Oklahoma Memory Care Institute
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 3333 East 28th Street, Tulsa, Oklahoma 74114
- CMS Provider Number
- 375468
- Inspections on file
- 20
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Oklahoma Memory Care Institute during CMS and state inspections, most recent first.
Multiple cognitively impaired residents experienced abuse or suspected abuse when one resident was found on the floor in a room with another resident pulling at their pants and partially exposing their underwear behind a makeshift barricade; in a separate case, a resident who was usually cheerful became tense and frightened, later found with fingertip‑sized bruises and crescent‑shaped skin tears after a CMA overheard two CNAs speaking about the resident in a derogatory manner; and in another incident, a CNA reported seeing a coworker strike a resident’s arm/hand several times after being hit by the resident, while the accused CNA described the contact as tapping in response to being grabbed, all occurring despite an abuse‑prevention policy.
The facility failed to follow its Abuse, Neglect and Exploitation policy requiring background checks for contracted staff by not screening a personal care worker privately hired by a family to provide care and companionship to a resident. The aide had been caring for the resident for several years and continued after the resident’s admission, but no background check was completed. The DON reported not realizing that a background check was required for a family-contracted caregiver, and a corporate nurse confirmed that the facility had not followed the screening portion of its policy.
A resident with dementia eloped from the facility due to inadequate supervision. The resident, severely impaired in decision-making, left through an unsecured window and was later found at a convenience store. The facility failed to conduct necessary rounds, leading to the resident's undetected departure.
A facility failed to report injuries of unknown origin for a resident with vascular dementia and frequent falls. Despite incident reports documenting bruising on two occasions, these were not reported to the state. The DON acknowledged the oversight, unable to locate the required state reports, while a later injury was reported, showing inconsistency in reporting practices.
The facility failed to maintain resident dignity by not addressing residents by their preferred names and by standing while assisting residents during meals. Staff used terms like 'grandma' and 'momma' instead of preferred names for residents with Alzheimer's or dementia. Additionally, the DON and ADON were observed standing while feeding dependent residents, contrary to the facility's policy to sit during mealtimes to ensure dignity.
The facility failed to ensure safe mechanical lift transfers for two residents, both requiring two staff members as per their care plans. One resident with dementia and heart failure was transferred by a single CNA, and another with Alzheimer's was similarly transferred, despite repeated in-service training for staff on the requirement for two-person assistance.
The facility failed to date opened insulin vials, pens, and glucose check strips on a medication cart. An LPN was unable to provide opening dates for these items, which were intended for multiple residents. The DON confirmed that staff were required to date these items upon opening, and that medication carts were monitored monthly by the pharmacy consultant.
The facility did not maintain documentation of COVID-19 vaccine education for staff, as required by their policy. During a review, it was found that there was no documentation for two CNAs regarding their education on the COVID-19 vaccination. The administrator confirmed that while discussions occurred during orientation, no records were kept.
A resident with dementia was inaccurately assessed regarding their medication regimen. The admission assessment incorrectly documented the resident as being on an anticoagulant, while they were actually on Plavix, an antiplatelet medication. The MDS coordinator admitted to the coding error, and the DON confirmed that the corporate office reviewed the assessments for accuracy.
A facility failed to monitor a resident with COPD during nebulizer treatments. The resident had orders for ipratropium-albuterol every six hours, but staff did not ensure the full treatment was administered. A CNA turned off the nebulizer prematurely, and an LPN left the resident unattended with the mask on, leading to uncertainty about the medication received. The DON confirmed that staff should stay with residents during treatments.
A resident with Alzheimer's and a history of falls was inaccurately assessed for bed rail safety, with the evaluation incorrectly noting no cognitive or balance issues. The ADON based assessments on limited observations, and the DON admitted the assessment was inaccurate. Maintenance staff failed to perform regular safety checks, leading to a gap between the mattress and bed rail, contrary to facility policy.
The facility failed to maintain infection control during meal times. The DON and ADON were observed assisting residents with meals without sanitizing their hands after touching food items directly. The DON later confirmed that staff should not touch residents' food or straws with bare hands.
A facility failed to monitor and maintain bed rails for a resident with Alzheimer's and dementia, despite a policy requiring proper use and maintenance. The Director of Maintenance only checked bed rails when informed of issues, leading to a significant gap between the mattress and bed rail, compromising safety.
