Riverside Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Arkoma, Oklahoma.
- Location
- 1008 Arkansas Street, Arkoma, Oklahoma 74901
- CMS Provider Number
- 375371
- Inspections on file
- 23
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Riverside Health Services during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and identified risk for pressure ulcers developed a new in-house acquired stage 2 pressure ulcer to the buttock. Nursing documentation indicated that family, physician, and wound nurse were notified and wound care was initiated per an unsigned order, but the ADON later acknowledged not notifying the physician and could not identify who gave the wound care order. The attending physician reported not managing wounds or writing the documented order, and the wound care NP stated they first assessed the wound nearly two weeks after its onset and had no prior notification. The wound care schedule initially did not list the resident for wound rounds, and the DON could not explain the omission, demonstrating a failure to promptly notify the physician and secure valid treatment orders for a significant change in condition.
A resident with severe cognitive impairment, dependence for repositioning, and documented skin integrity issues developed an in-house acquired stage 2 pressure ulcer to the buttock and later an unstageable pressure ulcer to the ankle despite identified risk and preventive care plan interventions. The care plan called for use of positional devices, a therapeutic air mattress, skin monitoring each shift, and an every-hour turning schedule, but EHR task documentation showed the resident was not repositioned every hour as ordered. The wound care company did not initially see the resident on one of its scheduled visits after the first ulcer was identified, and when later assessed, the buttock wound was classified as unstageable and larger than first documented. A CNA reported hourly repositioning as the primary preventive measure but could not recall other interventions, while the physician stated they did not manage wounds and did not write the wound care order attributed to them, indicating reliance on the wound care company for pressure ulcer management.
The facility failed to ensure CMAs had current advanced gastrostomy certifications while administering medications via PEG tubes. A resident’s MARs over several months showed that three CMAs with expired or undocumented gastrostomy credentials repeatedly gave medications through a PEG tube. One CMA reported believing they were allowed to pass PEG tube meds and perform feedings, while the DON later stated that two CMAs supposedly had certifications that were not reflected in the nurse aide registry, and no documentation was produced to verify those credentials.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility failed to ensure dependent residents were repositioned every two hours, leading to the development and worsening of pressure ulcers. A resident, initially without pressure ulcers, developed severe wounds due to inadequate repositioning and documentation. Staff interviews revealed a lack of documentation and monitoring, contributing to the deficiency.
A facility failed to document physician visits for a resident with chronic respiratory failure, despite the physician and DON confirming the visits occurred. The facility's policy requires documentation of all services and changes in condition, but the resident's medical records lacked physician progress notes.
The facility did not ensure RN coverage for eight consecutive hours, seven days a week, during October 2024 and January 2025. The CASPER report highlighted the absence of RN coverage on multiple days, and payroll documents confirmed this deficiency. The business office manager and DON acknowledged the lack of RN coverage on the specified dates.
A facility failed to update the PASARR Level II assessment for a resident with a new diagnosis of a serious mental health condition. The resident had pseudobulbar affect and a mood affective disorder, but the PASARR Level I assessment did not reflect a serious mental illness. The DON acknowledged the oversight and stated a referral should have been made.
