North County Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Collinsville, Oklahoma.
- Location
- 2300 West Broadway, Collinsville, Oklahoma 74021
- CMS Provider Number
- 375504
- Inspections on file
- 23
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at North County Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A CMA was observed administering oral medications to multiple residents consecutively without performing hand hygiene between each resident, despite facility policy and prior training requiring handwashing before medication administration. This lapse was noted during the preparation and administration of various medications, including pain relievers, muscle relaxants, and gastric agents.
A resident was prescribed and administered Seroquel, an antipsychotic, for unspecified dementia with behavioral disturbances and anxiety, despite facility policy requiring antipsychotics only for specific, indicated conditions. Staff interviews confirmed the medication was used for dementia-related behaviors, and the DON acknowledged it was not approved for this diagnosis, resulting in a deficiency for unnecessary medication use.
A resident's MDS discharge assessment was completed but not transmitted to the CMS QIES ASAP system within the required 7-day period. The MDS coordinator acknowledged the oversight, and the DON reported not monitoring the export status of MDS records due to limited training. This resulted in a failure to comply with facility policy and federal regulations regarding timely MDS data transmission.
A resident with severe cognitive impairment and multiple diagnoses was denied re-entry to the facility after an overnight stay with family, despite only being provided 24 hours of medication and not intending a permanent discharge. The administrator refused to allow the resident to return, there was no discharge documentation, and the resident was left without appropriate notice or placement, resulting in a deficiency for improper discharge procedures.
A facility failed to manage controlled medications properly, resulting in the misappropriation of narcotics for three residents. Despite policies requiring reconciliation, numerous lapses in procedure were found, including missing counts and improper staff signatures. The DON acknowledged the issues but failed to monitor compliance effectively, allowing the deficiencies to persist.
The facility failed to complete baseline care plans within 48 hours of admission for three residents, citing reasons such as staff absence and weekend admissions. This resulted in delays and, in one case, a complete lack of a baseline care plan.
The facility failed to develop comprehensive care plans for the use of bed rails for four residents, despite physician orders allowing therapeutic devices. The care plans were not completed in a timely manner, and one resident's comprehensive care plan was entirely missing due to staff shortages.
The facility failed to attempt alternative interventions and assess the risk of entrapment before using bed rails for three residents. The DON confirmed that staff did not follow the policy requiring these steps.
The facility failed to complete the required yearly performance reviews for two CNAs. The last documented skills performance for both CNAs was completed in 2022. The DON confirmed that no skills performance checks had been completed for the year 2023 and was unaware of the requirement.
The facility failed to maintain an infection prevention and control program, including proper catheter and incontinent care, and did not implement a water treatment program to prevent Legionella. Staff did not follow hand hygiene protocols, and the water management program was not instituted.
The facility failed to ensure two residents were offered the choice to formulate advanced directives. One resident had chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy, and chronic respiratory failure with hypoxia, while the other had embolism and thrombosis of an unspecified vein, edema, hypokalemia, and cerebral fluid drainage. The clinical records for both residents did not document that they or their representatives were offered the choice to formulate an advanced directive.
The facility failed to complete an admission assessment for a resident with multiple diagnoses, including congestive heart failure and dementia, within the required timeframe. The MDS coordinator cited a backlog due to a staff nurse's family emergency.
The facility failed to complete quarterly assessments within the required time frame for two residents. One resident with respiratory failure, congestive heart failure, and cerebrovascular disease had an incomplete assessment, and another resident with dementia, schizoaffective disorder, and auditory hallucinations also had an overdue assessment.
The facility failed to submit a resident's assessment data to CMS within the required seven days. A resident with urinary tract infection and cellulitis had their quarterly assessment completed but not submitted until over a month later. The MDS coordinator was unaware of the delay's cause.
The facility failed to develop a discharge summary for a resident, including a recapitulation of the stay, medication reconciliation, and a post-discharge plan. The resident had multiple diagnoses and was discharged to another facility, but the necessary documentation was missing.
The facility failed to notify the physician and implement interventions for a resident with significant weight loss. Despite a dietary order for daily supplements, the resident experienced weight loss and was observed eating without being offered the prescribed supplements. The MDS Coordinator confirmed the physician was not informed of the weight loss.
The facility failed to ensure a resident's nutritional issues were supervised by a physician, resulting in significant weight loss. Despite a dietary order for supplements, the resident was observed eating without being offered the prescribed supplement, and the physician was not notified of the weight loss.
