Senior Suites Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Broken Arrow, Oklahoma.
- Location
- 3501 W Washington Street, Broken Arrow, Oklahoma 74012
- CMS Provider Number
- 375528
- Inspections on file
- 26
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Senior Suites Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete Section C (cognitive patterns) of the MDS for four sampled residents, including on admission, quarterly, and annual assessments. Despite a written policy stating that MDS assessments would be conducted and submitted according to federal and state timeframes, these assessments were marked as "not assessed" in the cognitive section. During interviews, the MDS coordinator acknowledged that the cognitive sections should have been assessed and answered, and the DON was unable to explain why they were left incomplete, confirming they should have been completed.
Surveyors found that required MDS assessments were not electronically submitted to CMS within the required timeframe for two residents. Facility policy assigns responsibility to the assessment coordinator or designee to ensure timely submission of assessments in accordance with federal and state guidelines. Record review showed that one resident’s discharge assessment and another resident’s annual assessment had not been submitted, and the MDS coordinator confirmed that the RN who reviewed and signed these assessments did not complete the submission process.
The facility failed to conduct required quarterly care plan meetings with two cognitively intact residents and their representatives, contrary to its own policy and leadership expectations. One resident with multiple sclerosis and dementia had not had a care plan meeting since late the previous year and reported that care plan meetings were not being held. Another resident with a history of stroke and hypertension had not had a care plan meeting for many months, and a family member reported that a recently scheduled meeting was canceled due to lack of available staff, with no subsequent meetings held. The SSD acknowledged that quarterly care plan meetings were not being completed as required, and the DON stated that care plan meetings should occur on admission, quarterly, and as needed.
Surveyors found that the facility’s binding arbitration agreement did not clearly state that signing was not required for admission, despite facility policy stating arbitration is voluntary and not a condition of admission or care. The form used for multiple residents only indicated that signing was not a precondition to the “furnishing of services,” without explicitly addressing admission. During interview, the SSD acknowledged that this wording did not clearly communicate that admission was not dependent on signing the arbitration agreement.
Surveyors found that the facility’s binding arbitration agreements did not include required provisions for mutual selection of a neutral arbitrator or for a mutually convenient venue, despite the facility’s policy stating these elements must be present. For multiple residents, the arbitration forms either signed or presented for signature lacked any language about both parties choosing an arbitrator together and instead specified that, if no venue was agreed upon, arbitration would default to being held at the facility. During interview, the SSD confirmed they did not see any description of an arbitrator selection process in the agreement and understood the venue to default to the facility if mutual agreement could not be reached.
A resident with a PEG feeding tube and severely impaired cognition was cared for without required Enhanced Barrier Precautions (EBP) despite a facility policy stating that residents with indwelling medical devices, including feeding tubes, require gown and gloves for tube care and use. The resident’s room lacked EBP signage and readily accessible PPE, and the treatment administration record did not include an EBP order. On several occasions, an LPN and an RN performed PEG residual checks, tube feeding, medication administration, and a dressing change using only hand hygiene and gloves, without donning gowns, even though the DON later confirmed that gown and gloves were required for this resident’s PEG-related care.
A resident with moderate cognitive impairment was receiving a daily antidepressant (fluoxetine 10 mg) under a physician’s order, and the care plan directed staff to monitor and document medication side effects and effectiveness. Facility policy required proactive monitoring and documentation of side effects for all medications, including psychotropics. However, review of the treatment administration record over several months showed no documentation of side effect monitoring for this resident, and the DON confirmed that no such monitoring had occurred, despite many residents in the facility receiving psychotropic medications.
The facility failed to follow its F609 abuse reporting policy requiring that allegations of abuse be reported to state and local authorities within two hours. A family member informed staff of an alleged act of abuse involving a resident, but the DON did not notify the administrator until a later staff meeting, and the administrator did not submit reports to the state survey agency and local law enforcement until several days after staff first learned of the allegation. Both the administrator and DON acknowledged in interviews that the allegation should have been reported when staff were initially informed by the family.