The facility failed to provide financial quarterly statements for four residents with dementia who had monies deposited in the facility's resident trust. The BOM, new to their position, forgot to issue the required statements, resulting in no accounting of the residents' funds being provided.
A resident with gout did not receive necessary toenail care despite multiple indications in their records. The facility's staff, including a CMA and an LPN, acknowledged the resident's toenails were long and irregularly shaped but lacked the tools and knowledge to address the issue. A podiatrist visit was canceled due to a viral outbreak, and the resident transferred before receiving care. The DON confirmed the lack of documentation for toenail care.
Failure to Prevent Resident‑to‑Resident Sexual Incident and Staff Physical/Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to maintain an abuse‑free environment for multiple cognitively impaired residents. Facility policy on abuse, neglect, and exploitation required written procedures to prohibit and prevent abuse and to establish a safe environment, including for residents’ consensual sexual relationships and prevention of sexual abuse. Despite this, one resident with severe cognitive impairment and wheelchair dependence was found on the floor in another resident’s room, with that other resident sitting on the bed and holding the waistband of the resident’s pants and pulling downward, exposing the edge of the underwear. The doorway was partially blocked by a wheelchair, and other equipment was arranged in a crescent shape around the resident on the floor, and the resident was initially anxious. Staff reported that the resident who was pulling at the clothing was confused and did not know where they were or what they had done. Another incident involved a resident with a BIMS score of 0, indicating severe cognitive impairment and complete dependence in ADLs. A CMA reported overhearing two CNAs in this resident’s room referring to the resident in a derogatory manner. When the CMA entered the room shortly afterward, the CNAs were gone, and the resident, who usually laughed when the CMA entered, was instead tense, with their back straight and arms drawn tightly into the body. The CMA asked if the CNAs had hurt the resident, and the resident, who was rarely verbal but sometimes gave one‑ or two‑word responses, answered yes. Subsequent nursing assessment documented that the resident appeared frightened, with several small, round bruises approximately one to two centimeters in size and two crescent‑shaped skin tears on the right forearm, similar in size and shape to fingernails. A third incident involved another resident with severe cognitive impairment and dependence in ADLs. A state reportable incident documented that one CNA stated they witnessed another CNA “pop” the resident on the arm/hand after the resident hit the CNA following a change. The CNA accused of striking the resident stated they had only tapped the resident on the wrist four times because the resident allegedly grabbed them by the waist and chest. These events, involving physical and verbal mistreatment and an attempted removal of clothing from a cognitively impaired resident, occurred despite the facility’s written policy prohibiting abuse and requiring prevention of abuse, neglect, and exploitation.
Failure to Conduct Required Background Check on Private Caregiver
Penalty
Summary
The facility failed to follow its Abuse, Neglect and Exploitation policy requiring background, reference, and credentials checks for potential employees, contracted temporary staff, students, volunteers, and consultants by not performing a background check on a personal care worker (PCW #1) who was providing care to a resident. The policy, implemented in 01/2026, specified that such screening was to be conducted on all categories listed, but record review and interviews showed that no background check had been completed for PCW #1. PCW #1 reported being a home health aide contracted by the family of Resident #5 to provide care and companionship and had continued in this role after the resident moved into the facility in 09/2025. The DON stated they were unaware that the facility was required to perform a background check on an individual contracted by a family to provide care to a specific resident and doubted that any check had been done, and the corporate nurse confirmed that the facility had not performed a background check on PCW #1 and acknowledged that the screening portion of the policy had not been followed. This deficiency centers on the facility’s inaction in implementing its own abuse-prevention screening requirements for an individual providing direct care and company to a resident under a private arrangement with the family, despite the clear policy language that encompassed contracted staff.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to supervise and prevent a resident from eloping, which led to a past noncompliance Immediate Jeopardy situation. The resident, who had a diagnosis of dementia and was severely impaired in daily decision-making, managed to leave the facility undetected. On the evening of January 29, 2025, the resident barricaded their door with a chair, and by the following morning, the facility received a call from a local hospital regarding the resident's whereabouts. An investigation revealed that the resident was last seen in the facility the previous night, and their room's window was found open with the screen removed. The resident was discovered at a convenience store and transported to a local hospital by ambulance, where they were found uninjured. The resident was returned to the facility and placed under continuous supervision. The incident highlighted the facility's failure to provide adequate supervision to prevent elopement, as the staff did not conduct the necessary rounds to monitor the resident's whereabouts. The deficiency was identified for one of the three sampled residents reviewed for supervision.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin to the required state agencies for one of the three sampled residents reviewed for such injuries. The resident in question had diagnoses including vascular dementia, anxiety, and frequent falls. Incident reports revealed two instances of injuries of unknown origin, with bruising noted on the temple and right upper thigh on two separate occasions. However, these incidents were not reported to the state, as confirmed by the absence of state reports for these dates. The Director of Nursing (DON) acknowledged the oversight, stating that they were unable to locate the state reports for these incidents and did not know why they were not completed. The facility did report a later injury involving a right subcapital femoral neck fracture to the state, indicating inconsistency in reporting practices.
