New Hope Retirement & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcalester, Oklahoma.
- Location
- 1220 East Electric Blvd, Mcalester, Oklahoma 74501
- CMS Provider Number
- 375384
- Inspections on file
- 24
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at New Hope Retirement & Care Center during CMS and state inspections, most recent first.
A resident who had a physician's order for BIPAP with oxygen at 3 LPM during sleep and naps was repeatedly observed resting in bed without the BIPAP machine in use, and the mask was left on the bedside table. An RN confirmed the resident should have been using the BIPAP during naps, but the order was not followed.
The facility did not ensure that all dietary staff received required training in safe food handling practices for the prevention of foodborne illness. When surveyors requested verification of food handler training, the administrator could only provide certificates for five of seven dietary employees and acknowledged that one cook and one dietary aide had not completed the required training. Meals prepared and served by the dietary department were provided to dozens of residents, but two staff members involved in food service lacked documented safe food handling education.
Surveyors found that during a noon meal service, the kitchen served a different entrée and side dishes than those listed on the posted weekly menu, while still serving the same dessert and bread item. The administrator reported that 37 residents received nutrition from the kitchen for this meal. Although facility policy required that any menu substitutions be recorded on a substitution form along with the reason for the change, the dietary manager stated that items were substituted because the planned foods were not available and acknowledged that substitutions and reasons were not documented and that they were unaware of any substitution form.
Surveyors found that the facility failed to follow food safety and sanitation standards, including storing expired coleslaw and cottage cheese, keeping unlabeled juice in the refrigerator, and not consistently documenting refrigerator and freezer temperatures. Freezers lacked visible thermometers, and the food preparation and dry storage floors were damaged, rough, and had debris and dark buildup, with boxes of apple juice stored directly on the floor. A cook prepared lunch without checking or recording final food temperatures and reported not knowing this was required, while the dietary manager confirmed there was no process or log for cooked food temperatures despite policies requiring labeling, dating, and use of a thermometer for internal temperatures.
An allegation of abuse involving a resident with dementia and behavioral disturbances was not reported to the state agency within the required timeframe. The administrator conducted an internal investigation but decided not to submit an incident report, resulting in a failure to comply with mandatory reporting policies.
A resident’s quarterly assessment was inaccurately coded to show that the resident was receiving anticoagulant therapy, while the corresponding medication administration record for the same period showed no anticoagulant medications ordered or administered. During interview, the MDS coordinator confirmed the resident was not on anticoagulation and that the assessment coding was erroneous.
Surveyors observed that the medication storage room contained multiple expired items, including syringes with needles, lubricating jelly packets and tubes, and bisacodyl suppositories. An RN present during the observation acknowledged that these expired medications and supplies should have been removed. The facility had 37 residents at the time, and the deficiency centered on the failure to ensure timely removal of expired drugs and related supplies from the medication room.
Surveyors found that the facility did not fully implement its Legionella water management program as part of its infection prevention and control efforts. The written policy required a water management team that included the infection preventionist, administrator, medical director or designee, director of maintenance, and director of environmental services, along with a detailed water system diagram and identification of areas prone to waterborne bacteria. Record review showed a 2025 shower head cleaning schedule with quarterly entries for three quarters but no documentation for the fourth quarter. In interviews, the infection preventionist reported not knowing they were part of the water management team, and the administrator acknowledged the absence of a required water system diagram and missing October documentation, while noting that 37 residents were residing in the facility.
Surveyors observed multiple ceiling tiles with brown water stains and sagging in the dining room and several resident rooms, caused by persistent roof leaks that occurred during rain. The maintenance supervisor and administrator confirmed the roof had not been permanently repaired, despite management's awareness of the issue, resulting in a failure to maintain a safe, clean, and homelike environment as required by facility policy.
A resident with urinary retention and a congenital bladder neck obstruction, who had an indwelling urinary catheter and physician orders for regular catheter care, did not have a comprehensive care plan developed for catheter care and maintenance. The absence of this care plan was confirmed by the MDS coordinator.