The facility failed to maintain an ice machine in a sanitary condition. An observation revealed a black substance inside the ice machine used by all 44 residents. The machine was cleaned only every six months, and there was no regular monitoring or documentation of its cleanliness.
The facility failed to conduct regular inspections of beds and bed rails for three residents, contrary to their policy. One resident with severe cognitive impairment had an assist bar attached, while two residents with intact cognition had bed rails but were unaware of any safety assessments. The Maintenance Supervisor confirmed no routine inspections were conducted.
The facility failed to follow physician orders for wound care for a resident with a sacral pressure ulcer. The wound vac was observed not in use, and the resident reported it had been off since Saturday due to a nurse's unfamiliarity with its operation. Staff confirmed the wound vac frequently came off and was not always reapplied promptly.
A resident with impulse disorder and dementia exhibited multiple instances of verbally abusive behavior towards other residents. Despite these documented behaviors, the DON and the administrator did not classify these incidents as verbal abuse and failed to implement the facility's abuse policy, leading to a failure in protecting other residents.
The facility failed to report allegations of verbal abuse involving a resident with impulse disorder and dementia to the administrator and OSDH as required by their abuse policy. Multiple incidents of the resident's verbally abusive behavior were documented, but notifications to the administrator or DON were not consistently recorded, and reports were not submitted to OSDH within the mandated timeframe.
The facility failed to provide abuse training upon hire for four employees, including three CNAs and one housekeeper, as required by their abuse policy. The DON and administrator confirmed that no abuse training had been provided since the facility changed ownership.
Failure to Perform Hand Hygiene Between Residents During Medication Administration
Penalty
Summary
Facility staff failed to follow infection control practices during medication administration for three of eight sampled residents. On multiple occasions, a Certified Medication Aide (CMA) was observed preparing and administering oral medications to residents without sanitizing or washing hands between residents. The CMA prepared medications for one resident, assisted with administration, and then proceeded to prepare and administer medications to subsequent residents without performing hand hygiene. This sequence was observed with three different residents, each receiving various prescribed oral medications, including pain medication, muscle relaxants, anticonvulsants, expectorants, and gastric protective agents. Facility policy required staff to wash their hands prior to administering medications and after handling items potentially contaminated with blood, body fluids, or secretions. Despite this, the CMA did not adhere to these protocols, as confirmed by direct observation. The Director of Nursing (DON) stated that all CMAs had completed training on medication administration and infection control, including the requirement for hand hygiene between residents.
Unnecessary Antipsychotic Medication Prescribed for Dementia
Penalty
Summary
A deficiency was identified when a resident was prescribed and administered Seroquel, an antipsychotic medication, for the diagnosis of unspecified dementia with behavioral disturbances and anxiety. Facility policy states that antipsychotic medications should only be used when necessary to treat specific, indicated conditions. However, the medication administration record showed the resident received Seroquel twice daily over several days for dementia, a diagnosis for which the medication is not approved. Staff interviews revealed that the primary behaviors observed were attempts by the resident to leave the facility and statements about needing to go to work. Further interviews with a certified medication aide, an LPN, and the DON confirmed that the medication was being used for dementia-related behaviors and anxiety. The DON acknowledged awareness that CMS does not approve Seroquel for the treatment of dementia and that the resident had been on the medication since admission for these behaviors. The documentation and staff responses did not indicate a specific, approved psychiatric diagnosis justifying the use of the antipsychotic, resulting in the finding of unnecessary medication use.
Failure to Transmit MDS Discharge Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) discharge assessment record was transmitted within the required 7-day timeframe for one of the sampled residents. According to facility policy, all MDS assessments, including discharge records, are to be completed, encoded, and transmitted to the CMS QIES ASAP system in accordance with OBRA regulations. Record review showed that a resident was discharged on 03/01/25, and while the MDS discharge record was completed, it was not transmitted as required. The MDS coordinator acknowledged that the record had been completed but not exported, attributing the failure to an error on their part. Further interviews revealed that the DON reviewed and signed MDS assessments as they became due but did not monitor whether records had been exported or were incomplete, citing minimal training in the MDS process. The corporate nurse consultant, new to their role, had planned to audit two medical records weekly but indicated a need to reconsider this approach after learning of the missed transmission. The deficiency was identified through record review and staff interviews, confirming the lapse in timely MDS data transmission.
