Oak Hills Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jones, Oklahoma.
- Location
- 1100 West Georgia, Jones, Oklahoma 73049
- CMS Provider Number
- 375117
- Inspections on file
- 39
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 4 (2 serious)
Citation history
Health deficiencies cited at Oak Hills Living Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of wandering risk was able to leave the secured dementia unit by exiting through a window and crawling under a fence. Despite care plan interventions for increased visual checks and window alarms, staff failed to conduct required rounds, with some staff admitting to not checking on the resident during the night shift and being observed sleeping. The resident was found several miles away with minor injuries, indicating a failure in supervision and neglect.
A resident with moderate cognitive impairment and a history of elopement risk was not provided with the increased supervision and visual checks outlined in their care plan. Staff failed to perform required rounds, allowing the resident to leave the facility unsupervised, resulting in the resident being found by police and transported to the hospital with minor injuries.
A resident with a history of depression and anxiety, and with intact cognition, was subjected to verbal abuse by a certified dietary manager after a request for assistance escalated into a mutual exchange of profanity. The incident involved the resident throwing a cup and the staff member responding inappropriately, with the event confirmed through interviews and camera footage.
Two residents were involved in a physical altercation in a common area, during which one resident, who had moderate cognitive impairment, was beaten and sustained a fractured femur after falling. The aggressor, also with cognitive and psychiatric diagnoses, struck and threw objects at the other resident before staff intervened. Prior to the incident, staff had not received behavior management training, and the facility's abuse prevention policy was not effectively implemented, leading to the deficiency.
A resident with bipolar disorder and anxiety discovered unauthorized transactions on their SSI debit card after a CNA borrowed it under false pretenses. The card was used for unauthorized purchases, including a nail salon and ATM withdrawals. The facility's administrator confirmed the misappropriation, which is considered a form of abuse.
A resident was threatened by another resident with a history of aggressive behavior exacerbated by alcohol consumption. Despite staff intervention, the incident was not reported as abuse according to facility policy. The facility failed to implement new interventions or adequately report previous incidents, contributing to an Immediate Jeopardy situation.
The facility failed to provide ordered wound care for two residents, resulting in harm to one. A resident with multiple diagnoses did not receive prescribed care for a gluteal fold wound, which worsened due to lack of treatment. Additionally, care coordination was poor, with missing documentation and communication failures. Another resident did not receive daily wound care as ordered, with documentation gaps confirming the deficiency.
The facility failed to ensure proper sanitization of dishes due to inadequate chemical levels in the low temperature dishwasher. The Dietary Manager discovered the sanitizer was empty and, despite refilling it, could not achieve the required chloride levels. Staff continued using the dishwasher without proper sanitization checks, and inappropriate chemical strips were used to measure sanitizer levels. The administrator eventually shut down the dishwasher and switched to paper products.
The facility failed to investigate allegations of abuse and aggression involving two residents. One resident, with schizophrenia, made inappropriate propositions to others, while another, with bipolar disorder, exhibited aggressive behavior and threatened others. Despite these incidents, no investigations or incident reports were completed, as confirmed by the DON and regional staff.
The facility failed to complete timely assessments for two residents. One resident's last assessment was an annual assessment, and no discharge assessment was completed after their death. Another resident's last assessment was an admission assessment, and no discharge assessment was completed despite billing cessation. Staff confirmed the assessments were not completed within the required timeframe.
The facility failed to ensure proper infection control during wound care for two residents, with an LPN and RN not following hand hygiene and glove-changing protocols. Additionally, infection control logs for residents with staph infections were incomplete, lacking critical information such as infection sites and organism identification.
A facility failed to implement its antibiotic stewardship program for a resident with a staph infection. The resident was prescribed clindamycin without a culture to confirm the infection, contrary to facility policy. The infection control log lacked documentation of the organism and resolution date. The DON and ADON were unclear about their roles in tracking infections, and the wound NP identified potential infection sources within the facility.
