Okemah Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Okemah, Oklahoma.
- Location
- 112 North Woody Guthrie, Okemah, Oklahoma 74859
- CMS Provider Number
- 375420
- Inspections on file
- 20
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Okemah Care Center during CMS and state inspections, most recent first.
A resident with bipolar, mood disorder, and schizoaffective disorder eloped from the facility. Although interventions were implemented following the incident, the care plan was not updated to reflect these changes. The administrator later confirmed that the care plan should have been revised.
The facility failed to use privacy curtains for two residents during care, leading to privacy breaches. One resident with cerebral palsy was observed uncovered in bed without adequate curtain coverage. Another resident with a pressure ulcer and dementia was exposed during pericare and wound care, with staff acknowledging the curtain should have been used.
The facility failed to complete required Braden skin assessments and weekly skin assessments for two residents. One resident with a Stage 4 pressure ulcer did not have documented assessments since April, despite being at high risk. Another resident, at risk for pressure ulcers, had incomplete and unsigned assessments, with no documentation since April. The facility's policy for weekly skin assessments was not followed, and a resident's heel condition was not documented.
The facility failed to monitor side effects of antidepressants for four residents, despite having a policy in place. A resident with depressive disorder was not monitored for side effects of Trazadone and Escitalopram. Another resident with recurrent depressive disorder was not monitored for Pristiq and Trintellix side effects. A third resident with mood disorder and anxiety was not monitored for Lexapro side effects, and a fourth resident with bipolar disorder was not monitored for Bupropion and Trazodone side effects. Interviews confirmed the lack of documentation for side effect monitoring.
The facility did not ensure the dietary manager was certified, as required by state regulations. The dietary manager, who started in March 2022, was enrolled in a certification course but had not taken the exam. This affected the food services for 42 residents.
The facility failed to maintain kitchen sanitation and food safety, affecting 42 residents. Observations revealed mold-like substances, unclean areas, unlabeled food items, and a malfunctioning dishwasher lacking sanitization fluid. Staff interviews highlighted gaps in cleaning schedules and supply ordering issues.
A facility failed to accurately document a resident's code status, showing them as a full code despite having a signed DNR. Staff interviews revealed inconsistencies in updating the code status list, with the last update occurring the previous year. This highlights a lack of a reliable system for maintaining current documentation.
The facility failed to maintain a clean and homelike environment, with unaddressed water spills and accumulated dirt and dead insects in common areas. Additionally, strong urine odors persisted in the rooms of two residents, with staff failing to take timely action to address these issues.
A resident in the facility did not have a comprehensive activity care plan, as required by facility policy. The resident expressed dissatisfaction with the lack of activities, noting that bingo occurred infrequently and that they often had nothing to do but watch TV. The activities calendar lacked specific times and locations, and staff confirmed that activities were infrequent. The facility's MDS coordinator admitted that activities were not care planned individually for all residents, contributing to the deficiency.
A facility failed to administer tube feeding bolus according to a physician's order for a resident with anorexia and cachexia. The resident's meal intake percentages, crucial for determining tube feeding administration, were inconsistently documented, leading to potential non-compliance with the physician's order. An LPN noted blanks in medical records for eating and fluid intake tasks, indicating incomplete or late documentation, which contributed to the deficiency.
The facility failed to ensure a medication error rate below 5% when a CMA did not instruct two residents to chew their prescribed 81 mg aspirin tablets, as required by physician orders. This was confirmed by a Corporate Nurse Consultant.
The facility failed to ensure proper PPE use during care for a resident with a Stage 4 pressure ulcer, as one CNA did not wear PPE while assisting with care. Additionally, a syringe used for tube feeding was improperly stored without a protective barrier, posing a risk of contamination. An LPN confirmed the syringe should have been covered and placed on a napkin to dry.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to update the care plan for a resident who had eloped, despite interventions being put in place following the incident. The resident, who had diagnoses including bipolar disorder, mood disorder, and schizoaffective disorder, eloped on 10/29/24. An incident report was documented on 10/30/24, noting the elopement and the implementation of new interventions. However, there was no documentation of these interventions in the resident's care plan. On 12/27/24, the administrator acknowledged that the care plan should have been updated.
Failure to Use Privacy Curtains for Resident Care
Penalty
Summary
The facility failed to ensure the use of privacy curtains for two residents, leading to a breach of privacy. Resident #9, diagnosed with cerebral palsy and severe intellectual disabilities, was observed on multiple occasions lying uncovered in bed without the privacy curtain being pulled. The curtain in the room did not extend fully, leaving the resident exposed. Staff, including a CNA and the Administrator, confirmed that the curtain did not provide adequate privacy, and the resident was exposed from the hallway. Resident #21, who had a pressure ulcer, dementia, and depressive disorder, was also observed without the privacy curtain being used during care. The resident was exposed to the hallway while receiving pericare and wound care from staff, including a CNA and an LPN. Despite having a roommate, the privacy curtain was not pulled during the care procedures. Staff acknowledged that the curtain should have been used during such treatments, indicating a failure to maintain resident privacy.
