Park Place Healthcare And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 1530 Ne Grand Blvd, Oklahoma City, Oklahoma 73117
- CMS Provider Number
- 375582
- Inspections on file
- 28
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Park Place Healthcare And Rehab during CMS and state inspections, most recent first.
A resident at risk for pressure ulcers, with impaired mobility and a sacral fracture, had a care plan calling for weekly skin assessments and a pressure-reducing mattress, but charge nurse assessments documented only redness and no open areas despite later identification of three stage 2 ulcers on the buttocks. During incontinent care, a CNA observed open areas and applied vitamin A&D ointment after reporting the issue to an RN, yet there were no physician orders for wound treatment and the wound care nurse initially did not have the resident on the wound list. The resident was also found on a regular mattress rather than the ordered pressure-relieving surface, while nursing staff and the DON gave conflicting accounts about whether such a mattress was in place and what constituted a pressure-relieving mattress.
A resident with generalized pain, gout, and liver cirrhosis had a care plan and physician order for oxycodone 5 mg every six hours as needed, but did not receive the ordered oxycodone on an overnight shift when pain was reported as severe. The MAR showed oxycodone was given on earlier shifts, yet there was no documentation of administration overnight. The resident reported being told there was no nurse available to give narcotics and was instead offered Tylenol, which they refused due to a liver condition and prior instructions from a transplant physician. The overnight LPN stated they were the only nurse on duty, refused to accept the narcotic lockbox keys, did not know where the keys were, and therefore did not administer oxycodone when requested. Facility leadership later confirmed that medications were to be administered as ordered and that the resident’s oxycodone should have been provided.
The facility failed to accurately report direct care staffing hours to CMS for multiple dates on the 3 p.m. to 11 p.m. shift, despite having higher actual hours documented in payroll records. For several days across two consecutive months, the Quality of Care report submitted to CMS showed substantially fewer direct care staffing hours than those reflected in the facility’s payroll detail, while the resident census remained in the mid-60s. During an interview, a corporate nursing officer confirmed that the staffing information submitted to CMS was not accurate.
A resident with diabetes and intact cognition had multiple FSBS readings above 350 mg/dL, for which 10 units of Humalog insulin were administered per sliding-scale orders that also required notifying the MD when FSBS was between 350 and 400. Review of progress notes and MAR showed no documentation that the MD was notified for any of these elevated readings. The resident reported their blood sugars had been well controlled prior to admission but had become significantly higher in the facility. An RN confirmed the notification requirement in the insulin order, acknowledged that no MD notification was documented for the elevated FSBS values, and the DON stated staff should notify the physician when orders direct them to do so.
A resident with documented left-sided weakness, renal failure, and heart failure was observed with a contracted left hand held in a fist and an inability to raise the left arm above shoulder level, yet the admission and comprehensive assessments recorded no upper extremity impairment despite the resident being cognitively intact. A CNA reported the resident could not use the left hand and had left arm weakness, and the MDS coordinator, who stated they gather assessment data by chart review and direct observation, acknowledged the assessment should have reflected the left-hand contracture and arm weakness but did not.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for several residents. One resident with left-sided weakness and a contracted hand had no care plan problem for limited ROM, no therapeutic devices, and no restorative or ROM interventions, despite staff recognizing the impairment. Another resident with protein-calorie malnutrition and significant documented weight loss had a care plan requiring meal replacement supplements when eating 50% or less of meals, but staff did not provide the ordered health shakes, and the resident reported not receiving supplements. A third resident, dependent for transfers and using a mechanical lift as confirmed by staff and observation, did not have lift use included in the care plan, even though the MDS coordinator stated such interventions should be documented.
Surveyors found multiple infection control failures during incontinent care. In one case, a CNA caring for a resident with dementia and bowel/bladder incontinence dropped a soiled pad on the floor and continued care and room adjustments without changing gloves, contrary to facility policy requiring soiled linen to be bagged at bedside. In another case, a CNA caring for a resident who was occasionally incontinent placed soiled wipes and a soiled brief on the bed, then handled the resident’s stuffed animal, clean linens, bedside table, bed controls, call light, and clean supplies while still wearing contaminated gloves. For a resident on EBP for a pressure ulcer and skin infection, a CNA performed high-contact care (brief change with fecal soiling) wearing gloves but no gown, and continued tasks after brief removal without an appropriate glove change, despite the EBP policy and care plan requiring gown and glove use for such activities.
A resident with left-sided weakness and a contracted left hand was observed with the hand tightly closed into a fist and unable to raise the left arm above shoulder height, without any therapeutic devices in place. The resident, who was cognitively intact, reported no use of the left hand and no therapies or devices to maintain or improve function. Facility records did not document upper extremity impairment or a hand contracture on admission, and staff, including CNAs and an LPN, confirmed there were no orders for therapeutic devices or ROM exercises and that the resident was not on restorative services. The DON stated that residents with limited ROM or contractures should be in therapy or the restorative program and acknowledged this had not occurred for this resident since admission.
A resident with protein-calorie malnutrition, pancytopenia, renal insufficiency, cirrhosis, and moderate cognitive impairment experienced significant weight loss while consuming only 25–50% of meals. The care plan required meal replacement supplements when 50% or less of a meal was eaten, and the dietician ordered health shakes three times daily with meals. Over an extended period, there was no documentation that these health shakes were provided, and staff confirmed the resident did not receive supplements despite poor intake and an untouched meal tray observed at the bedside.
A resident with a sacral fracture and mobility abnormalities, who was cognitively intact, had physician orders for weekly skin assessments. During incontinent care, three open areas were observed on the coccyx and buttocks, but a same-day weekly skin assessment documented no open areas and only noted redness. The following day, the wound care nurse identified three stage 2 pressure areas with specific measurements, and the resident had previously reported a small open area on their bottom. The DON confirmed the weekly assessment showed no open areas, and an LPN admitted not completing a full head-to-toe skin assessment or clearly visualizing the coccyx and buttocks, despite existing training that weekly skin checks must cover all skin areas.
A resident with a documented diagnosis of depression, prescribed fluoxetine and identified as cognitively intact, did not receive a psychiatric consultation despite facility criteria and a physician order indicating such a consult was needed when certain behaviors occurred. The resident was observed tearful, reported feeling too depressed to get out of bed and at risk of missing dialysis, and was described by staff as easily upset, socially withdrawn, and having refused dialysis multiple times. Activity records also showed no participation in activities during a full month, even though activities were noted as very important to the resident, and the DON acknowledged the resident met the facility’s criteria for psychiatric consultation, which was not obtained.
Surveyors found that the facility’s medication error rate exceeded 5% after two residents received incorrect medication doses during an observed med pass. One resident was given a single 25 mcg vitamin D3 tablet instead of the prescribed 50 mcg dose, and another resident received only one senna tablet instead of the ordered two tablets for constipation. CMAs later acknowledged they had not followed the physician orders, and the DON stated staff were expected to follow the rights of medication administration and the punch-initial-give method.
A resident with a sacral fracture, gait abnormalities, and intact cognition had physician orders for weekly skin assessments, but the required assessment was not completed accurately. During incontinent care, the resident was observed with three open areas on the coccyx and buttocks, while a weekly skin assessment documented the prior night by an LPN recorded no open areas and only coccyx redness. A subsequent assessment by the wound care nurse identified stage 2 open areas on the coccyx and both buttocks. The LPN later admitted not performing a complete head-to-toe skin assessment or visualizing the coccyx and buttocks, despite facility policy requiring objective, complete, and accurate documentation based only on observed findings.