Resident Denied Re-Entry After Overnight Absence Without Proper Discharge Notice
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, anoxic brain damage, PTSD, and bipolar disorder was not allowed to return to the facility after an overnight stay with family. The resident had signed out of the facility for an overnight visit, was provided with 24 hours of medication, and was expected to return the following day. Upon attempting to return, the resident was informed by the DON that they were no longer considered a resident, based on information from the administrator, despite the resident's statement that they had not intended to discharge themselves permanently. There was no documentation of a formal discharge for the resident, and the facility was unable to produce any discharge paperwork. The administrator refused to allow the resident to re-enter the facility, even after being informed by police that the resident had nowhere else to go. The administrator paid for a one-night hotel stay for the resident, but did not facilitate their return to the facility or provide the required discharge notice and documentation as outlined in the facility's policy and regulatory requirements. Interviews with staff confirmed that the resident had only planned an overnight stay and had not expressed intent to leave the facility permanently. The facility's failure to provide proper discharge notice, documentation, and to allow the resident to return after a temporary absence resulted in a deficiency related to improper discharge procedures.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure the proper management and reconciliation of controlled medications, leading to the misappropriation of narcotics for three residents. Resident #4, who had diagnoses including abnormal posture and weakness, was missing 60 tablets of Hydrocodone. The medication was delivered by the pharmacy, but discrepancies were found during a routine check. Similarly, Resident #8, diagnosed with chronic pain, was missing 30 tablets of Hydrocodone. The medication was delivered, but the facility could not account for the missing quantity. Resident #7, with cervical disc degeneration, was also affected, with 56 tablets of Hydrocodone unaccounted for, despite the medication being delivered months earlier. The facility's Controlled Substances policy required reconciliation of medications upon receipt, administration, and at the end of each shift. However, the review of Controlled Substance Card Count Sheets revealed numerous instances where medications were not counted, and staff signatures were missing or improperly recorded. The same employee often signed as both the on-coming and off-going staff member, indicating a lack of proper oversight and accountability. These lapses in procedure contributed to the misappropriation of medications. The Director of Nursing (DON) acknowledged the issues, stating that they were first made aware of the misappropriation when staff reported missing medications. Despite initial investigations and reconciliation efforts by a consultant pharmacist, further discrepancies were discovered. The DON admitted to not monitoring staff compliance with medication reconciliation procedures, which allowed the deficiencies to persist. The administrator confirmed that the DON was responsible for ensuring residents were free from medication misappropriation by reviewing count sheets, but this oversight was not effectively implemented.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for three residents. Resident #31, who had multiple diagnoses including osteomyelitis, stage four pressure ulcer, diabetes, and hypertension, was admitted on [DATE], but the baseline care plan was completed six days later. The care plan coordinator acknowledged the delay, attributing it to their absence from work. Similarly, Resident #45, admitted with diagnoses such as non-traumatic intracranial hemorrhage and dementia, had their baseline care plan initiated four days after admission. The MDS coordinator explained that the delay was due to the admission occurring over a weekend, and the baseline care plan was not initiated until the care plan staff member returned to work. They also mentioned that any nurse could initiate a baseline care plan, but it was typically completed by the MDS/Care plan staff nurse. Resident #246, who had diagnoses including congestive heart failure, dementia, and anxiety, was admitted on [DATE], but there was no documentation of a baseline care plan in the EHR. The MDS coordinator stated that they had been helping with the baseline care plans but had fallen behind, resulting in the failure to complete a baseline care plan for this resident. These findings indicate a systemic issue in the timely completion of baseline care plans, particularly when admissions occur over weekends or when key staff members are absent.
Failure to Develop Comprehensive Care Plans for Bed Rails
Penalty
Summary
The facility failed to develop a comprehensive care plan to include the use of bed rails for four residents reviewed for accident hazards. Resident #16, diagnosed with primary osteoarthritis, had an assist bar attached to their bed that was not care planned until 04/02/24, despite a physician's order dated 11/21/23 allowing the use of therapeutic devices. Resident #23, diagnosed with multiple sclerosis and generalized muscle weakness, had half-size bed rails on each side of their bed since admission, but these were not care planned until 04/02/24, even though a physician's order dated 07/25/23 permitted the use of therapeutic devices. Resident #146, diagnosed with a broken internal joint prosthesis, had side rails attached to their bed since admission, but these were not care planned until 04/03/24, despite a physician's order dated 01/30/24 allowing the use of therapeutic devices. Resident #246, diagnosed with congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome, was admitted to the facility, but there was no documentation of a comprehensive care plan available. The MDS stated that the other person helping with assessments and care plans had been out, causing delays in completing the care plans. The DON confirmed that the bed side rails had not been care planned for residents #16, 23, and #146 in a timely manner or in accordance with facility policy.