A resident with non-Alzheimer's dementia and intact cognition engaged in abusive behavior toward another resident, including physical contact and attempting to tie a neck pillow around the other resident's neck. Although the incident was reported and immediate supervision was provided, the resident's care plan was not updated to reflect the new behaviors or interventions, contrary to facility policy.
A resident with an indwelling urinary catheter exhibited odorous brown drainage at the catheter entry site over several days, as documented by nursing staff. Despite physician orders to monitor and report signs of infection, there was no documentation that the physician was notified. The resident was later hospitalized for a complicated UTI and hypotension.
The facility did not post complete staffing information as required. Observations revealed that the whiteboard at the nursing station lacked the facility name, projected staffing hours, and actual staffing hours, only showing the date, census, and staff/title. The DON was unaware of the specific requirements for staffing documentation.
The facility failed to date and cover urinary catheter bags for two residents, leading to a deficiency. One resident with overactive bladder, paraplegia, and a stage 4 sacral pressure ulcer was observed with an undated and uncovered catheter bag. Another resident with urine retention and congenital bladder neck obstruction was repeatedly observed with an undated and uncovered catheter bag. The DON confirmed the deficiency.
The facility failed to document physician's orders for DNR status for three residents, despite having DNR care plans and signed consent forms. The MDS coordinator was unaware of the requirement for a physician's order, resulting in the oversight.
The facility failed to notify the physician of out-of-parameter blood sugar levels for two residents with diabetes. One resident had a blood sugar of 458, and another had multiple instances of blood sugar levels exceeding 400, yet there was no documentation of physician notification. Staff interviews confirmed that the physician should have been notified, and the lack of documentation indicated this did not occur.
The facility failed to ensure accurate assessments for two residents. One resident was incorrectly documented as taking an anticoagulant instead of an antiplatelet medication, due to an error in the auto-populated medication section. Another resident's admission assessment failed to document their hospice services admission, despite a physician's order. The MDS coordinator acknowledged both errors.
A resident with muscle spasm, pain, and anxiety disorders was prescribed Tramadol for pain relief. Despite a care plan and physician order requiring daily pain monitoring, the facility failed to document the resident's pain status as required. The resident reported persistent pain, with some relief from medication, but the DON confirmed that monitoring was not completed as ordered.
A facility failed to ensure a resident receiving Risperidone, an antipsychotic medication, had an appropriate diagnosis. The resident, diagnosed with dementia without behavioral disturbances, anxiety disorders, and unspecified mood affective disorder, was cognitively intact and prescribed 0.5 mg of Risperidone twice daily. The care plan required monitoring for behaviors related to the medication, but the DON and pharmacist confirmed the absence of a proper diagnosis for the antipsychotic use.
A facility failed to document the coordination of care between hospice services and the facility for a resident with chronic obstructive pulmonary disease. Despite a physician's order for hospice admission, the resident's admission assessment did not reflect hospice services, and the administrator could not provide hospice documentation, including the plan of care.
A resident with a history of peripheral vascular disease and osteoporosis developed multiple pressure ulcers that were not adequately documented or treated in a timely manner. The facility failed to notify the physician promptly and did not implement sufficient preventative measures, as required by their policy. The administrator acknowledged the lack of action and documentation, and the resident had limited access to wound care specialists.
A facility failed to include critical medical needs in a baseline care plan for a resident with a right hip fracture, osteoarthritis, hypertension, anxiety, and impulse disorder. The resident returned from the hospital with an infected hip incision, requiring a JP drain, urinary catheter, wound vac, PICC line with IV antibiotics, and had wounds to the coccyx and buttocks. The baseline care plan did not address these needs, as confirmed by the DON.
Failure to Follow Physician's Order for BIPAP Use During Sleep and Naps
Penalty
Summary
The facility failed to follow a physician's order for respiratory care for one resident who required the use of a BIPAP machine with oxygen at 3 LPM during sleep and naps. On three separate occasions, the resident was observed resting in bed during nap times without the BIPAP machine turned on, and the mask was found on the bedside table rather than in use. The physician's order, dated 07/14/25, specifically required the BIPAP to be used at bedtime and while napping. An RN confirmed that the resident should have had the BIPAP on during naps, indicating the order was not followed as required.