A resident did not receive multiple prescribed medications as ordered, with several missed doses documented as blanks on the MAR and no explanations provided. Facility staff confirmed that these medications were not administered or documented according to policy.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment was not maintained to minimize risks, and supervision protocols were insufficient.
Multiple residents with intact cognition were involved in verbal altercations, including threats of physical harm, and one resident produced a knife and attempted to jab it at a nurse. The facility did not consistently document 1:1 supervision, failed to update care plans after the incidents, and did not ensure all staff received required abuse and neglect training. Another resident reported being treated roughly and spoken to harshly by a CNA, leading to feelings of being unsafe. These failures resulted in deficiencies related to abuse, neglect, and inadequate supervision.
The facility did not notify law enforcement after an incident in which a resident made explicit threats of physical harm, including threats to set another resident on fire and use a weapon, and later brandished a knife at a nurse. Staff separated the involved residents and reported the incident to the state agency, but there was no documentation that law enforcement was contacted, as required by facility policy.
The facility did not update the care plans for two residents after incidents involving threats and aggressive behavior, including one resident producing a knife and making verbal threats, and another resident verbally threatening harm to others. Both residents had documented behavioral and mental health histories, but their care plans were not revised to address these incidents, despite facility policy and staff statements indicating that care plans should be updated following such events.
The facility did not determine if three residents wished to formulate an advance directive, as required by their policy. The business office manager stated that if residents were unsure or wanted to discuss with family, the form was left blank, indicating no current advance directives.
The facility failed to maintain safe flooring in the common area, with floor slats pulled away and corners sticking up, creating a tripping hazard for mobile residents, staff, and visitors. Maintenance was observed gluing slats down multiple times, and resident council members expressed concerns about the floor causing trouble even for those in wheelchairs. The administrator acknowledged the issue and provided documentation of bids to replace the flooring.
The facility failed to secure medication carts when not in use, as observed on two occasions. A medication cart was found unlocked and unattended by the nursing station, and another was observed unlocked on hall 600 with no staff present. Staff interviews confirmed that leaving carts unlocked was against policy, which mandates that all drugs be stored in locked compartments.
A facility failed to maintain infection control during medication administration to a resident with a PEG tube. An LPN did not wear a gown as required by the Enhanced Barrier Precautions policy, which mandates gown and glove use during high-contact care activities involving indwelling devices. The policy aims to reduce the transmission of multidrug-resistant organisms, and supplies were available outside the resident's room, but the protocol was not followed.
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling devices. A resident with a foley catheter and pressure wounds and another with a gastric tube were not provided with appropriate EBP. Staff used only gloves without gowns, and there was a lack of understanding of EBP among staff. No EBP signs were posted, and the DON and ADON could not identify residents needing EBP, indicating systemic issues in infection control.
The facility did not provide mail delivery to residents on Saturdays, contrary to their Resident Rights policy. Although mail was delivered on Saturdays, it was not distributed until Monday, as confirmed by the activities director and resident council members. The DON acknowledged this issue, affecting 47 residents.
A facility failed to notify a physician upon receiving culture and sensitivity results from a urinalysis for a resident with acute cerebrovascular insufficiency, communication deficit, and UTI. The facility's policy requires prompt physician consultation for treatment alterations. The resident was prescribed Cephalexin, but documentation lacked culture results and physician notification. The lab results were released and finalized, but the ADON confirmed no progress note indicated physician notification.
The facility did not complete baseline care plans within the required 48-hour timeframe for two residents. One resident, with multiple diagnoses including ESRD and cognitive impairment, had no baseline care plan upon readmission. Another resident's baseline care plan was completed late. Staff confirmed these oversights, indicating a failure to adhere to the facility's policy.
The facility failed to provide an activity program that meets residents' individual or group needs, leading to potential social isolation. The Activities Director noted residents' dislike for scheduled activities and used personal funds for crafts. Two residents with good cognitive functioning had unmet preferences for activities like being around animals and attending religious services. The DON acknowledged funding issues and plans to identify resident preferences.
An LPN left a medication cart unlocked while administering medication to a resident, contrary to facility policy requiring carts to be locked. The LPN admitted to being flustered, leading to the oversight. This incident was observed on one of the two medication/treatment carts in the facility, which houses 47 residents.
The facility failed to provide evening snacks to several residents who required them, despite having a policy to offer nourishing snacks at bedtime. Residents in a specific hall, who needed help leaving their rooms, were not offered snacks, and there was no documentation to show they were provided on multiple occasions. The DON was aware of the issue but it persisted.
A resident with multiple diagnoses was involved in an altercation with the facility administrator, who responded aggressively during a dispute over a camera. The resident's care plan was delayed, and the administrator was suspended pending investigation. Staff were uncertain about reporting abuse due to the absence of a current administrator.
A facility failed to complete a comprehensive assessment within 14 days of admission for a resident. The resident's 5-day/admission assessment was not completed by the required date, and it remained incomplete even after the deadline had passed.
A facility failed to implement a comprehensive care plan for a resident with ESRD and chronic kidney disease. The policy requires a person-centered care plan with measurable objectives, but no dialysis or nutrition care plan was found. The ADON confirmed the absence of these plans and acknowledged that the existing care plan did not meet the necessary requirements.
A facility failed to complete necessary dialysis orders and monitoring for a resident requiring such services. The Hemodialysis Policy required specific documentation and monitoring, which were not present in the resident's records. Staff interviews revealed a lack of awareness and adherence to the policy, with an LPN admitting to not assessing the resident's dialysis shunt and an undated bandage remaining on the resident's arm.
The facility did not ensure daily nurse staffing information was updated, with missing data for RNs, LPNs, CNAs, and CMAs on multiple days. The DON stated they were waiting to total actual hours worked before updating the sheet.
A facility failed to follow its antibiotic stewardship policy for a resident with a UTI, communication deficit, and cerebrovascular insufficiency. The resident was prescribed Cephalexin without reviewing culture and sensitivity results, which were not communicated to the physician. The DON admitted antibiotics were often prescribed before receiving C&S results, and the ADON confirmed no physician notification was documented, indicating a failure in the facility's process for appropriate antibiotic use.
A resident was unable to reach the call light while sitting in a wheelchair next to the bed, as the cord was too short. A CNA confirmed the call light was out of reach and mentioned that the policy is to have it within reach. The resident's roommate would use their call light if assistance was needed.
The facility failed to provide scheduled showers for two residents who required assistance with ADLs. One resident missed 22 days of showers, while another missed multiple scheduled baths over three months. Both the residents and staff confirmed the missed showers, and the DON acknowledged the lack of documentation.
The facility failed to complete ongoing assessments of a resident pre and post dialysis as required by their Hemodialysis policy. Documentation was missing for multiple dates in February, March, and April 2024. An LPN confirmed the lack of assessments after reviewing the records.
The facility failed to implement an antibiotic stewardship program and did not conduct ongoing monitoring. A resident had physician's orders for azithromycin and doxycycline hyclate, but there was no documentation of monitoring for these antibiotics. The DON and Infection Preventionist confirmed the lack of monitoring.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who received Part A skilled services and remained in the facility after discharge from these services. The MDS coordinator confirmed that the SNF ABN could not be located.