A resident’s family reported an alleged act of abuse by a CNA to the DON during a care plan meeting, but the DON did not immediately initiate an investigation or remove the CNA from duty as required by facility policy. Facility records showed the CNA continued working several shifts after the allegation was known to the DON, and the administrator was not informed until later, at which point the CNA was suspended and the incident was reported to state authorities and law enforcement.
The facility failed to provide required written notices of transfer or discharge to residents or their representatives prior to transfers. The facility’s transfer/discharge policy did not include the requirement for written notification, and a resident sent to an acute care hospital for behaviors did not receive written notice before being transferred. An LPN reported never having heard of or provided written transfer notices, and the DON stated they were unaware of the requirement and confirmed that such notices had not been given, despite multiple resident discharges in the preceding months.
A resident was admitted and remained in the facility long enough to require a comprehensive, person-centered care plan per facility policy, but no such care plan was ever developed or documented in the EMR. The facility’s policy required completion of a comprehensive care plan within a set timeframe following the MDS admission assessment, yet both the MDS coordinator and the DON confirmed they could not locate any comprehensive care plan for this resident and acknowledged that it should have been completed within 14 days of the comprehensive assessment.
Surveyors found that the facility did not have a qualified activity director in place for a census of 74 residents, despite posted schedules for group activities such as coffee and conversations, bible study, and stretching. Residents were observed playing bingo with an automated bingo machine while a CMA sat at the table, rather than a qualified activities professional directing the program. A social worker reported that they or other staff assisted with activities and were unsure how long the facility had been without an activity director, and the administrator confirmed there had been no full-time activity director for several weeks, even though resident rights materials stated that a program of activities would be provided to meet residents’ needs and interests.
The facility failed to maintain and document required temperature monitoring for one of two medication refrigerators. During observation of a medication room with the DON, surveyors found a full-size refrigerator containing medications without a temperature log for the current month attached. Review of the facility’s Storage of Medications policy showed that medications must be stored under proper temperature controls. The DON stated they were unable to locate the missing temperature log and acknowledged that it should have been kept on the refrigerator and completed.
Surveyors found that a mini refrigerator in a medication room, which the DON stated was designated for resident food items, contained both food and a urine specimen. The refrigerator held bacon, protein shakes, ice cream, and mighty shakes, as well as a urine specimen cup half-filled with a yellow substance, sealed in a plastic lab bag, and labeled with the name of a former resident. The specimen was placed directly on top of the ice cream and mighty shakes. The DON acknowledged that the urine specimen should not have been stored in that refrigerator and identified this as an infection control issue, with 74 residents residing in the facility at the time.
A resident who required stand-by assist with ambulation did not have a functioning call light in their room and bathroom/bathing area. When the resident pressed the call light, the corridor light above the door did not activate and the room number did not appear on the nurses’ station monitor. The resident reported the call light had not worked even after the cord was replaced. Review of the maintenance logbook showed no prior entries for call light repairs until a CNA documented that this resident’s call light and another room’s call light were not working. Staff, including a CMA and CNA, reported that call lights and monitors did not always work and that problems occurred almost daily, while the DON acknowledged that issues had been reported verbally rather than documented as required by facility policy.
A computer displaying protected health information was left open and unattended on a medication/treatment cart at a nurses station, with no staff present. A CMA later closed the computer, and both the administrator and the assigned RN confirmed that the computer should not have been left open with resident information visible.
A medication/treatment cart was found unlocked and unattended at a nurses station, with medications left on top, contrary to facility policy requiring secure storage. The assigned RN was not present, and a CNA later locked the cart. Both the administrator and RN acknowledged the cart should have been secured to prevent access by residents or visitors.
A resident with atrial fibrillation missed multiple doses of amiodarone due to facility staff's misunderstanding of administration parameters. The CMA and LPNs had incorrect interpretations of when to withhold the medication, leading to significant missed doses. The DON later clarified the correct parameters with the physician.
The facility's kitchen environment and equipment were not maintained in a clean and safe condition, affecting meal preparation for 83 residents. Observations included a broken container used for pureeing food, standing water, dust, mold, and structural damage in the kitchen and dish machine room. Staff were aware of these issues but cited budget constraints for not addressing them.
