Ranchwood Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yukon, Oklahoma.
- Location
- 824 South Yukon Parkway, Yukon, Oklahoma 73099
- CMS Provider Number
- 375229
- Inspections on file
- 43
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Ranchwood Nursing Center during CMS and state inspections, most recent first.
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 orders for levothyroxine for hypothyroidism and divalproex for dementia did not receive multiple scheduled doses because the medications were not available in the building. Review of the MAR showed several early-morning levothyroxine doses and morning divalproex doses marked as held due to unavailability or lacking documentation. CMAs reported that medications were ordered when supplies were low and that unavailable medications were left on the MAR while notifying nursing staff, pharmacy, and the DON, while leadership stated medications should be reordered earlier and STAT if needed. These discrepancies in practice led to repeated missed doses of the resident’s prescribed medications.
A treatment cart on one hall was left unlocked and unattended in the hallway while an LPN entered a resident room, despite facility policy requiring carts to be locked when out of sight and clearly visible when unlocked. During this time, a resident approached the front of the unattended cart and spoke with the LPN from the doorway while the LPN remained inside the room. In interviews, the LPN minimized the significance of leaving the cart unlocked, and facility leadership, including the regional consultant and DON, confirmed that policy required treatment/medication carts to be locked whenever staff were not in attendance.
A CNA failed to follow infection control and hand hygiene protocols while providing perineal care to a resident who was dependent for toileting, frequently incontinent, and had active UTI and septicemia. After cleaning stool, the CNA wiped feces from a gloved hand onto the bed pad and then continued care, touching the resident, linens, wipes package, and cleaning solution without changing gloves. The CNA then removed the soiled pad, dressed the resident, handled bed covers, and took out the trash without performing hand hygiene, contrary to facility policy requiring glove removal and hand hygiene after feces removal and before applying new gloves and clean linens.
An LPN left a treatment cart in a hallway with a laptop unlocked and the EMR visible while going into a resident room, leaving the screen facing the hallway. During this time, a resident approached the cart and faced the exposed screen while speaking to the LPN. Facility policy required resident health information to remain private and MAR or EMR information to be closed or covered when not in direct use, but the LPN reported not knowing how to lock the computer screen, resulting in resident medical information being visible in a public area.
A resident who was cognitively intact, occasionally incontinent, and dependent for bed mobility was found to have a bed with a visible urine wet ring on the mattress and wet linens placed on the floor, along with a strong urine odor and a saturated brief in the trash. A CNA reported the resident was wet when being gotten out of bed for therapy and that only the resident’s clothes were changed, not the bed linens. The DON stated staff were expected to check incontinent residents at least every two hours, provide perineal care, and change soiled linens as needed, and confirmed observing the wet linens and wet ring on the bed.
Three residents with significant physical or cognitive impairments did not consistently receive scheduled showers or baths, and staff failed to document bathing as required by facility policy. Interviews with residents, family members, and staff confirmed that bathing was not provided on scheduled days and that records were incomplete or missing, making it impossible to verify that care was delivered as planned.
Three residents experienced multiple missed doses of prescribed medications, including antihypertensives, insulin, anticonvulsants, and anticoagulants, with no explanations documented in the medical records. Facility staff confirmed that there was no way to verify if the medications were given, as proper documentation was not completed, resulting in a deficiency in pharmaceutical services.
An LPN failed to follow infection control protocols during wound care for a resident with pressure ulcers, including not wearing a gown as required by Enhanced Barrier Precautions, and not performing hand hygiene or changing gloves after incontinent care and between wound sites. The resident had a history of pressure ulcers and malnutrition, and the LPN was not aware of the EBP requirements. The DON confirmed that proper infection control procedures were not followed.
A resident with intellectual disabilities and reduced mobility fell in the bathroom, sustained a head injury, and was transported to the hospital. Facility staff did not notify the resident's family or representative about the fall or hospital transfer, as required by policy. The family only learned of the incident when contacted by hospital staff, and facility staff cited confusion with the new EHR system as a reason for the failure to notify.
A resident who required significant assistance with bathing did not have any documented evidence of receiving bathing services during their stay. Staff were unaware of the resident's bathing schedule, and the DON could not provide records to show that bathing was performed, resulting in a failure to meet the resident's care needs.