The facility failed to ensure a resident's wall was in good repair, compromising the homelike environment. The resident, who was nonverbal and had cerebral infarction, had three deep scrapes on the wall by the head of the bed. Although a CNA was aware of the issue and reported it to another staff member, it was not communicated to maintenance, and the Maintenance Supervisor was unaware of the need for repair.
A resident with hypertension received hydralazine and carvedilol despite blood pressure readings below the ordered parameters. Both an LPN and the ADON confirmed the medications should have been held according to the physician's orders.
The facility failed to review a PRN lorazepam order after 14 days of use for a resident. The medication was prescribed with an indefinite end date and was administered multiple times over three months. The DON confirmed that PRN anti-psychotic orders should be re-evaluated every two weeks.
A CNA was observed transporting dirty pads without bagging them, briefly setting them on the floor before placing them in the soiled room. The CNA admitted to not following the facility's Handling Soiled Linen policy due to a lack of available bags.
Failure to Implement Skin Care Interventions and Provide Appropriate Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions to prevent skin breakdown and to provide appropriate treatment for existing pressure ulcers for one resident. The resident was admitted with diagnoses including an unspecified sacral fracture and abnormalities of gait and mobility, and was assessed as at risk for developing pressure ulcers, requiring assistance with rolling and perineal hygiene. The resident’s care plan, initiated on 02/05/26, included monitoring and documenting skin changes, using a pressure reducing/relieving mattress, and completing weekly skin assessments as ordered. However, skin assessments documented by the charge nurse on 02/05/26 and 02/12/26 indicated only coccyx redness and no open areas, despite subsequent findings of open wounds. On 02/12/26, during incontinent care, the resident was observed with three open areas on the coccyx and buttocks, and a CNA applied vitamin A&D ointment to the wounds. The CNA later stated they were aware of one open spot and reported the skin issue to an RN, and asked if there was anything else to use for treatment, being told to use vitamin A&D ointment. The RN stated they did not remember being informed of the wounds and believed the resident only had redness, with their last observation occurring the previous week. The resident reported not being aware of having three wounds. A wound care nurse’s skin assessment on 02/13/26 documented three stage 2 open areas on the right buttock, left buttock, and upper buttocks, and the wound care nurse initially stated the resident did not have a wound and was not on their wound care list. Physician orders for the month showed no wound treatment orders in place. The facility also failed to ensure the ordered pressure reducing mattress intervention was in place. On 02/13/26, the resident was observed lying on a regular mattress, and the CNA confirmed the resident did not have a pressure relieving mattress on the bed. The RN stated that all residents, including this resident, had pressure relieving mattresses, while the DON indicated that a pressure relieving mattress could mean pillows or wedges and was not aware the resident had wounds. Later, the resident was observed with a navy-blue pressure relieving mattress, and the wound care nurse clarified that the previous mattress had been a regular mattress and that not all residents had pressure relieving mattresses. The wound care nurse stated the resident’s wound would be considered facility-acquired and that having a pressure reducing mattress could have helped in preventing it.
Failure to Administer Ordered Oxycodone Due to Lack of Access to Narcotic Keys
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication as prescribed and to ensure access to ordered narcotics for a resident with generalized pain. Facility policies required medications to be administered in accordance with prescriber orders and emphasized appropriate assessment and treatment of pain. The resident’s care plan identified generalized pain with an intervention to administer analgesics as ordered, and a physician’s order prescribed oxycodone 5 mg every six hours as needed for pain. The resident had diagnoses including gout and liver cirrhosis and a BIMS score of 12, indicating moderate cognitive impairment. Medication administration records for the reviewed period showed the resident received oxycodone on the day and evening shifts on one date, with documented pain scores of 4/10 and 6/10, but there was no documentation that oxycodone was administered on the overnight shift. A nurse’s note documented that the resident requested oxycodone during the overnight shift and was told there was no primary nurse available to administer narcotics. The resident was offered Tylenol instead, but refused, stating they could not take Tylenol due to their liver condition and reporting that their liver transplant physician had advised against Tylenol. The resident later stated they hurt all over all the time, that they received oxycodone every six hours, and that they had been denied oxycodone due to no available staff. A CMA reported the resident frequently complained of pain and that oxycodone had been ordered as needed until it was changed to a routine every-six-hour schedule. The LPN on duty during the overnight shift stated they were the only nurse on duty, refused to accept the narcotic lockbox keys for the resident’s hall, did not know where those keys were, and therefore did not administer oxycodone when the resident, who rated their pain 10/10, requested it. The DON stated facility policy was to administer medications as ordered and that the resident’s oxycodone should have been given and an alternative to Tylenol should have been available.
Inaccurate PBJ Staffing Hours Reported to CMS
Penalty
Summary
The deficiency involves the facility’s failure to accurately report direct care staffing hours to CMS through the Payroll-Based Journal (PBJ)/Quality of Care reporting system for specific dates in December 2025 and January 2026. For the 3 p.m. to 11 p.m. shift in December 2025, the Quality of Care report submitted to CMS showed significantly lower direct care staffing hours than those documented in the facility’s payroll detail report. On 12/20, with a census of 62, 52.32 hours were reported to CMS while payroll showed 91.51 hours; on 12/24, with a census of 63, 37.40 hours were reported while payroll showed 63.27 hours; on 12/27, with a census of 63, 61.18 hours were reported while payroll showed 86.99 hours; and on 12/28, with a census of 61, 61.00 hours were reported while payroll showed 98.69 hours. A similar pattern occurred in January 2026 for the 3 p.m. to 11 p.m. shift, where the Quality of Care report again reflected inaccurate direct care staffing hours compared to the payroll detail. On 01/03, with a census of 65, 33.75 hours were reported versus 104.74 hours on payroll; on 01/20, with a census of 66, 38.21 hours were reported versus 64.10 hours; on 01/21, with a census of 66, 41.11 hours were reported versus 65.13 hours; on 01/24, with a census of 65, 72.50 hours were reported, which matched the payroll; on 01/27, with a census of 64, 37.83 hours were reported versus 75.80 hours; on 01/28, with a census of 64, 38.44 hours were reported versus 64.92 hours; and on 01/31, with a census of 64, 47.50 hours were reported versus 76.73 hours. During an interview on 02/18/26 at 12:05 p.m., the corporate nursing officer acknowledged that the facility had not accurately submitted staffing information to CMS. At the time, the administrator had identified that 63 residents resided in the facility.
Failure to Notify Physician of Elevated Blood Glucose per Insulin Order
Penalty
Summary
The facility failed to notify a physician when a resident’s finger-stick blood sugar (FSBS) exceeded 350 mg/dL, as required by the resident’s insulin order and the facility’s physician notification policy. The policy stated that licensed nurses are responsible for notifying medical staff of significant changes in condition and documenting the date, time, physician name, actions taken, and resident response. A physician’s order dated 12/31/25 for Humalog insulin directed staff to administer 10 units subcutaneously before meals for FSBS levels of 350–400 mg/dL and to notify the medical doctor. Record review for February showed multiple FSBS readings above 350 mg/dL for this resident, with corresponding administration of 10 units of Humalog insulin on several dates and times. Despite these elevated FSBS readings and the explicit order to notify the physician when FSBS was between 350 and 400, there was no documentation in the progress notes or medication administration record that the provider had been notified. The resident, who had a diagnosis of diabetes and intact cognition with a BIMS score of 14, reported that their blood sugar had been well controlled (around 100–200) prior to admission and that it had reached as high as 370 in the facility. During interviews, an RN confirmed that the process for insulin administration included obtaining and documenting FSBS and that physician notifications should be documented in progress notes. The RN acknowledged that the resident’s order required physician notification for FSBS of 350–400, could not locate any such documentation, and stated that the provider had not been notified for an FSBS of 375. The DON also stated that staff should notify the physician if the order stated to do so.