A resident with chronic respiratory conditions was observed self-administering medication without a current physician's order or recent safety assessment. The care plan was outdated, and staff failed to supervise the resident during nebulizer treatments, contrary to facility policy. Interviews revealed a lack of evaluation for self-administration, and the MDS coordinator confirmed the absence of a current order.
A facility failed to accurately document medical records for a resident with chronic pain syndrome and anxiety disorder, who required daily wound care for a shoulder wound. Despite physician orders for weekly skin assessments and daily wound care, two assessments documented no open areas. An RN observed a wound on the resident's shoulder, contradicting the assessments. The DON noted that documentation accuracy was subjective, based on staff observations.
A facility failed to provide and document wound care as ordered for a resident with pressure ulcers. The resident had an unstageable pressure injury on the left heel and a deep tissue pressure injury on the right lateral heel. Physician orders for specific treatments were not documented as completed on several occasions, leading to uncertainty about whether the treatments were performed. Interviews with the ADON revealed that staff did not document the completion of treatments, contributing to the deficiency.
A resident with respiratory conditions was observed self-administering a nebulizer treatment without staff supervision, contrary to facility policy requiring licensed staff to administer medications and supervise treatments. The resident had no physician's order to self-administer, and staff confirmed they were not evaluated for this capability.
A resident with vasculitis and other conditions developed wounds on their legs and feet, but the facility failed to notify the physician as required. An LPN provided wound care without proper documentation or physician notification, misunderstanding the facility's policy. The DON and regional clinical director confirmed the policy was not followed, resulting in a deficiency.
The facility failed to maintain safe and clean shower rooms, with issues such as rust stains, peeling paint, and improper storage in hall 500, a broken shower chair and dirty laundry in hall 100, and a cold, powerless shower room in hall 600. Staff acknowledged these problems, and the administrator planned to remodel the affected areas.
The facility did not implement its QAPI program for incident reporting in a case of alleged sexual abuse involving a resident. Despite policies requiring evaluation and analysis to prevent recurrence, the incident report lacked documentation of QAPI or prevention plans. The administrator confirmed no such programming was completed or planned.
A medication cart was found unlocked and unattended, contrary to the facility's policy requiring all medication storage compartments to be locked when not in use. An LPN confirmed the policy, highlighting a failure to adhere to the established procedures.
The facility failed to provide a clean and homelike environment for two residents. A resident with diabetes was found with soiled linens due to incontinence, and the CNA noted a shortage of bottom sheets. Another resident with cellulitis had an unmade bed, contrary to the facility's policy. These observations highlight lapses in maintaining cleanliness and comfort.
The facility failed to prevent infection spread by allowing soiled linen to be placed on the floor in a resident's room. CNA #1 left the linens on the floor due to a full linen barrel, intending to return later. CNA #2 confirmed that the protocol was to bag and transport linens to the dirty utility room if the barrel was full.
A facility failed to report an alleged abuse incident involving a resident with alcoholic hepatic failure and bipolar disorder. The resident was involved in a disruptive event, attempting to hit another individual and making threatening remarks. Despite police intervention, no incident report was filed with the OSDH, and the administrator was unaware of the incident.
A facility failed to conduct laboratory tests as ordered by a physician for a resident with hypokalemia and hyponatremia. The resident had a monthly order for a CMP, but there was no documentation of the test being conducted in three separate months. The DON confirmed the oversight during an interview.
The facility failed to maintain an ice machine in a sanitary condition, with white and brown residue observed on its surfaces. The CDM claimed daily cleaning but acknowledged the presence of coffee and hard water stains. A resident noted the need for more frequent cleaning.
A resident with paranoid schizophrenia and other conditions was placed on a locked unit without proper assessment or documentation, leading to their departure against medical advice. The facility failed to follow its policy on involuntary seclusion and unauthorized restraint.