A facility failed to assess a resident with dementia for bed rail use before installation. The resident's medical record lacked an assessment, and bed rails were observed on both sides of the bed. The administrator noted that the assessment page did not automatically populate, leading to the oversight.
A facility failed to follow its Enhanced Barrier Precautions policy during wound care for a resident with a sacral pressure ulcer. The policy required gowns and gloves for such care, but an RN and an LPN only wore gloves. The RN stated no additional measures were needed, and the LPN indicated gowns and masks were used only for MRSA cases. The administrator confirmed that gowns should have been worn.
The facility did not secure a surety bond with adequate coverage for the resident trust account, which had a balance of $18,330, while the bond covered only $10,000. The business office manager identified 15 residents with funds in the account. The corporate regional manager confirmed the bond's insufficiency and stated that the issue had been noticed the previous month, but it remained unresolved.
A facility failed to deposit a resident's personal funds exceeding $50 into an interest-bearing account separate from operational accounts. The resident had a credit balance of $1,471.00 in the facility's accounts receivable account, which was not transferred to the trust account. The corporate business office manager stated the funds were left in the operating system at the family's request, despite it not being interest-bearing. The corporate regional manager confirmed that resident funds should not be commingled with operating funds.
The facility failed to ensure timely availability of medications for a resident with acute kidney failure, resulting in a delay of over 24 hours in administering a prescribed antibiotic, contrary to facility policy requiring STAT orders to be fulfilled within four hours.
The facility failed to have an administrator of record between 11/23/23 and 01/18/24. The previous administrator left on 11/23/23, and the new administrator started on 01/18/24. The current administrator could not identify an interim administrator during this period, and no documentation was provided. This affected the management of the facility, which housed 76 residents.
Incomplete MDS Cognitive Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate and complete Minimum Data Set (MDS) assessments, specifically in Section C: Cognitive Patterns, for four of twenty-one sampled residents. A facility document titled “MDS Completion and Submission Timeframes,” dated October 2023, stated that the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. However, record review showed that a quarterly assessment for Resident #57 dated 11/01/25, an admission assessment for Resident #87 dated 11/21/25, an annual assessment for Resident #44 dated 12/11/25, and a quarterly assessment for Resident #69 dated 12/12/25 all had Section C marked as “not assessed” and left incomplete. During interviews on 02/12/26, the MDS coordinator acknowledged in each case that Section C should have been assessed and answered, and the DON stated they could not explain why Section C was not completed and confirmed it should have been assessed and answered correctly. These findings occurred in a facility where the administrator identified that 74 residents resided, and the deficiency was identified through record review and staff interviews focused on MDS accuracy for sampled residents.
Failure to Submit MDS Assessments to CMS Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit required Minimum Data Set (MDS) resident assessments to CMS within the mandated timeframe. Facility policy dated 10/01/23 states that the assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS’ Internet Quality Improvement Evaluation System in accordance with current federal and state guidelines, which require submission within 7 days of assessment. Record review showed that a discharge assessment for Resident #27, dated 11/07/25, and an annual assessment for Resident #13, dated 12/30/25, had not been submitted to CMS. During an interview on 02/10/26 at 1:55 p.m., the MDS coordinator confirmed that the MDS assessments for Resident #13 and Resident #27 were not submitted to CMS by the RN who reviewed and signed the assessments. The administrator reported that 74 residents resided in the facility at the time of the survey, and the two residents cited were part of the sample reviewed for MDS submission compliance.
Failure to Hold Required Quarterly Care Plan Meetings With Residents and Representatives
Penalty
Summary
The deficiency involves the facility’s failure to hold required quarterly care plan meetings with residents and/or their representatives, despite policy stating that residents and their representatives are encouraged to participate in the development and implementation of care plans. For one resident with multiple sclerosis and dementia, an annual assessment documented a BIMS score of 14, indicating the resident was cognitively intact, and the record showed the last care plan meeting occurred in November 2024. During interview, this resident stated the facility had not been having care plan meetings. The Social Services Director (SSD) acknowledged that quarterly care plan meetings had not been completed as required, and the DON stated that care plan meetings should occur upon admission, every quarter, and as needed. For another cognitively intact resident with a BIMS score of 13 and diagnoses including stroke and hypertension, the health record showed the last care plan meeting was held in early May 2024. The resident’s family member reported they had not had any care plan meetings and stated that a care plan meeting scheduled for the prior month was canceled because no staff were available to attend at the scheduled time. The family member further stated they were informed by staff that they were trying to get back to having regular care plan meetings. The SSD again confirmed that quarterly care plan meetings were not being held as required, and the DON reiterated that care plan meetings should be conducted upon admission, quarterly, and as needed.