Failure to Complete Required Skin Assessments
Penalty
Summary
The facility failed to ensure that Braden skin assessments and weekly skin assessments were completed for two residents reviewed for wound care. Resident #21, who had a diagnosis of a Stage 4 pressure ulcer on the right buttock, did not have documented weekly skin assessments since April 19, 2024, despite being at high risk for pressure ulcers as per a Braden Scale assessment dated December 29, 2023. LPN #1, responsible for these assessments, admitted that they did not complete weekly skin assessments if the resident had outside wound care visits unless another issue was identified. The Director of Nursing confirmed that LPN #1 was responsible for completing and documenting these assessments in the computer. Resident #13, diagnosed with Alzheimer's disease and cognitive impairment, was also at risk for pressure ulcers according to a Braden Scale assessment. However, their skin assessments were incomplete, unsigned, and contained blanks. The last documented skin assessment was in April 2024, despite the resident having a healed wound as of March 28, 2024. The Corporate Nurse Consultant confirmed that the policy for weekly skin assessments and Braden assessments was not followed, and no skin assessments had been completed since April 2024. Additionally, Resident #13's left heel was observed to have dry flaky skin and a scabbed area, which was not documented in the nurse notes.
Failure to Monitor Antidepressant Side Effects
Penalty
Summary
The facility failed to monitor for side effects related to the use of antidepressants for four residents who were part of a sample reviewed for unnecessary medications. The facility's policy on monitoring antidepressants was not followed, as there was no documentation of side effect monitoring for the residents involved. Resident #1, diagnosed with depressive disorder and depression, was prescribed Trazadone and Escitalopram Oxalate, but there was no documentation of side effect monitoring for several months. Similarly, Resident #3, with recurrent depressive disorder, was prescribed Pristiq and Trintellix, but their treatment administration records lacked documentation of side effect monitoring, despite the care plan specifying the need to monitor for specific side effects. Resident #32, diagnosed with unspecified mood disorder and anxiety, was prescribed Lexapro and Lamotrigine, but there was no documentation of side effect monitoring for Lexapro. Resident #40, with bipolar disorder, was prescribed Bupropion and Trazodone, but side effect monitoring was not documented for these medications. Interviews with the Corporate Nurse Consultant and an LPN confirmed the lack of side effect monitoring, which was supposed to be documented on the treatment administration record. This oversight indicates a failure to adhere to the facility's policy on monitoring antidepressant side effects, potentially leading to the administration of unnecessary drugs.
Non-compliance with Dietary Manager Certification
Penalty
Summary
The facility failed to ensure that the designated dietary manager met the state requirements for dietary management. The dietary manager, who began their role in March 2022, was not certified as a dietary manager. Documentation showed that the dietary manager was enrolled in a course for certification, with a transaction dated March 2022 and module grades recorded in December 2022. However, there was no evidence that the dietary manager had taken the certification exam. The administrator confirmed that the dietary manager had not completed the certification process. This deficiency affected the food and nutrition services provided to 42 residents receiving meals from the kitchen, out of the 43 residents residing in the facility.
Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a manner that promotes food safety and sanitation, affecting 42 residents who received services from the kitchen. Observations during an initial tour revealed several deficiencies, including a black substance along the back trim of the sink, a black wet substance on the floor under the sink and dishwasher, and a rusty metal box overflowing with suds. Additionally, there were two metal knives and a blue-handled wrench on the floor next to canned goods, and debris was found under the shelf with cans. Food items such as desserts and bread were not labeled or dated, and milk containers lacked opening dates. A three-tiered cart had food debris on all corners and shelves, and the dishwasher temperature did not reach the required 120 degrees, with no dishwashing wash or sanitation fluid available. Interviews with staff revealed gaps in the cleaning schedule and a lack of awareness regarding the need to date opened bread. The dietary manager acknowledged the presence of mold-like substances and unclean areas under the dishwasher. The dishwasher was tested twice, showing no sanitization detected on the strip, and the sanitizer and wash buckets were found empty. The dietary manager mentioned issues with ordering supplies from the dishwasher company, leading to delays and back orders, which contributed to the lack of necessary cleaning agents.