Failure to Accurately Assess Resident’s Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively and accurately assess a resident’s physical condition, specifically upper extremity function, as required upon admission and periodically thereafter. Observation on 02/11/26 at 8:48 a.m. showed the resident’s left hand was contracted and completely closed into a fist, with no therapeutic devices in place, and the left arm could not be raised above shoulder height. The resident stated at that time that they had no use of their left hand and could not raise their left arm above their shoulders. A Physician’s Progress Note dated 11/14/25 documented left-sided weakness, and the resident’s admission assessment dated 11/23/25 showed admission with renal failure and heart failure. Despite these findings, the admission assessment documented no impairment to the upper extremities and showed a BIMS score of 14, indicating the resident was cognitively intact. Further interviews confirmed the discrepancy between the resident’s actual condition and the documented assessment. On 02/12/26 at 9:54 a.m., a CNA reported that the resident was unable to use their left hand and had left arm weakness. On 02/12/26 at 10:38 a.m., the MDS coordinator explained that comprehensive assessment information is collected by reading the chart and personally seeing the patient. When asked, the MDS coordinator acknowledged that the comprehensive assessment did not show any upper extremity impairments and stated that it should have reflected the resident’s left-hand contracture and left arm weakness. The facility had a policy titled Resident Assessments, dated 11/2019, indicating appropriate resident assessments were to be completed, but this was not followed for this resident’s upper extremity status.
Failure to Develop and Implement Comprehensive Care Plans for ROM, Nutrition, and Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for multiple residents. For one resident with left-sided weakness, surveyors observed a contracted left hand closed into a fist and limited ability to raise the left arm above shoulder height, with no therapeutic devices in place. The resident reported having no use of the left hand and no therapies or devices to maintain or improve function. Staff, including CNAs and an LPN, confirmed the resident had left-hand contracture and weakness, was not on restorative services, had no therapeutic devices, and did not receive range of motion exercises. The DON acknowledged that the resident had not been admitted to therapy or the restorative program since admission, despite having limited range of motion and contracture, and the MDS coordinator confirmed the care plan did not address the upper extremity impairment or related interventions. Another deficiency was identified for a resident with protein-calorie malnutrition and significant weight loss, whose care plan required staff to offer a meal replacement supplement when 50% or less of a meal was consumed. Weight records showed a decline from 170 pounds to 155 pounds over approximately two months, and a dietician’s note documented an 8.8% weight loss in one month and 15.3% in six months, with meal intake ranging from 25–50%. The dietician recommended health shakes three times daily with meals. The resident stated they were not receiving any meal supplements despite liking them, and a CNA confirmed the resident did not receive health shakes or additional supplements when eating 50% or less of meals. The DON stated the resident should have been receiving health shakes when 50% or less of meals were consumed. A further deficiency was found for a resident dependent on staff for transfers and with severe cognitive impairment, who was observed being transferred with a mechanical lift by staff. The significant change in status assessment documented dependence for transfers, and multiple staff members, including CNAs and the resident, reported that a lift was used for transfers and had been in use since the CNA’s employment at the facility. Despite this, the resident’s care plan, revised earlier in the month, did not include the use of a mechanical lift for transfers. The MDS coordinator, responsible for completing care plans, stated that lift use should be documented on the care plan when used, and acknowledged that this resident’s care plan did not address the use of a lift for transfers.
Inadequate glove use, linen handling, and EBP adherence during incontinent care
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control program related to incontinent care and enhanced barrier precautions. For one resident with dementia and senile degeneration of the brain who was incontinent of bowel and bladder, a CNA donned gloves and began incontinent care, placing a clean brief on the bedside table, removing a soiled brief with fecal matter, and cleaning the resident. The CNA then placed a new brief and pad under the resident, removed the old pad and dropped it on the floor, and continued to adjust the resident’s brief, bed, sheet, call light, and bedside table without changing gloves. The CNA later picked up the pad and trash bag from the floor and disposed of them before removing gloves and performing hand hygiene. The facility’s policy required soiled linen to be collected at the bedside and placed in a linen bag, and the CNA acknowledged they should not have placed the pad on the floor and should have changed gloves twice during incontinent care. For another resident who was occasionally incontinent and required staff assistance with perineal care, a CNA donned gloves, prepared clean supplies, and unfastened a urine-soiled brief. The CNA tucked the soiled brief between the resident’s legs, wiped the resident, and placed dirty wipes on the foot of the bed on top of the sheet. The CNA rolled the resident, tucked the soiled brief under them, applied a clean brief, and then removed the soiled brief and placed it at the foot of the bed on top of the sheet. While still wearing the same soiled gloves, the CNA handed the resident a stuffed animal, adjusted clean sheets, moved the bedside table, used the bed remote, and handed the call light to the resident. The CNA also reached into their jacket pocket with contaminated gloves to handle clean gloves and a trash bag roll before finally doffing gloves and exiting the room. The CNA later stated they should have changed gloves after touching the dirty brief and should not have placed soiled items on the bed or touched clean items and supplies with contaminated gloves. For a third resident on enhanced barrier precautions due to a pressure ulcer and other specified local skin infections, an EBP sign and PPE were present outside the room. A CNA used hand sanitizer, donned gloves, prepared a clean brief, and changed gloves before unfastening a brief and discovering feces. The CNA wiped the resident, tucked the soiled brief under them, and applied a clean pad and brief. After removing the soiled brief and disposing of it, the CNA pulled the clean brief into place and then doffed gloves. The CNA donned another pair of gloves from their jacket pocket, positioned a pillow, covered the resident with a blanket, lowered the bed, placed a fall mat, removed and replaced the trash bag, and then doffed gloves and washed their hands. The facility’s EBP policy required gown and glove use for high-contact care activities such as changing briefs, and the resident’s care plan specified PPE use throughout their stay or until wounds healed. The CNA later stated that EBP meant washing hands or using sanitizer, wearing gloves and a gown, and acknowledged they did not think about wearing a gown during incontinent care and should have changed gloves after removing the soiled brief. The DON stated the facility’s process required changing gloves between clean and dirty surfaces and wearing gloves and a gown for incontinent care for residents on EBP.
Failure to Provide ROM Interventions and Therapeutic Devices for Contracture
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises and therapeutic devices to maintain or improve mobility for a resident with a left-hand contracture and left-sided weakness. On observation, the resident’s left hand was contracted and completely closed into a fist, with no therapeutic devices in place, and the left arm could not be raised above shoulder height. The resident reported having no use of the left hand and being unable to raise the left arm above the shoulders, and stated that no therapeutic devices or therapies were being used to maintain or improve function. The facility’s Restorative Nursing Services policy stated that residents would receive restorative nursing care as needed to promote optimal safety and independence. Record review showed the resident was admitted with renal failure and heart failure and had a physician’s note documenting left-sided weakness, but the admission assessment did not identify upper extremity impairment or a left-hand contracture, despite the resident being cognitively intact with a BIMS score of 14. Multiple staff interviews confirmed that the resident was not on restorative services, had no orders for therapeutic devices for the left-hand contracture, and was not receiving ROM exercises. The DON stated that residents with limited ROM or contractures should be admitted to therapy or the restorative program and acknowledged that this resident had not received restorative assistance since admission, despite needing interventions such as a rolled-up washcloth in the hand and passive ROM exercises.