A resident with diabetes and renal disease reported missing doses of Ozempic, a medication they were prescribed weekly. The resident's medication pen, with two doses remaining, went missing after being left out to warm by an RN. The incident was reported to the DON, who did not initiate an investigation or inform the administrator. The administrator later confirmed they were unaware of the incident, leading to a deficiency in the facility's response to the alleged violation.
A resident admitted with type 2 diabetes and a stage 4 pressure ulcer did not have a comprehensive MDS assessment completed within the required time frame. The DON confirmed the absence of this assessment after reviewing the resident's clinical record.
A resident with pneumonia and deep vein thrombosis was mistakenly given medications intended for another resident due to improper identification methods by a CMA. The error involved administering aspirin, buspirone, linezolid, and potassium chloride. The DON acknowledged the incident but lacked documentation of a review or staff training to prevent recurrence.
The facility failed to ensure safe food handling practices by allowing unwrapped cereal bowls to be stacked on the tray line, leading to potential contamination. A kitchen aide noted that the bowls should have been wrapped, and the dietary manager confirmed the issue as an infection control concern, with no policy in place to address it. The DON reported that 101 residents received meals from the kitchen.
The facility failed to maintain a homelike environment, with observations of torn carpets, damaged tiles, exposed wires, and strong urine odors. Residents expressed dissatisfaction, and the housekeeping supervisor confirmed the disrepair. The Regional Directors acknowledged the unsafe conditions and lack of adherence to the facility's policy.
A resident with Hypertensive Chronic Kidney Disease and Anxiety Disorder reported an alleged abuse incident to a CMA, who failed to document it as required by the facility's policy. The incident was reported during a shift change, but no incident report was completed, as confirmed by the DON.
The facility failed to complete quarterly MDS assessments within the required 92-day period for two residents. One resident with morbid obesity and hypotension did not have an assessment completed by the due date following an ARD of 04/25/24. Another resident with epilepsy and major depressive disorder also missed the assessment deadline after an ARD of 04/06/24. A corporate nurse confirmed the oversight.
A facility failed to ensure accurate MDS documentation for a resident's discharge status. The MDS records incorrectly indicated a discharge to the hospital, while nursing notes and physician orders confirmed a discharge home. The MDS Coordinator acknowledged the coding error, and the Administrator noted the absence of a policy for handling such inaccuracies.
A resident with Parkinson's disease, dementia, and bipolar disorder fell due to a torn and frayed carpet in their room, resulting in a skin tear and pain. Despite the facility's policy to investigate and prevent future falls, the intervention plan only included educating the resident to use their walker and did not address the carpet issue. Observations confirmed the carpet had been in disrepair for at least a year, and maintenance was aware but did not complete repairs.
A facility failed to maintain a resident's dignity by not covering their catheter bag with a vanity bag, as required by policy. The resident, admitted with acute respiratory failure and cellulitis, had their catheter bag observed uncovered and visible from the hallway on two occasions. Staff interviews confirmed the policy breach, with a CNA and LPN acknowledging the requirement to cover the bag, while a corporate nurse was unsure of the policy details.
A facility failed to ensure a resident was offered the choice to formulate an advance directive. The policy requires the Director of Admission to complete and scan the Advanced Directive Acknowledgment Form into the resident's EMR during admission. However, a resident with multiple sclerosis and paraplegia had no documentation in their EMR indicating assistance with formulating an advance directive. Corporate Nurse #1 confirmed the absence of an acknowledgment after auditing the charts.
The facility failed to report allegations of abuse, neglect, and resident-to-resident altercations to the OSDH for seven residents. Incidents involving mistreatment by staff and inappropriate behavior were not documented or reported within the required time frames, leading to a significant deficiency in compliance with regulations.
The facility failed to investigate multiple allegations of abuse and neglect reported by residents, including incidents involving staff treatment and resident altercations. Despite documentation of these complaints, the facility did not conduct thorough investigations as required by their policies.
