Sand Springs Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Sand Springs, Oklahoma.
- Location
- 1025 North Adams, Sand Springs, Oklahoma 74063
- CMS Provider Number
- 375285
- Inspections on file
- 23
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 5 (2 serious)
Citation history
Health deficiencies cited at Sand Springs Nursing And Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident, independent in dressing, transfers, and toileting, reported that a CNA entered the room after a late-night shower, remained there for an extended period, and engaged in oral sex and attempted intercourse, which the resident described as not forced but initiated by the CNA. The resident consistently repeated this account to the DON, administrator, and APS, including details of the CNA touching the resident’s chest, placing the resident’s hand on his genital area, exposing himself, and then receiving oral sex followed by an attempted sexual act. Staff statements supported that the CNA was in the resident’s room for an unusually long time, was unaccounted for elsewhere on the unit, and was providing care on a hall to which he was not assigned. The facility substantiated the allegation of sexual abuse, demonstrating a failure to protect the resident from sexual abuse by staff.
A cognitively intact resident with multiple medical conditions was subjected to sexual abuse by a CNA who was unaccounted for during their shift and provided care in an unassigned area. The facility failed to prevent unauthorized staff access and did not adequately supervise staff, resulting in a substantiated incident of sexual abuse.
A facility failed to assess and monitor the use of bed rails for a resident with multiple diagnoses, including diabetes and obesity. The resident's bed had an ill-fitting mattress and quarter rails, with no informed consent or proper safety assessments conducted. The DON was unaware of the rail use and unsure of the responsibility for bed safety assessments.
A resident with paraplegia and diabetes mellitus was not assisted out of bed for several days due to inadequate staffing at the facility. Despite having a physician's order to be up in a chair daily, the resident remained in bed, and their room was observed to be unclean. Staff interviews confirmed that staffing shortages prevented CNAs and LPNs from completing required tasks, and housekeeping staff reported insufficient personnel to maintain cleanliness.
The facility did not post updated nurse staffing information daily in a high visibility area. Observations on multiple days revealed that the staffing board, located at the nurses' station near the front door, displayed outdated data. The DON confirmed that the staffing information was not updated daily as required.
A facility failed to administer Eliquis as ordered for a resident with multiple diagnoses, including acute embolism and thrombosis. Despite hospital discharge orders specifying the dosage, the resident's MAR did not document the administration of Eliquis. An LPN admitted the resident and entered the orders into the system, but the medication was not given. The DON confirmed the oversight after reviewing the orders.
The facility failed to implement enhanced barrier precautions for three residents requiring such measures. A resident with multiple diagnoses had signage for gown and glove use, but an LPN was unaware of the precautions. Another resident with ESBL in the urine had PPE available, yet a CNA did not use it during care. Additionally, a resident with a stage four pressure ulcer did not receive proper gown use from an LPN and ADON during wound care.
A resident's room was consistently found to be unclean, with full trash cans, soiled linens on the floor, and food debris present. The resident, who has paraplegia and diabetes, reported inadequate housekeeping services. Staff interviews revealed that insufficient housekeeping staff led to rooms not being cleaned properly.
A resident with paraplegia and diabetes, dependent on staff for transfers, was not assisted out of bed despite a physician's order to be up daily. The resident reported not being out of bed for several days, and staff confirmed this, citing understaffing as a reason for the lack of assistance.
A facility failed to perform weekly skin assessments for a resident with conditions like diabetes and obesity, as required by their care plan. The assessments were not completed in June, leading to the resident experiencing discomfort and developing pressure areas on both hips. These areas were discolored and at risk of opening if untreated, as confirmed by an LPN and the DON.
A facility failed to comply with regulations for administering psychotropic medications to a resident with dementia. Seroquel was prescribed without an appropriate diagnosis, and Ativan was ordered PRN without a 14-day stop date. The MAR showed frequent administration of both medications. The DON acknowledged responsibility for ensuring compliance with these requirements.
A resident with dementia had a progress note indicating their hand was deep purple, swollen, and painful, and the physician was notified. However, the medical director later stated that the report they received did not mention pain or discoloration. A text message to the doctor reported the hand as swollen and not painful, with a photograph that did not show discoloration.
A facility failed to inspect bed frames, mattresses, and bed rails regularly, leading to a deficiency in the care of a resident using side rails. The resident's mattress did not fit the bed frame, exposing the metal frame and requiring rolled blankets for adjustment. The DON was unaware of the resident's use of quarter rails and admitted to a lack of routine safety assessments, despite the facility's policy requiring such checks.
