Pleasant Valley Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskogee, Oklahoma.
- Location
- 1120 Illinois Street, Muskogee, Oklahoma 74403
- CMS Provider Number
- 375451
- Inspections on file
- 20
- Latest survey
- September 5, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pleasant Valley Health Care Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairments were not evaluated for their capacity to consent to sexual activity, leading to an immediate jeopardy situation. Despite documented incidents of inappropriate sexual behavior, the facility failed to assess or document the residents' ability to consent, nor were care plans updated to address these behaviors. The facility's inaction resulted in a deficiency with potential for more than minimal harm.
The facility failed to ensure dignified mealtime assistance for two residents with cognitive impairments. Staff members were observed standing over residents while feeding them, contrary to the facility's policy that requires staff to be seated. The CNA involved was unaware of this policy, and the DON confirmed the expectation for staff to be seated during feeding assistance.
The facility did not ensure that information on filing complaints and contacting the Ombudsman was accessible to residents. During an interview, ten residents were unaware of how to contact the Ombudsman or report complaints. The information was posted on a bulletin board but was placed too high for easy access. The Administrator admitted the forms needed to be lowered.
The facility failed to make past survey results readily accessible to residents. Ten residents were unaware of where to find these reports. The survey results were placed in a binder on a bulletin board, mounted five feet above the floor, and attached to a chain, limiting access. The Administrator acknowledged the issue with the binder's height.
The facility failed to report abuse investigations and incidents involving three residents within the required timeframe. A resident with cognitive deficits reported verbal abuse by a CNA, but the incident was reported late. Another resident with intellectual disabilities experienced rough handling and alleged molestation, with delays in notifying the Nurse Aide Registry. A third resident with Alzheimer's was involved in unreported altercations and inappropriate behavior. The DON acknowledged the lack of reporting, citing residents' rights.
The facility failed to conduct thorough investigations into abuse allegations and resident altercations. A resident reported rough handling by staff, but the investigation was incomplete. Another resident was involved in multiple altercations without proper incident reporting or investigation. Additionally, an LPN allegedly used inappropriate language towards a resident, but the investigation was insufficient, and the incident was not reported to the nursing board.
Two residents with cognitive impairments exhibited inappropriate behaviors, including sexual misconduct and aggression, but their care plans were not updated to address these issues. Despite multiple documented incidents, the care plans lacked interventions or strategies to manage the behaviors, as confirmed by the DON.
The facility did not ensure RN coverage for eight consecutive hours daily, as required, affecting 83 residents. On several occasions in May, June, and July, RN coverage was insufficient, with hours worked ranging from 4.93 to 7.80 hours. Human Resources confirmed that the DON or ADON should cover these gaps, but this did not happen on the specified dates.
A facility failed to follow its policy for administering medications via enteral tube for a resident with a gastrostomy tube. A CMA was observed crushing medications into a powder without diluting them before administration, contrary to the policy requiring dilution and flushing with water. The CMA admitted to not following the procedure due to forgetting a spoon, despite being aware of the correct method.
The facility's medication error rate was 8.11%, exceeding the acceptable threshold of 5%. Two residents were affected: one was not instructed to chew a prescribed aspirin, and another did not receive Mylanta due to its unavailability and had issues with Potassium Chloride ER administration. These errors highlight a failure in medication administration protocols.
The facility failed to prevent bare hand contact with food during meal service for a resident with dementia, as a CNA used bare hands to serve bread. Additionally, the dishwashing machine was not properly monitored, resulting in inadequate chlorine levels for sanitation. The dietary manager resorted to using disposable serving items due to the issue.
The facility failed to prevent cross-contamination by improperly handling soiled linens and not using enhanced barrier precautions for a resident with a gastric tube. A CNA did not bag soiled items before transporting them, and a CMA did not don a gown when accessing a resident's gastrostomy tube, despite facility policies requiring these actions. Staff were unclear about the meaning of indicators for PPE use.
The facility failed to accurately code Resident Assessments for two residents. One resident, admitted to hospice care, had their hospice status omitted from the Annual Resident Assessment. Another resident, discharged home with family, was incorrectly documented as discharged to a hospital. These inaccuracies were confirmed by MDS Coordinators during reviews.
A resident with a stage four pressure wound did not receive a physician-recommended HBA1C test due to it being listed as a recommendation rather than an order. The test was pending for several months, and the oversight was only identified and addressed after a review by the facility's administration.