Failure to Attempt Alternatives and Assess Risks Before Using Bed Rails
Penalty
Summary
The facility failed to attempt alternative interventions before using bed rails for three residents and did not assess the risk of entrapment for two of these residents. Resident #16, who had severe cognitive impairment and chronic pain, was observed with an assist bar attached to their bed without documentation of alternative interventions or a risk assessment. Similarly, Resident #23, who had multiple sclerosis and intact cognition, was found with half-size bed rails on each side of their bed without any documented attempts at alternative interventions. Resident #23 confirmed that no alternatives were tried before the bed rails were used. Resident #146, who had a broken internal joint prosthesis and intact cognition, also had bed rails attached to their bed without documentation of alternative interventions or a risk assessment. The DON confirmed that alternative interventions were not attempted and risk assessments were not performed for residents #16 and #146 before the use of bed rails. The facility staff did not follow the policy related to the use of bed rails, which requires attempts at alternative interventions and risk assessments before installation.
Failure to Complete Yearly Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete the required yearly performance reviews for two certified nurse aides (CNAs), specifically CNA #2 and CNA #4. The last documented skills performance for both CNAs was completed on 09/22/22. During an interview on 04/04/24, the Director of Nursing (DON) reviewed the skills performance checklists and confirmed that no skills performance checks had been completed for the year 2023 for any current CNAs. The DON admitted to being unaware of the requirement for yearly performance reviews.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of infections. For one resident with a catheter and multiple pressure ulcers, a CNA did not follow the enhanced barrier precautions posted on the resident's door. The CNA did not wear a gown and failed to wash their hands between glove changes while providing catheter care and repositioning the resident. The Director of Nursing confirmed that the CNA should have used the appropriate PPE and followed proper hand hygiene protocols. Another resident, who was incontinent of bowel and bladder, did not receive proper infection control measures during incontinent care. The CNA assisting the resident did not change gloves or wash hands between removing the soiled undergarment and placing a clean one on the resident. The CNA later acknowledged that they should have changed gloves and washed hands during the care process. Additionally, the facility did not implement a water treatment program to prevent Legionella. The administrator admitted that the new water management program provided by the corporation had not been instituted. There was no documentation of preventive measures such as flushing toilets in unoccupied rooms, and no risk assessment or water management team had been established. The maintenance supervisor confirmed that no assessment of the facility's piping had been conducted to identify potential areas of standing water.
Failure to Offer Advanced Directives
Penalty
Summary
The facility failed to ensure residents were offered the choice to formulate advanced directives for two residents. Resident #4, who had diagnoses including chronic kidney disease - stage 3, type 2 diabetes mellitus with diabetic neuropathy, and chronic respiratory failure with hypoxia, did not have documentation in their clinical records indicating that they or their representative were offered the choice to formulate an advanced directive. Similarly, Resident #7, with diagnoses including embolism and thrombosis of unspecified vein, edema, hypokalemia, and cerebral fluid drainage, also lacked documentation in their clinical records showing that they or their representative were offered the choice to formulate an advanced directive. The Director of Nursing identified that 41 residents resided in the facility at the time of the survey.
Failure to Complete Timely Admission Assessment
Penalty
Summary
The facility failed to ensure an admission assessment for a resident was completed within the required timeframe. The resident, who had diagnoses including congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome, was admitted to the facility, but the Electronic Health Record (EHR) did not document an admission assessment. The MDS coordinator stated that the staff nurse responsible for completing the MDS assessments had been out for a family emergency, causing a backlog in assessments.
Failure to Complete Quarterly Assessments on Time
Penalty
Summary
The facility failed to complete quarterly assessments within the required time frame for two residents out of 13 whose assessments were reviewed. Resident #32, who had diagnoses including respiratory failure, congestive heart failure, and cerebrovascular disease, had a quarterly assessment dated 12/15/23 completed, but the subsequent assessment dated 03/15/24 was still in progress as of 04/03/24. The MDS coordinator confirmed that the assessment was not completed on time. Similarly, Resident #14, with diagnoses including dementia, schizoaffective disorder, and auditory hallucinations, had a quarterly MDS assessment with an ARD date of 03/12/24 that was still in progress as of 04/02/24. The MDS coordinator acknowledged that this assessment was also not completed and submitted on time.