Failure to Provide Ordered Nutritional Supplements to Resident With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements and to follow the resident’s care plan interventions to prevent avoidable weight loss. A resident with protein-calorie malnutrition had a care plan dated 10/10/25 directing staff to offer a meal replacement supplement whenever 50% or less of a meal was consumed. The resident’s weight log showed a decline from 170 pounds on 12/05/25 to 158.5 pounds on 01/05/26, and further to 155 pounds on 02/04/26. A dietician’s note dated 01/20/26 documented significant weight loss of 8.8% in one month and 15.3% in six months, with meal intake ranging from 25–50% of meals. The dietician recommended health shakes three times daily with meals, but there was no documentation that these health shakes were provided on multiple consecutive days. During observation on 02/11/26 at 9:16 a.m., the resident was seen lying in bed with eyes closed and an untouched breakfast tray on their walker seat. The resident’s admission assessment dated 12/20/25 showed diagnoses including pancytopenia, renal insufficiency, and cirrhosis of the liver, and a BIMS score of 12 indicating moderate cognitive impairment. On interview, the resident stated they did not receive any meal supplements and expressed that they liked them but did not know why they were no longer provided. CNA #2 confirmed the resident did not receive health shakes or additional supplements when consuming 50% or less of meals, noting the resident never ate much and had little appetite. The DON later stated the resident should have been receiving health shakes when 50% or less of meals were consumed, confirming that the ordered nutritional interventions were not implemented.
Incomplete Weekly Skin Assessment Leads to Missed Stage 2 Pressure Areas
Penalty
Summary
The facility failed to ensure accurate completion of a weekly skin assessment for one resident, resulting in missed identification of multiple open areas on the coccyx and buttocks. The resident had diagnoses including an unspecified fracture of the sacrum and abnormalities of gait and mobility, and was cognitively intact with a BIMS score of 15. A physician order dated 01/23/26 required a weekly skin assessment every Thursday on the night shift. On 02/12/26 at 10:40 a.m., the resident was observed during incontinent care with three open areas on the coccyx and buttocks. However, a skin assessment documented later that same day at 10:58 p.m. by the charge nurse indicated there were no open areas and only noted a reddened coccyx. Subsequent documentation and interviews confirmed the discrepancy. A wound care nurse’s skin assessment on 02/13/26 identified three stage 2 open areas: one on the right buttock measuring 1.5 cm by 1.5 cm, one on the left buttock measuring 1.5 cm by 1.5 cm, and one on the upper buttocks measuring 1 cm by 0.5 cm. The resident had also stated on 02/10/26 that they had a small open area on their bottom. The DON acknowledged that the 02/12/26 weekly skin assessment showed no open areas, and LPN #1 later stated they did not perform a complete head-to-toe skin assessment and, to their knowledge, did not visualize the coccyx and buttocks during the weekly skin assessment, despite facility training that weekly skin assessments must include all areas of the skin.
Failure to Provide Required Behavioral Health Services for Depressed Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with identified depression. The resident’s admission assessment documented a diagnosis of depression, indicated that participation in activities was very important to them, and showed they were cognitively intact with a BIMS score of 14. A physician’s order dated 11/11/25 directed that the resident receive a psychiatric consultation for mental health needs if criteria were met, and another order dated 12/20/25 prescribed fluoxetine 20 mg daily for depression. Despite these orders and the resident’s diagnosis, review of physician progress notes showed no psychiatric consultations, and an activity note indicated the resident did not participate in any activities during December 2025. Surveyor observations and staff interviews further demonstrated unmet behavioral health needs. On 02/11/26, the resident was observed tearful in their room and reported feeling depressed to the point of not wanting to get out of bed and potentially missing dialysis because of their depression. A CNA stated the resident was easily upset and isolated in their room, and an LPN reported the resident was not social, stayed in their room, and had refused dialysis several times. The DON stated that residents on antidepressants who exhibited behaviors such as refusing dialysis, isolating in their room, and refusing care met the criteria for psychiatric consultation, and acknowledged that this resident should have been seen for such a consultation, which had not occurred.
Medication Error Rate Exceeds 5% Due to Incorrect Dosing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 7.41% during a medication pass observation involving four sampled residents, with two residents receiving incorrect doses. For one resident, a CMA administered one tablet of vitamin D3 25 mcg from house stock instead of the prescribed vitamin D3 50 mcg, and later acknowledged that two 25 mcg tablets should have been given to follow the physician’s order. For another resident, a CMA administered one tablet of senna despite a physician’s order for two tablets once daily for constipation, and subsequently confirmed that only one tablet had been given instead of the ordered two. The DON stated that staff were expected to follow the rights of medication administration, use the punch-initial-give method, and adhere to physician orders. The administrator reported that 63 residents resided in the facility at the time of the survey, and the identified errors during the observed medication pass contributed to the facility’s overall medication error rate exceeding the 5% threshold.
Inaccurate Weekly Skin Assessment and Documentation for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate weekly skin assessments were documented for a resident with pressure-related skin issues, resulting in a discrepancy between nursing documentation and the resident’s actual skin condition. A physician’s order directed that the resident receive a weekly skin assessment every Thursday on night shift. The resident’s admission assessment documented diagnoses including an unspecified fracture of the sacrum and abnormalities of gait and mobility, and indicated intact cognition with a BIMS score of 15. During an incontinent care observation, the resident was seen with three open areas on the coccyx and buttocks. However, a weekly Skin Assessment by the charge nurse completed the previous night documented no open areas and only redness to the coccyx, while a subsequent skin assessment by the wound care nurse the next day identified stage 2 open areas on the coccyx and both buttocks. The LPN who completed the weekly skin assessment acknowledged that, contrary to facility policy requiring complete and accurate documentation and a head-to-toe assessment, they did not perform a complete skin assessment and, to their knowledge, did not visualize the coccyx and buttocks, and the DON stated nurses were to document only observed findings on the skin assessment. The wound care nurse identified that there were 12 residents with wounds in the facility, and Resident #26 was one of three sampled residents reviewed for pressure ulcers and skin conditions in whom this documentation failure was identified.