Failure to Notify Physician and Obtain Valid Orders for New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the physician of a new pressure ulcer and to obtain a valid, signed treatment order for one resident. The facility’s Notification of Changes policy required prompt consultation with the resident’s physician and notification of the resident’s representative when there was a change requiring alteration of treatment. An admission assessment dated 12/02/25 documented that the resident was severely impaired for daily decision making, dependent for rolling, at risk for developing pressure ulcers, and did not have a pressure ulcer at that time. A weekly nursing evaluation on 11/27/25 showed normal skin findings. On 12/06/25, a nurse progress note documented that the resident developed a new, in-house acquired stage 2 pressure ulcer to the left gluteus, with exposed dermis and specific measurements. The note stated that the family, physician, and wound nurse were notified, and an unsigned physician order dated 12/07/25 directed application of Mesitran Soft Wound Gel and Medi-honey with dressing changes. The treatment administration record showed that wound care was provided as ordered. However, the ADON later stated that the wound care order obtained on 12/07/25 was not signed by a physician, did not recall who gave the order or how it was received, and acknowledged they did not notify the physician of the wound, believing the wound care company would sign the order and that writing orders was outside their scope of practice. Additional documentation showed that the wound care company’s nurse practitioner first assessed the buttock pressure ulcer on 12/19/25, classifying it as unstageable and measuring it at different dimensions, and noted the wounds had been present for five days without being able to determine if they were improving or worsening. The wound care clinical schedule dated 12/12/25 did not list the resident to be seen by the wound care company, and the DON could not explain why the resident was not on the list. The wound care nurse practitioner did not recall any prior notification about the resident’s pressure ulcer before 12/19/25. The attending physician stated they did not treat wounds, did not write wound care orders, and did not write the 12/07/25 order, indicating that wound management was handled by the wound care company. These findings show that the facility did not follow its own policy to promptly notify and consult the physician when the resident experienced a significant change in condition requiring altered treatment.
Failure to Prevent and Manage Pressure Ulcers for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and worsening of pressure ulcers for one resident with known skin integrity risks. The resident’s baseline care plan noted existing skin integrity issues and ordered zinc cream to the bottom twice daily for prevention of skin breakdown. An admission assessment later documented that the resident was severely impaired in daily decision making, dependent for rolling from side to side, and at risk for pressure ulcer development, with no pressure ulcers present at that time. Despite these identified risks, a nursing progress note shortly thereafter documented a new, in‑house acquired stage 2 pressure ulcer to the left gluteus, with exposed dermis and specific wound measurements, and the family, physician, and wound nurse were notified. Subsequent documentation showed evolving and additional pressure ulcers and gaps in wound management. A care plan for impaired skin integrity included interventions such as use of positional devices, a therapeutic air mattress, monitoring skin integrity every shift, notifying the physician for treatment orders, and continuing an every‑hour turning schedule. However, the wound care company’s clinical schedule did not show the resident as being seen on one of the dates they were in the facility, even though the pressure ulcer had already been identified. When the wound care company nurse practitioner eventually assessed the buttock wound, it was classified as unstageable with larger dimensions than initially documented, and the practitioner could not determine if the wound was improving or worsening. A later nursing skin evaluation documented a new, in‑house acquired unstageable pressure ulcer to the left ankle. Physician orders were written for specific wound treatments and for the resident to be turned every hour from left to right only, but the electronic health record task tab for two subsequent months showed the resident was not repositioned every hour as ordered. A CNA stated that prevention for this resident consisted of repositioning every hour and that documentation of repositioning was in the task tab, but could not recall other interventions. The physician reported that they did not treat pressure ulcers or write wound care orders, stating that the wound care company managed wounds, and denied writing the wound care order dated 12/07/25. The wound care nurse practitioner stated they treated wounds weekly and assessed the resident’s pressure ulcer on 12/19/25, without recalling prior notification. The DON confirmed that the wound care company was present on multiple dates and that the resident’s pressure ulcer was identified before one of those visits, but the resident was not seen by the wound care company on that earlier visit, and also confirmed that documentation did not show the resident was turned and repositioned every hour as ordered.