Arbitration Agreement Lacked Clear Statement That Signing Was Not Required for Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure its binding arbitration agreement contained an explicit statement that signing the agreement was not a condition of admission, as required by its own policy and regulatory expectations. The facility’s Binding Arbitration Agreements policy dated 11/2023 stated that arbitration agreements are voluntary, that residents are not compelled, pressured, or coerced to enter into such agreements, and that it would be unambiguously communicated that arbitration is optional and not required as a condition of admission or to receive care. However, the actual arbitration agreement form used for three sampled residents included language stating only that execution of the arbitration agreement was not a precondition to the “furnishing of services” to the resident by the facility, without clearly addressing admission status. Record review showed that one resident’s representative signed the arbitration agreement, another resident’s representative refused to sign, and a third resident signed the agreement, all on the same form containing the “furnishing of services” language. For each of these residents, the agreement did not explicitly state that admission to the facility was not dependent on signing the arbitration agreement. During an interview, the SSD acknowledged that the portion of the binding arbitration agreement using the phrase “furnishing of services” did not clearly state that admission to the facility was not contingent on signing the agreement and stated that the wording was not clear enough. The administrator identified that 74 residents resided in the facility at the time of the survey.
Failure to Include Mutual Arbitrator and Venue Provisions in Arbitration Agreements
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its binding arbitration agreements contained required stipulations for the mutual selection of a neutral arbitrator and a mutually convenient venue, as outlined in its own Binding Arbitration Agreements policy dated 11/2023. The policy stated that arbitration agreements must provide for the selection of a neutral, impartial arbitrator agreed upon by both parties, and that the venue must be convenient to and agreed upon by both parties, with consideration of the resident’s ability to get to the venue. Record review showed that the facility’s standard arbitration agreement form did not include language about mutual selection of an arbitrator, and instead specified that if the parties could not agree on a venue, the arbitration would occur at the facility. For one resident, an arbitration agreement dated 04/02/25 was signed by the resident’s representative on 04/15/25 and lacked any stipulation regarding mutual selection of an arbitrator, while stating that if no venue was agreed upon, arbitration would take place at the facility. For another resident, an arbitration agreement dated 07/28/25, which the resident’s representative refused to sign, also lacked language on mutual arbitrator selection and contained the same default venue-at-the-facility clause. A third resident’s arbitration agreement, dated and signed on 01/07/26, similarly omitted any provision for mutual selection of an arbitrator and included the same venue default. During an interview on 02/12/26 at 12:34 p.m., the SSD, after reviewing the binding arbitration agreement, stated they did not read anything about the process of choosing an arbitrator and explained that while the venue would be selected mutually, if the parties could not agree, arbitration would occur at the facility.
Failure to Use Enhanced Barrier Precautions for PEG Tube Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) policy for a resident with a percutaneous endoscopic gastrostomy (PEG) feeding tube. The resident, who had severely impaired cognition, a feeding tube, and a diagnosis of transient ischemic attack, was observed in a room without EBP signage and without readily accessible personal protective equipment. Facility policy dated 04/01/25 specified that residents with indwelling medical devices, including feeding tubes, required EBP, with staff wearing a gown and gloves for feeding tube care or use. The treatment administration record for the resident for the month of February did not include any order for enhanced barrier precautions. On multiple observed occasions, licensed nursing staff did not follow the EBP requirements while providing PEG tube-related care to this resident. An LPN checked PEG tube residuals and flushed the tube using only hand hygiene and gloves, without donning a gown. On two separate occasions, an RN checked residuals, administered scheduled medications and feeding via the PEG tube, and later performed a dressing change to the PEG tube site, each time wearing gloves but not a gown. The DON confirmed that enhanced barrier precautions, including gown and gloves, should have been used for this resident during direct care, PEG tube feeding, and medication administration, and the RN acknowledged failing to wear a gown during these procedures.
