertension, and renal insufficiency did not receive Lasix at the physician-ordered times on multiple occasions. Audit reports showed several doses were administered late, and staff interviews revealed inconsistent adherence to the facility's medication timing protocol. The facility did not ensure medications were given as ordered, resulting in a deficiency related to timely medication administration.
A resident with a history of skin breakdown and high risk for pressure ulcers was admitted with moisture associated skin damage, but the facility failed to accurately assess, document, and care plan for the condition. There was a lack of timely wound care interventions, inconsistent documentation, and poor communication among staff, leading to the progression of a sacral wound to a stage IV pressure ulcer with severe infection and sepsis, ultimately resulting in the resident's death.
The facility failed to ensure enhanced barrier precautions were used during catheter care for two residents with indwelling urinary catheters. Despite the presence of PPE and signage, CNAs did not use gowns as required. Both CNAs admitted to not using gowns, and the DON and infection preventionist confirmed staff had been educated on PPE use.
A resident with dementia and dysphagia had their dietary needs publicly displayed on sheets of paper near the nurses' station, compromising their dignity. RN #1 acknowledged that this information should not be visible to the public and stated that staff could access dietary needs through the care plan and lunch tickets.
The facility failed to ensure residents were offered the choice to formulate an advance directive, as evidenced by the lack of documentation for three residents. One resident with dementia and dysphagia had no advance directive acknowledgment, another with Alzheimer's and sepsis had incomplete social service assessment, and a third resident's advance directive form was only signed on the day of the survey. The Social Services Director confirmed the absence of a form to document advance directives upon admission.
The facility failed to develop comprehensive care plans for four residents, including those with multiple sclerosis, hypertension, and Alzheimer's disease. The MDS assessments were completed, but the care plans were not fully developed as required. Additionally, a resident with Alzheimer's was not weighed as per their care plan, missing 31 out of 37 opportunities.
A resident with cognitive communication deficit and other conditions was abused by a CNA, who was witnessed and videotaped yelling and kicking the resident. The incident was not reported immediately due to the witnessing CNA's fear, violating the facility's abuse policy.
Failure to Provide Timely Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient staff to answer call lights in a timely manner for one of three sampled residents reviewed for call light response. Call light logs revealed multiple instances where the resident's call light remained active for extended periods, including durations of over an hour and, in one case, more than three hours. Documentation showed that the resident had to call out for help and was found on the bathroom floor after attempting to get assistance for an extended period. The resident reported having to wait 15 to 45 minutes on several occasions for staff to respond to their call light, sometimes resorting to calling the security desk for help at night. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including heart failure, hypertension, and renal insufficiency. The resident required substantial to maximum assistance with activities of daily living, including transfers and toileting, and was considered a fall risk. Despite these needs, the resident reported being left unattended on the toilet for at least 30 minutes, leading them to slide to the floor and crawl toward the door to seek help. Staff interviews confirmed that call light response times varied, with some staff indicating that response times could be longer during busy periods such as mealtimes. Interviews with facility staff, including the DON, LPNs, and CNAs, revealed inconsistencies in the expected and actual response times to call lights. While some staff stated that the expected response time was two minutes, others considered up to 15 minutes to be timely, especially during busy periods. The DON acknowledged that call light response times were monitored only randomly or in response to complaints and that there were issues with staff acknowledging but not turning off call lights, which could affect the accuracy of response time records.
Failure to Secure Medications in Unattended Treatment Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were secured in accordance with professional standards. On two separate occasions, treatment carts containing medications such as insulin, Narcan, lidocaine patches, and various antiseptics were found unlocked and unattended. On the second floor, a treatment cart was left unlocked next to the nurses' station while staff were present but not attending to the cart. The key to the cart was found in an open compartment, and staff admitted to leaving it there for easy access, contrary to facility protocol. The cart remained unlocked and unattended for several minutes, with staff unable to provide a reason for this lapse. A similar incident occurred on the first floor, where another treatment cart was observed unlocked and unattended around the corner from the nurses' desk. Staff walked past the cart without securing it, and a CNA accessed supplies from the cart. When questioned, staff acknowledged that the cart should not have been left unlocked and stated it was an oversight. The Director of Nursing confirmed that facility policy required carts to be locked when out of sight and that keys should be kept on the nurse, not left in or near the cart.
