Parkhill North Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Salina, Oklahoma.
- Location
- 319 North Owen Walters Blvd, Salina, Oklahoma 74365
- CMS Provider Number
- 375322
- Inspections on file
- 18
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Parkhill North Nursing Home during CMS and state inspections, most recent first.
The facility failed to obtain and monitor physician-ordered laboratory tests for two residents with severe cognitive impairment and medical conditions requiring lab monitoring. One resident had orders for CBC and CMP every six months and was care planned for lab monitoring related to pressure ulcer risk, but required labs were not completed as ordered. Another resident with hypertension and on Valproic Acid had orders for CBC, CMP, LFT, and Valproic Acid levels every six months, yet these labs were not completed as scheduled. The DON acknowledged that the labs had not been done and that monthly monitoring of lab reports, as expected, was not occurring, without being able to explain the cause.
Surveyors found that the facility lacked a full‑time dietary manager and that kitchen staff were inadequately trained in basic food safety, sanitation, and diet-specific meal preparation for residents. Over several observations, no dietary manager was present, staff allowed an aide without a hair cover to scoop ice, a dietary aide stepped on a box of potatoes to tie a shoe, and a cook handled food-contact surfaces and plated food with bare hands without handwashing. A broken blender lid was operated using a butter knife, personal drinks were stored in the kitchen, and an open can of pears was improperly stored in the refrigerator. Pureed and regular diet trays were not served according to the RD‑approved menu, with pureed residents receiving incomplete meals and regular diet residents receiving reduced portions. Multiple staff, including cooks and dietary aides, reported they did not know what an extended menu was, did not know food temperature danger zones or proper hot/cold holding temperatures, and had minimal training, while leadership acknowledged there was no dietary manager and that oversight was informal and limited.
Surveyors found that meals were not prepared or served according to the dietician-approved extended menus for both regular and pureed diets. During observed meal services, pureed trays were missing required items such as pureed bread and specified components of pureed chicken noodle soup, and regular diet trays were served with reduced portions and substitutions not reflected on the menu. Kitchen staff used an unsafe method to operate the blender and reported they did not follow or were unaware of the extended menu, instead relying on what was written on a board by another cook. Staff, including the DON, acknowledged a lack of a dietary manager, limited training, and poor oversight of dietary practices.
Surveyors found extensive food safety and sanitation deficiencies, including unsealed holes and gaps in the kitchen ceiling, a visibly soiled ice machine, and staff and non-kitchen personnel entering the kitchen without hair restraints. Dietary staff were observed stepping on an open box of potatoes, touching counters and food-contact surfaces with bare hands, improperly storing an open can of pears in the refrigerator, handling plates and grilled cheese sandwiches with bare hands, and keeping an open personal drink in the kitchen. An unsealed bag of bread was stored on top of a toaster. Interviews showed that cooks and a dietary aide lacked knowledge of leftover storage requirements, proper cooling, temperature danger zones, hot/cold holding temperatures, extended menus, and pureed diet requirements. The DON and staff reported there was no dietary manager, food handler permits were not required, and oversight of kitchen operations was handled informally by the activities director and a long-term cook, while the DON was unaware of structural issues in the recently renovated kitchen.
A commercial blender used to prepare puree meals for six residents was operated with a broken cover and an improvised safety override. A cook placed canned carrots and lasagna into the blender, used a cracked and damaged cover, and bypassed the blender’s safety mechanism with a butter knife to start and run the equipment. The cover was visibly cracked, and the locking plastic component was missing, yet the blender continued to be used to prepare puree meals served to residents.
The facility failed to conduct and document routine safety inspections of bed frames and side rails used by a resident with intact cognition who was repeatedly observed in bed with bilateral quarter side rails in the up position around the shoulders and head. The maintenance supervisor reported that beds and rails were only checked and repaired when issues were reported, and there was no established program for routine inspections. The DON believed beds and rails were inspected before use but confirmed there was no documentation of such inspections and no policy or procedure governing bed frame and bed rail use and inspection.
A resident received quetiapine for vascular dementia with agitation despite a facility policy that did not permit antipsychotic use for any form of dementia. Physician orders directed scheduled morning and bedtime doses, and the MAR showed the medication was administered on multiple consecutive days. The DON confirmed antipsychotics were not approved under the policy for dementia, while an LPN reported giving quetiapine for the resident’s aggression but did not know whether it was an approved treatment indication. The DON also noted that multiple residents in the facility were receiving antipsychotic medications.