Failure to Submit Assessment Data Timely
Penalty
Summary
The facility failed to ensure assessments were encoded and submitted to CMS within seven days of completion for one of the 13 residents whose assessments were reviewed. Resident #16, who had diagnoses including urinary tract infection and cellulitis, had a quarterly assessment completed on 02/27/24, but it was not submitted until 04/03/24. During the survey, the resident was observed in a manual wheelchair and mentioned they had been receiving an antibiotic for cellulitis but were unsure if they were still taking it. The MDS coordinator stated that someone at the corporate offices submitted the assessment on 04/03/24 and did not know why it had not been submitted within the required timeframe.
Failure to Develop Discharge Summary
Penalty
Summary
The facility failed to develop a discharge summary for a resident, including a recapitulation of the resident's stay, a reconciliation of the resident's medications, and a post-discharge plan of care. The resident had diagnoses including a fracture of the right fibula, osteoarthritis, chronic stage four kidney disease, and diabetes. An admission assessment documented the resident was cognitively intact. A discharge assessment indicated the resident was discharged to another facility in a different state. However, the MDS coordinator confirmed that the discharge summary was not documented in the nursing notes, and there was no summary of the resident's stay, interventions, or medication reconciliation.
Failure to Notify Physician and Implement Interventions for Weight Loss
Penalty
Summary
The facility failed to ensure the physician was notified of significant weight loss and did not implement interventions to maintain or prevent further weight loss for a resident diagnosed with tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis. The resident's care plan indicated that supplements or alternates should be offered if the resident ate less than 50% of meals or refused meals. Despite a dietary order for a house supplement every day shift for weight loss, the resident experienced a weight loss from 145.2 lbs to 137.4 lbs. Observations on multiple occasions showed the resident eating without being offered the prescribed supplements. Additionally, the MDS Coordinator confirmed that the physician was not notified of the significant weight loss.
Failure to Supervise Nutritional Issues by Physician
Penalty
Summary
The facility failed to ensure that a resident's nutritional issues were supervised by a physician, leading to a significant weight loss. The resident, who had diagnoses including tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis, was admitted with a care plan that included offering supplements if the resident ate less than 50% of meals or refused meals. Despite a dietary order for a house supplement every day shift for weight loss, the resident's weight dropped from 145.2 lbs to 137.4 lbs over a month. Observations on multiple occasions showed the resident eating without being offered the prescribed supplement. Additionally, the MDS Coordinator confirmed that the physician was not notified of the significant weight loss, indicating a lapse in communication and adherence to the care plan.
Facility Failed to Maintain Ice Machine Sanitation
Penalty
Summary
The facility failed to maintain an ice machine in a sanitary condition. During an observation, a staff member wiped the inside of an ice machine located in an employee-only hallway next to the kitchen, and the cloth came back with a black substance. The Director of Nursing (DON) confirmed that all 44 residents received ice from this machine. The facility's Sanitation policy, dated November 2022, required the food service area to be maintained in a clean and sanitary manner. The Dietary Manager (DM) stated that the ice machine was cleaned once every six months. The administrator provided documentation of cleanings for two ice machines, dated December 29, 2023, and January 31, 2024, but no other documentation was available. The DM later stated that the dirty ice machine had been turned off and the second machine had not been working for several weeks and was due for repair. The facility did not monitor the ice machines for cleanliness on a schedule and did not document inspections of the ice machines.
