Pocola Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Pocola, Oklahoma.
- Location
- 200 Home Street, Pocola, Oklahoma 74902
- CMS Provider Number
- 375188
- Inspections on file
- 21
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pocola Health And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral disturbances repeatedly engaged in inappropriate sexual behaviors with other cognitively impaired residents. Despite staff interventions and the facility's policy requiring prevention and investigation of abuse, supervision was inconsistently applied, and documentation of one-on-one monitoring was missing for extended periods. Staff interviews confirmed lapses in monitoring, resulting in the facility's failure to protect residents from sexual abuse.
A resident with severe cognitive impairment and a history of vascular dementia was administered another resident's medications by a CMA, resulting in hospitalization for adverse reactions including hypotension and hyponatremia. Review of staff files and interviews revealed that CMAs had not received regular competency evaluations, and medication administration was not routinely observed by the DON. A similar medication error involving the same resident had previously occurred without effective follow-up.
A resident with severe cognitive impairment and multiple medical conditions was administered another resident's medications by a CMA who had not received regular competency evaluations. The error resulted in the resident being hospitalized for adverse reactions, including hypotension and hyponatremia. Review of staff files showed inconsistent or missing skills assessments for several CMAs, and the DON confirmed that annual competencies had not been completed consistently.
The facility failed to follow its abuse policy by not immediately reporting abuse allegations for two residents. One resident, with multiple diagnoses including schizophrenia, reported verbal abuse by an aide, while another resident with dementia and Alzheimer's Disease reported being physically mishandled. In both cases, the incidents were not reported to the OSDH within the required two-hour timeframe, and the DON was not promptly informed.
The facility failed to report allegations of abuse involving two residents to the OSDH within the required two-hour timeframe. One resident reported verbal abuse, while another reported physical mishandling. Both incidents were documented, but the state incident reports were faxed several hours later, exceeding the mandated reporting period. The DON confirmed the delay in reporting.
The facility failed to conduct thorough abuse investigations for two residents. One resident reported verbal abuse by an aide, while another reported being physically mishandled. Both investigations lacked critical documentation, including resident statements and details of interviews. The DON acknowledged the absence of documented interviews, as the investigations were conducted together due to the incidents involving the same staff member.
A CNA recorded and posted a video on social media mocking and verbally abusing a resident with Alzheimer's and other disorders. The resident appeared to be crying while the CNA laughed. The DON terminated the CNA and reported the incident to the state.
The facility failed to post the required staffing information in an easily accessible manner for residents and visitors. The information was placed on a bulletin board six feet from the floor, making it difficult to read, and did not include the census or staffing hours for each employee. The DON was unaware of the regulations regarding the accessibility of posted staffing information.
The facility failed to store food in accordance with professional standards, affecting all 53 residents who received meals from the kitchen. Observations included an unlocked ice machine, an uncovered trash can, improperly stored and dated food items, and unsanitary conditions in the ice machine. The Dietary Manager acknowledged these issues and admitted to lapses in hand hygiene and food safety practices.
The facility failed to follow infection control guidelines, with staff not performing hand hygiene during meal assistance and wound care, and the IP testing a resident for COVID-19 without proper PPE in a communal area.
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 13 employees. Payroll records confirmed these employees were permitted to work without the required checks, and the BOM and administrator were unaware of this oversight until the survey.
The facility failed to ensure residents were fully assessed for the use of side rails for four of the 35 sampled residents. Observations revealed that residents with various diagnoses were using bed rails without proper assessments documented in their EHRs. The DON acknowledged the lack of documentation and stated that bed rail assessments would start being documented routinely.
The facility failed to ensure DNR forms were complete and legal for two residents. One resident's DNR form lacked the required two witnesses, and another resident's DNR form was not dated. The DON confirmed these deficiencies during interviews.
The facility failed to ensure accurate MDS assessments for four residents, leading to incorrect documentation of medical conditions and care needs. Issues included misreporting anticoagulant use, hearing ability, fall incidents, and urinary incontinence.
The facility failed to notify OHCA of a resident with serious mental illness who stayed long-term. The resident had diagnoses including generalized anxiety disorder, major depressive disorder, and schizophrenia. A PASRR I screening indicated no need for PASRR II for a short stay, but the resident's care plan and annual assessment were inconsistent. The DON acknowledged the oversight.