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 Ensure Availability of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for one resident. Facility policy dated 01/2024 required medications to be administered as prescribed in accordance with manufacturers’ specifications and good nursing practices. Physician orders for the resident included divalproex 125 mg by mouth every 12 hours for unspecified dementia and levothyroxine 150 mcg by mouth in the early morning for hypothyroidism. Review of the resident’s February 2026 MAR showed multiple instances where levothyroxine doses were held due to unavailability on 02/07, 02/08, 02/14, 02/15, and 02/16 at 6:00 a.m., and one instance on 02/12 at 6:00 a.m. with no documentation. The MAR also showed divalproex doses held on 02/15 and 02/16 at 9:00 a.m. due to unavailability. During interviews, CMA #2 stated the process to ensure medications were available was to order medications daily, typically when the supply was down to five days or less, and to call the pharmacy and notify the nurse if a medication was not in the building. CMA #2 also stated that when a medication was not available, they left the medication up on the MAR and notified the nurse, pharmacy, and then the DON. The DON and regional consultant stated medications should be ordered when down to a seven-day supply and, if not available, the physician and DON should be notified and the medication ordered STAT from the pharmacy. CMA #1 confirmed that an “H” on the MAR indicated a hold and verified that the resident’s levothyroxine and divalproex doses on the specified February dates were held because the medications were unavailable and needed to be ordered STAT, indicating the medications were not in the building at those times.
Unattended Unlocked Treatment Cart Left Accessible in Hallway
Penalty
Summary
The facility failed to ensure a treatment cart on hall 8 was secured when staff were not in attendance, contrary to facility policy requiring medication carts to be closed and locked when out of sight of the medication nurse. On 03/04/26 at 12:26 p.m., an LPN left the treatment cart unlocked in the hallway and went inside a resident room, positioning the cart slightly sideways near the wall with the front of the cart facing the hallway. At 12:27 p.m., an unidentified resident approached the front of the unattended, unlocked treatment cart and spoke to the LPN from the doorway while the LPN remained inside the room. The facility’s Medication Administration policy, dated 01/2024, stated that during medication administration the cart must be kept closed and locked when out of sight and must be clearly visible to the personnel administering medications when unlocked. When interviewed at 12:29 p.m., the LPN stated they did not think leaving the cart unlocked was a big deal because they returned quickly. Later, at 2:32 p.m., the regional consultant and the DON confirmed that the policy and procedure for treatment/medication cart storage required carts to be locked anytime staff were not in attendance of the cart. The administrator identified that 105 residents resided in the facility at the time of the survey.
Failure to Follow Hand Hygiene and Glove Protocol During Perineal Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices, specifically hand hygiene and glove use, during perineal care for one resident. During an observation of incontinent care, a CNA performed perineal care on a resident who was dependent for toileting and bed mobility and frequently incontinent of bowel and bladder. After the resident had a bowel movement, the CNA wiped stool from the resident and was observed wiping stool from their gloved hand onto the pad under the resident. Without changing gloves, the CNA then placed a clean brief under the resident, touched the wipes package, placed it on the resident's table, turned the resident, and continued to touch the resident, the wipes package, and a cleaning solution with the same contaminated gloves. The CNA continued the care by fastening the clean brief, removing the soiled pad and placing it at the foot of the bed, and putting clean pants on the resident, all without changing gloves. The CNA then touched the resident's covers and draw sheet with the same gloved hands. At the end of care, the CNA removed their gloves, took the trash, and left the room without performing hand hygiene after glove removal or before handling the trash. There was no observation that hand hygiene was performed at any point. The facility's perineal care policy required staff to remove feces, dispose of gloves and used supplies, perform hand hygiene, and then apply new gloves before placing a new brief and changing linens. The resident involved had active diagnoses of urinary tract infection and septicemia. In a subsequent interview, the CNA stated that gloves were supposed to be changed after cleaning stool and after completing incontinent care and acknowledged they did not think they changed their gloves because they were nervous.
Unsecured Computer Screen Exposed Resident Medical Records
Penalty
Summary
The facility failed to maintain privacy and confidentiality of residents' medical records when a laptop on a treatment cart in hall 8 was left unlocked with the electronic medical record visible while unattended. During observation, an LPN left the treatment cart positioned in front of a resident room with the computer screen facing the hallway and went inside the room, leaving the screen exposed and displaying resident medical information. While the LPN was inside the room, a resident approached the cart, faced the computer, and spoke to the LPN from the doorway, with the medical record still visible on the screen. The facility’s Medication Administration policy stated that resident health information must remain private and that MAR pages containing resident health information must remain closed or covered when not in direct use. The LPN stated they did not think leaving the screen exposed was a big deal because they returned quickly and also stated they were unsure how to lock the computer screen. The regional consultant and DON later stated that the policy and procedure for securing computers was to minimize or close the screen when not actively in use by staff. The administrator identified that 105 residents resided in the facility at the time of the survey, and the deficiency was cited for 1 of 1 treatment cart observed with an unsecured computer displaying medical records in a public hallway area.