Failure to Monitor and Document Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure ongoing side effect monitoring for a resident receiving a psychotropic medication. Facility policy on monitoring and reduction of unnecessary medications required staff to proactively monitor medication side effects, document findings, and collaborate with providers to adjust or discontinue medications when appropriate. A physician’s order dated 08/29/25 directed that Resident #19 receive fluoxetine 10 mg PO daily, and a quarterly assessment dated 12/12/25 documented that the resident, who had a BIMS score of 12 indicating moderate cognitive impairment, routinely received an antidepressant. The resident’s care plan, dated 12/31/25, included an intervention for depression specifying that medications were to be administered as ordered and that side effects and effectiveness were to be monitored and documented. However, review of the treatment administration record from 08/29/25 through 02/10/26 revealed no documentation of side effect monitoring, and on 02/11/26 the DON confirmed that no side effect monitoring had taken place for this resident. This deficiency involved one of five sampled residents reviewed for unnecessary medications, and the DON identified that 60 residents in the facility were receiving psychotropic medications.
Failure to Timely Report Alleged Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to timely report an allegation of abuse to the Oklahoma State Department of Health (OSDH) and local law enforcement within two hours of becoming aware of the allegation, as required by its Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation – F609 policy. The policy, dated 2001, stated that all reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, would be reported to local, state, and federal agencies as required by regulations, and that such reports would be made within two hours. An initial incident report showed that on 01/27/26 facility staff were informed by a family member of an alleged act of abuse against Resident #10, one of three sampled residents reviewed for abuse, in a facility with 74 residents. However, the incident report documented that the administrator did not report the allegation to OSDH and local law enforcement until 02/03/26. In interview, the administrator stated they first became aware of the allegation on 02/03/26 during a morning staff meeting when the DON reported learning of the incident on 01/27/26, and acknowledged the reports should have been made on 01/27/26 when staff were first informed by the family. The DON confirmed in interview that they informed the administrator of the alleged abuse at the staff meeting on 02/03/26 and acknowledged they should have reported it earlier.
Failure to Timely Investigate Abuse Allegation and Remove Alleged Perpetrator from Duty
Penalty
Summary
The deficiency involves the facility’s failure to timely investigate an allegation of abuse and to prevent the alleged perpetrator from working with the alleged victim in accordance with its abuse policy. The facility’s Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation – F609 policy required that all reports of resident abuse be thoroughly investigated by management, that the alleged perpetrator and victim be kept apart, and that the alleged perpetrator be placed on leave until the investigation was completed. An initial incident report documented that on 01/27/26, facility staff were informed by a family member of an alleged act of abuse against Resident #10, and that the family member identified CNA #1 as the alleged perpetrator. The Director of Nursing (DON) stated they learned of the accusation during a care plan meeting on 01/27/26. Despite this knowledge, facility records showed that CNA #1 continued to work at the facility on 01/29/26, 01/30/26, and 01/31/26, after the DON had been made aware of the allegation and before the administrator began the investigation on 02/03/26. The incident report also showed the administrator did not report the incident to the state survey agency and local law enforcement until 02/03/26. The administrator stated they first learned of the allegation against CNA #1 on 02/03/26 during a morning staff meeting with the DON, at which time they suspended CNA #1 and initiated the investigation. The DON later acknowledged that CNA #1 had not worked since 01/31/26 and stated they should have begun the investigation when they first learned of the allegation and immediately suspended the nurse aide.