The facility failed to develop a comprehensive care plan for a resident experiencing weight loss, despite physician's orders for nutritional supplements and health shakes. The MDS coordinator confirmed the absence of a care plan addressing the resident's weight loss.
The facility failed to ensure residents were not catheterized unless required by a clinical condition and did not assess the continued need for an indwelling urinary catheter for two residents. One resident had a catheter placed for isolation purposes due to ESBL, which is not a proper diagnosis for catheter use. Another resident had a catheter placed due to ESBL and E. coli in their urine, with no physician's orders for catheter care or changing the catheter. The infection preventionist confirmed there was no policy for catheterizing residents with UTIs.
The facility failed to ensure the physician documented a rationale on a consultant pharmacist recommendation for a resident with multiple diagnoses, including CHF and Alzheimer's. The MRR policy also lacked timeframes for the process steps, as confirmed by the DON.
The facility failed to ensure that a resident did not receive psychotropic medication unless for a specific diagnosed condition. The resident was prescribed Seroquel for Alzheimer's Disease, but a medication review later marked the diagnosis as mood disorder. The DON acknowledged the need for prompt diagnosis changes.
The facility failed to provide consistent dietitian services for a resident with multiple health issues, despite recommendations for nutritional supplements and health shakes. The last dietitian visit was in August 2023, and the care plan lacked documentation of these recommendations.
The facility failed to develop and implement a QAPI plan to identify and address problems. The QAPI meetings were sporadic, with the last meeting in September 2023. The DON confirmed that there was no formal policy and procedure for QAPI, and meetings were not held regularly. The DON mentioned that a QAPI meeting would likely be held after the current month due to a COVID outbreak in February.
The facility failed to ensure that the QAA committee met at least quarterly, with the last documented meeting in September 2023. The DON confirmed that meetings were not held regularly and were only convened to address specific issues. A QAA meeting was anticipated due to a recent COVID outbreak.
Failure to Prevent and Monitor Sexual Abuse Among Residents
Penalty
Summary
The facility failed to adequately monitor and prevent sexual abuse involving a resident with severe cognitive impairment and behavioral disturbances. The resident, diagnosed with unspecified dementia and severe cognitive impairment, was repeatedly found in situations with another resident where inappropriate sexual behaviors were observed or alleged. Documentation shows that the resident was found in another resident's room, with both individuals on the bed and one resident's pants unzipped. There were also multiple reports of the resident making sexually suggestive gestures and engaging in inappropriate physical contact, such as holding hands and touching another resident's upper body. Staff and nursing notes indicate that these incidents were recurrent, with the resident being redirected or separated from others on several occasions. Despite these interventions, the inappropriate behaviors continued, and there were lapses in the implementation and documentation of one-on-one supervision. The facility's policy required thorough investigation and prevention of abuse, but the records show inconsistent monitoring and supervision, with periods where one-on-one documentation was missing for several days, even after the DON had indicated that such supervision was necessary until the behavior was resolved. Interviews with staff confirmed that the resident's behaviors were known and that supervision was inconsistently applied, with activity staff and nurses rotating responsibility for monitoring. The DON determined when to start and stop one-on-one supervision, but there was no clear or consistent protocol followed, and the resident continued to interact primarily with cognitively impaired residents. The failure to maintain consistent supervision and prevent further incidents resulted in the facility not protecting residents from sexual abuse as required by policy.
Failure to Ensure CMA Competency Leads to Medication Error and Hospitalization
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) were properly trained and competent to administer medications as ordered, resulting in a significant medication error. On one occasion, a CMA reported to a registered nurse that they may have given the wrong medications to a resident. Review of camera footage confirmed that the resident was administered another resident's medications. The resident, who had diagnoses including aphasia, vascular dementia, and cerebrovascular disease, was sent to the emergency room after the error was discovered. The resident was later admitted to the intensive care unit for adverse reactions, including hypotension and hyponatremia, after receiving multiple medications not prescribed to them. The resident involved had a care plan indicating a risk for hypotension and a recent assessment showing severe cognitive impairment. The medications administered in error included a diuretic, blood pressure medication, antidepressant, antianxiety medication, pain medication, and antiparkinsonian medication. The incident note documented a critically low blood pressure at the time paramedics arrived, and hospital records confirmed the resident required interventions to stabilize their blood pressure due to the medication error. Review of employee files revealed that several CMAs had not received regular skills evaluations or competency check-offs since their initial hire, with some files lacking any evidence of annual competency assessments. Interviews with the DON and CMAs confirmed that annual competencies had not been consistently completed for at least two years, and the DON acknowledged that medication administration was not routinely observed. Additionally, a similar medication error involving the same resident and another CMA had occurred previously, resulting in hospitalization, but no substantial interventions were implemented at that time.