Failure to Ensure Safe Food Handling Training for All Dietary Staff
Penalty
Summary
The facility failed to ensure all dietary staff received training in safe food handling practices for the prevention of foodborne illness. During a record review and interview, surveyors requested verification of food handler training for all dietary staff, and the administrator later provided training certificates for only five of seven dietary employees. It was identified that one cook and one dietary aide had not received the required food handler training, despite the administrator identifying that 37 residents received meals from the dietary department. This deficiency centers on the lack of documented and completed safe food handling training for these two dietary staff members.
Failure to Follow Posted Menu and Document Menu Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned menu and document menu substitutions during a noon meal service. Surveyors observed that at 12:30 p.m. on 12/22/25, the kitchen served chicken fried steak, mashed potatoes and gravy, cream corn, a dinner roll, and pineapple crisp, while the posted week five menu specified crumb crusted chicken, savory rice, Brussels sprouts, a dinner roll, and pineapple crisp. The administrator identified that 37 residents received nutrition from the kitchen for this meal. The facility had an undated policy titled “Menu Substitution” stating that menu substitutions would be recorded on a substitution record form and that the reason for the change would be noted. During the same observation, the dietary manager stated they were working off the week five menu and had to substitute items because the planned menu items were not available, but also acknowledged they did not document substitutions or specific reasons for them and were not aware of any substitution form. No additional resident-specific medical histories or conditions were documented in the report beyond the number of residents receiving nutrition from the kitchen.
Food Service Sanitation, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility’s food service operations affecting 37 residents who received nutrition from the kitchen. In the kitchen refrigerator, they observed a container of prepared coleslaw and a container of cottage cheese that remained in storage past the manufacturer’s use-by dates, as well as two unlabeled plastic pitchers containing juice-like liquids without any preparation or use-by dates. Review of the Daily Refrigerator and Freezer Temperature Log for December showed missing temperature documentation for two consecutive days. Six chest freezers containing frozen food items were observed without visible thermometers inside. The dietary manager acknowledged that thermometers had been ordered and that staff had not been checking freezer temperatures because there were no thermometers present. Surveyors also observed environmental and procedural deficiencies in food preparation and storage. The food preparation area between the stove, steam table, and counters had missing floor tiles, and the dry food storage area floor had rough surfaces with debris and a buildup of dark matter. Two cardboard boxes of apple juice drink blend were stored directly on the floor under shelving in the dry storage room. During a lunch meal preparation observation, a cook prepared food without checking or documenting final cooking temperatures, and later stated they did not know they were supposed to check temperatures when food was finished cooking. The dietary manager stated there was no process or log in place for cooked and served food temperatures, while existing facility policies required refrigerated food to be covered, dated, and labeled, and required use of a meat thermometer to check internal temperatures.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with dementia, behavioral disturbances, hyperlipidemia, anxiety disorder, and migraines to the state agency within the required 2-hour timeframe. According to facility policy, all alleged violations and substantial incidents must be reported to the state agency. On the date in question, a staff member was observed being rough and speaking loudly to the resident while assisting them to a chair. The incident was reported to the facility administrator, who immediately initiated an internal investigation, including a camera review by the corporate office. However, the administrator determined the incident was not reportable and did not submit an incident report to the state agency, resulting in noncompliance with reporting requirements.
Inaccurate MDS Coding for Anticoagulation Therapy
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident receiving anticoagulation therapy. A quarterly assessment dated 11/05/25 documented that Resident #25 was receiving anticoagulant therapy. However, review of the resident’s November 2025 medication administration record showed no anticoagulant medication was ordered or administered for this resident. During an interview on 12/31/25 at 12:42 p.m., the MDS coordinator confirmed that Resident #25 did not take an anticoagulant medication and acknowledged that the assessment had been coded in error.