A resident with severe cognitive impairment was receiving lorazepam PRN for anxiety and divalproex daily, as documented on the MAR, yet the quarterly and annual MDS assessments indicated the resident had not received antianxiety or anticonvulsant medications during the applicable 7-day look-back periods. The MDS coordinator reported reviewing MARs when completing assessments but could not explain the omission of lorazepam and stated that, because the resident did not have a seizure diagnosis, divalproex was not coded as an anticonvulsant on the assessments.
A resident was admitted with a BIMS score indicating intact cognition, but no baseline care plan was developed within 48 hours of admission. Review of the electronic and paper records confirmed the absence of a baseline care plan. The MDS coordinator reported that either they or the ADON typically complete baseline care plans, and the ADON acknowledged that the plan was not completed because they were off work during the relevant period.
A resident with dementia, delusions, and documented wandering behavior was assessed multiple times as having impaired cognition and risk factors for wandering and elopement, including resistance to placement, confusion, and a history of wandering. A quarterly wandering/elopement assessment completed by an LPN indicated that any single "yes" response required wandering/elopement precautions, yet the resident’s care plan, created under the responsibility of the ADON, contained no problem, goals, or interventions addressing wandering or elopement risk. During interview, the ADON confirmed the absence of such care plan entries and acknowledged they should have been included.
A resident with severely impaired cognition, delusions, and documented wandering behavior was assessed as an elopement risk and met criteria for wandering/elopement precautions, yet was able to access the front exit and had previously gone outside into the parking lot without staff initially realizing it. Multiple CNAs and LPNs later acknowledged that the resident had been found outside on at least one prior occasion but did not report the incident to administration, and the DON learned of it only through the surveyor. Staff accounts conflicted with the DON’s belief that a CNA had never lost sight of the resident during the prior event.
A resident with obstructive uropathy and an indwelling urinary catheter had a physician order and care plan directing monthly catheter changes, with the due date documented on the MAR but not completed. The resident reported receiving routine catheter care but no catheter change for the month, while an LPN believed a hospice nurse had performed the change. The DON later confirmed the hospice nurse had not changed the catheter, clarified that the charge nurse was responsible for catheter changes, and acknowledged there was no monitoring system in place to ensure indwelling urinary catheters were changed per physician orders.
A resident with orders for thrice-weekly dialysis was assessed by an LPN prior to transport, but the facility failed to maintain ongoing communication with the contracted dialysis provider. The facility’s dialysis policy did not address continued communication with the dialysis center, and the LPN reported never using the facility’s dialysis communication form or sending pre- or post-dialysis assessment information during two years of employment. The DON confirmed that the communication form had not been used or sent to the dialysis center in years and that the facility did not receive routine information about the resident’s dialysis sessions, aside from nutrition documentation from the dialysis center’s nutritionist.
The facility did not maintain RN coverage for eight consecutive hours on several days in April 2024, as required. The DON confirmed the lack of coverage during an interview, affecting the care of 36 residents.
Failure to Obtain and Monitor Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory tests were obtained as ordered by physicians for two residents. Facility policy titled "Lab and Diagnostic Test Results-Clinical Protocol" dated November 2018 stated that physicians would order diagnostic and lab testing based on residents' needs and staff would process test requisitions and arrange for tests. For one resident, a physician order dated 04/11/25 required a CBC and CMP every six months in April and October. The resident’s quarterly assessment dated 10/31/25 documented a BIMS score of 2, indicating severe cognitive impairment for daily decision making, and no current pressure ulcers. The care plan, revised 10/31/25, identified the resident as at risk for pressure ulcers and directed staff to monitor labs as ordered by the physician. Record review showed that the ordered labs were not completed in April or October 2025, and the DON confirmed the labs had not been completed and could not explain why. For a second resident, a physician order dated 03/12/24 required a CBC, CMP, LFT, and Valproic Acid level every six months in April and October. An annual assessment dated 10/09/25 showed the resident was severely impaired in cognition for daily decision making and had hypertension. The care plan, revised 10/09/25, documented hypertension and directed staff to monitor labs as ordered. Clinical record review did not show that the ordered labs were completed in October 2025. The DON stated that these labs had not been completed and reported they were supposed to monitor lab reports monthly but did not know why that monitoring was not being done.