Failure to Provide Timely Incontinent Care and Change Soiled Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and change soiled linens for a resident who required assistance with activities of daily living. Surveyors observed a strong urine odor and an overly urine-saturated brief in the trash can in the resident’s room in the early afternoon. The resident’s bed had a visible wet ring in the center of the mattress, and the blanket, sheet, and cloth pad that had been removed from the bed and placed on the floor were wet. The facility’s perineal care policy required staff to provide perineal care in accordance with standards of practice to prevent skin breakdown and infection, dispose of used supplies, perform hand hygiene, and apply a new brief and change linens as needed. The resident’s admission assessment showed the resident was cognitively intact, occasionally incontinent of bladder, required partial/moderate assistance with toileting, and was dependent for bed mobility. The resident stated they were not soiled and reported staff had gotten them out of bed just before lunch. A CNA reported that when they went to the room around 1:00 p.m. or earlier to get the resident out of bed for therapy, the resident was wet, and the CNA changed the resident’s clothes but did not make the bed afterward. The CNA verified the sheet and linens were wet. The DON stated that staff were expected to check incontinent residents at least every two hours, clean and dry them if soiled, and change linens as needed when soiled, and confirmed observing the wet linens and wet ring on the resident’s bed.
Failure to Provide and Document Scheduled Bathing for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents dependent on staff for bathing received scheduled showers or baths, as required by their care plans and facility policy. For each of the three residents reviewed, there was a lack of documentation showing that showers or baths were provided on the scheduled days across multiple weeks in February, March, and April. The facility's policy required staff to provide bathing services and document any refusals or missed baths, but records were incomplete or missing. Interviews with residents and family members confirmed that showers were not consistently provided as scheduled, and staff were unable to produce documentation to verify that bathing occurred as required. The residents involved had significant care needs, including hemiplegia, hemiparesis, intellectual disabilities, reduced mobility, heart failure, and muscle weakness. Assessments indicated that these residents required partial to maximum assistance with bathing and were cognitively intact or moderately impaired. Despite these needs, the facility did not maintain adequate records or ensure that scheduled bathing was completed, as confirmed by the DON, staffing coordinator, and administrator, who acknowledged the lack of documentation and inability to verify that care was provided as scheduled.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for three residents who were sampled for timely medication administration. Review of the facility's policy indicated that medications should be given within a defined window of time, and any missed doses should be documented with an explanation. However, medication administration records for all three residents showed multiple missed doses of various prescribed medications, with no explanations documented in the medical records for these omissions. For one resident with diagnoses including hypertensive chronic kidney disease and type II diabetes mellitus, missed doses included antihypertensives, insulin, and other critical medications over several days. Another resident with a history of convulsions, encephalitis, and edema had missed doses of anticonvulsants, diuretics, and statins, again with no documentation explaining the missed doses. A third resident with chronic kidney disease, atrial fibrillation, and insomnia also had several missed doses of anticoagulants, diuretics, and other medications, with no recorded reasons for the omissions. Interviews with facility staff, including the corporate nurse consultant and the DON, confirmed that there was no way to determine if the missed doses were actually administered, as staff were not documenting appropriately on the medication records. The lack of documentation and unexplained missed doses directly contravened facility policy and physician orders, resulting in a deficiency related to pharmaceutical services and medication administration.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to follow infection prevention and control protocols during wound care for a resident with pressure ulcers. The LPN performed hand hygiene and donned gloves prior to starting, but did not wear a personal protective gown as required under Enhanced Barrier Precautions (EBP) for residents with wounds. During the procedure, the resident was found to be incontinent of bowel, and the LPN cleaned the area but did not perform hand hygiene or change gloves before proceeding with wound care on the resident's left lower back and sacrum. The LPN also touched personal items, wrote on wound dressings, applied a new brief, and repositioned the resident without changing gloves or performing hand hygiene between these activities. Facility policies required the use of gowns and gloves during high-contact care activities, such as wound care, under EBP, and specified hand hygiene before and after care, especially when hands become soiled. The resident involved had a history of pressure ulcers and protein-calorie malnutrition, with physician orders for specific wound care procedures. The LPN later acknowledged not being educated on EBP and was unaware of the need for a gown during wound care for residents with pressure ulcers. The Director of Nursing confirmed that EBP should have been followed and that the LPN's actions did not meet infection control standards.