Failure to Evaluate Capacity for Consent in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to evaluate two residents for their capacity to consent to sexual activity, leading to an immediate jeopardy situation identified by the Oklahoma State Department of Health. Resident #18, who had a history of sexually inappropriate behaviors and was diagnosed with unspecified dementia, was observed engaging in sexual activity with Resident #51, who had severe cognitive impairment due to Alzheimer's Disease. Despite these observations, there was no documentation of an evaluation of their capacity to consent, nor were there care plans or assessments addressing their sexual activity. The facility's policy on Abuse, Neglect, and Exploitation, which includes guidelines for preventing sexual abuse and ensuring residents' capacity to consent, was not adhered to. The policy requires establishing a safe environment and documenting determinations of capacity to consent to sexual contact. However, the facility did not provide evidence of such evaluations or incident reports to the state health department, even after multiple incidents involving Resident #18's inappropriate sexual behaviors were documented in behavior notes. The Director of Nursing (DON) acknowledged that both residents had severely impaired cognitive abilities, yet no interventions were put in place to address the risk of sexual abuse or to update the residents' care plans to reflect their sexual behaviors. The facility's inaction in assessing and documenting the residents' capacity to consent to sexual activity, despite clear indications of cognitive impairment, resulted in a deficiency with the potential for more than minimal harm.
Removal Plan
- All staff are inserviced on sexual behaviors with residents with decreased BIMS and when to report incidents.
- Designee began assessing all BIMS greater than 9 in the facility for any sexual abuse from resident #18. All residents assessed had not had any form of sexual abuse while in the facility.
- Compliance with reporting allegations of abuse/neglect/exploitation policy has been reviewed with all staff. All staff have been inserviced and all new hires will continue to be inserviced upon hire.
- MDS updated Resident #18 care plan for sexual behaviors. Monitoring order in place every shift.
- Designee will review 24 hour reports and will report any new behaviors in morning meetings.
- Nurse Practitioner to evaluate and treat Resident #18. Resident evaluation to consent to sexual activity and sexual consent form was completed on Resident #18 and Resident #51.
- DON reviewed all behavior notes assessing for any resident to resident sexual abuse. No other instances were found.
- Resident #18 and Resident #51 were educated on sexual activity.
- Nursing staff will initiate the Evaluation for Sexual Consent Form upon any observed sexual behaviors between residents.
- Follow up regarding Resident #18 sexual consent, family consented to companionship but not the act of sex itself. Follow up regarding Resident #51: Family consented to companionship but not the act of sex itself.
Failure to Maintain Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to ensure that staff members assisted residents with eating in a dignified manner, as observed during meal service in the assisted dining room. Two residents, one with vascular dementia and obsessive-compulsive behavior, and another with unspecified dementia and mild neurocognitive disorder, were not assisted in accordance with the facility's policy. The policy, revised in July 2024, mandates that staff should be seated while feeding residents to promote and maintain dignity. However, during observations, staff members were seen standing over the residents while feeding them, which is contrary to the policy. Resident #12, who had severe cognitive impairment and was dependent on staff for eating, was fed by a CMA who stood over them, giving bites of food and drinks while standing. Similarly, Resident #75, who required supervision or touching assistance for eating, was fed by a CNA who also stood over them, despite an empty chair being available. The CNA was unaware of the policy regarding the positioning of staff while assisting residents with meals. The DON confirmed that staff should be seated while assisting residents with eating, indicating a lapse in adherence to the facility's policy.
Inaccessible Complaint and Ombudsman Information
Penalty
Summary
The facility failed to ensure that information on how to file a formal complaint with the state agency and contact the Ombudsman was readily accessible to residents. During a group interview with ten residents, it was revealed that none of them were aware of who their Ombudsman was or where to find information on how to contact them or report a complaint to the state survey office. The residents speculated that the information might be posted on a bulletin board in C Hall. Upon inspection, the bulletin board did contain the necessary information, but it was placed too high, with the bottom of the forms approximately 5 feet above the floor, making it difficult for residents to access. The Administrator acknowledged that the forms needed to be lowered to be more accessible to all residents.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that past survey results were readily available for residents to review. During a resident group interview, ten residents reported that they were unaware of where to find previous survey results and did not know they could access these reports. An observation revealed that the survey results were placed in a binder on a bulletin board in C Hall, mounted approximately five feet above the floor. The binder was attached to a chain, allowing it to be lowered only to about three feet above the floor, making it difficult for residents to access without assistance. The Administrator acknowledged that the binder might be positioned too high and needed to be relocated to a more accessible location.