Lack of Dietary Management and Inadequate Food Safety Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full‑time dietary manager and to ensure kitchen staff had the competencies and skills necessary to safely perform food and nutrition service duties for 39 residents receiving meals from the kitchen. On multiple observations across several days and times, no dietary manager was present in the kitchen. Staff interviews confirmed the facility did not have a dietary manager, and the DON stated that an activities director and a cook informally monitored dietary staff. A cook reported being told a dietary manager was unnecessary because a registered dietician visited monthly, and the DON acknowledged difficulty hiring dietary staff and that the facility did not require food handler permits. Surveyors observed repeated food safety and sanitation issues. A hospice aide entered the kitchen without a hair covering and scooped ice from a cooler in front of kitchen staff who did not intervene or offer a hair net. A dietary aide stepped onto an open box of russet potatoes stored under a prep table to tie their shoe, then returned their foot to the floor. A large Styrofoam drink cup belonging to a dietary aide was stored on a top shelf in the kitchen. A cook handled multiple kitchen surfaces and equipment with bare hands, pushed a metal can lid down into a gallon can of pears and stored it in the refrigerator, then handled a plate by covering the food-contact surface with their palm and fingers before placing a grilled cheese sandwich on it and delivering it to a resident’s room, returning to the kitchen and handling leftovers and trash without washing hands. A broken blender lid required staff to use a butter knife to engage the safety lock before pureeing foods. The facility also failed to ensure staff followed menus and diet orders and understood basic dietary procedures. Pureed meals were not prepared according to the menu: a cook chose not to puree bread sticks on the menu, stating residents on pureed diets would not eat pureed bread, and a pureed plate was served with pureed lasagna, carrots, and dessert but no bread. A pureed tray requested by a CNA was served as mashed potatoes, applesauce, and chicken broth without noodles or meat, while a regular diet tray consisted of half a grilled cheese sandwich, diced peaches, and chicken noodle soup despite bread being available. Staff, including cooks and dietary aides, stated they did not know what an extended (RD‑approved) menu was, did not know food temperature danger zones or proper hot/cold holding temperatures, and did not know proper leftover cooling and storage requirements. One dietary aide stated the biggest problem in the kitchen was lack of management and training, and the DON stated one cook was considered “untrainable.”
Failure to Follow Dietician-Approved Menus and Puree Diet Requirements
Penalty
Summary
The deficiency involves the facility’s failure to provide meals according to the registered dietician–approved menus, including required items and portions, for both regular and pureed diets during two observed meal services. Surveyors observed cook #1 pureeing canned carrots and lasagna using a blender that was started by sliding a butter knife between the housing and cover to engage the safety mechanism. During the noon meal, a pureed plate was served with pureed lasagna, carrots, and a whipped dessert, but without the required breadstick/bread component, despite the extended menu specifying pureed garlic bread and defined scoop sizes for each pureed item. Cook #1 stated they would not puree breadsticks and reported that residents would not eat pureed bread, and that substitutions were written on a paper on the wall for the registered dietician to review. During the evening meal observation, surveyors noted a partial loaf of white bread on top of the toaster and observed a dietary aide providing a pureed tray consisting only of mashed potatoes, applesauce, and chicken broth without noodles or meat, instead of the specified pureed chicken noodle soup, pureed pimento cheese sandwich, pureed vegetable blend, pureed bread, and pureed pears. A regular diet tray was served as half of a grilled cheese sandwich, diced peaches, and chicken noodle soup, rather than the full menu of chicken noodle soup, pimento cheese sandwich, cucumber onion salad, saltine crackers, and pears. Multiple dietary staff, including cook #2 and dietary aides, reported they were unaware of the extended menu, did not know dietary requirements for pureed diets, and followed what was written on the board by the daytime cook. The DON confirmed there was no dietary manager, that cook #1 functioned as an interim lead, and acknowledged issues with the evening cook’s training, while staff also cited lack of management and training in the kitchen.