Inaccurate Code Status Documentation for Resident
Penalty
Summary
The facility failed to maintain an accurate process for identifying a resident's code status, specifically for one resident among ten reviewed. The resident in question had a signed Do Not Resuscitate (DNR) order dated May 13, 2022, which was documented in their hard chart. However, an undated form titled 'Full Code' was observed on the inside of a cabinet door at the nurse's station, incorrectly indicating that the resident was a full code. This discrepancy highlights a failure in the facility's process to ensure that the resident's code status was accurately communicated and updated. Interviews with staff revealed inconsistencies in the understanding and execution of the process for updating code status lists. An LPN stated that the list was updated monthly or every other month, while the Director of Nursing confirmed the resident's DNR status but acknowledged the incorrect full code listing. A corporate nurse consultant admitted that the list was not accurate and should be updated with any change in the care plan. The failure to update the list since the previous year further underscores the lack of a reliable system to ensure accurate and current documentation of residents' code statuses.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by observations of unclean conditions in the dining and television rooms. On multiple occasions, a puddle of water was observed on the floor near a coke machine in the television room, posing a potential hazard to residents, including one in a wheelchair. Despite being aware of the water, staff members, including CNAs and the dietary manager, did not take action to clean the area or notify housekeeping. Additionally, the windows in both the dining and television rooms were found to have accumulated dust, dirt, dead flies, and mouse droppings, which were not addressed by the staff. The facility also failed to prevent lingering urine odors in the rooms of two residents. Strong urine odors were noted in the hallway and in the rooms of these residents on several occasions. In one instance, a corporate nurse consultant identified a wet brief in the trash as the source of the odor in one resident's room. Despite these observations, the odors persisted over multiple days, indicating a lack of timely and effective cleaning and maintenance practices by the facility staff.
Failure to Develop Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for activities for a resident, identified as Resident #38, who was reviewed for activities. The facility's policies require that care plans incorporate goals and objectives to achieve the resident's highest level of independence and that these plans are reviewed and revised at least quarterly. However, it was found that Resident #38 did not have an activities care plan, and the MDS coordinator confirmed that activities were not care planned individually for all residents, only for specific cases such as level 2 PASRR, bedridden, or during COVID isolation. Observations and interviews revealed that Resident #38 expressed dissatisfaction with the lack of activities, stating that there was nothing to do but sit, sleep, and watch TV. The resident mentioned that bingo occurred only once a month and that they occasionally went out for a van ride twice a year. The activities calendar lacked times and locations for the activities, and the activity director admitted to forgetting to include these details. The activity director also stated that Resident #38 declined activities and preferred watching TV, participating in bingo 2-3 times a month depending on their mood. Further interviews with staff, including a CNA and the activity director, indicated that activities were infrequent, occurring maybe once a week, and that the resident sometimes participated in bingo. The administrator acknowledged the lack of specific times on the activities calendar and noted that some listed activities, such as a podiatrist visit, were not actual activities. Despite these issues, there were no complaints from residents about the activities. The corporate nurse consultant stated that they would expect each resident to have an activity care plan, highlighting the deficiency in the facility's care planning process.
Failure to Administer Tube Feeding According to Physician's Order
Penalty
Summary
The facility failed to administer tube feeding bolus according to the physician's order for a resident diagnosed with anorexia and cachexia. The resident had a physician's order for Osmolite to be given four times a day, with specific instructions to hold the feeding if the resident consumed more than 50% of their meal. However, discrepancies were found in the documentation of the resident's meal intake percentages, which were crucial for determining whether the tube feeding should be administered. The lack of documentation on specific dates in May 2024, as noted by the Corporate Nurse Consultant, indicated that the facility did not consistently record the resident's meal intake, leading to potential non-compliance with the physician's order. Additionally, the facility's policy on intake, measuring, and recording, which required accurate documentation of fluid intake, was not adhered to. An LPN acknowledged the presence of blanks in the medical records for tasks related to eating and fluid intake, suggesting that either the tasks were not completed or were documented late. This lack of documentation and adherence to the facility's policy contributed to the failure in providing appropriate pharmaceutical services to meet the resident's needs, as required by the physician's orders.
Medication Administration Error
Penalty
Summary
The facility failed to maintain a medication error rate below 5% as observed during a medication administration review. Two residents, one with hypertension and mood disorder and another with atherosclerosis of native arteries of extremities, were involved in the deficiency. Both residents had physician orders for an 81 mg chewable aspirin tablet to be administered once daily. However, during medication administration, the Certified Medication Aide (CMA) did not instruct either resident to chew the aspirin tablet as required. This oversight was confirmed by a Corporate Nurse Consultant, who stated that the medication should be chewed unless otherwise directed by a physician.
Inadequate PPE Use and Improper Syringe Storage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) during care provision for a resident with a Stage 4 pressure ulcer, dementia, and depressive disorder. During an observation, two CNAs were present in the room with the resident, who was exposed without privacy. One CNA did not wear PPE while assisting with positioning and changing the resident's shorts, despite the requirement for enhanced barrier precautions (EBP) for residents with indwelling medical devices or wounds. The CNA admitted to not receiving training on PPE use for EBP at the facility, although they had been trained at a previous job. Additionally, the facility failed to store a syringe used for tube feeding in a manner that prevents cross-contamination for a resident with unspecified congestive heart failure. Observations revealed a tube feeding syringe placed on a dresser without a protective barrier, with the plunger end exposed. An LPN confirmed that the syringe should have been covered and placed on a napkin to dry, and that food should not have been left in the room. The LPN acknowledged that the syringe was improperly left open, posing a risk of contamination.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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