Failure to Ensure CMA Competency Leads to Significant Medication Error
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) were adequately trained and competent to administer medications as ordered, resulting in a significant medication error. On one occasion, a CMA reported to an RN that they may have given the wrong medications to a resident. Review of camera footage confirmed that the resident was administered another resident's medications. The resident, who had diagnoses including aphasia, vascular dementia, and cerebrovascular disease, was at risk for hypotension and had a severely impaired cognitive function as indicated by a BIMS score of 3. Following the medication error, the resident was sent to the emergency room after being found with a blood pressure of 146/21. The resident was admitted to the intensive care unit for adverse reaction to medication, hypotension, and hyponatremia. Documentation showed the resident had been given multiple medications not prescribed to them, including a diuretic, blood pressure medication, antidepressant, antianxiety medication, pain medication, and antiparkinsonian medication. The resident required interventions to stabilize their blood pressure while the effects of the incorrect medications wore off. Review of employee files revealed that several CMAs had not received regular skills evaluations or competency check-offs since their hire or for extended periods, with some having no record of annual skills assessments. The DON acknowledged that annual CMA competencies had not been completed consistently for the last two years and that medication administration was not routinely observed. It was also noted that a similar medication error involving the same resident had occurred previously, resulting in hospitalization, but only limited education was provided to the involved CMA and no further interventions were implemented.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy by not immediately reporting allegations of abuse for two residents. The policy requires that all alleged violations and abuse be reported to the charge nurse, who must then notify the Administrator and Director of Nursing (DON) immediately, and report to the appropriate agencies within a two-hour timeline. In the case of the first resident, who had diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia, an incident was reported where the resident was verbally abused by an aide. Although the incident was reported to the Assistant Director of Nursing (ADON) and the DON was investigating, the state incident report was not faxed to the Oklahoma State Department of Health (OSDH) until several hours later. For the second resident, who had diagnoses including a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease, an incident occurred where the resident reported being physically mishandled by a staff member. The DON was not made aware of this incident until later in the afternoon, and the state incident report was also delayed in being faxed to the OSDH. The DON confirmed that the staff did not notify them or the administrator of the allegations of abuse in a timely manner, and neither incident was reported to the OSDH within the required two-hour timeframe as per the facility's policy.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe. The facility's abuse policy mandates that all alleged violations and/or abuse reported to the charge nurse must be assessed and reported to the appropriate agencies within two hours. In the first incident, a resident with diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia reported verbal abuse by an aide. The incident was documented at 3:15 p.m., but the state incident report was not faxed to OSDH until 7:36 p.m., exceeding the two-hour requirement. In the second incident, a resident with a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease reported being physically mishandled by a staff member, causing back pain. This incident was documented at 9:30 a.m., but the state incident report was not faxed until 7:38 p.m. The Director of Nursing (DON) acknowledged during an interview that neither incident was reported within the required timeframe, indicating a failure to adhere to the facility's abuse reporting policy.
Incomplete Abuse Investigations for Two Residents
Penalty
Summary
The facility failed to conduct a thorough abuse investigation for two residents who were reviewed for abuse. The first resident, who had diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia, reported that an aide verbally abused them using offensive language. The incident was reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who initiated an investigation. However, the investigation lacked critical documentation, including a statement from the resident, statements from all involved staff, and details about the residents interviewed. Additionally, there was no documentation of the date, time, or number of residents interviewed. The second resident, with diagnoses including a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease, reported being physically mishandled by a staff member, which caused them pain. The incident was reported, and the DON was aware and investigating. Similar to the first case, the investigation was incomplete, lacking documentation of resident interviews and statements from all involved staff. The DON stated that the investigations for both residents were conducted together due to the incidents involving the same staff member and occurring simultaneously, but acknowledged the absence of documented interviews.