Expired Medications and Supplies Found in Medication Storage Room
Penalty
Summary
Surveyors identified a failure to ensure removal of expired medications and supplies from the facility’s medication storage room, contrary to requirements that drugs and biologicals be properly labeled and stored. During an observation of the medication room with a registered nurse, surveyors found multiple expired items, including a box of 25-gauge needles with 3 ml syringes, a box of 21-gauge needles with 3 ml syringes, several packets and tubes of lubricating jelly, and multiple bisacodyl suppositories, all past their labeled expiration dates. The administrator reported that 37 residents resided in the facility at the time of the survey. During the same observation, the RN accompanying the surveyor acknowledged that the expired medications and supplies should already have been removed from the medication room. No additional information was provided about specific residents’ medical histories or conditions in relation to these expired items.
Failure to Implement Legionella Water Management Program and Involve Infection Preventionist
Penalty
Summary
The facility failed to ensure its Legionella water management program, which is part of the infection prevention and control program, was implemented as written and included the participation of the infection preventionist. The written policy dated 1/2022 specified that the water management team must include the infection preventionist, the administrator, the medical director or designee, the director of maintenance, and the director of environmental services, and referenced a detailed description and diagram of the facility’s water system and identification of areas that could promote growth and spread of waterborne bacteria. Record review showed a 2025 cleaning schedule for shower heads with quarterly entries completed for January, April, and July, but no documentation for October. During interview, the infection preventionist stated they did not know they were on the water management team, and the administrator stated there was no diagram for a water management program and confirmed there was no documentation for October 2025 in the logbook. The administrator identified that 37 residents resided in the facility at the time of the survey.
Failure to Maintain Safe and Homelike Environment Due to Ongoing Roof Leaks
Penalty
Summary
The facility failed to maintain the physical environment in good repair, as evidenced by multiple observations of ceiling tiles with large brown watermark stains and sagging tiles in the dining room and several resident rooms. The stained and sagging ceiling tiles were noted around and near air vents, and the maintenance supervisor confirmed these issues were due to ongoing water leaks from the roof, which occurred every time it rained. The maintenance supervisor reported that while stained and sagging tiles were replaced frequently, the underlying issue of the leaking roof had not been permanently addressed. The administrator acknowledged that the roof had been leaking since their employment began and that management was aware of the problem but had not taken permanent action to resolve it. The facility's policy required a safe, clean, comfortable, and homelike environment, which was not upheld due to these ongoing environmental deficiencies.
Lack of Comprehensive Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing indwelling urinary catheter care and maintenance for one resident with a documented need for such care. Record review showed that the resident had medical diagnoses including urinary retention and congenital bladder neck obstruction, and a physician's order was in place to change the catheter every 30 days and perform catheter care every shift and as needed. The resident was assessed as cognitively intact and was known to have an indwelling urinary catheter. However, review of the resident's care plan revealed no documentation or plan for catheter care and maintenance. The MDS coordinator confirmed that a comprehensive care plan for urinary catheter care had not been developed for this resident, despite it being required.
Failure to Update Care Plan After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to update a resident's care plan following an incident of abusive behavior involving two residents. According to the facility's policy, care plans are to be revised as new information about a resident's condition becomes available, and interventions should address the underlying sources of problem areas. Despite this, after an incident where a resident with non-Alzheimer's dementia and intact cognition was observed pushing another resident and attempting to tie a neck pillow around their neck, no updates or new interventions were added to the resident's care plan. The incident was reported to the appropriate authorities, and immediate actions were taken to separate the residents and provide one-on-one supervision for the resident involved in the abusive behavior. A review of the resident's care plan, last revised after the incident, showed no documentation of the behaviors or any new interventions related to the event. The MDS coordinator confirmed that the care plan was not updated following the incident, despite facility policy requiring updates after significant changes in a resident's health or behavior. The lack of care plan revision occurred even though the resident's assessment indicated ongoing cognitive and behavioral concerns.