Failure to Prevent Elopement Due to Inadequate Supervision and Rounds
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident who required increased visual checks. The resident, who had a diagnosis including Wernicke's encephalopathy and a moderate cognitive impairment (BIMS score of 8), was identified as a wandering risk and had previously expressed a desire to leave the facility. Despite being placed on a secured dementia unit and having a care plan that called for increased visual checks and window alarms, the resident was able to exit the facility by going out a window and crawling under a fence. The window alarms were not yet installed at the time of the incident, and staff monitoring was insufficient, as rounds were not conducted as required. Staff interviews and record reviews revealed that the resident was not checked on regularly during the night shift, with some staff admitting to only seeing the resident at the beginning of the shift or not conducting rounds at the required intervals. Video review confirmed that staff were not performing rounds and were observed sleeping during the shift. The resident was found by police several miles from the facility and returned with minor abrasions and bruising. The facility's policy required adequate staffing and supervision at all times, which was not maintained, resulting in neglect of the resident.
Failure to Implement Elopement Interventions Leads to Resident Leaving Facility
Penalty
Summary
The facility failed to implement care plan interventions for a resident with a known history of elopement risk. The resident, who had Wernicke's encephalopathy and moderate cognitive impairment as indicated by a BIMS score of 8, was assessed as a wandering risk and was independent with ambulation. The care plan, revised prior to the incident, indicated the resident was insisting on leaving and had been placed on a secured dementia unit with increased visual checks. However, staff did not consistently perform or document the required rounds, with one CMA admitting to not conducting rounds at 3:00 a.m. and being unsure if any other rounds were done, instead spending most of the shift at the nurse's station watching television. The facility's policy required routine checks at least every two hours and more frequently for high-risk residents, but this was not followed for the resident in question. As a result of these lapses, the resident was able to leave the facility unsupervised and was later found by police on the side of the road, complaining of leg pain and weakness, and was transported to the hospital. Upon return, the resident was noted to have healing abrasions on both shins. Interviews with staff and review of video footage confirmed that staff did not follow the care plan interventions or facility policy for increased supervision and rounding for residents at high risk for elopement.
Resident Exposed to Verbal Abuse by Dietary Manager
Penalty
Summary
A deficiency occurred when a resident with a history of major depressive disorder and anxiety disorder, and with intact cognition, was not protected from verbal abuse by a staff member. The incident began when the resident requested assistance from the certified dietary manager to have their cup washed. The dietary manager responded by asking the resident to wait, which led to the resident becoming upset and using profanity toward the staff member. The certified dietary manager then reciprocated by using profanity toward the resident. During the altercation, the resident threw a cup toward the employee, and staff intervened to stop the situation. No physical injuries were noted to the resident at the time. Further investigation, including interviews and review of facility camera footage, confirmed that verbal abuse occurred. The resident reported that the certified dietary manager grabbed their hand and hit their arm with the door, describing the interaction as annoying and rude. A dietary aide who witnessed the event confirmed that both the resident and the dietary manager used inappropriate language, with the resident initiating the use of profanity. The incident was substantiated as abuse following the facility's investigation.
Failure to Protect Resident from Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse inflicted by another resident, resulting in a serious injury. Two residents were involved in a physical altercation in a common area, during which one resident was beaten by the other. The assaulted resident, who had moderately impaired cognition and was independent with sit-to-stand transfers, lost balance during the altercation, fell to the floor, and sustained a displaced intertrochanteric fracture of the left femur, requiring surgical repair. Documentation indicates that the resident was sitting in a wheelchair in the TV area when the other resident approached and began hitting them, leading to the fall and subsequent injury. The resident who initiated the altercation had diagnoses including anxiety and major depressive disorder, with moderate cognitive impairment. During the incident, this resident was observed striking the other resident multiple times and throwing objects. Staff intervened after the altercation had already escalated, and emergency services were called. The resident who was assaulted was transported to the emergency room for evaluation and treatment of the leg fracture, while the aggressor was later transferred to a mental health facility for psychiatric evaluation and treatment. Prior to the incident, there was no evidence of behavior management training for staff, and the facility's abuse and neglect policy was not effectively implemented to prevent the altercation. The incident was documented in nursing notes and care plans, and interviews confirmed that staff had not received relevant training before the event. The deficiency centers on the facility's failure to ensure the safety of residents from physical abuse by another resident, resulting in significant harm.