Failure to Conduct Regular Bed and Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of resident beds and did not inspect beds for safety prior to the attachment and use of bedrails for three residents. The facility's policy, dated August 2022, required bed frames, mattresses, and bed rails to be checked for compatibility and size before use, and for maintenance staff to routinely inspect all beds and related equipment. However, observations and interviews revealed that these inspections were not being performed. Resident #16, with severe cognitive impairment, was observed with an assist bar attached to their bed. Resident #23, with intact cognition, had half-size bed rails on each side of their bed and was unaware of any safety assessments or inspections. Resident #146, also with intact cognition, had side rails attached to their bed and did not recall any assessments or inspections prior to their use of the bed. The Maintenance Supervisor confirmed that they had not been informed about the need for routine inspections or pre-use inspections of bed rails and had not conducted any such inspections. The Director of Nursing (DON) acknowledged that the facility had not been following the policy regarding bed and bed rail inspections. The report documented that 17 residents at the facility used bed rails, and the facility had a total of 44 residents. The lack of adherence to the policy and the absence of routine inspections posed potential safety risks for the residents using bed rails. The DON stated that they would ensure compliance with the policy in the future, but no corrective actions were documented in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure physician orders were followed for wound care for Resident #7, who had a pressure ulcer of the sacral region and diabetes mellitus. The physician's order dated 02/20/24 required the sacral wound to be cleaned with normal saline and a wound vac to be applied. However, on 03/26/24, the wound vac was observed at the resident's bedside but not in use. The resident reported that the wound vac had been off since Saturday because the nurse on duty was unfamiliar with its operation and did not return to reapply it. LPN #1 confirmed that the wound vac sometimes comes off or gets soiled and that the nurse on duty might not be able to reapply it. Additionally, LPN #1 was unsure if the wound vac was supposed to have been discontinued on 03/14/24 and stated they would contact the wound physician for clarification. The DON stated that the nurse accompanying the wound physician was responsible for entering orders into the resident's medical record, and the charge nurses were responsible for ensuring the wound vac was in place and functioning properly. It was later confirmed that the wound vac had not been discontinued until 03/26/24. CNA #1, who provided care for Resident #7 on 03/26/24, also confirmed that the wound vac had not been in place all day and mentioned that it frequently came off. The DON reiterated that the charge nurses were responsible for ensuring the wound vac was in place and functioning properly. This failure to follow physician orders and ensure proper wound care led to a deficiency in the care provided to Resident #7.
Failure to Implement Abuse Policy for Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse policy for verbal abuse in the case of a resident with impulse disorder and dementia. The resident exhibited multiple instances of verbally abusive behavior towards other residents, including cursing, yelling, making derogatory comments, and threatening physical harm. Despite these documented behaviors, the Director of Nursing (DON) and the administrator did not classify these incidents as verbal abuse and therefore did not implement the facility's abuse policy. The DON and the administrator reviewed the incidents as behavioral issues rather than abuse, leading to a failure in policy implementation. The resident's care plan noted their tendency to become moody and verbally abusive, with interventions suggested to manage these behaviors. However, the facility's staff, including the DON and the administrator, did not follow the abuse policy despite multiple documented incidents of verbal abuse. The DON admitted to lacking experience with verbal abuse and misclassifying the incidents, while the administrator acknowledged the oversight and failure to implement the abuse policy. This resulted in a failure to protect other residents from verbal abuse by the resident in question.
Failure to Report Verbal Abuse Incidents
Penalty
Summary
The facility failed to ensure allegations of verbal abuse were reported to the administrator and the Oklahoma State Department of Health (OSDH) for one resident who was reviewed for abuse. The facility's abuse policy required employees to report all incidents of possible abuse immediately to their supervisor, who would then report to the administrator or person on call. The policy also mandated that the nursing facility must report allegations to OSDH immediately, but not later than two hours after the allegation is made. Despite this policy, multiple behavior notes documented incidents where Resident #6 exhibited verbally abusive behavior towards other residents, but there was no documentation that the administrator or Director of Nursing (DON) had been notified in some instances, and reports were not submitted to OSDH as required. Resident #6, who had diagnoses including impulse disorder and dementia, displayed a pattern of verbally abusive behavior towards other residents. Incidents included cursing, name-calling, and making derogatory comments. On several occasions, the behavior notes indicated that the administrator or DON were notified, but there were also instances where this notification was not documented. Interviews with staff revealed that while some reported incidents to the administrator or DON, they failed to document these notifications. The DON admitted that they had not reported the incidents to OSDH, acknowledging that they should have done so. The administrator also confirmed that they had not submitted reports to OSDH for the verbal abuse incidents involving Resident #6, indicating a failure to follow the facility's abuse reporting policy.
Failure to Provide Abuse Training Upon Hire
Penalty
Summary
The facility failed to ensure that staff received abuse training upon hire for four employees (three CNAs and one housekeeper) out of five employee files reviewed. The facility's abuse policy, dated 02/17/22, mandates that all new employees receive in-service training on abuse prohibition before working a shift. However, a review of the employee files for CNA #1, CNA #2, CNA #3, and housekeeper #1, who were hired between 11/11/23 and 01/04/24, revealed that they had not received the required abuse training. The Director of Nursing (DON) confirmed that the facility had not provided abuse training upon hire since the ownership change several months ago. The administrator also acknowledged that no employee abuse training had been provided since the new company took over in September 2023.
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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