Failure to Notify Physician of Catheter Site Infection Signs
Penalty
Summary
The facility failed to notify the physician of signs and/or symptoms of a potential infection at the urinary catheter entry site for a resident with an indwelling urinary catheter. According to the facility's policy, nursing staff are required to document a comprehensive assessment and notify the physician when infection is suspected, including providing details of the assessment, observed symptoms, and the time symptoms were first noted. The resident in question had a history of urinary retention, congenital bladder neck obstruction, and recurrent urinary tract infections, and was cognitively moderately impaired. Physician orders were in place to monitor the catheter site for infection and report any signs to the physician. Despite multiple nurse notes documenting odorous brownish and tannish brown drainage from the catheter site over several days, there was no documentation that the physician was notified of these symptoms. Interviews with nursing staff confirmed that the physician should have been notified, but there was no record of such communication. The resident was later admitted to the hospital for a complicated urinary tract infection and hypotension, and the planned suprapubic catheter placement was not performed at that time.
Failure to Post Complete Staffing Information
Penalty
Summary
The facility failed to post the required staffing information as mandated. During observations on two separate occasions, it was noted that the staffing information was documented on a whiteboard at the nursing station. However, the facility name, projected staffing hours, and actual staffing hours were not included in the documentation. The observations took place on 11/05/24 and 11/07/24, where only the date, census, and staff/title were documented. Furthermore, during an interview, the Director of Nursing (DON) admitted to being unaware of the specific staffing information required to be documented on the staffing board.
Failure to Date and Cover Urinary Catheter Bags
Penalty
Summary
The facility failed to adhere to proper urinary catheter care protocols for two residents, leading to a deficiency. Resident #11, who had diagnoses including overactive bladder, paraplegia, and a stage 4 sacral pressure ulcer, was observed with a urinary catheter bag that was neither dated nor covered, despite a physician's order for catheter care per facility guidelines. This was confirmed by the Director of Nursing (DON) on a subsequent date. Similarly, Resident #35, diagnosed with retention of urine and congenital bladder neck obstruction, was observed multiple times with a urinary catheter bag that was not dated or covered. The observations were made while the resident was sitting in a recliner in their room, and the deficiency was acknowledged by the DON. Both residents were among the four identified by the DON as having urinary catheters, yet the facility failed to ensure their catheter bags were dated and covered as required.
Failure to Document DNR Orders for Residents
Penalty
Summary
The facility failed to ensure that Do Not Resuscitate (DNR) orders were properly documented for three residents, despite their advance directives indicating a preference for DNR status. Resident #4, diagnosed with type 2 diabetes mellitus and cerebral infarction, had a DNR care plan and signed consent form but lacked a physician's order for DNR. Similarly, Resident #7, with Parkinson's, dementia, behavioral disturbance, and anxiety, had a DNR care plan and a consent form signed by their Power of Attorney (POA), yet no physician's order was present. Resident #10, suffering from chronic kidney disease stage 3, type 2 diabetes mellitus, and congestive heart failure, also had a DNR care plan and signed consent form without a corresponding physician's order. The MDS coordinator was unaware that a physician's order was necessary for DNR residents, leading to this oversight.
Failure to Notify Physician of Out-of-Parameter Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician of out-of-parameter blood sugar levels for two residents with diabetes. Resident #21, diagnosed with type 2 diabetes with autonomic polyneuropathy, had a physician's order to notify the physician if blood sugar levels were below 70 or above 400. On October 2, 2024, the resident's blood sugar was recorded at 458, but there was no documentation indicating that the physician was notified. Similarly, Resident #31, with type 2 diabetes mellitus, had a physician's order to notify the physician if blood sugar levels were below 60 or above 400. There was no documentation of physician notification for several instances where the resident's blood sugar exceeded 400, specifically on September 20, 24, 27, 30, and October 14, 2024. Interviews with RN #1 and the Director of Nursing confirmed that the physician should have been notified, and the lack of documentation indicated that this did not occur.
Inaccurate Resident Assessments for Medications and Hospice Services
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents. One resident, with diagnoses including heart failure and cerebral infarction, was documented as taking an anticoagulant in their assessment, despite a physician's order indicating they were taking an antiplatelet medication, aspirin. The MDS coordinator acknowledged the error, noting that the medication section of the assessment was auto-populated and the mistake was not caught. Another resident, diagnosed with atrial fibrillation and chronic obstructive pulmonary disease, was admitted to hospice services, but their admission assessment did not reflect this. The MDS coordinator confirmed the omission upon review of the assessment.