Widespread Food Safety, Sanitation, and Training Deficiencies in Dietary Services
Penalty
Summary
Surveyors identified multiple failures in the facility’s food service operations affecting 39 residents who ate meals prepared in the kitchen. The physical kitchen environment had several unsealed holes and gaps in the ceiling, including around an electrical conduit pipe, loose bell fixture with exposed wiring and screw holes, separated crown molding, and an unsealed hole near a ceiling rack over a food preparation table. The ice machine contained a black and brown mucous-like substance along the drip pan edges and dark buildup inside and outside the water tubing. A hospice aide entered the kitchen without a hair restraint and scooped ice from a cooler in the center of the kitchen without being corrected or offered a hair cover by kitchen staff who were present. Surveyors observed multiple breaches of food handling and infection control practices by dietary staff. A dietary aide stepped onto the top of an open box of russet potatoes stored on the bottom shelf of a food preparation table to tie their shoe. Cook staff were seen touching multiple kitchen counter surfaces and the food preparation table with bare hands. One cook pushed the metal lid of a gallon can of pears down into the can and stored it open in the refrigerator, then handled a plate by covering the food-contact surface with their palm and fingers, placed a grilled cheese sandwich on the plate with bare hands, delivered it to a resident’s room, and returned to the kitchen without washing their hands before resuming leftover storage and trash disposal. An open personal Styrofoam drink cup with lid and straw was present on a kitchen shelf, and an unsealed plastic bag of white bread was stored on top of the toaster. Staff interviews revealed significant gaps in dietary training, oversight, and knowledge of food safety standards. One cook stated they did not know the requirements for storing leftover foods, had not been taught how to properly cool leftovers, did not know the temperature danger zone for foods, and were unaware of proper hot and cold holding temperatures, extended menus, or specific dietary requirements for residents on pureed diets. A dietary aide similarly reported not knowing about extended menus, temperature danger zones, or holding temperatures, though they acknowledged that touching plate surfaces and food with bare hands, having personal drinks in the kitchen, and stepping on a box of potatoes were unsanitary. The DON and kitchen staff reported there was no dietary manager, that the activities director and a long-term cook informally monitored kitchen duties and ordered food, that food handler permits were not required, and that some kitchen staff were considered “not trainable.” The DON also stated they were unaware of the holes in the recently renovated kitchen.
Improper Use of Broken Blender to Prepare Puree Meals
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe working order when a commercial blender used to prepare puree meals was operated with a broken cover and an improvised safety override. During observation, a cook poured canned carrots into the blender bowl, placed a broken cover onto the bowl, and used a butter knife to engage the safety mechanism and start the blender. The cook then blended canned carrots and lasagna using this same bowl with the broken cover and the butter knife to bypass the safety feature. The blender cover was observed to be cracked in several places, and the plastic portion that locked the blender bowl in place was missing and appeared to have broken off. The cook stated that the top of the blender used to puree foods was broken and that they had to work the safety with a butter knife to get the blender to operate. Six residents were identified as receiving puree meals prepared in the kitchen using this blender. No additional resident medical history or clinical conditions were documented in the report beyond the fact that six residents consumed puree meals prepared with this equipment.
Failure to Conduct and Document Routine Bed and Side Rail Safety Inspections
Penalty
Summary
The deficiency involves the facility’s failure to ensure routine inspection of a resident’s bed and side rails, as required for safety. One resident was repeatedly observed in bed with bilateral quarter side rails in the up position around the shoulders and head on multiple dates, with the rails attached to the bed frame. An annual MDS assessment showed this resident had a BIMS score of 13, indicating intact cognition and normal memory and thinking abilities. Despite the ongoing use of these bed rails, there was no evidence that the bed frame or side rails had been routinely inspected for safety. During interviews, the maintenance supervisor, who had been in the role for 1.5 years, stated that their practice was to repair beds or rails only when an issue was reported and to assemble new beds when they arrived, but confirmed there was no program for routine inspection of bed frames and bed rails. The DON stated they believed beds and bed rails were inspected before resident use but acknowledged there was no documentation of such inspections. The DON also confirmed there was no policy or procedure in place regarding the use and inspection of bed frames and bed rails. These actions and inactions resulted in the failure to conduct and document routine safety inspections for beds and side rails used by residents.