Failure to Notify Resident's Representative After Hospital Transfer Due to Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative after the resident experienced a fall that resulted in a head injury and required transport to the hospital. The resident, who had intellectual disabilities, reduced mobility, and was cognitively intact, fell in the bathroom, sustained a swollen area above the left eye, and was subsequently sent to the emergency room for evaluation. The facility's policy required notification of family or representatives in the event of significant injury or transfer to another healthcare setting. Despite this policy, the resident's family was not informed by the facility about the fall or the hospital transfer. Instead, the family was contacted by hospital emergency room staff to pick up the resident after evaluation. Interviews with facility staff revealed confusion regarding the location of emergency contact information in the new EHR system, with multiple staff members assuming others had notified the family. The DON confirmed that staff were looking in the wrong area of the EHR and acknowledged that the family should have been notified according to policy.
Failure to Provide and Document Bathing Assistance
Penalty
Summary
The facility failed to provide bathing services for a resident who required substantial to maximum assistance with bathing, as documented in their admission assessment. The facility's policy required staff to provide bathing services within standard practice guidelines. During the resident's stay, a CNA was unaware of the resident's shower schedule, and the interim DON was unable to locate any documentation indicating that bathing was provided. This lack of documentation and staff awareness resulted in the failure to ensure the resident received necessary bathing care as required by facility policy and the resident's assessed needs.
Failure to Investigate Missing Medication Doses
Penalty
Summary
The facility failed to conduct a thorough investigation after receiving an allegation of missing doses of medication for a resident diagnosed with type 2 diabetes mellitus and end-stage renal disease. The resident was prescribed Ozempic 2mg via subcutaneous injection every Wednesday. According to the Medication Administration Record (MAR), the medication was administered as ordered in December and early January. However, the resident reported issues with receiving the correct dosage for three weeks in December and mentioned not receiving the medication at all for one week. Additionally, the resident reported that their Ozempic pen, which had two doses remaining, went missing after being left out to warm by a registered nurse (RN). The RN confirmed that the pen was missing and reported the incident to the Director of Nursing (DON), who attempted to locate the pen but did not initiate an investigation or report the incident to the administrator. The pharmacist corroborated that there should have been two doses remaining in the pen based on the prescription fill dates. When questioned, the administrator stated they were unaware of the incident and acknowledged that an investigation should have been initiated. This lack of action and communication led to a deficiency in the facility's handling of the alleged violation.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required time frame for a resident. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, an admission assessment must be completed no later than the 14th day of the resident's admission. A resident, who was admitted with diagnoses including type 2 diabetes mellitus and a stage 4 pressure ulcer of the sacral region, did not have a comprehensive MDS assessment documented in their electronic health record (EHR). The Director of Nursing (DON), upon reviewing the resident's clinical record and consulting with the MDS coordinator, acknowledged that no comprehensive MDS assessment had been completed since the resident's admission.
Medication Administration Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure that a resident did not receive the wrong medications, affecting one of the three sampled residents reviewed for medication administration. The incident involved a resident with diagnoses of pneumonia and deep vein thrombosis, who was mistakenly given medications intended for another resident. The medications administered in error included aspirin, buspirone, linezolid, and potassium chloride. This error was documented in an incident report and a nurse's note, both dated December 25, 2024. The Director of Nursing (DON) acknowledged the incident but did not provide documentation that the Quality Assurance and Performance Improvement (QAPI) committee reviewed the incident or that staff, including the Certified Medication Aide (CMA) involved, received in-service training to prevent recurrence. The CMA responsible for the error stated that residents are identified using pictures in the Electronic Health Record (EHR), names posted outside doors, and personal familiarity over time. However, this method failed to prevent the medication error.