Failure to Schedule Required ENT Follow-Up Appointment
Penalty
Summary
A deficiency occurred when the facility failed to schedule a follow-up appointment with an ENT physician for a resident who had been evaluated in the emergency room for a recurrent nosebleed. The resident, who was cognitively intact and had a diagnosis of heart failure, was discharged from the hospital with instructions to follow up with an ENT within five to seven days. Upon return to the facility, there was no documentation in the clinical record or appointment log indicating that the required ENT appointment had been scheduled. Interviews with facility staff revealed that the ADON was responsible for scheduling resident appointments and reviewing hospital records for necessary referrals. The ADON confirmed that, at the time of the resident's readmission, they did not identify the need for an ENT follow-up. The DON stated that there was no known monitoring process in place to ensure that appointments and referrals were scheduled, and could not explain why the ENT appointment was missed. The resident reported not being notified of or attending an ENT appointment during their stay.
Failure to Administer Ordered Nutritional Supplement for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that nutritional supplements ordered for the treatment of a pressure ulcer were consistently administered to a resident with severe cognitive impairment and multiple medical diagnoses, including coronary artery disease, hypertension, and Alzheimer's disease. The resident was assessed as having increased protein needs due to a stage three pressure ulcer, and a physician's order was in place for liquid protein to be given twice daily. However, review of medication administration records revealed that the supplement was not given on eight occasions out of thirty opportunities, with several missed doses lacking documented reasons or being attributed to the supplement not being available or on order from the pharmacy. Interviews with nursing staff indicated confusion regarding the ordering and administration process for the supplement, with one LPN stating that medications were ordered electronically and should be administered upon arrival, and the ADON noting that the supplement should have been available as house stock. Despite these protocols, the supplement was not administered as ordered, and staff were unable to provide consistent explanations for the missed doses, indicating a breakdown in ensuring the resident received the prescribed nutritional intervention for pressure ulcer care.
Failure to Administer Medications at Ordered Times
Penalty
Summary
The facility failed to ensure that medications were administered at the ordered times for one of three sampled residents reviewed for medication administration. According to the facility's policy, medications are to be administered by licensed nurses or other authorized staff as ordered by the physician, following the six rights of medication administration, including the right time. For a resident with diagnoses of heart failure, hypertension, and renal insufficiency, physician orders specified that Lasix was to be administered twice daily at 7:00 a.m. and 2:00 p.m. However, medication administration audit reports showed multiple instances where Lasix was not given at the ordered time, with doses being administered significantly later than scheduled on several dates. Interviews with staff revealed inconsistencies in following the facility's protocol regarding medication timing. An LPN stated that there was a one-hour window before and after the ordered time for administration, but acknowledged that some doses were given outside this window and could not explain the delays. The DON confirmed the protocol and stated that nurses should report late administrations, but there was no indication that this occurred. The documentation and staff interviews demonstrate that the facility did not consistently adhere to its own medication administration policies, resulting in late administration of prescribed medications.
Failure to Assess, Monitor, and Intervene for Pressure Ulcer Risk and Treatment
Penalty
Summary
A deficiency was identified when the facility failed to properly assess, monitor, and intervene for a resident with a history of skin breakdown and at high risk for pressure ulcers. Upon admission, the resident was documented as having moisture associated skin damage to the right gluteus, but there was no documentation of a deep tissue injury or other wounds. Despite this, there was a lack of accurate and timely documentation regarding the resident's skin condition, and the baseline care plan did not address any skin issues or concerns. The facility also failed to initiate appropriate treatment orders for the skin damage present on admission, and there was no evidence of wound care interventions until a pressure ulcer was later identified. Throughout the resident's stay, multiple nursing notes, skin checks, and care plan reviews continued to document the presence of moisture associated skin damage, but did not identify or address the development of a pressure ulcer. The Braden scale assessments initially indicated a low risk for pressure ulcers, and there was inconsistency in the documentation of the resident's skin status. The care plan eventually noted the resident was at risk for skin breakdown due to incontinence, but did not specifically address the presence or treatment of a pressure ulcer. Weekly wound tracking and physician notes later documented the progression of a sacral wound from suspected deep tissue injury to a stage IV pressure ulcer, with significant necrotic tissue and exudate, and additional wounds on the right heel and left foot. Communication failures were evident, as changes in the resident's skin condition were not consistently reported to the care team or reflected in the care plan. There was a delay in obtaining and following physician orders for wound care, and discrepancies existed between the frequency of ordered dressing changes and what was scheduled in the electronic medical record. The lack of timely and coordinated interventions contributed to the deterioration of the resident's skin condition, ultimately resulting in severe infection, sepsis, and death due to complications from an infected sacral decubitus ulcer.