Antipsychotic Medication Used for Dementia Contrary to Facility Policy
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident did not receive an antipsychotic medication for a diagnosis of dementia, contrary to the facility’s own policy. The 2025 policy titled "Monitoring of Anti-Psychotics" specified that residents were only to be prescribed antipsychotic medications if they had one of the listed diagnoses, and no form of dementia was included on that list. Despite this, physician orders dated 11/19/25 directed that Resident #10 receive quetiapine 25 mg every morning and 50 mg at bedtime for a diagnosis of vascular dementia, unspecified severity, with agitation. The December 2025 medication administration record showed the resident received both the morning and bedtime doses of quetiapine on multiple consecutive days from 12/01/25 through 12/11/25. During interviews, the DON confirmed that antipsychotic medications were not approved under facility policy for the treatment of dementia, and an LPN reported administering quetiapine for the resident’s aggression toward other residents but stated they did not know whether the medication was approved for treating dementia with aggression. The DON also identified that a total of 11 residents in the facility were receiving antipsychotic medications, indicating that the reviewed resident was among a broader group of residents on such therapy. The documentation and interviews together showed that the antipsychotic was ordered and administered for a dementia-related diagnosis that was not permitted under the facility’s antipsychotic monitoring policy, and that nursing staff lacked knowledge about whether the use of quetiapine for dementia with aggression was in accordance with approved indications.
Inaccurate MDS Coding of Antianxiety and Anticonvulsant Medication Use
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for a resident in relation to antianxiety and anticonvulsant medication use. Record review showed that the resident had an order for lorazepam 1 mg every four hours as needed for anxiety from 07/02/25 through 07/16/25 and received a dose on 07/15/25 at 9:26 p.m. The resident was also ordered and received divalproex 125 mg daily from 07/01/25 through 07/16/25. However, the quarterly assessment dated 07/15/25 documented that the resident, who was assessed as severely impaired in cognition for daily decision making, had not received an antianxiety or anticonvulsant medication during the seven-day look-back period, despite the documented administration of both medications. An annual assessment dated 10/09/25 again showed the resident as severely impaired in cognition for daily decision making and indicated that the resident had not received an anticonvulsant during the seven-day look-back period. This conflicted with the October 2025 medication administration record, which showed the resident was ordered and received divalproex 125 mg daily and had doses administered on 10/03/25, 10/04/25, 10/05/25, 10/07/25, and 10/08/25. During interview, the MDS coordinator stated they reviewed the medication administration records when completing assessments and did not know why the lorazepam use was not accurately coded. The MDS coordinator further explained that because the resident did not have a diagnosis of seizures, they did not code divalproex as an anticonvulsant received during the seven-day look-back periods for either the quarterly or annual assessments.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop a baseline care plan within 48 hours of admission for one resident. Record review showed that the resident was admitted on 06/20/25 and had a BIMS score of 13, indicating the resident was cognitively intact for daily decision making. Review of the clinical record did not show that a baseline care plan had been completed for this resident. During interviews, MDS coordinator #1 stated that they or the ADON were responsible for completing baseline care plans and, after reviewing both the electronic clinical record and the paper chart, could not locate a baseline care plan for the resident. The ADON confirmed that they were responsible for completing baseline care plans and acknowledged that a baseline care plan had not been completed within 48 hours of admission for this resident because the ADON had been off work on those days. The DON identified that 39 residents resided in the facility at the time of the survey, and the deficiency was identified for 1 of 14 sampled residents whose care plans were reviewed.
Failure to Care Plan for Resident at Risk for Wandering and Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan addressing wandering and elopement risk for a resident who had been assessed as at risk. An MDS admission assessment dated 12/01/24 documented that the resident’s cognition was moderately impaired, and that the resident experienced delusions and wandered one to three days in the previous seven days. A quarterly wandering/elopement assessment completed by an LPN on 09/02/25 showed "yes" responses to questions about resistance to being placed in the facility, a history of wandering, confusion and disorientation, and indications of dementia. The assessment form’s instructions stated that a single "yes" answer required the resident to be placed on wandering/elopement precautions. A subsequent MDS admission assessment dated 12/04/25 showed the resident’s cognition had declined to severely impaired, with continued delusions and wandering one to three days in the previous seven days. Despite these findings, the resident’s care plan revised on 12/06/25 contained no problem, goals, or interventions related to wandering or elopement risk. During an interview on 12/18/25, the ADON, who stated they were responsible for creating resident care plans, reviewed the care plan and confirmed there were no entries addressing wandering or elopement. The ADON acknowledged that, given the resident’s dementia and wandering behavior, problems related to wandering and elopement should have been included in the care plan.