Failure to Administer Medications as Ordered and Document on MAR
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one of three residents sampled for medication administration. Review of the resident's Medication Administration Record (MAR) for September 2025 revealed multiple missed doses of prescribed medications, including atorvastatin, doxepin, mirtazapine, Singulair, Zyprexa, carvedilol, buspirone, gabapentin, carafate, and hydrocodone-acetaminophen. There were blanks on the MAR for these medications on specific dates, and no explanations for the missed doses were documented in the medical record. Interviews with facility staff confirmed that blanks on the MAR indicated that the medications were either not in the facility or not given, and that the medications in question did not appear to have been administered as ordered. The certified medication aide and the Assistant Director of Nursing (ADON) both acknowledged that the medications had not been signed out or given according to the facility's policy and physician orders. The resident involved was noted to have intact cognition at the time of the deficiency.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse, Neglect, and Inadequate Supervision
Penalty
Summary
The facility failed to ensure residents were free from verbal abuse, implement interventions to protect residents from potential physical abuse, and prevent neglect. Multiple residents with intact cognition were involved in a series of verbal altercations, including threats of physical harm. One resident made repeated verbal threats to another, including threats to set them on fire and have them shot, while another resident responded with threats of physical violence. These altercations escalated to the point where one resident produced a knife and attempted to jab it at a nurse, demonstrating a clear risk of physical harm. Documentation revealed that, although the facility reported separating the involved residents and placing them on one-on-one (1:1) supervision, there was no consistent documentation to confirm that 1:1 supervision was provided for each shift during the investigation. Additionally, care plans for the residents involved were not updated to reflect the interventions taken in response to the incidents. Staff interviews indicated a lack of clarity regarding who was responsible for 1:1 supervision during certain shifts, and there was no evidence that all staff had received the required in-service training on abuse, neglect, and misappropriation as claimed in the facility's incident report. Another incident involved a resident who reported being treated roughly and spoken to harshly by a CNA, including being told they would only be changed every two hours and experiencing pain during care. The resident expressed feeling unsafe with the CNA, and the facility's investigation led to the CNA's termination. However, staff interviews indicated that not all staff were aware of the incident or the findings of the investigation. The facility's failure to provide adequate documentation, update care plans, and ensure staff training contributed to the deficiencies identified by surveyors.
Failure to Report Resident Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse involving three residents to local law enforcement, as required by its own abuse, neglect, and exploitation policy. The incident involved verbal threats of physical harm among residents during a smoking break, with one resident making explicit threats to set another on fire and have them shot, and another resident responding with threats of physical violence. Staff intervened by separating the residents and placing two of them on one-to-one observation for the duration of the investigation. The incident was reported to the state agency, but there was no documentation that law enforcement was notified, despite the facility's policy stating that law enforcement should be contacted when applicable. Resident assessments indicated that all three residents involved had intact cognition, with relevant diagnoses including depression, anxiety disorder, schizophrenia, heart failure, hypertension, aphasia, parkinsonism, and a history of traumatic brain injury. During the incident, one resident retrieved a small knife from their purse and attempted to jab a nurse while simultaneously handing over the knife, after being informed that possessing a knife on the property was illegal. This resident was subsequently sent out for a psychiatric evaluation due to continued aggressive and violent behavior, as documented in behavioral health hospital records. Interviews with staff and the administrator confirmed that the residents were separated and placed on one-to-one observation, and that the incident was reported internally and to the state agency. However, the administrator stated that law enforcement would only be notified if a resident agreed to it, and could not provide documentation that residents declined law enforcement involvement. Staff accounts corroborated the sequence of events, including the verbal threats and the incident involving the knife. The lack of notification to law enforcement constituted a failure to follow the facility's abuse reporting policy.
Failure to Update Care Plans After Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to update the care plans for two residents after incidents of abusive and aggressive behavior were observed. Specifically, after an altercation involving threats of physical harm between residents, including one resident making verbal threats and another responding with threats of their own, both individuals were placed on 1:1 supervision for the duration of the investigation. Despite documentation in the facility's incident report that care plans would be updated as appropriate, there were no updates made to the care plans of either resident to address the incidents or the observed behaviors. One resident, with a history of depression, anxiety disorder, and schizophrenia, was involved in an incident where they made verbal threats to another resident and later produced a small knife, refusing to surrender it to the DON and attempting to jab the nurse with it. This resident continued to display verbal outbursts and was eventually admitted to a behavioral health hospital due to being a danger to others and exhibiting increased aggression and violent behavior. The care plan for this resident did not reflect the incident involving the knife or the threats made to others. Another resident, with diagnoses including hypertension, aphasia following cerebral infarction, parkinsonism, and a history of traumatic brain injury, was reported to have verbally threatened another resident with bodily harm. The resident was separated from others and later evaluated by a mental health provider, who documented the resident's account of the incident and their understanding of the consequences of their behavior. However, the care plan for this resident was not updated to address the threats made. Interviews with facility staff revealed a lack of clarity and consistency regarding the process for updating care plans following such incidents.
Failure to Determine Residents' Advance Directive Preferences
Penalty
Summary
The facility failed to determine if residents wished to formulate an advance directive for three of the thirteen sampled residents whose advance directive acknowledgements were reviewed. The facility's undated Advanced Directives policy requires that upon admission, it should be identified if a resident has an advance directive and if not, determine if the resident wishes to formulate one. However, for Resident #27, the advance directive was not signed, nor did it indicate whether they had or wanted an advance directive. For Residents #46 and #49, their advance directives were signed but did not indicate whether they had or wanted an advance directive. The business office manager stated that during admission, they discuss the advance directive with residents and representatives and upload the directive and acknowledgment into the computer. If the resident is unsure or wants to discuss it with family, the form is left blank, which the manager stated would correctly document that they have no advance directives currently.
Unsafe Flooring in Common Area
Penalty
Summary
The facility failed to provide a safe flooring environment in the common area where all halls connect, posing a potential tripping or injury hazard. Observations revealed that two floor slats were completely pulled away from the floor near the nurses' station, and maintenance was seen gluing them down and holding them with boxes while the glue dried. Multiple other floor slats had been previously glued back down, with corners sticking up, creating a hazard for mobile residents, staff, and visitors. Resident council members expressed concerns about the floor causing trouble even for those in wheelchairs. The administrator acknowledged that the floor had been spot-fixed multiple times and provided documentation of bids obtained to replace the flooring, recognizing it as a potential injury hazard.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were secured when not in use, as observed on two separate occasions. On February 10, 2025, at 4:44 p.m., the medication cart for halls 100 and 200 was found unlocked and unattended by the nursing station, with keys still in the lock. On February 13, 2025, at 7:55 a.m. and again at 9:37 a.m., the medication cart on hall 600 was observed to be unlocked with no staff present. The facility's Medication Storage policy, dated January 8, 2024, mandates that all drugs and biologicals be stored in locked compartments under proper temperature controls. Interviews with staff, including an LPN and a certified medication aide, confirmed that leaving the carts unlocked was against policy, and they acknowledged their failure to comply with the policy. The administrator also confirmed that the policy required medication carts to be locked unless within sight of the nurse or medication aide.
Infection Control Breach During PEG Tube Medication Administration
Penalty
Summary
The facility failed to maintain infection control and follow evidence-based practices (EBP) during medication administration to a resident with a percutaneous endoscopic gastrostomy (PEG) tube. During an observation, an LPN was seen administering crushed medications through the PEG tube without wearing a gown, which is required under the facility's Enhanced Barrier Precautions policy. Although the LPN washed their hands and wore gloves, they did not adhere to the full EBP protocol, which mandates the use of a gown and gloves during high-contact care activities involving indwelling medical devices. The facility's Enhanced Barrier Precautions policy, which aims to reduce the transmission of multidrug-resistant organisms (MDROs), specifies that gowns and gloves should be worn during care activities involving indwelling devices, such as feeding tubes, even if the resident is not known to be infected or colonized with an MDRO. The LPN acknowledged the requirement to wear a gown but did not do so, and the Director of Nursing confirmed that the policy requires staff to wear gowns and gloves for residents with indwelling devices. Supplies for these precautions were available outside the resident's room, but the protocol was not followed during the observed medication administration.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling medical devices, as observed in two cases. Resident #39, who had a foley catheter and pressure wounds, was not provided with appropriate EBP. During observations, staff members were seen using only regular gloves without gowns when performing care activities such as transferring, bathing, and wound care. The staff, including a CNA and an LPN, demonstrated a lack of understanding of EBP, with one staff member mistakenly believing it referred to a cream application. Additionally, there were no EBP signs posted on the resident's door, indicating a lack of communication and adherence to the facility's EBP policy. Similarly, Resident #40, who had a gastric tube, was also not provided with the necessary EBP. An LPN administering enteral feeding and flushing urinary catheters used only hand sanitizer and gloves, without additional PPE. The LPN admitted to being unsure about what EBP entailed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the absence of EBP signage and were unable to identify which residents required EBP, highlighting a systemic issue in the facility's infection prevention and control program.