Failure to Maintain Resident Dignity in Address and Dining
Penalty
Summary
The facility failed to ensure residents were treated with dignity by not addressing them by their preferred names and by not maintaining dignity during mealtimes. Specifically, three residents with Alzheimer's disease or dementia were not called by their preferred names as outlined in their care plans. Instead, staff members used terms like 'grandma' and 'momma,' which were not requested by the residents. This was acknowledged by the staff, including a CNA and an LPN, who admitted to using these terms as habits or terms of endearment, despite knowing the residents' preferred names. Additionally, the facility did not maintain dignity during dining for several residents who were dependent on staff for meals. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were observed standing while assisting residents with meals, contrary to the facility's policy that staff should be seated while feeding residents to promote dignity. The DON acknowledged the issue, citing the size of wheelchairs and geri chairs as a reason for not sitting, but confirmed that staff should sit to maintain residents' dignity during meals.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure safe mechanical lift transfers for two residents, both of whom required assistance from two staff members according to their care plans. Resident #21, diagnosed with dementia, anxiety, and heart failure, was observed being transferred by a single CNA using a mechanical lift, contrary to the care plan initiated on 02/28/24, which required two staff members. The CNA admitted to transferring the resident alone because the resident requested it, despite the care plan's stipulations. Similarly, Resident #18, with Alzheimer's and dementia, was also transferred by a single CNA using a mechanical lift, despite the care plan initiated on 12/29/23, which required two staff members for transfers. The DON acknowledged that two staff members were required for all mechanical lift transfers and noted that staff had been repeatedly in-serviced on this requirement, but the training had not been effective in changing staff behavior.
Failure to Date Opened Insulin and Glucose Strips
Penalty
Summary
The facility failed to ensure that insulin was dated when opened on one of the two medication carts observed for medication storage. During an observation, it was noted that several insulin vials and pens, as well as glucose check strips, were opened and not dated on treatment cart #1. The medications involved included a Lantus insulin vial, Fiasp flex touch pen, insulin aspart pens, Basaglar pen, and Levemir pen, which were intended for multiple residents. LPN #1, who was present during the observation, was unable to provide the dates when these items were opened. The Director of Nursing (DON) confirmed that staff were required to date insulin and glucose check strips upon opening and that medication/treatment carts were monitored monthly by the pharmacy consultant.
Failure to Document COVID-19 Vaccine Education for Staff
Penalty
Summary
The facility failed to maintain documentation that staff were educated and offered the COVID-19 vaccine, as required by their policy dated 06/27/23. This deficiency was identified during a record review and interviews, where it was found that there was no documentation for two employees regarding their education on the COVID-19 vaccination. Specifically, the infection preventionist and the administrator confirmed the absence of documentation for CNA #2 and CNA #4, respectively. The administrator acknowledged that while discussions about the COVID-19 vaccination occurred during new employee orientation, no records of the education or information provided were maintained for any staff members.
Inaccurate Medication Assessment for a Resident
Penalty
Summary
The facility failed to ensure accurate assessments for a resident diagnosed with dementia. The admission assessment inaccurately documented that the resident was on an anticoagulant medication and not on an antiplatelet medication. However, a review of the physician orders revealed that the resident was actually on Plavix, an antiplatelet medication, and there was no documentation of an anticoagulant medication being ordered. The MDS coordinator acknowledged the error, stating that the medication was incorrectly coded as an anticoagulant instead of an antiplatelet medication. The Director of Nursing confirmed that the corporate office reviewed the assessments for accuracy.