Failure to Timely Report Abuse and Incidents
Penalty
Summary
The facility failed to report the results of abuse investigations to the State within the required 24-hour timeframe for three residents. Resident #15, who had a cognitive communication deficit and chronic kidney disease, reported verbal abuse by a CNA on July 3, 2024. However, the incident was not reported to the administration until July 8, 2024, and the final report was submitted on July 11, 2024. The delay was attributed to the CNA forgetting to report the incident in a timely manner. Resident #44, diagnosed with multiple conditions including mild intellectual disabilities and schizophrenia, reported rough handling by a staff member on June 26, 2024. Although the initial report was filed on the same day, the Nurse Aide Registry was not notified until July 2, 2024. Additionally, another incident involving an allegation of molestation by a CNA was reported late to the Nurse Aide Registry on August 20, 2024, after management became aware of the incident on August 19, 2024. Resident #51, with Alzheimer's Disease and severe cognitive impairment, was involved in several incidents that were not reported to the State. These included altercations with other residents and inappropriate sexual behavior with another cognitively impaired resident. Despite these events being documented in progress notes, no incident reports were filed with the State or other required agencies. The DON acknowledged that these incidents were not reported, citing the residents' rights as a reason for not taking further action.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation involving Resident #44, who reported that a staff member was too rough while providing care. The investigation was incomplete as it did not include interviews with all potential witnesses or other residents who might have been affected by the staff member involved. The Director of Nursing (DON) acknowledged the lack of a comprehensive investigation, admitting that not all necessary interviews were conducted to ensure the safety of all residents. Resident #51 was involved in multiple incidents of resident-to-resident altercations, including aggressive behavior and inappropriate sexual conduct. Despite these incidents being documented in progress notes, there were no corresponding incident reports or investigative notes in the clinical record. The DON confirmed that no investigations were initiated for these incidents, as they were not reported, highlighting a failure in the facility's process for handling resident altercations. Resident #14 reported an incident where an LPN allegedly used inappropriate language and gestures towards them. Although the LPN was initially suspended, the investigation was insufficient as it did not include interviews with other staff or residents who might have witnessed the incident. Furthermore, the facility did not report the LPN to the Oklahoma State Board of Nursing, as required by their abuse policy. The facility's failure to conduct a thorough investigation and report the incident to the appropriate authorities constitutes a deficiency in their handling of abuse allegations.
Failure to Revise Care Plans for Behavioral Issues
Penalty
Summary
The facility failed to revise care plans for two residents, #18 and #51, who exhibited significant behavioral issues. Resident #18, diagnosed with unspecified dementia, displayed inappropriate sexual behaviors on multiple occasions, including exposing themselves and attempting to touch others inappropriately. Despite these documented incidents, Resident #18's care plan did not include any interventions or strategies to address these behaviors. The care plan was last updated on 08/06/24, but it did not reflect the resident's ongoing behavioral issues. Similarly, Resident #51, diagnosed with Alzheimer's Disease and malignant neoplasm of the bronchus and lung, exhibited aggressive and inappropriate behaviors, such as yelling, swatting at other residents, and attempting to pull another resident out of a chair. Additionally, Resident #51 was involved in inappropriate sexual behavior with Resident #18. Despite these incidents, Resident #51's care plan did not address these behaviors or include any interventions. The Director of Nursing confirmed that the care plan did not cover the resident's behavioral issues.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days a week, as required. This deficiency was identified through observation, record review, and interviews. The facility, which housed 83 residents, did not meet the required RN coverage on multiple occasions in May, June, and July. Specific dates were noted where RN coverage fell short, with hours worked ranging from 4.93 to 7.80 hours instead of the mandated eight hours. Human Resource personnel confirmed that on days without adequate RN coverage, the Director of Nursing (DON) or Assistant Director of Nursing (ADON) would need to cover, but this did not occur on the listed dates.