Failure to Deliver Mail on Weekends
Penalty
Summary
The facility failed to provide mail delivery to residents on Saturdays, as required by their Resident Rights policy. The policy stated that mail would be delivered by facility staff, and on weekends, it would be delivered by the RN supervisor. However, interviews with eight members of the resident council revealed that mail was not distributed on weekends. Additionally, the activities director confirmed that while mail was delivered on Saturdays, it was not passed out until Monday. This discrepancy in mail distribution was acknowledged by the Director of Nursing (DON), who identified that 47 residents resided in the facility.
Failure to Notify Physician of Urinalysis Results
Penalty
Summary
The facility failed to notify the physician upon receiving culture and sensitivity results from a urinalysis for a resident reviewed for unnecessary medication. The facility's Notification of Changes policy, dated February 2023, mandates prompt consultation with the resident's physician under circumstances requiring treatment alteration. The resident had diagnoses including acute cerebrovascular insufficiency, communication deficit, and urinary tract infection. The antibiotic stewardship book and documentation lacked the culture and sensitivity results with the urinalysis. Progress notes did not document physician notification of the culture results. A physician's order dated August 14, 2024, prescribed Cephalexin 500 mg twice daily for seven days. An infection note dated August 20, 2024, indicated the resident continued on Cephalexin for a UTI. The lab results were first released on August 14, 2024, and finalized on August 18, 2024. On August 23, 2024, the ADON confirmed the absence of a progress note indicating physician notification.
Failure to Complete Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were completed in a timely manner for two residents out of a sample of 13. According to the facility's policy, a baseline care plan should be developed within 48 hours of a resident's admission. Resident #27, who was readmitted with diagnoses including metabolic encephalopathy, chronic kidney disease, end-stage renal disease (ESRD), and cognitive impairment, did not have a baseline care plan located. The Assistant Director of Nursing (ADON) confirmed that a baseline care plan had not been completed for this resident, and the current care plan was only initiated on 07/09/24. Similarly, Resident #147, who was admitted on an unspecified date, had a baseline care plan documented with a completion date of 08/20/24, which was not within the required 48-hour timeframe. A nurse consultant acknowledged that the baseline care plan for Resident #147 was not initiated in a timely manner.
Inadequate Activity Program for Residents
Penalty
Summary
The facility failed to ensure that an ongoing activity program was designed to meet the individual or group needs of residents, which increased the potential for social isolation and adverse effects on residents' well-being. On a specific date, the Activities Director was observed walking around the nurses' station and stated that no residents wanted to participate in the scheduled word search activity. The Activities Director mentioned that residents expressed dislike for what they referred to as 'kid games' and that they were following the activity schedule set by the previous Activities Director. The current Activities Director also noted that they had been using personal funds to purchase crafts that residents enjoy, due to a lack of facility funding. The report highlights specific residents whose activity preferences were not being met. One resident, with a BIMS score indicating good cognitive functioning, expressed preferences for being around animals, listening to music, participating in group activities, and attending religious services. Another resident, also with good cognitive functioning, preferred being around animals and keeping up with the news. The Director of Nursing (DON) acknowledged the lack of adequate funding for sufficient activity options and mentioned plans to identify resident preferences and schedule religious services, with a staff member willing to assist if external services could not be arranged.
Medication Security Lapse
Penalty
Summary
The facility failed to ensure the security of medications during an observation of medication administration. On August 22, 2024, at 9:20 a.m., an LPN was observed leaving a medication/treatment cart unlocked while entering a resident's room to administer medication. This incident occurred on Hall 500, one of the two medication/treatment carts observed. The LPN later explained on September 22, 2024, at 9:24 a.m., that the cart was left unlocked because they were flustered, acknowledging that the facility's policy requires carts to be locked. The facility houses 47 residents, and this lapse in protocol was identified during the survey.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to ensure that evening snacks were offered to four of the eleven sampled residents who required them. The facility's policy stated that residents should be offered a nourishing snack at bedtime according to their needs, preferences, and requests. However, residents residing in hall 100, who required extensive help to leave their rooms, were not offered snacks. The Director of Nursing (DON) identified 46 residents who received meals from the kitchen, and the Dietary Manager (DM) stated that snacks were prepared before the kitchen closed and left at the nurses' station for distribution. Despite this, residents complained about not receiving snacks, and there was no documentation to indicate that snacks were offered on multiple dates. Interviews with residents revealed that they consistently were not offered evening snacks, with some residents stating they never received them. The DON acknowledged that this was a known issue in the past and claimed to have addressed it, but the problem persisted. The lack of documentation and the residents' statements indicate a failure in the facility's process to ensure snacks were delivered as per the policy, particularly affecting those who needed assistance to access them.
Failure to Protect Resident from Abuse by Administrator
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving the administrator and a resident. The resident, who had diagnoses including hemiplegia, schizoaffective disorder, and epilepsy, was involved in an altercation with the administrator. The incident occurred when the resident was in the human resources office expressing concerns about their camera being removed. The administrator responded aggressively by slamming their hands on the desk and challenging the resident to repeat their words. This incident was documented in an Initial and Final State Reportable Incident form, indicating a failure to ensure the resident was free from abuse. The resident's care plan had not been initiated until several days after the incident, and their admission assessment was incomplete. The Director of Nursing (DON) explained that the camera was removed because the administrator believed the resident was not allowed to have audio, despite the family having signed consent for both audio and video. The administrator was suspended pending investigation, and the Assistant Director of Nursing (ADON) took statements from staff and witnesses. Staff members were in-serviced on abuse policies and procedures, but there was confusion among staff about reporting abuse, as they were unsure of the current administrator's role.
Incomplete Admission Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days of admission for a resident. The resident was admitted on an unspecified date, and the 5-day/admission assessment had a reference day set for August 9, 2024. However, by August 21, 2024, it was noted that the admission assessment should have been completed by August 18, 2024. As of August 23, 2024, the admission assessment remained incomplete.
Failure to Implement Comprehensive Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with end-stage renal disease (ESRD) and chronic kidney disease. The facility's policy mandates the development of a person-centered care plan with measurable objectives and timeframes based on the resident's comprehensive assessment. However, upon review, it was found that there was no dialysis or nutrition care plan for the resident. The Assistant Director of Nursing (ADON) confirmed the absence of these care plans and acknowledged that the existing fluid volume overload care plan did not meet the requirements for assessing and monitoring nutrition for a dialysis resident.