Misappropriation of Resident's Funds by CNA
Penalty
Summary
The facility failed to protect a resident's personal funds from misappropriation, resulting in a deficiency related to abuse. The incident involved a resident diagnosed with bipolar disorder and anxiety, who discovered unauthorized transactions on their SSI debit card. The resident reported that a CNA had borrowed the card under the pretense of using it for gas and groceries, but instead, the card was used for various unauthorized purchases, including a nail salon, gas station, ATM withdrawals, and a cell phone carrier. The resident confirmed that they did not authorize these transactions, nor did they receive the services or goods associated with them. The facility's administrator acknowledged the issue when the resident checked their card transactions using a medication aide's phone. The administrator confirmed that the facility's policy for misappropriation of funds is termination, as it is considered a form of abuse. Despite the facility's policy, the incident highlights a failure to prevent the wrongful use of a resident's belongings or money, as evidenced by the unauthorized use of the resident's SSI debit card by a staff member.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an Immediate Jeopardy situation. On December 25, 2024, Resident #18 was threatened by Resident #54, who brandished a railroad track nail with the intent to attack. Despite the intervention of staff, including a nurse and a nurse aide, the incident was not reported as abuse according to the facility's policy. The Director of Nursing (DON) did not consider the event as abuse, citing that the residents were on different halls, and no documentation was made at the time of the incident. Resident #54 had a history of aggressive behavior, often exacerbated by alcohol consumption. Previous incidents were documented where Resident #54 exhibited belligerent and threatening behavior towards other residents and staff, often while intoxicated. Despite these documented behaviors, the facility did not implement new interventions or adequately report these incidents as required by their policies. The DON and other staff members failed to recognize the pattern of behavior as abuse, and no incident reports were filed for several occurrences. The facility's policies on abuse and neglect, as well as incident reporting, were not followed. The DON and other staff members did not take appropriate action to ensure the safety of Resident #18 and others, as evidenced by the lack of incident reports and failure to implement necessary interventions. The facility's inaction and failure to adhere to their policies contributed to the Immediate Jeopardy situation, as the safety and well-being of residents were compromised.
Deficiencies in Wound Care Management
Penalty
Summary
The facility failed to provide appropriate wound care as ordered for two residents, leading to actual harm in one case. Resident #12, who had multiple diagnoses including vasculitis and MASD, did not receive the prescribed wound care for a left gluteal fold wound, which increased in size due to the lack of treatment. The physician's order for this wound care was not transferred to the MAR/TAR for December 2024 or January 2025, and there was no documentation that the care was provided during this period. Additionally, the facility did not obtain an order before providing wound care to new wounds on Resident #12's feet, and staff failed to notify the nurse when a dressing became dislodged. Resident #12's condition was further complicated by a lack of coordination in care. The 24-hour report book did not document the new wound on the resident's right thigh, and there was no communication about the wounds on the resident's feet. LPN #2, who was responsible for the resident's care, admitted to not documenting the findings of the resident's skin condition after an incident involving the removal of socks by a hospice aide. The LPN also failed to obtain a physician's order for wound care provided to the resident's feet until several days after the incident. Resident #57 also experienced a deficiency in wound care. The resident had a physician's order for daily wound care on a left shoulder wound, but the care was not documented as provided on one occasion. The resident reported that the dressing change did not always happen as ordered, and the January 2025 TAR confirmed that the wound care was not documented on a specific date. The DON acknowledged that if the documentation was blank, it indicated that the care was not provided.