Failure to Utilize Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were utilized during indwelling urinary catheter care for two residents. Both residents had diagnoses of obstructive and reflux uropathy and were on enhanced barrier precautions due to the presence of indwelling urinary catheters. Despite the presence of personal protective equipment (PPE) bins and signage indicating enhanced barrier precautions outside the residents' doors, the certified nursing assistants (CNAs) providing care did not use gowns as required. CNA #1 and CNA #2 both acknowledged that they were supposed to use gowns and gloves during catheter care but admitted to not doing so during their respective observations. The Director of Nursing (DON) and the infection preventionist confirmed that staff had been educated on the use of PPE for residents on enhanced barrier precautions, yet the CNAs failed to adhere to these protocols during the observed care activities.
Resident Dignity Compromised by Public Display of Dietary Information
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as observed in the case of a resident with dementia and dysphagia. The resident was admitted with a physician's order for a regular pureed texture diet with nectar thick consistency liquids. During an observation, the resident was seen sitting near the nurses' station with two 8 x 10 sheets of paper displaying their dietary requirements, including their name and the need for nectar thick liquids. These signs were visible to the public, which was acknowledged by RN #1 as inappropriate, stating that such information should not be publicly displayed. RN #1 also mentioned that staff could access the resident's dietary needs through the care plan and lunch tickets available during meal times.
Failure to Offer Advance Directive Choices
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate an advance directive, as evidenced by the lack of documentation for three residents. Resident #7, who was admitted with dementia and dysphagia, had a physician's order and care plan indicating full code status, but there was no advance directive acknowledgment or social services assessment documenting the resident's choice. Similarly, Resident #40, admitted with Alzheimer's and sepsis, had a care plan indicating DNR status, yet the social service assessment lacked information regarding the resident's choice to accept or decline an advance directive. Resident #208's case further highlights the deficiency, as their social service history and initial assessment did not contain any information regarding advance directives. During an interview, the Social Services Director admitted that there was no form to document whether a resident had advance directives upon admission. It was revealed that the forms provided to the survey team were newly created on the day of the survey, and Resident #208's form was signed on the same day, despite the resident being admitted earlier.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, as required by their policy. Resident #50, diagnosed with cellulitis of the abdominal wall and multiple sclerosis, did not have a comprehensive care plan completed after the admission MDS assessment was finalized on May 18, 2024. Similarly, Resident #41, with diagnoses including hypertension, a fracture of the left femur, and a transient ischemic attack, also lacked a comprehensive care plan following the completion of their admission MDS assessment on April 25, 2024. In both cases, the MDS Coordinator confirmed that the care plans were not fully completed. Resident #111, who had cerebral infarction, congestive heart failure, and heart failure, was admitted without a comprehensive care plan after their MDS assessment was completed on June 17, 2024. Additionally, Resident #40, diagnosed with Alzheimer's disease and morbid obesity, had a care plan that required weekly weight monitoring due to malnutrition risk. However, the facility failed to obtain the resident's weight on 31 out of 37 opportunities. The MDS Coordinator acknowledged that Resident #40 was not being weighed according to their care plan.
Failure to Immediately Report Abuse
Penalty
Summary
The facility failed to implement their abuse policy by not immediately reporting an incident of abuse. A resident with diagnoses including cognitive communication deficit, displaced intertrochanteric fracture, and depression was subjected to abuse when a CNA was witnessed and videotaped yelling and kicking the resident. The incident occurred at approximately 5:30 a.m. and was not reported to the administrator until 2:30 p.m. the same day. The delay in reporting was due to the witnessing CNA's fear of the abusive CNA. The facility's policy requires immediate reporting of abuse, which was not followed in this case.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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