Failure to Prevent and Report Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident, assessed as an elopement risk, from exiting the building and entering the parking lot without staff awareness. The resident had an MDS admission assessment showing moderately impaired cognition with delusions and wandering behaviors, and a subsequent MDS showing severely impaired cognition with continued delusions and wandering. A quarterly wandering/elopement assessment documented multiple “yes” responses to risk questions, which per the tool’s instructions required placement on wandering/elopement precautions. Despite this, the resident was observed by surveyors attempting to open the front door, repeatedly pushing on the door latch until a staff member intervened. Staff interviews revealed that the resident had previously exited the facility without staff initially knowing, and was later found outside near the front parking lot. Multiple CNAs and LPNs acknowledged awareness of at least one prior incident in which the resident was outside the building, but none could recall the exact date, and the involved LPNs and CNA stated they did not report the incident to administration. The DON stated they only became aware of the prior exit when informed by the surveyor and indicated that staff were supposed to report such incidents, but this had not occurred. There were conflicting accounts between the DON and CNAs regarding whether a particular CNA had maintained visual contact with the resident during the incident, with several CNAs stating that CNA was not present when the resident was found outside.
Failure to Change Indwelling Urinary Catheter as Ordered
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter was changed as ordered by the physician for one resident. Observation on 12/17/25 showed Resident #19 in bed with an indwelling urinary catheter. A physician order dated 06/10/25 directed that the catheter be changed monthly on the 9th and as needed, and a quarterly assessment dated 12/04/25 documented that the resident, who had a BIMS score of 15 indicating cognitive intactness, had an indwelling urinary catheter and obstructive uropathy. The care plan revised on 12/04/25 also specified that the catheter was to be changed every month and as needed. The medication administration record for 12/01/25 through 12/17/25 showed the catheter was scheduled to be changed on 12/09/25, but there was no documentation that this was completed. On 12/17/25, the resident reported receiving catheter care but stated the catheter had not been changed in December. LPN #3 stated they believed the hospice nurse had changed the catheter on 12/09/25, while on 12/18/25 the DON confirmed the hospice nurse had not changed it and stated that the charge nurse was responsible for catheter changes and that there was no monitoring in place to ensure catheters were changed as ordered. This deficiency centers on the missed monthly catheter change for Resident #19 despite clear physician orders, care plan directives, and MAR entries, combined with staff misunderstanding about who performed the change and the absence of a monitoring system to verify that indwelling urinary catheters were changed as ordered.
Failure to Maintain Ongoing Communication With Dialysis Provider
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of dialysis-related care and services for a resident who required routine dialysis. The resident had a physician’s order, dated 01/30/25, to be sent to a contracted dialysis provider every Monday, Wednesday, and Friday. On 12/17/25 at 10:08 a.m., an LPN was observed conducting a pre-dialysis assessment of this resident. Review of the facility’s policy titled “Dialysis-General Guidelines and Management,” dated 01/2008, showed the policy did not address ongoing or continued communication between the dialysis center and the facility. During interviews, the LPN stated they had never used the facility’s dialysis communication form to document pre- and post-dialysis assessments or to send pre-dialysis assessment information to the dialysis center, despite having worked at the facility for two years. The LPN reported they believed this was because the dialysis center would not complete their portion of the form or return it. The DON confirmed that the dialysis communication form existed but had not been completed or sent to the dialysis center in years. The DON further stated that the facility had not received routine communication back from the dialysis center regarding the resident’s dialysis sessions, with the only regular documentation coming from the dialysis center’s nutritionist about nutrition.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. The deficiency was identified through a review of the nursing schedule for April 2024, which documented the absence of RN coverage for eight consecutive hours on specific dates: April 5, April 8, April 9, and April 10, 2024. During an interview on June 5, 2024, the Director of Nursing (DON) confirmed that there was no RN coverage on these dates. The facility had 36 residents at the time of the report, but no specific details about the residents' conditions or medical history were provided in relation to the deficiency.
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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