Failure to Follow Medication Administration Policy via Enteral Tube
Penalty
Summary
The facility failed to adhere to its policy for administering medications via enteral tube for a resident with a gastrostomy tube. The policy required flushing the tube with water before and after administering medications, diluting medications appropriately, and using a clean oral syringe. However, during an observation, a Certified Medication Aide (CMA) prepared medications for a resident by crushing tablets into a fine powder and placing them into a plastic water cup without adding any liquids. The CMA then administered the medications through the gastrostomy tube without diluting them, contrary to the facility's policy. The CMA was observed using an eight-ounce container of tap water to flush the tube, mixing parts of the Jevity with the medications, and repeating the process until all medications and Jevity were administered. The CMA admitted to not diluting the medications due to forgetting to bring a spoon, despite being aware of the correct procedure. This incident involved a resident who had multiple medications prescribed, including clopidogrel bisulfate, lactulose, and Jevity, among others, to be administered via the gastrostomy tube.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 8.11%. This deficiency was identified during a survey where 37 medication administration opportunities were observed, and three errors were noted. Two residents were affected by these errors. Resident #43, who had a physician's order for a chewable aspirin to be taken daily for atherosclerotic heart disease, was not instructed to chew the aspirin as required. Instead, the medication was placed in a cup with other medications, and the resident swallowed it without chewing, as confirmed by the Certified Medication Aide (CMA) involved. Additionally, Resident #13, who had orders for medications to be administered via a gastrostomy tube, did not receive Mylanta as prescribed due to its unavailability. The CMA also failed to administer Potassium Chloride ER as ordered, citing that the medication could not be crushed and there were no alternative orders for administration through the gastrostomy tube. These actions and inactions contributed to the facility's failure to adhere to the required medication administration protocols, leading to the noted deficiency.
Deficiencies in Food Handling and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper food handling practices during lunch meal service, as observed with a resident diagnosed with unspecified dementia and mild neurocognitive disorder. The resident, who required supervision or assistance for eating, was served by a CNA who used bare hands to pick up and offer a slice of bread to the resident. The CNA was unaware of the policy regarding bare hand contact with food and later stated they would need to ask another staff member about it. The Director of Nursing mentioned that staff were allowed to touch food with bare hands if they sanitized their hands first, although this was not adhered to during the incident. Additionally, the facility did not adequately monitor the dishwashing machine to ensure proper sanitation. A dietary aide tested the chlorine level in the dishwashing machine, which showed a reading of 10 ppm, below the required 50-100 ppm. The dietary manager confirmed the inadequate chlorine level and called maintenance for assistance. In the meantime, the dietary manager decided to use paper serving containers and plastic utensils for lunch service due to the improper sanitation of dishes.
Infection Control Deficiencies in Linen Handling and Barrier Precautions
Penalty
Summary
The facility failed to handle soiled linens properly, leading to potential cross-contamination. During an observation, a CNA provided incontinent care to a resident with cognitive communication deficit and persistent mood disorder. The resident was found with stool on their buttock and back, and the CNA removed the soiled shirt and sling, tossing them on the ground instead of bagging them as per the facility's policy. The CNA later placed the soiled items on the lid of a soiled linen barrel in the hallway without bagging them, contrary to the facility's laundry services policy. Additionally, the facility did not ensure the use of enhanced barrier precautions when accessing a resident's gastric tube. A CMA administered medications and nutritional supplements to a resident with a gastrostomy tube and ESBL resistance without donning a gown, as required by the facility's enhanced barrier precautions policy. The CMA was unaware of the meaning of the green star on the resident's door, which indicated the need for enhanced barrier precautions. This lack of understanding was also evident among other staff members, as an LPN was unsure of the PPE requirements and the significance of the green star.
Inaccurate Resident Assessments for Hospice and Discharge Status
Penalty
Summary
The facility failed to ensure accurate coding of Resident Assessments for two residents. Resident #58, diagnosed with dysphagia following a cerebral infarction, was admitted to hospice care as per a physician's order. However, the Annual Resident Assessment did not document the hospice care received, despite the MDS Coordinator acknowledging that the life expectancy less than six months section was marked, but hospice care was not. Similarly, Resident #85, who had a displaced intertrochanteric fracture of the left femur, was discharged home with family, as noted in a Nurses' Note. However, the Discharge Resident Assessment inaccurately documented the discharge status as a short-term general hospital, which was confirmed by MDS Coordinator #2 upon review.
Failure to Obtain Physician-Ordered Lab Test
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were obtained for a resident with a stage four pressure wound on the left heel. The Wound Care Physician recommended an HBA1C test in the Wound Evaluation and Management Summary notes starting from May 15, 2024. However, subsequent notes on multiple dates indicated that the HBA1C was pending, and there was no documentation that the test was ever obtained. The issue arose because the HBA1C was listed under recommendations rather than orders, leading to the wound care nurse not seeing it. The Administrator confirmed that the test was only ordered on August 15, 2024, after the oversight was identified.
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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