Failure to Provide Required Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written notices of transfer or discharge to residents or their representatives prior to transfer, as evidenced by record review and staff interviews. The facility’s Transfer or Discharge policy dated April 2025 did not include the requirement to notify the resident or their representative in writing before a transfer or discharge. For one resident (Res #92) of three sampled for discharges, a nurse’s note dated 01/03/26 at 11:23 a.m. documented that the resident was sent to an acute care hospital for behaviors, but there was no written notice of transfer provided prior to this transfer. During an interview on 02/11/26 at 1:19 p.m., an LPN stated they had not heard of a written notice of transfer and had never given such a notice to any residents they had transferred or discharged. In a separate interview on 02/11/26 at 1:22 p.m., the DON stated they were unaware of the requirement for a written notice of transfer to be given to a resident or their representative prior to transfer or discharge and acknowledged that the facility had not been providing these notices to residents. The DON identified that 60 residents had been discharged during the three months prior to the survey, indicating that the lack of written transfer or discharge notices extended beyond the single sampled resident and reflected a broader practice consistent with the incomplete policy and staff unawareness of the requirement.
Failure to Develop Comprehensive Care Plan for Admitted Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable objectives and timetables for one resident, identified as #91, as required by its March 2022 Care Plans, Comprehensive, Person-Centered policy. The policy stated that comprehensive care plans must be completed within seven days of the required MDS assessment and no more than 21 days after admission. Admission records showed the resident was admitted on 10/07/25 and discharged on 11/23/25, and an admission assessment dated 10/14/25 confirmed the admission date. Review of the electronic medical record revealed that no comprehensive care plan had been developed for this resident during their stay. On 02/11/26 at 12:24 p.m., the MDS coordinator was unable to locate a comprehensive care plan for this resident in the electronic medical record and acknowledged that the resident had been in the facility long enough that a care plan should have been developed, stating it should have been completed no later than 14 days after the admission MDS assessment. At 12:48 p.m. the same day, the DON also confirmed they could not locate a comprehensive care plan for the resident and stated that both their expectation and facility policy required the comprehensive care plan to be developed within 14 days of completion of the resident’s comprehensive assessment.
Lack of Qualified Activity Director for Resident Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional, resulting in the absence of a full-time activity director for a census of 74 residents. On multiple observations, residents were seen participating in bingo games in the dining area, with an automated bingo machine calling numbers and a CMA present at the table, rather than a qualified activity director leading or overseeing the program. The posted activity board listed scheduled group activities such as coffee and conversations, bible study, and stretch sessions, but there was no indication of a qualified activities professional coordinating or conducting these programs. A Resident Rights poster stated the facility would provide a program of activities designed to meet residents’ needs and interests, yet the social worker reported that either they or another staff member would assist with activities and did not know how long the facility had been without an activity director. The administrator confirmed that the facility did not currently have a full-time activity director and that it had been “some weeks” since one was in place, acknowledging they were in the process of hiring but leaving the activities program without a qualified director during that period. No specific resident medical histories or clinical conditions were described in relation to this deficiency, only that 74 residents resided in the facility at the time of the survey.
Failure to Maintain Temperature Log for Medication Refrigerator
Penalty
Summary
The facility failed to ensure proper monitoring of medication refrigerator temperatures in one of two medication storage refrigerators, as required for safe storage of drugs and biologicals. During observation of medication room [ROOM NUMBER] with the DON, surveyors noted a full-size refrigerator containing medications that did not have a temperature record log attached for February 2026. Review of the facility’s Storage of Medications policy, dated 2001, showed that drugs and biologicals were to be stored under proper temperature controls. In an interview, the DON reported that they searched but were unable to locate the missing temperature log for the medication refrigerator in medication room [ROOM NUMBER] and stated that the log should have been kept on the refrigerator and completed in full. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Urine Specimen Improperly Stored in Refrigerator Used for Resident Food
Penalty
Summary
Surveyors observed that a mini refrigerator in medication room [ROOM NUMBER], designated for storing resident food items, contained both food and a urine specimen, in violation of infection control and food safety standards. On 02/10/26 at 9:33 a.m., the refrigerator was found to hold a box of bacon, two protein shakes, one individual-sized ice cream, and two mighty shakes, along with a urine specimen cup that was half-filled with a yellow substance and sealed in a plastic lab bag. The specimen cup, labeled with the name of a former resident, was placed directly on top of the ice cream and mighty shakes containers. At 9:37 a.m., the DON confirmed that the mini refrigerator in medication room [ROOM NUMBER] was intended solely for resident food storage and acknowledged that the urine specimen should not have been stored there, identifying it as an infection control issue. The facility administrator reported that 74 residents resided in the facility at the time of the survey. The report does not provide additional clinical details or medical history about the former resident whose name appeared on the urine specimen cup, nor does it describe the condition of any specific resident at the time of the deficiency.