Inadequate Sanitization in Low Temperature Dishwasher
Penalty
Summary
The facility failed to ensure that the low temperature dishwasher had the appropriate amount of chemicals to sanitize dishes, as observed during three out of four checks of the dishwasher's chemical sanitization levels. The Dishwashing by Use of a Machine policy required checking the machine during each procedure to ensure proper dispensing of detergent, wetting agent, and chemical sanitizer. However, during an observation, the Dietary Manager (DM) found that the chemical sanitizer did not register on the chemical strip, indicating it was empty. Despite adding sanitizer and priming the dishwasher, the DM was unable to achieve the required 50 to 100 parts per million (ppm) of chloride. The DM admitted to not checking the sanitizer level that morning and planned to call the dishwash company for assistance. Despite the issue, staff continued to use dishes processed through the low temperature dishwasher without sanitizing them in the sink, as initially suggested by the DM. Further attempts to measure the sanitizer levels using different chemical strips provided by maintenance were unsuccessful, as the strips were not appropriate for checking chloride levels in a low temperature dishwasher. The maintenance director and administrator were informed of the inappropriate strips, and the administrator was later notified that the dishwasher had been used for over 24 hours without proper sanitization checks. Consequently, the administrator decided to shut down the dishwasher and switch to using paper products until the issue was resolved.
Failure to Investigate Allegations of Abuse and Aggression
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents. Resident #18, diagnosed with unspecified schizophrenia, was reported to have made inappropriate sexual propositions to other residents. Despite the admission of these actions by Resident #18, there was no documentation of an investigation being completed for the incident. The Director of Nursing (DON) and the regional nurse confirmed that no incident report was done. Resident #54, with diagnoses including bipolar and major depressive disorder, exhibited aggressive and threatening behavior while intoxicated. This resident was involved in multiple incidents, including threatening other residents and staff, and brandishing a railroad track nail with the intent to attack Resident #18. Despite these serious incidents, there was no documentation of investigations being completed. The DON and the regional director of client care confirmed that no incident reports were filed, and the incidents were not reported to the state agency as required by the facility's policy.
Failure to Complete Timely Resident Assessments
Penalty
Summary
The facility failed to ensure timely completion of resident assessments for two residents. For Resident #67, the last assessment was an Annual Resident Assessment dated 8/23/24, and there was no discharge assessment completed despite the resident's death in the facility on 9/06/24. The billing census indicated that billing had stopped on 9/26/24, but the required discharge assessment was not completed within 14 days of the discharge. Similarly, for Resident #98, the last assessment was an Admission Resident Assessment dated 8/12/24, and there was no discharge assessment completed even though billing had stopped on 8/26/24. MDS #1 confirmed that the discharge assessment for Resident #98 was not completed within the required 14-day timeframe, and there was no reason provided for this omission. LPN #5 also acknowledged that both discharges had not been completed within the required time frame.
Infection Control Deficiencies in Wound Care and Documentation
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for two residents. One resident with multiple wounds, including vasculitis and MASD, was observed receiving wound care from an LPN who did not follow proper hand hygiene and glove-changing protocols. The LPN used the same gauze to clean wounds multiple times, did not sanitize hands between glove changes, and used a resident's personal marker without sanitizing hands. Additionally, the resident's urinary catheter bag was improperly stored on the floor, exposing it to potential contamination. Another resident with a wound on the left shoulder did not receive wound care as ordered on specific days. An RN performed wound care without changing gloves or sanitizing hands after cleaning the wound and before applying a clean dressing. The resident expressed concerns about the inconsistency in receiving wound care as prescribed. The facility also failed to maintain accurate infection control logs for residents with staph infections. The logs lacked essential information such as the site of infection, organism identification, and resolution dates. The facility's infection control map did not identify organisms of infection, hindering the ability to identify trends and address potential outbreaks effectively.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively for a resident with a staph infection. The resident, who had a history of schizoaffective disorder and an unspecified open wound on the right ankle, was prescribed clindamycin without a culture being performed to confirm the presence of a staph infection. The facility's policy required that antibiotics be prescribed based on pathogen susceptibility, but this was not adhered to as the wound NP diagnosed and treated the infection without laboratory confirmation. The infection control log also lacked documentation of the organism present and the date the infection was resolved. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were involved in tracking infections, but there was a lack of clarity and transition in responsibilities. The DON admitted that the usual process for suspected infections involved culturing wounds, which was not done in this case. The wound NP identified potential sources of infection within the facility, such as a couch and coffee machine, which were addressed by cleaning. However, the facility's failure to follow its antibiotic stewardship policy and the absence of a culture to guide antibiotic therapy contributed to the deficiency.