Resident Abuse Incident Involving Social Media
Penalty
Summary
The facility failed to ensure a resident was free from abuse. A CNA recorded a video of a resident with Alzheimer's disorder, dementia, depression disorder, and anxiety disorder, mocking and verbally abusing the resident while they were sitting in their wheelchair. The resident appeared to be crying, and the CNA was laughing at them. This video was then posted on social media, which was discovered by the Director of Nursing (DON) shortly after it was posted. The DON immediately called everyone involved into their office and terminated the CNA responsible for the video. Another CNA who was aware of the recording but did not report it was given a written warning. The incident was reported to the state, and the video was retained for investigation purposes. The facility conducted an in-service training on abuse and reporting abuse for all employees following the incident.
Failure to Post Accessible Staffing Information
Penalty
Summary
The facility failed to post the required staffing information in a manner easily accessible to residents and visitors. On 03/06/24 at 10:00 a.m., the surveyor was unable to locate the posted staffing information. An RN indicated that the information was on a bulletin board on the 200 Hall outside the dining room entrance. The posted staffing information was observed on an 8.5 x 11 piece of copy paper pinned to a bulletin board approximately six feet from the floor, making it difficult to read unless directly in front of the board and looking up ten inches. Additionally, the posted staffing information did not document the census or staffing hours for each employee. The information remained in the same location and without the required details for the remainder of the survey. On 03/08/24 at 10:00 a.m., the DON questioned why residents couldn't tilt their heads up to read the information and was informed of the regulations regarding posted staffing requirements and accessibility for residents and visitors.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, affecting all 53 residents who received meals from the kitchen. During an observation, the ice machine in the dining room was found unlocked, and a large trash can by the hand washing sink was missing its lid, which was found on the floor behind the trash can. Additionally, the freezer contained bags of French fries and onion rings that were open to the air and not dated when they had been opened. The Dietary Manager (DM) acknowledged that these items should not be open to air and should be dated when opened. Further observations revealed that the ice machine had a brown/black substance on a clean cloth used to wipe it, and the DM admitted they did not know what the substance was. The DM also stated that the ice machine should be locked when not in use, but staff often failed to lock it. Additionally, the DM entered the kitchen without washing their hands and expressed concerns about contaminating their hands by touching the trash can lid. The DM mentioned that a surveyor from the previous year had advised that the trash only needed to be covered when being transported. The DM confirmed that staff entering the kitchen should wash their hands.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff followed infection control guidelines, leading to potential spread of communicable diseases. Observations revealed that a CNA assisting residents with eating did not perform hand hygiene after scratching their face, touching their clothing, or handling dirty dishes. Another CNA also failed to perform hand hygiene between assisting different residents. The Infection Preventionist (IP) confirmed that staff should use hand hygiene between residents and after touching something dirty while assisting residents to eat. Additionally, a registered nurse (RN) did not follow proper hand hygiene protocols during wound care. The RN washed their hands before care and applied gloves but did not perform hand hygiene after cleaning a resident who had a bowel movement. The RN also failed to perform hand hygiene between removing the old dressing, cleaning the wound, and applying skin prep. Furthermore, the IP was observed testing a resident for COVID-19 in a communal activity room without proper personal protective equipment (PPE), which could have potentially spread the infection to others in the facility.
Failure to Obtain Criminal Background Checks for Employees
Penalty
Summary
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 13 of 74 employees hired between 2016 and 2024. The facility's Abuse Prevention Policy mandates that candidates for employment be screened for a potential history of abuse, neglect, or mistreatment before employment, including obtaining criminal background checks. However, the facility did not have criminal background checks for 13 employees, including CNAs, CMAs, and a laundry staff member. Payroll records confirmed that these employees were permitted to work without the required background checks, and the BOM and administrator were unaware of this oversight until it was brought to their attention during the survey. The BOM reported that criminal background checks could not be done for some employees because they had not been fingerprinted. Additionally, the BOM incorrectly believed that if an employee returned within three years of separation, a new background check was not required. The DON and administrator were also unaware of the lack of background checks for these employees. The facility's failure to adhere to its own abuse prevention policy and ensure that all employees had completed criminal background checks upon hire led to this deficiency.