Failure to Maintain Operational Call Light System for Resident Room and Bathroom
Penalty
Summary
The facility failed to ensure that the call light system was operational for a resident’s room and bathroom/bathing area, as required by its policy and resident care needs. During observation, the resident identified as #94 activated their call light, but the corridor light above the door did not illuminate or sound, and the call light system monitor at the nurses’ station did not display the room number. The resident reported that the call light had not been working, stating that maintenance had replaced the cord but the system still did not function. The resident’s baseline care plan indicated a need for stand-by assistance with ambulation, yet the resident had no functioning call light or bell available at the time of the initial observation. Further observations and interviews showed that the issue with nonfunctioning call lights was ongoing and not documented in the maintenance logbook. On review of the maintenance logbook, there were no entries indicating call lights needing repair until a CNA documented that the call light in this resident’s room and another room were not working. Staff interviews revealed that the call light system’s lights and monitors did not always work, and a CNA reported experiencing issues with call lights not working almost daily. The DON stated that there was no prior written documentation of call light problems because staff had been reporting them verbally rather than through the logbook, despite the facility’s policy requiring defective call lights to be reported to maintenance or administration to be addressed promptly.
Unattended Computer Displayed PHI on Medication Cart
Penalty
Summary
A deficiency occurred when a computer displaying protected health information was left open and unattended on top of a medication/treatment cart at nurses station 3. This was observed on the morning of 05/30/25, with the computer showing resident information and no staff member present at the cart. When a certified medication aide (CMA) arrived, they closed the computer but were unaware of the nurse assigned to the cart's whereabouts. The administrator and the registered nurse assigned to the cart both confirmed that the computer should not have been left open with resident information visible. The facility had 95 residents at the time of the incident. No specific residents were identified as being directly affected in the report, and no medical history or condition of residents was mentioned in relation to the deficiency.
Unattended Unlocked Medication Cart with Medications Left Accessible
Penalty
Summary
A medication/treatment cart on station 3 was observed to be unlocked and unattended at the nurses station, with a bottle of Hysept wound cleanser and a medicine cup containing an unidentified gel left on top. The facility's policy requires all compartments containing medications and biologicals to be locked when not in use and for carts to not be left unattended if open or accessible. At the time of the observation, the nurse assigned to the cart was not present, and a CNA subsequently locked the cart. Both the administrator and the assigned RN confirmed that the cart should have been locked and that medications should not have been left on top, acknowledging that residents or visitors could have accessed the medications. The facility had 95 residents at the time of the incident.
Failure to Administer Cardiac Medication as Prescribed
Penalty
Summary
The facility failed to administer a cardiac medication, amiodarone, as prescribed for a resident diagnosed with atrial fibrillation. The physician's order required the resident to receive 100 milligrams of amiodarone daily, with monitoring of blood pressure and heart rate. However, the resident missed a significant number of doses over a period from September to November, with six out of 18 doses missed in September, 11 out of 31 in October, and four out of seven in early November. On a specific day in November, a Certified Medication Aide (CMA) did not administer the medication, citing incorrect instructions regarding blood pressure parameters. Interviews with facility staff revealed a lack of understanding and consistency in administering the medication. The CMA and two Licensed Practical Nurses (LPNs) had varying interpretations of when to withhold the medication based on blood pressure and heart rate readings, none of which aligned with the physician's order. The Director of Nursing (DON) acknowledged the absence of specific instructions in the order and the significance of the missed doses. The DON later clarified the correct parameters with the physician, who specified holding the medication only if the heart rate was below 50 beats per minute, not based on blood pressure readings.