Failure to Revise Care Plan for Self-Administration of Medication
Penalty
Summary
The facility failed to revise the care plan for a resident who was observed self-administering medication without a current physician's order or a recent medication self-administration safety screen. The resident, diagnosed with chronic obstructive pulmonary disease and acute and chronic respiratory failure with hypoxia, had a care plan that documented a physician's order for unsupervised self-administration of Albuterol sulfate, initiated and revised in June 2022. However, there was no updated documentation or physician's order for the resident to self-administer medications, despite a new order for ipratropium-albuterol inhalation solution dated September 2024. During observations, the resident was seen using a nebulizer without staff supervision, contrary to the facility's policy that staff should remain with residents during nebulizer treatments. Interviews with staff, including an RN and the Director of Nursing, revealed that the resident had not been evaluated for self-administration of medications, and staff were expected to supervise the entire treatment. The MDS coordinator confirmed that the care plan was based on an outdated self-administration assessment and acknowledged the absence of a current order for self-administration in the resident's clinical record.
Inaccurate Medical Record Documentation for Resident with Wound Care Needs
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for one of the sampled residents, identified as Resident #57. This resident had diagnoses including chronic pain syndrome and anxiety disorder. A physician order dated December 9, 2024, required a weekly skin assessment on Tuesdays during the evening shift, and another order dated January 9, 2025, specified daily wound care for a wound on the resident's left shoulder. However, two skin assessments dated January 14, 2025, documented no open areas, despite the resident having a wound that required daily care. This discrepancy was noted during an observation on January 14, 2025, when RN #1 was seen removing a dressing from the resident's left shoulder, revealing a wound with minimal yellow drainage. LPN #3, who completed one of the skin assessments, stated that they had documented no open areas for Resident #57, despite the resident being treated for a wound on their left shoulder. The Director of Nursing (DON) explained that the nurse completing the skin assessment was responsible for the documentation and that the accuracy of the documentation was subjective, based on what the staff observed and recorded. This failure to accurately document the resident's medical condition and treatment needs led to a deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Document and Perform Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with pressure ulcers. The resident had an unstageable pressure injury on the left heel and a deep tissue pressure injury on the right lateral heel. Physician orders were in place for specific wound care treatments, including cleansing with normal saline, applying Santyl and calcium alginate, and covering with appropriate dressings. However, the treatment administration records (TAR) for December 2024 and January 2025 showed that the prescribed treatments were not documented as completed on several occasions, including the 31st of December and the 6th and 18th of January. Interviews with the Assistant Director of Nursing (ADON) revealed that the staff did not document the completion of wound care treatments in the TAR, leading to uncertainty about whether the treatments were actually performed. The ADON expressed hope that the treatments were done despite the lack of documentation. The failure to document and potentially perform the ordered wound care treatments contributed to the deficiency identified during the survey.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure that qualified staff were present during the administration of medication for a resident who was observed self-administering a nebulizer treatment. The facility's policy, revised in April 2019, states that medications should be administered safely and only by licensed individuals, and residents may self-administer medications only if deemed capable by their physician and care planning team. However, the administrator confirmed that no residents in the facility had orders to self-administer medications. Resident #57, diagnosed with chronic obstructive pulmonary disease and respiratory failure, was observed using a nebulizer without staff supervision. The resident reported performing breathing treatments every six hours and turning off the nebulizer themselves, although they did not keep the medication in their room. RN #1 confirmed that the resident had not been evaluated for self-administration and stated that staff were supposed to stay with the resident during treatments. The Director of Nursing and the administrator reiterated that staff should supervise residents during nebulizer treatments and ensure proper equipment maintenance.