Unsafe Food Handling Practices in Tray Line
Penalty
Summary
The facility failed to ensure safe food handling practices during meal preparation and distribution, specifically regarding the sanitary condition of cereal bowls on the tray line. On September 3, 2024, it was observed that bowls of cereal were unwrapped, stacked, and stored in a manner that allowed the bottom of the bowls to come into contact with the cereal product. This practice was contrary to the expected standard, as reported by Kitchen Aide #1, who stated that the bowls were supposed to be wrapped and not stacked on each other. On September 10, 2024, the Dietary Manager acknowledged that the handling of the cereal bowls was an infection control issue and confirmed that there was no existing policy to address this specific issue. The Director of Nursing (DON) indicated that 101 residents received nutritional meals from the kitchen, highlighting the potential impact of this deficiency on a significant number of residents.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment, as observed during a survey. The observations revealed several deficiencies, including torn and raised carpets, missing and damaged tiles, peeling wallpaper, exposed wires, and strong odors of urine. These issues were noted in multiple rooms and hallways, indicating a widespread problem. The facility's Resident Room Cleaning policy aimed to provide a clean and safe environment, but the maintenance work order log showed that repairs were not completed, and some issues had persisted for at least a year. Residents expressed dissatisfaction and concern about the unsafe and unclean conditions, with one resident reporting a fall due to the carpet tear. The housekeeping supervisor acknowledged the disrepair and stated that maintenance was aware of the issues but had not effectively addressed them. The Regional Director of Plant Operations and the Regional Director of Operations confirmed the unsafe conditions and admitted that the facility did not maintain a homelike environment, as required by their policy.
Failure to Document Alleged Abuse Incident
Penalty
Summary
The facility failed to document an alleged abuse incident involving a resident diagnosed with Hypertensive Chronic Kidney Disease and Anxiety Disorder. The facility's policy, dated 06/23/17, requires that all incidents of alleged abuse or neglect be documented on incident reports and forwarded to the Abuse Counselor. However, on 09/20/24, it was found that there was no record of an initial report for the alleged abuse reported by the resident. An LPN reported that a CMA had received the allegation from the resident on 09/06/24 during a shift change but failed to document it. The Director of Nursing confirmed that the company policy mandates the person receiving the allegation to complete an incident report, which was not done in this case.
Failure to Complete Timely Quarterly Assessments
Penalty
Summary
The facility failed to ensure that quarterly assessments for residents were completed within the required 92-day timeframe. Specifically, two residents, identified as Resident #1 and Resident #25, did not have their Minimum Data Set (MDS) assessments completed within the stipulated period. Resident #1, who was admitted with diagnoses including morbid obesity and hypotension, had a quarterly assessment with an Assessment Reference Date (ARD) of 04/25/24, but no subsequent assessment was completed by 07/25/24. Similarly, Resident #25, admitted with conditions such as epilepsy and major depressive disorder, had an ARD of 04/06/24, but no assessment was completed by 07/05/24. Corporate Nurse #1 confirmed the absence of these assessments upon review, acknowledging the oversight.
Inaccurate MDS Discharge Documentation
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) records accurately reflected the resident's discharge status. Specifically, the MDS assessment records incorrectly documented that the resident was discharged to the hospital, while nursing notes and physician orders indicated that the resident was discharged home. This discrepancy was identified during a review of the resident's records, which included a phone call arrangement for the resident to be discharged home and physician orders confirming the discharge home. The MDS Coordinator acknowledged the error in coding the resident's discharge status. Additionally, the facility's Administrator reported that there was no existing policy for addressing inaccurate MDS documentation.
Failure to Maintain Safe Environment Leads to Resident Fall
Penalty
Summary
The facility failed to maintain a safe environment for its residents, resulting in a fall incident involving a resident with Parkinson's disease, dementia, and bipolar disorder. The resident, who was cognitively intact and used a walker for ambulation, fell due to uneven flooring and not using their walker. The incident report noted a skin tear and pain in the resident's left arm as a result of the fall. Despite the facility's Fall Management policy, which requires immediate investigation and intervention to prevent future falls, the intervention plan only included educating the resident to use their walker and did not address the torn and frayed carpet that contributed to the fall. Observations and interviews revealed that the carpet in the resident's room was torn and frayed, with strings and raised areas, and the bathroom tiles were missing or damaged. The housekeeping supervisor confirmed the carpet had been in disrepair for at least a year, and maintenance was aware of the issue. However, the Director of Plant Operations was unaware of the damaged carpet and acknowledged that the work order for repairs was not completed. The failure to repair the carpet and ensure a safe environment directly contributed to the resident's fall.