Kitchen Environment and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-repaired kitchen environment, which affected the preparation and serving of meals to 83 residents. Observations revealed that a cook was using a cracked and broken container to puree pork, which required manual pressure to keep it in place during use. The kitchen environment was found to have several issues, including standing water on the floor, a dusty box fan blowing air across food preparation areas, and a ceiling vent covered in dust. Additionally, there was visible light penetration around the exterior door, which could allow vermin access, and various stains and holes in the ceiling and walls of the kitchen and dish machine room. Further inspection showed peeling paint, missing drywall, and a black substance identified as mold around the ice machine. The kitchen had dirt, food particles, and expired insects along the baseboards, and grease stains on the walls of the dry storage room. The kitchen staff and maintenance personnel were aware of these issues, including the broken container and the poor drainage contributing to standing water, but cited budget constraints as a reason for not addressing them. The presence of mold and other unsanitary conditions in the kitchen environment posed a risk to food safety and hygiene.
Failure to Assess Bed Rail Use for a Resident
Penalty
Summary
The facility failed to ensure that residents were assessed for the use of bed rails prior to their installation, specifically for one resident who was reviewed for bed rails. This deficiency was identified through observation, interview, and record review. The resident in question had a diagnosis that included dementia. Upon reviewing the resident's medical record, it was found that there was no assessment conducted for the use of bed rails. During an observation, bed rails were noted to be up on both sides of the resident's bed. The facility's administrator acknowledged that the bed rail assessment page did not automatically populate in their system, requiring nurses to manually access it, which did not occur for this resident.
Failure to Adhere to Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy during wound care for a resident with a sacral pressure ulcer. The facility's policy required the use of gowns and gloves for high-contact resident care activities, such as wound care. However, during an observation, a registered nurse (RN) and a licensed practical nurse (LPN) sanitized their hands and donned gloves but did not wear gowns while treating the resident's pressure ulcer. When questioned, the RN stated that no additional infection control measures were necessary before starting the wound care. The LPN later mentioned that gowns and masks were only worn if the resident had MRSA. The facility administrator confirmed that gowns should have been worn during the wound care as per the facility's EBP policy.
Insufficient Surety Bond Coverage for Resident Trust Account
Penalty
Summary
The facility failed to secure a surety bond with sufficient coverage for the resident trust account balance. A review of the current surety bond revealed that it had coverage of only $10,000, while the resident trust account's monthly bank statement showed a balance of $18,330. The business office manager identified 15 residents with money in the trust account who were current residents. The corporate regional manager confirmed that the surety bond was insufficient and acknowledged that they had noticed the discrepancy the previous month and contacted the insurance company, but the issue had not been corrected.
Failure to Properly Manage Resident Personal Funds
Penalty
Summary
The facility failed to comply with regulations regarding the management of resident personal funds. Specifically, the facility did not deposit personal funds exceeding $50 into an interest-bearing account separate from the facility's operational accounts for one resident. A review of the resident's account revealed a credit balance of $1,471.00 in the facility's accounts receivable account, which was not transferred to the facility's trust account. The corporate business office manager acknowledged that the funds were left in the operating system at the family's request, despite the operating system not being an interest-bearing account. Additionally, the corporate regional manager confirmed that resident funds should not be commingled with operating funds.
Failure to Ensure Timely Availability of Medications
Penalty
Summary
The facility failed to ensure medications were available for a resident who required them. The resident, diagnosed with acute kidney failure, returned from a local hospital with a discharge order for the antibiotic cefepime to be administered every 12 hours. However, the medication was not administered until over 24 hours later, despite facility policy stating that emergency or STAT medication orders should be fulfilled within four hours. The Assistant Director of Nursing (ADON) confirmed that antibiotics are considered STAT orders and should be available within the specified timeframe. The Administrator also acknowledged that the new order for antibiotics should have been available within four hours.
Failure to Maintain Administrator Coverage
Penalty
Summary
The facility failed to have an administrator of record for a period between 11/23/23 and 01/18/24. The previous administrator left their position on 11/23/23, and the new administrator began on 01/18/24. During an interview on 02/26/24, the current administrator was unable to identify who, if anyone, served as the interim administrator during this period. By the end of the survey, the facility did not provide any documentation related to administration coverage for the interim period. This deficiency affected the management and operation of the facility, which housed 76 residents at the time of the survey.
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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