Failure to Protect a Resident From Sexual Abuse by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by staff. A cognitively intact resident with a BIMS score of 15, and diagnoses including heart failure, DVT, HTN, depression, and bipolar disorder, was care planned as independent with dressing, transfers, and toileting, requiring no staff assistance for these tasks. There was no documentation indicating any prior history of the resident seeking sexual encounters with caregivers. Despite this, a CNA entered the resident’s room around the time of or after a late-night shower and remained there for an extended period, during which the resident later reported engaging in oral sex and attempted intercourse with the CNA. The resident provided a handwritten statement describing that after taking a shower between approximately 12:30 a.m. and 1:00 a.m., the CNA came into the room, offered help with dressing, and then initiated oral sex followed by an attempt at intercourse. The resident stated they were not forced and characterized the encounter as consensual or out of curiosity. The DON and administrator both documented interviews in which the resident consistently reported having performed oral sex on the CNA in the shower and again in the room, and that they attempted intercourse. Other staff statements corroborated the CNA’s unexplained presence with the resident at that time, including one CNA who noted that the CNA was in the resident’s room for an unusually long period and could not be located elsewhere on the unit. Additional staff and APS documentation further detailed the resident’s account that the CNA rubbed the resident’s chest area, placed the resident’s hand on the CNA’s genital area, exposed himself, and that the resident then performed oral sex, followed by an attempt at sexual intercourse while the CNA commented that the resident was “tight.” The administrator acknowledged awareness of the sexual abuse allegation and that the CNA had been providing care to the resident on a hall to which the CNA was not assigned and was unaccounted for approximately 45 minutes during the shift. The facility ultimately substantiated the allegation of sexual abuse based on the consistency of the resident’s description and the alignment of staff interviews with the reported timeline, establishing that the resident was not protected from sexual abuse by a staff member.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from sexual abuse by staff. The incident involved a cognitively intact resident with diagnoses including heart failure, DVT, hypertension, depression, and bipolar disorder. The facility's records indicated that a certified nursing assistant (CNA) was found to be missing from their assigned area for 45 minutes during a shift and was discovered to have been providing care to the resident on a hall where they were not assigned. An investigation substantiated that an oral sex interaction occurred between the CNA and the resident. The failure to ensure the resident's safety and prevent unauthorized staff access led to the substantiated incident of sexual abuse. The facility's lack of adequate supervision and monitoring of staff assignments contributed to the occurrence of the abuse, as the CNA was able to interact with the resident without detection for a significant period of time.
Failure to Assess and Monitor Bed Rail Use
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for a resident, leading to a deficiency. The resident, who had diagnoses including diabetes mellitus, morbid obesity, and hypertension, was observed using a halo rail/Ubar on their bed to assist with turning and repositioning. However, the facility did not conduct a proper assessment for the use of side rails, nor did they ensure the mattress fit correctly on the bed frame. Additionally, there was no informed consent obtained prior to the use of side rails, and the facility did not monitor the safety and maintenance of the side rails. The Director of Nursing (DON) was unaware of the resident's use of quarter rails and acknowledged that the mattress did not fit the bed frame. The DON was also unsure about who was responsible for assessing and monitoring the beds for safety and the use of rails. It was noted that the bed frame and rails should be assessed at least monthly, but there was no evidence of such assessments or monitoring being conducted. The DON provided a side rail consent form and a restraints assessment for the resident, but these documents were completed without a date, indicating they were likely filled out after the surveyor's inquiry.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of a resident with paraplegia and diabetes mellitus, identified as Resident #33. The resident was dependent on staff for transfers and had a physician's order to be up in a chair daily to facilitate wound healing. However, the resident reported not being assisted out of bed since the previous week, despite expressing a desire to do so. Observations confirmed the resident's room was not maintained in a clean condition, with full trash cans, soiled linens on the floor, and food debris present. Staff interviews revealed that the resident had not been assisted out of bed due to staffing shortages, with CNAs and LPNs acknowledging that required tasks were not always completed. Housekeeping staff also reported insufficient staffing levels, which impacted their ability to maintain cleanliness in the resident's room. The housekeeping supervisor and a housekeeper both confirmed that rooms were not being deep cleaned appropriately due to a lack of staff. The CNA responsible for the resident's care stated they were often the only aide on the hall and were frequently pulled away, preventing them from assisting the resident as needed. This deficiency highlights the facility's failure to provide sufficient nursing and housekeeping staff to meet the needs of its residents, as outlined in their policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily in a high visibility area, as required. On June 17, 2024, at 10:35 a.m., the nurse staffing board was not observed in any high visibility area. Subsequently, on June 19, 2024, at 12:44 p.m., a staffing board was found posted at the nurses' station near the front door, but the data was dated June 18, 2024. This outdated information was still posted on June 20 and June 21, 2024, indicating that the staffing data had not been updated daily as required. The Director of Nursing (DON) confirmed that the staffing data was supposed to be updated daily but acknowledged that it was not.