Failure to Assess Bed Rail Use for Residents
Penalty
Summary
The facility failed to ensure residents were fully assessed for the use of side rails for four of the 35 sampled residents. Resident #11, who had diagnoses including CHF, chronic kidney disease, and Alzheimer's Disease, was observed multiple times with bed rails up on both sides of the bed. The resident's EHR did not contain bed rail assessments, and the LPN confirmed that bed rail assessments had only recently started without a proper template. The resident's POA was informed of the risks but still wanted the bed rails to prevent the resident from trying to get out of bed, despite the resident not having the strength to do so. Resident #22, diagnosed with generalized anxiety disorder, major depressive disorder, diabetes mellitus with diabetic neuropathy, CHF, and schizophrenia, was also observed using bed rails without proper assessments documented in the EHR. The resident stated they used the bed rails for positioning and had never fallen out of bed. The LPN confirmed that bed rail assessments for this resident had not been completed. Resident #42, with diagnoses including CHF, Alzheimer's Disease, anxiety disorder, and insomnia, was observed with bed rails up and a bed alarm in place. The EHR did not contain assessments for bed rails, although a waiver was signed by the resident's POA. Similarly, Resident #45, with diagnoses including unspecified osteoarthritis, COPD, and primary osteoarthritis of both shoulders, was observed using bed rails and an air mattress without documented assessments. The DON stated that nurses assess the side rails daily but do not document these assessments in the chart, and they would start utilizing a bed rail assessment form routinely.
Incomplete and Illegal DNR Forms
Penalty
Summary
The facility failed to ensure DNR forms were complete and legal for two residents. One resident with diagnoses including CHF, chronic kidney disease, and Alzheimer's Disease had a DNR form signed by the resident's POA but lacked the required two witnesses. Another resident with diagnoses including major depressive disorder, anxiety disorder, and osteoarthritis had a DNR form signed by the POA but it was not dated. The DON confirmed these deficiencies during interviews.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of MDS assessments for four residents. One resident with a history of deep vein thrombosis was incorrectly documented as not being on an anticoagulant, despite physician orders and care plans indicating otherwise. Another resident, who was blind and hard of hearing, was inaccurately assessed as having adequate hearing. Additionally, a resident who experienced two falls, one resulting in a subdural hematoma, had these incidents omitted from their significant change assessment. Lastly, a resident with a Foley catheter due to urinary retention was incorrectly documented as always incontinent of urine, despite observations and statements confirming the presence of the catheter. These inaccuracies in MDS assessments were identified through observations, record reviews, and interviews with staff and family members. The discrepancies highlight a failure in the facility's assessment process, leading to incorrect documentation of residents' medical conditions and care needs. This failure could potentially impact the quality of care provided to the residents, as accurate assessments are crucial for developing appropriate care plans and interventions.
Failure to Notify OHCA of Resident with Serious Mental Illness
Penalty
Summary
The facility failed to notify the Oklahoma Health Care Authority (OHCA) of a resident with a serious mental illness who stayed in the facility long-term. The resident had diagnoses including generalized anxiety disorder, major depressive disorder, and schizophrenia. A PASRR I screening dated 06/26/14 indicated the resident had a serious mental illness, and it was documented that a PASRR level II was not required for a short stay for therapy. However, the resident's care plan, revised 08/26/22, noted ongoing concerns related to schizophrenia and the use of psychotropic medications. An annual assessment dated 09/19/23 incorrectly documented that the resident was not considered to have a serious mental illness. The Director of Nursing (DON) later acknowledged that another staff member failed to conduct a new PASRR I when the resident stayed long-term in the facility.
Failure to Develop Comprehensive Care Plan for Weight Loss
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident experiencing weight loss. The resident had diagnoses including diabetes mellitus type 2, abdominal hernia, and major depressive disorder. Physician's orders were documented for nutritional supplements, health shakes, and protein powder to address the resident's weight loss. Despite these orders, a care plan dated 02/04/24 did not document the resident's weight loss. The MDS coordinator confirmed on 03/07/24 that there was no care plan for the resident's weight loss, indicating a lapse in the facility's care planning process.