Failure to Notify Physician of Resident's Skin Condition Change
Penalty
Summary
The facility failed to notify the physician when a resident experienced a change in their skin condition that required medical intervention. Resident #12, who had diagnoses including vasculitis, bipolar disorder, and schizoaffective disorder, developed wounds on their lower legs and feet. The facility's policy required documentation of physician notification for new or worsening wounds, but this was not adhered to in this case. On January 14, LPN #2 was observed providing wound care to Resident #12 and noted that the resident had dressings on their feet, which were not dated. LPN #2 admitted to completing a dressing change with a hospice nurse the previous day and stated that they could not touch the resident's feet until evaluated by wound care. The resident's feet had been raw and flaky, and the issue with the feet occurred on January 10. LPN #2 stated they had texted the hospice but were unsure if the doctor was notified, indicating a lapse in communication and documentation. The DON and regional clinical director confirmed that the facility's policy required notifying the provider for new wounds. However, LPN #2, a new nurse, misunderstood the policy and failed to notify the physician or obtain proper orders for the wound care provided. The regional clinical director stated that hospice should have been notified, but the process was not followed correctly, leading to a deficiency in care for Resident #12.
Deficiencies in Shower Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in three of the four shower rooms observed. In the hall 500 shower room, rust stains from safety bars could not be removed, and the floor paint was peeling. The room was also used for storage, with various items blocking access to the sink and toilet. A shower bench was found with an unattached seat plank. Housekeeper #1 and CNA #2 acknowledged these issues, with CNA #2 stating that residents still received showers there and that the room was due for remodeling. In the hall 100 shower room, a full dirty laundry basket was left on the floor, and the floor paint was peeling. A shower chair was missing a wheel, which was found inside the shower stall. CNA #3 confirmed the laundry basket should have been moved and that the floor had been in poor condition since April 2024. The administrator was aware of the storage issue in hall 500 and planned to remodel it first. Additionally, the hall 600 shower room had no power due to a broken exhaust fan, and the temperature was very cold, as noted by the maintenance director.
Failure to Implement QAPI for Incident Reporting
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) program for incident reporting in the case of an alleged sexual abuse incident involving one of the five sampled residents. The facility's policy on Abuse and Neglect required administration to evaluate and analyze occurrences to prevent future incidents. Additionally, the Internal Investigations Guidelines policy mandated a review at QAPI committee meetings for further actions. However, the incident report dated 11/20/24 lacked documentation of any QAPI or prevention plan. By 12/05/24, the final incident report still showed no evidence of QAPI or prevention programming being completed or planned. The administrator confirmed that no such programming was undertaken for the alleged incident of abuse and neglect.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that a medication cart was securely locked and attended to, as required by company policy and procedure. The Storage of Medications policy, dated November 2020, specifies that compartments containing drugs and biologicals, including medication carts, must be locked when not in use and should not be left unattended. On December 5, 2024, at 10:59 a.m., medication cart #1 on hall 500 was observed to be unlocked and unattended. At 11:05 a.m., an LPN confirmed that medication carts are supposed to be locked and attended to, indicating a lapse in adherence to the facility's medication storage policy.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, as observed during a survey. Resident #3, who has a diagnosis of diabetes, was found in bed with soiled linens, including a white fitted sheet and blanket with large brown rings. The CNA attending to Resident #3 acknowledged the resident's recent incontinence and noted that the bed linens had not been changed since the start of the shift due to a shortage of bottom sheets. The CNA also mentioned that there was an opportunity for staff to observe and change the bed linen earlier. Resident #2, diagnosed with cellulitis of the right lower limb, was found with an unmade bed during the survey. Despite the facility's policy that beds should be made in the morning, Resident #2's bed remained unmade for an extended period. CNA #1 confirmed that the bed should have been made earlier in the day, indicating a lapse in maintaining the expected standard of cleanliness and comfort for the resident.
Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices by allowing soiled linen to be placed on the floor in one of the five rooms observed. During an observation on October 31, 2024, at 3:07 p.m., bed linen, including a wet pad with brown fecal matter, a wet fitted sheet, a flat sheet, a blanket, and a gown, were found on the floor in a resident's room. CNA #1 admitted to changing a resident and leaving the soiled linens on the floor because the linen barrel was full and they intended to return after assisting another resident. CNA #2 confirmed that the protocol was to place dirty linens in a plastic bag and transport them to the dirty utility room if the barrel was full.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the Oklahoma State Department of Health (OSDH). The incident involved a resident with diagnoses of alcoholic hepatic failure without coma and bipolar disorder. A nursing note documented that the resident was involved in a disruptive incident where they were yelling, attempting to hit another individual, and smelled of alcohol. The resident was combative and made threatening remarks towards other residents, necessitating police intervention. Despite the severity of the incident, there was no documentation that an incident report was filed with OSDH. The facility's administrator, who is the designated abuse coordinator, was unaware of the incident until it was reviewed during the survey.
Failure to Conduct Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were conducted as ordered by the physician for a resident diagnosed with hypokalemia and hyponatremia. The resident had a physician's order for a Comprehensive Metabolic Panel (CMP) to be conducted monthly, starting from a specified date, to monitor their condition. However, there was no documentation indicating that the CMP was obtained in June, August, and September of the same year. During an interview, the Director of Nursing (DON) confirmed that the CMP was ordered monthly but acknowledged that the labs were not obtained as per the physician's orders.
Ice Machine Sanitation Deficiency
Penalty
Summary
The facility failed to maintain an ice machine in a sanitary manner, as observed during a survey. The ice machine, located by the dining room, was found to have white and brown residue on its silver aluminum body and black cup stand/drain. Additionally, the side of the ice machine by the wall also had similar residue. The Certified Dietary Manager (CDM) stated that the ice machine was cleaned daily and attributed the residue to coffee and hard water stains. Despite the CDM's efforts to clean the machine, the residue remained, particularly on the side of the machine, which the CDM admitted had not been cleaned. A resident also commented that the ice machine required more frequent cleaning.
Failure to Prevent Involuntary Seclusion
Penalty
Summary
The facility failed to ensure a resident was free from involuntary seclusion. Resident #1, who had diagnoses including paranoid schizophrenia, hypertension, and coagulation defect, was placed on a locked unit without proper assessment or documentation. The resident's quarterly assessment indicated intact cognition, and their care plan did not include interventions for placement on a locked unit. After an incident where the resident was accused of inappropriate behavior outside the facility, the AIT decided to move the resident to a locked unit without conducting a comprehensive assessment or obtaining clinical criteria from the IDT and physician. The resident expressed dissatisfaction with the move and eventually left the facility against medical advice (AMA). The AIT admitted that no assessment was completed, and there was no documentation to show that the placement was the least restrictive option. The facility's policy on involuntary seclusion and unauthorized restraint requires that residents on a secured unit must meet clinical criteria based on a comprehensive assessment, and interventions must meet the resident's psychosocial needs. However, in this case, the AIT moved the resident to a locked unit based solely on observed behaviors without following the required procedures. The CNO acknowledged that a psychological evaluation or doctor's order should have been obtained before making such a decision. This failure to follow protocol resulted in the resident feeling confined against their will and ultimately leaving the facility AMA.
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.
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.
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 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.
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 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.
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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