Failure to Monitor Resident During Nebulizer Treatment
Penalty
Summary
The facility failed to ensure proper monitoring of a resident during nebulizer treatments, as observed in the case of a resident with chronic obstructive pulmonary disease. The resident had a physician's order for ipratropium-albuterol to be inhaled every six hours. However, during an observation, a CNA was seen turning off the nebulizer machine and removing the mask without ensuring the resident had completed the treatment. On another occasion, an LPN administered the medication but left the room with the nebulizer mask still on the resident, who was later observed holding the mask away from their face. The LPN admitted to not knowing how much medication the resident had received and was informed only after the incident that they were required to stay with the resident throughout the treatment. The DON confirmed that nurses were expected to remain with residents during nebulizer treatments to ensure the full treatment was administered. This lack of supervision and monitoring during the nebulizer treatments led to the deficiency identified in the report.
Inaccurate Bed Rail Assessment and Maintenance Deficiency
Penalty
Summary
The facility failed to accurately assess a resident for the safe use of bed rails, leading to a deficiency in care. The resident, who had Alzheimer's disease, dementia, and a history of repeated falls, was identified as a high fall risk. Despite this, the Bed Rail/Assist Bar Evaluation inaccurately documented that the resident had no cognitive deficit and no balance issues. The Assistant Director of Nursing (ADON) admitted to making these assessments based on the resident's ability to sit up in a chair, without a thorough evaluation. The Director of Nursing (DON) acknowledged that the assessment was not accurate and had not been reviewed after completion. Additionally, the facility's maintenance staff did not perform regular safety checks on the bed rails, only addressing them if informed of looseness. An observation revealed a significant gap between the mattress and the bed rail, posing a potential safety hazard. The facility's policy required appropriate alternative approaches before using bed rails and ensuring their correct installation and maintenance, which was not adhered to in this case.
Infection Control Breach During Meal Assistance
Penalty
Summary
The facility failed to maintain proper infection control practices during meal times, as observed during two separate meals. The Director of Nursing (DON) was seen assisting four residents with their morning meal, during which they picked up a biscuit with jelly using their bare hands and placed it into a resident's mouth without sanitizing their hands. Similarly, during the noon meal, the Assistant Director of Nursing (ADON) assisted a resident with a drink by touching the straw and then continued to assist other residents without sanitizing their hands. Additionally, the DON was observed handing a dinner roll to a resident without sanitizing their hands. The DON later acknowledged that staff should not directly touch residents' food or straws with their bare hands.
Failure to Monitor and Maintain Bed Rails
Penalty
Summary
The facility failed to ensure ongoing monitoring and supervision of bed rails for a resident with Alzheimer's disease, dementia, and a history of repeated falls. The facility's policy on the proper use of bed rails required appropriate alternative approaches before installing or using bed rails and ensuring their correct installation, use, and maintenance. However, the Director of Maintenance admitted that they only checked the bed rails if informed they were loose, rather than performing regular safety checks. During an observation, a significant gap was noted between the mattress and the bed rail on the resident's bed, indicating improper installation or maintenance.
Failure to Provide Financial Statements for Residents' Trust Accounts
Penalty
Summary
The facility failed to provide financial quarterly statements for four residents who had monies deposited in the facility's resident trust. The trust account balance statement, dated 10/15/24, documented that these residents, all diagnosed with dementia, had funds deposited in the facility trust. During an interview on 10/16/24, the Business Office Manager (BOM) admitted to being somewhat new to their position and acknowledged forgetting to provide the required quarterly financial statements to the residents and/or their representatives. As a result, none of the residents with funds in the resident trust received an accounting of their monies.
Failure to Provide Toenail Care
Penalty
Summary
The facility failed to provide appropriate toenail care for a resident who was admitted with a diagnosis of gout and required assistance with bathing and hygiene. The resident's clinical records indicated that toenail care was needed on multiple occasions, as documented in shower sheets dated from August to September. Despite these records, there was no documentation that toenail care was provided. A Certified Medication Aide (CMA) observed the resident's toenails to be long, thick, and irregularly shaped, and admitted to not knowing how to cut them. The Licensed Practical Nurse (LPN) also confirmed the condition of the toenails and expressed discomfort in cutting them due to a lack of appropriate tools and knowledge on where to document such care in the electronic medical record. The facility's social service director stated that the podiatrist, who was responsible for trimming toenails, visited every three months but the visit was canceled due to a viral outbreak. Consequently, the resident was not seen by the podiatrist before transferring to another facility. The Director of Nursing (DON) acknowledged that the resident's toenails should have been cut and confirmed the absence of documentation for toenail care in the resident's clinical record.
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.
Trusted by long-term care providers and associations.