Failure to Complete Dialysis Orders and Monitoring
Penalty
Summary
The facility failed to ensure that orders for dialysis were completed for a resident who required such services. The facility's Hemodialysis Policy, dated February 2023, outlined the necessary care and treatment for residents receiving hemodialysis, including specific documentation and monitoring requirements. However, for the resident in question, there were no orders for monitoring or assessing the dialysis shunt, nor were there details about the dialysis schedule or location. This lack of documentation was confirmed during an interview with the Assistant Director of Nursing (ADON), who noted the absence of necessary orders in the resident's electronic medical record. Observations and interviews with staff revealed further deficiencies in the care provided to the resident. A Certified Nursing Assistant (CNA) mentioned the resident's dialysis schedule but did not provide details about the care required for the dialysis shunt. An LPN admitted to not having assessed the resident's shunt on the day of observation and was unable to explain why the resident still had an undated bandage from dialysis. These findings indicate a failure to adhere to the facility's policy and ensure proper care and monitoring for the resident receiving dialysis.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted and updated. On August 21, 2024, at 11:17 a.m., the staffing sheet was observed to be completed for August 19, 2024, but only partially completed for August 20, 2024, missing the actual hours worked for RNs, LPNs, CNAs, and CMAs. Additionally, there was no staffing information available for August 21, 2024. By August 22, 2024, at 9:35 a.m., the staffing sheet had not been updated to include information for August 21 or August 22. It was only at 10:50 a.m. on August 22, 2024, that the staffing sheet was fully updated. The Director of Nursing (DON) explained that they had been waiting to total the actual hours worked for the staff before updating the sheet.
Failure to Follow Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program policy for a resident diagnosed with a urinary tract infection (UTI), communication deficit, and cerebrovascular insufficiency. The policy required that antibiotics be prescribed and administered under the guidance of the program, with culture and sensitivity (C&S) results communicated to the prescriber to determine the appropriateness of antibiotic therapy. However, the facility did not follow this protocol. The resident was prescribed Cephalexin 500 mg twice daily for seven days without the C&S results being reviewed or communicated to the physician. The culture was obtained on August 14, 2024, and received on August 18, 2024, but the results were not included in the antibiotic stewardship documentation. The Director of Nursing (DON) admitted that the facility often prescribed antibiotics before receiving C&S results and acknowledged that the prescribed Cephalexin was not listed on the culture and sensitivity report. The resident received the antibiotic from August 15, 2024, through August 21, 2024, and was later sent to the hospital due to behaviors. The Assistant Director of Nursing (ADON) confirmed that there was no progress note indicating physician notification, and the antibiotic stewardship policy was not followed. This oversight highlights a failure in the facility's process for ensuring appropriate antibiotic use, as required by their policy.
Inadequate Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that the emergency call cords were long enough to be reached by a resident when lying in bed. During observations, it was noted that the call light was on the floor and out of reach of a resident who was sitting in a wheelchair next to the bed. The resident was unable to reach the call light to request assistance to be put back to bed. A CNA confirmed that the call light cord was too short to reach the bed and mentioned that the policy is to have the call light within reach. The CNA also stated that the resident's roommate would use their call light if assistance was needed.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide showers for two residents who required assistance with activities of daily living (ADL). Resident #15, diagnosed with multiple sclerosis and morbid obesity, reported that their last bath was on 04/08/24, and records showed no documentation of a shower for 22 days between February 24, 2024, and March 18, 2024. The Director of Nursing (DON) confirmed the lack of documentation for this period. Resident #4, diagnosed with lack of coordination, muscle wasting, and atrophy, also did not receive scheduled baths. Their quarterly assessment indicated they required moderate assistance for bathing. Records showed that Resident #4 missed eight out of 13 scheduled baths in February 2024, nine out of 14 in March 2024, and three out of eight in April 2024. Both the resident and CNA #2 confirmed the missed baths, and the DON acknowledged the absence of documentation for these dates.
Failure to Complete Ongoing Dialysis Assessments
Penalty
Summary
The facility failed to complete ongoing assessments of a resident pre and post dialysis for one of the sampled residents reviewed for dialysis services. The Hemodialysis policy, revised on 10/01/23, required ongoing assessment and oversight of the resident before, during, and after dialysis treatment. However, the dialysis communication records for February, March, and April 2024 showed no documentation of pre, during, and post dialysis assessments for multiple dates. An LPN confirmed that these assessments were not completed for the specified dates after reviewing the resident's dialysis communication records and progress notes.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for one of five sampled residents reviewed for unnecessary medications and did not conduct ongoing monitoring of the program. The facility's policy, revised on 10/01/23, required an antibiotic stewardship program as part of the infection prevention and control program. However, there was no documentation of antibiotic use monitoring for several months in 2023 and 2024. Specifically, a resident had physician's orders for azithromycin and doxycycline hyclate, but there was no documentation of monitoring for these antibiotics in September 2023 and March 2024. The Director of Nursing (DON) and the Infection Preventionist confirmed the lack of monitoring during a review on 04/17/24.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who received Part A skilled services. The resident was admitted to Part A skilled services on November 22, 2023, and discharged from these services on November 30, 2023, but remained in the facility. There was no documentation indicating that the SNF ABN was provided to the resident. On April 16, 2024, the MDS coordinator confirmed that they could not locate the SNF ABN for the resident.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a resident's wall was in good repair, compromising the homelike environment for one of the 16 sampled residents. The resident had diagnoses including cerebral infarction and abnormalities of gait and mobility and was nonverbal. On observation, the resident's wall had three deep scrapes by the head of the bed. A CNA acknowledged awareness of the scrapes since February and reported them to another staff member, but it was unclear if the issue was communicated to maintenance. The Maintenance Supervisor confirmed they were unaware of the need for repair in the resident's room.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for a resident with a diagnosis of hypertension. The resident had physician's orders for hydralazine and carvedilol, both with specific parameters to hold the medication if the systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was less than 60. The April 2024 Medication Administration Record (MAR) documented that hydralazine was administered on two occasions when the resident's blood pressure was below the specified parameters. Similarly, carvedilol was also administered on the same two occasions despite the resident's blood pressure being below the ordered parameters. Both an LPN and the Assistant Director of Nursing (ADON) confirmed that the medications should not have been administered on those dates according to the physician's orders.
Failure to Review PRN Lorazepam Order After 14 Days
Penalty
Summary
The facility failed to review a PRN lorazepam order after 14 days of use for one resident. According to the facility's policy on the use of psychotropic medication, PRN orders for such drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration of 14 days. If the attending physician or prescribing practitioner believes that the PRN order should be extended beyond 14 days, they must document their rationale in the resident's medical record and indicate the duration for the PRN order. A physician order dated 02/23/24 prescribed lorazepam 0.5 mg to be given every 8 hours as needed for anxiety, insomnia, and restlessness, with an indefinite end date. The medication was administered once in February, twelve times in March, and eleven times in April. On 04/19/24, the Director of Nursing (DON) confirmed that PRN anti-psychotic orders should be re-evaluated every two weeks.
Improper Transport of Dirty Linen
Penalty
Summary
The facility failed to ensure dirty linen was transported in a manner to prevent cross-contamination. The Handling Soiled Linen policy, revised in October 2023, specified that linen should not touch the uniform or floor and should be collected and placed in a linen bag or designated receptacle. On April 17, 2024, at 6:38 a.m., a CNA was observed walking by the nurse's station with pads and a trash bag in his gloved hands. The CNA briefly set the pads on the floor by three blue bins before picking them up again and placing them in the soiled room. The CNA admitted to setting the dirty pads on the floor and acknowledged that the pads were supposed to be bagged during transport but stated there were not enough bags available.
Latest citations in Oklahoma
A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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