Improper Use of Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure residents were not catheterized unless required by a clinical condition and did not assess the continued need for an indwelling urinary catheter for two residents. Resident #29 was admitted with multiple diagnoses including stage 3 kidney disease and dementia. Despite having a urinary tract infection with ESBL, there was no documentation of a catheter in the care plan. The DON acknowledged that the catheter was used for isolation purposes, which is not a proper diagnosis for catheter use. The care plan was not updated to reflect the presence of the catheter, and the DON admitted that ESBL was not a valid reason for catheterization. Resident #25, diagnosed with chronic kidney disease stage 4 and dementia, had a 16 Fr indwelling urinary catheter placed due to ESBL and E. coli in their urine. There were no physician's orders for catheter care or changing the catheter. The infection preventionist confirmed there was no policy or protocol for catheterizing residents with urinary tract infections and admitted that catheterizing for a UTI likely does not meet criteria. The DON stated that catheters were used for residents who were difficult to keep in their rooms for isolation, but acknowledged that ESBL was not a proper diagnosis for catheter use.
Failure to Document Rationale for Medication Regimen Review
Penalty
Summary
The facility failed to ensure the physician documented a rationale on a consultant pharmacist recommendation for a resident whose medications were reviewed. The resident had diagnoses including CHF, Alzheimer's Disease, anxiety disorder, and insomnia. A medication regimen review (MRR) requested a reduction in several medications, but the physician documented to continue the current use of medications without providing a rationale. Additionally, the facility's MRR policy did not contain timeframes for the steps in the MRR process. The Director of Nursing (DON) confirmed that the policy lacked timeframes and stated that physicians usually document their decisions on the MRRs.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medication unless for a specific diagnosed condition. This was identified for one of five residents reviewed for unnecessary medication. The facility's policy stated that drug regimens should be free from unnecessary drugs and that psychotropic medications should only be used when necessary to treat a specific condition documented in the clinical record. A resident with diagnoses including CHF, Alzheimer's Disease, anxiety disorder, and insomnia was prescribed Seroquel 25mg twice a day for Alzheimer's Disease. A medication review requested an appropriate diagnosis for the use of Seroquel, and the physician later marked the diagnosis as mood disorder. The resident's care plan documented the use of Seroquel for Alzheimer's Disease. The Director of Nursing acknowledged that the diagnosis should be changed promptly upon receiving the medication review request from the physician.
Inconsistent Dietitian Services and Documentation
Penalty
Summary
The facility failed to provide consistent services from a registered dietitian for one of the two residents reviewed for nutrition. The resident had diagnoses of diabetes mellitus type 2, abdominal hernia, and major depressive disorder. Despite multiple recommendations from a registered dietitian for nutritional supplements and health shakes, the facility did not document these recommendations in the resident's care plan. Additionally, the facility's business manager stated that the last visit from a registered dietitian was in August 2023, despite the facility contracting for monthly visits. This inconsistency in dietitian services and lack of documentation led to the deficiency.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) plan to identify and address problems within the facility. Record review and interviews revealed that the facility did not have a policy and procedure for QAPI. The QAPI meetings were held sporadically, with the last meeting occurring in September 2023. On March 11, 2024, the Director of Nursing (DON) confirmed that QAPI meetings were not implemented regularly and that there was no formal policy and procedure to follow for QAPI. The DON stated that when issues arose, the administrator, DON, Assistant Director of Nursing (ADON), Minimum Data Set (MDS) coordinator, and Infection Preventionist would meet to address the problems. The DON also mentioned that a QAPI meeting would likely be held after the current month due to a COVID outbreak in February.
Failure to Hold Quarterly QAA Committee Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly, as required. A review of the QAA committee meetings revealed that the last documented meeting was in September 2023. There was no documentation of meetings in October, November, and December 2023, nor in January or February 2024. The Director of Nursing (DON) confirmed that QAA meetings were not held regularly and stated that meetings were only convened when specific problems needed to be addressed. The DON mentioned that a QAA meeting would likely be held after the current month due to a COVID outbreak in February.
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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