Failure to Monitor Resident's Pain as Ordered
Penalty
Summary
The facility failed to ensure proper monitoring of a resident experiencing pain. The resident, who was cognitively intact, had diagnoses including muscle spasm, pain, and anxiety disorders, and was prescribed Tramadol 50 mg as needed for pain. An admission assessment noted the resident experienced occasional pain rated six on a scale from 0 to 10. The care plan indicated the resident's pain should be relieved or controlled, and a physician order required staff to monitor the resident's pain daily across all shifts, documenting whether the resident experienced pain. However, the Director of Nursing (DON) confirmed that the monitoring was not completed as ordered, despite the resident reporting persistent pain in their left arm and leg, with some relief from the medication provided.
Lack of Appropriate Diagnosis for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication had an appropriate diagnosis or indication for the use of an antipsychotic medication. The resident, who had diagnoses including dementia without behavioral or psychotic disturbances, anxiety disorders, and unspecified mood affective disorder, was prescribed Risperidone, an antipsychotic medication, at a dose of 0.5 mg twice daily. The admission assessment indicated that the resident was cognitively intact and was receiving both an antipsychotic and an antianxiety medication. The care plan required staff to monitor the resident for behaviors, both verbal and non-verbal, for which the medication was being administered. However, upon review of the resident's clinical record, the Director of Nursing (DON) was uncertain if there was an appropriate diagnosis for the antipsychotic medication. Additionally, the facility pharmacist confirmed that the resident was receiving an antipsychotic medication without a corresponding diagnosis.
Lack of Hospice Care Documentation for Resident
Penalty
Summary
The facility failed to ensure proper documentation of the coordination of care between hospice services and the facility for a resident receiving hospice care. The resident, who had diagnoses including atrial fibrillation and chronic obstructive pulmonary disease, was admitted to hospice services with a physician's order dated 08/21/24. However, the admission assessment dated 08/27/24 did not document that the resident was receiving hospice services. Furthermore, on 11/06/24, the facility administrator was unable to provide any hospice documentation regarding the resident's hospice services, including the plan of care. This deficiency was identified during a review of records and interviews, affecting one resident out of the three identified by the Director of Nursing as receiving hospice services.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate treatment and services to prevent the worsening of pressure ulcers for a resident with a history of peripheral vascular disease, osteoporosis, and a fracture of the neck of the right femur. Upon admission, the resident did not have open pressure areas, but a small pressure area was noted on the buttocks shortly after. Despite this, there was a lack of consistent documentation and follow-up on the wound's condition until a week later when multiple open areas were identified on the resident's buttocks and sacrum. The wounds were not staged, and the physician was not notified until the day after the wounds were documented by the nursing staff. The facility's pressure ulcer policy requires aggressive and appropriate preventative measures, but the only documented intervention prior to the discovery of the wounds was repositioning every two hours. The treatment record showed that medication orders for the wounds were initiated only after the physician was notified, and a cushion for the wheelchair was ordered the following day. The facility's administrator acknowledged the lack of action and documentation, and the resident had only seen a wound care specialist once since the wounds were identified.
Failure to Include Critical Medical Needs in Baseline Care Plan
Penalty
Summary
The facility failed to ensure an accurate baseline care plan for a resident who was admitted with multiple complex medical needs. The resident had a history of a right hip fracture, osteoarthritis, hypertension, anxiety, and impulse disorder. Upon returning from the hospital, the resident had an infected right hip incision and required a JP drain, an indwelling urinary catheter, a wound vac to the right hip incision, a PICC line with IV antibiotics, and had wounds to the coccyx and buttocks. The baseline care plan initiated on 05/09/24 and updated on 05/21/24 did not address the resident's JP drain, indwelling urinary catheter, wound vac, PICC line, or wounds. The Director of Nursing acknowledged that the baseline care plan should have included these elements, indicating a lapse in the facility's care planning process for the resident's immediate needs.
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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