Failure to Administer Anticoagulant Medication as Ordered
Penalty
Summary
The facility failed to administer medication as ordered by the physician for a resident who was reviewed for unnecessary medication. The resident had diagnoses including acute embolism and thrombosis of unspecified deep veins of the lower extremity, cardiomyopathy, chronic systolic heart failure, hemiplegia to the left nondominant side, and anemia. A five-day assessment documented that the resident was cognitively intact and was receiving an anticoagulant medication. A hospital discharge order specified that the resident was to receive Eliquis 10mg by mouth twice a day for six days, then decrease to 5mg by mouth twice a day. However, the resident's Medication Administration Record (MAR) for June 2024 did not document that the resident received Eliquis as ordered. An LPN admitted the resident from the hospital and stated that physician orders were entered into the computer and faxed to the pharmacy, but was unsure why the medication was not on the MAR or why Eliquis had not been given. The Director of Nursing reviewed the hospital physician orders and confirmed that the resident had not received Eliquis as ordered.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program for enhanced barrier precautions (EBP) for three residents. Resident #29, who had multiple diagnoses including obstructive and reflux uropathy and diabetes mellitus, had signage indicating the need for gown and gloves, but an LPN was unaware of the precautions required. Despite the Director of Nursing (DON) stating that staff had been in-serviced on EBP, the lack of awareness by the LPN indicated a failure in implementing the program effectively. Resident #51, diagnosed with neuromuscular dysfunction of the bladder and other conditions, required EBP due to ESBL in the urine. Although signage and personal protective equipment (PPE) were available, a CNA failed to wear the necessary gown and gloves during catheter care and dressing assistance. The CNA acknowledged the oversight, and the DON confirmed the requirement for PPE. Similarly, Resident #46, with a stage four pressure ulcer, required EBP, but an LPN and the Assistant Director of Nursing (ADON) did not wear gowns during wound care, acknowledging the lapse afterward.
Failure to Maintain Clean Environment Due to Staffing Issues
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for a resident diagnosed with paraplegia and diabetes mellitus, who was dependent on staff for transfers. Observations of the resident's room over several days revealed consistent issues with cleanliness. The trash can was full, soiled linens were piled on the floor, and the floor was discolored and sticky. Additionally, soiled gloves and food debris were repeatedly found in the room, indicating a lack of proper cleaning. Interviews with the resident and staff highlighted systemic issues contributing to the deficiency. The resident expressed dissatisfaction with the housekeeping services, stating that they did not perform adequately. The housekeeping supervisor and a housekeeper both acknowledged that the rooms were not being cleaned properly due to insufficient staffing. The supervisor noted that CNAs were responsible for ensuring dirty linens were not left on the floor, but ultimately, housekeeping was responsible for maintaining cleanliness, which was not being achieved due to staffing shortages.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident diagnosed with paraplegia and diabetes mellitus. The resident was dependent on staff for transfers and had a physician's order to be up in a chair daily to aid wound healing. Despite this, the resident reported not being assisted out of bed since the previous week. Observations and interviews with staff confirmed that the resident had not been out of bed for several days. A CNA mentioned being unable to assist the resident due to being frequently pulled away and being the only aide on the hall. An LPN also confirmed not seeing the resident out of bed since late the previous week.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to complete weekly skin assessments as ordered for a resident with a potential for impaired skin integrity due to conditions such as diabetes mellitus, morbid obesity, and hypertension. The care plan indicated the need for weekly skin assessments to identify any new skin abnormalities, with documentation and physician notification required every Monday evening shift. However, the assessments were not conducted in June 2024, as confirmed by the Director of Nursing. Observations revealed that the resident experienced discomfort and had pressure areas on both hips, which were discolored and at risk of opening if left untreated.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications for a resident diagnosed with dementia. A physician's order dated April 4, 2024, prescribed Seroquel, an antipsychotic, to be administered at bedtime for dementia, which lacks an appropriate diagnosis for such medication. The Medication Administration Record (MAR) for April 2024 showed that Seroquel was administered 25 times. Additionally, a physician's order dated May 5, 2024, prescribed Ativan, an anti-anxiety medication, to be given every six hours as needed for agitation, without a 14-day stop date for the PRN order. The MAR for May 2024 documented that Seroquel was administered 31 times and Ativan 16 times. By June 19, 2024, Seroquel had been administered 18 times and Ativan 9 times. The Director of Nursing (DON) acknowledged the responsibility to ensure the PRN order had an end date and that the psychotropic medication had an appropriate diagnosis.
Inaccurate Resident Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy of resident records for a resident diagnosed with dementia. A progress note dated April 30, 2024, documented that the resident's hand was deep purple, swollen, and painful, and that the physician was notified. However, on June 20, 2024, the medical director stated that the report they received did not include information about pain or discoloration. An observation of a text message revealed that the staff reported to the doctor that the hand was swollen and not painful, and included a photograph that did not show discoloration of the resident's hand.
Failure to Inspect Bed Safety Equipment
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to a deficiency in the care of a resident who used side rails. The facility's policy prohibited the use of bed rails unless specific criteria were met and required that bed frames, mattresses, and bed rails be checked for compatibility to prevent entrapment risks. However, the facility did not adhere to this policy, as evidenced by the lack of routine inspections by maintenance staff to identify potential risks and problems. The deficiency was identified during an observation where a resident was found lying in bed with a mattress that did not fit the bed frame, leaving the metal frame exposed from midway down. Rolled blankets were used between the mattress and the quarter rails, indicating an improper fit. The DON was unaware of the resident's use of quarter rails and admitted that the mattress did not fit the bed frame. Furthermore, the DON was unsure who was responsible for assessing and monitoring the safety of beds and rails, although they acknowledged that such assessments should occur at least monthly. The resident had been using the current bed since 2019, highlighting a prolonged period without proper inspection.
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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