Failure to Cover Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of a resident by not covering a catheter bag with a vanity bag, as required by their policy. This deficiency was observed in the case of a resident who was admitted with acute respiratory failure with hypoxia and cellulitis. The facility's policy, revised on January 12, 2023, mandates that drainage bags should be covered with a privacy bag as necessary. However, during two separate observations, the resident's catheter bag was found uncovered and visible from the hallway, which was against the facility's policy. Interviews with staff members, including a CNA, an LPN, and a corporate nurse, confirmed the visibility of the uncovered catheter bag from the hallway. The CNA and LPN acknowledged that the facility's policy required the catheter bag to be covered with a vanity bag to maintain the resident's dignity. The corporate nurse, however, was unsure if the policy required the bag to be covered while in the resident's room. This inconsistency in policy understanding and implementation led to the deficiency in maintaining the resident's dignity.
Failure to Offer Advance Directive Formulation
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate an advance directive, as evidenced by the case of one resident among a sample of 32 whose advance directive acknowledgments were reviewed. The facility's policy, revised on March 27, 2023, mandates that the Director of Admission complete and scan the Advanced Directive Acknowledgment Form into the resident's electronic medical record (EMR) during the admission process. However, for a resident admitted with diagnoses including multiple sclerosis and paraplegia, there was no documentation in the EMR indicating assistance with formulating an advance directive. During an interview, Corporate Nurse #1 confirmed that an audit of the charts revealed the absence of an advanced directive acknowledgment for this resident.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure allegations of abuse were reported to the Oklahoma State Department of Health (OSDH) for seven residents. The facility's policy required timely investigation and reporting of abuse allegations to state and local agencies, but this was not adhered to. For instance, Resident #1 had multiple incidents where abuse was alleged, including being held down against their will and having their mouth covered by a staff member. These incidents were not reported within the required time frames, and some were not reported at all. Additionally, Resident #1's claims of being mistreated by staff were not followed up with proper investigations or timely reports to the OSDH. Resident #10 reported that a therapy staff member was not being nice, which was not reported to the OSDH. Similarly, Resident #11 mentioned that staff sometimes took a long time to answer call lights, especially in the evening and night, but this was also not reported. Resident #4 had multiple incidents, including making threats to another resident, leaving the facility without notifying anyone, and displaying inappropriate behavior in the dining room. These incidents were not reported to the OSDH as required. Other residents, including Resident #7, Resident #3, and Resident #9, also reported concerns about staff treatment and interactions with other residents. These allegations were not documented or reported to the OSDH. The Director of Nursing (DON) and Corporate RN acknowledged that these incidents should have been reported but were not. The facility's failure to report these allegations of abuse, neglect, and resident-to-resident altercations within the required time frames constitutes a significant deficiency in compliance with federal and state regulations.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to fully investigate allegations of abuse for nine of eleven sampled residents. The facility's policy on Abuse, Neglect, and Exploitation requires timely investigations upon receiving an allegation, but this was not adhered to in multiple instances. For example, Resident #1's complaints of being held down and having their mouth covered by a CNA were not investigated, and there was no documentation of an investigation into the resident's disruptive behavior to ensure other residents were not fearful. Similarly, Resident #10's and Resident #11's complaints about staff treatment were not investigated, despite being documented in incident reports. Resident #2, who had severe cognitive impairment, reported through a hospital liaison that a nurse had slapped them twice, but the facility only interviewed the resident's family and did not conduct a thorough investigation involving other residents or staff. Resident #4, who had moderate cognitive impairment, made threats to another resident and left the facility without notifying anyone, but these incidents were not investigated. Additionally, Resident #4's altercations with other residents in the dining room were not investigated. Other residents, including Resident #7, Resident #3, and Resident #9, also reported concerns about staff treatment and interactions with other residents, but these allegations were not investigated. The Director of Nursing (DON) and Corporate RN acknowledged that these incidents should have been investigated but were not. The lack of thorough investigations into these allegations of abuse and neglect indicates a significant deficiency in the facility's adherence to its own policies and regulatory requirements.
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.
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.
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 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.
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 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.
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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