Expired and Unverified CMA Gastrostomy Certifications During PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) held current advanced gastrostomy certifications before administering medications via gastrostomy (PEG) tubes. Record review showed that CMA #1’s advanced gastrostomy certification had expired, yet the October 2025 MAR for Resident #1 documented that CMA #1 administered medications through the resident’s PEG tube on multiple dates. The facility’s undated Medication Administration policy stated that medications are to be administered by licensed nurses or other staff legally authorized to do so in the state, in accordance with professional standards of practice. The DON identified that 24 residents in the facility received medications through PEG tubes. Further review revealed that CMA #2 and CMA #3 also lacked documented, current advanced gastrostomy certifications while administering PEG tube medications. CMA #2’s certification had expired, but October and November 2025 MARs for Resident #1 showed that CMA #2 administered medications through the PEG tube on several dates, and CMA #2 stated they were allowed to pass medications and perform feedings via PEG tube. CMA #3’s advanced gastrostomy certification was also not current, yet October, November, and December 2025 MARs for Resident #1 documented multiple instances of PEG tube medication administration by CMA #3. The DON initially stated that CMA #1 was the only CMA not certified to work the medication carts and later reported that CMA #2 and CMA #3 did have certifications, but they were not in the nurse aide registry and would be verified with the testing school. However, the facility did not provide documentation confirming current gastrostomy certification for CMA #2 and CMA #3 by the time of the survey.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Reposition Residents Leads to Pressure Ulcers
Penalty
Summary
The facility failed to implement a system to ensure that dependent residents were repositioned every two hours to prevent the development and worsening of pressure ulcers. During a tour of the facility, it was observed that none of the 32 dependent residents were positioned on their right side as per the repositioning schedule. The facility's policy required a consistent program for changing residents' positions, but this was not being followed, and there was no documentation of repositioning in the ADL book. Resident #2, who was at high risk for developing pressure ulcers, was not repositioned as required. Initially, Resident #2 did not have any pressure ulcers upon admission, but later developed a fluid-filled blister and an open area on the buttocks. Despite receiving wound care orders, the resident's condition worsened, with the pressure ulcer becoming unstageable and showing signs of infection, including a foul odor and drainage. The resident was eventually sent to the hospital with a diagnosis of a pressure ulcer and sepsis. Interviews with staff revealed a lack of documentation and monitoring of repositioning activities. CNAs stated they did not document when residents were turned, and there was no list of residents requiring repositioning. The DON acknowledged that the ADL book was not being used to document repositioning and that monitoring by charge nurses and the DON was not occurring as it should have been. This lack of a systematic approach contributed to the development and worsening of pressure ulcers in residents.
Incomplete Documentation of Physician Visits
Penalty
Summary
The facility failed to ensure complete and accurate documentation for one of the five sampled residents reviewed for medical records. The facility's policy on Charting and Documentation, revised in July 2017, mandates that all services provided to residents, progress toward care plan goals, and any changes in the resident's condition must be documented in the medical record. However, a review of the medical records for a resident admitted with chronic respiratory failure revealed the absence of physician progress notes. Despite the physician having seen the resident in person on two occasions, as confirmed by both the physician and the Director of Nursing (DON), these visits were not documented in the resident's medical records.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours, seven days a week, during two of the four months reviewed, specifically October 2024 and January 2025. The CASPER report for fiscal year Quarter 4 2024 indicated a lack of RN coverage on four or more days within the quarter. A review of payroll documents confirmed the absence of RN coverage on specific dates in October 2024 and January 2025. The business office manager confirmed that all available documentation had been submitted, but acknowledged that the Director of Nursing (DON) did not punch in and instead completed missed visit forms. The DON confirmed the lack of RN coverage on the specified dates.
Failure to Update PASARR Level II for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a new diagnosis of a serious mental health condition had an updated Pre-Admission Screening and Resident Review (PASARR) Level II assessment. This deficiency was identified for one resident who was reviewed for PASARR Level II. The resident had diagnoses including pseudobulbar affect and a mood affective disorder. A PASARR Level I assessment dated 10/26/18 indicated that the resident did not have a diagnosis of serious mental illness or other psychotic disorder. However, the annual assessment dated 11/09/24 showed that the resident was not considered by the state PASARR Level II process to have a serious mental illness and/or intellectual disability or a related condition. On 02/04/25, the Director of Nursing (DON) reviewed the resident's clinical record and acknowledged that the resident had a diagnosis of mood affective disorder and a psychotic disorder, and stated that a PASARR Level II referral should have been made to the Level of Care Evaluation Unit.
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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