Sequoyah East Nursing Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Roland, Oklahoma.
- Location
- 701 South Taylor Road, Roland, Oklahoma 74954
- CMS Provider Number
- 375394
- Inspections on file
- 28
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sequoyah East Nursing Center, Llc during CMS and state inspections, most recent first.
A resident with a documented history of assaulting staff was not consistently monitored or managed, resulting in the resident physically assaulting another resident with moderate cognitive impairment in the dining area. Staff interviews revealed a lack of ongoing behavioral monitoring or intervention, despite the facility's policy to protect all residents from abuse.
A resident was physically assaulted by another resident in the dining area, and the facility's investigation was limited to interviewing only the two residents involved and staff present at the time. No other residents were interviewed to determine if further harm had occurred, contrary to facility policy requiring comprehensive abuse investigations.
The facility failed to protect resident medical records from unauthorized access by former employees. An LPN accessed the EHR system after resigning, viewing multiple areas of a resident's documentation. Another LPN accessed the system after leaving employment, viewing several pages of records, including residents' MARs. The facility's EHR system allowed offsite access, which was not regularly monitored for unauthorized use.
The facility failed to provide adequate supervision to prevent falls for two residents, leading to multiple falls and injuries. Despite having care plans, the plans were not updated, resulting in repeated falls and significant injuries, including a severe head injury that led to a resident's death.
The facility failed to implement its Background Check Policy, resulting in incomplete and undocumented background checks for several employees. The business office manager admitted to not documenting reference or employment history checks and completing registry checks after the first day of employment. A review of employment records confirmed these deficiencies.
The facility staff failed to report allegations of abuse to their administrator within the required timeframe for four residents. Incidents involving residents with dementia, anxiety, heart failure, vascular dementia, cerebrovascular disease, neurocognitive disorder, and psychosis were reported late, contrary to the facility's abuse reporting policy.
The facility failed to revise care plans for falls for three residents, despite multiple falls and injuries. The MDS coordinator and DON acknowledged the care plans had not been updated, and the DON admitted to not attending care plan meetings or being aware of their responsibility to do so.
The facility failed to ensure showers were given as ordered for two residents. One resident with hypertension and emphysema received two showers and refused two, but missed nine other scheduled showers. Another resident with mild intellectual disabilities and anxiety received two showers and refused three, but missed eight other scheduled showers. CNA confirmed the discrepancies, and the administrator acknowledged responsibility.
A facility failed to ensure a CNA used gloves while providing personal care to two residents with severely impaired cognition, leading to a breach in infection prevention protocols. Multiple staff members reported witnessing the CNA's actions, and the DON confirmed the CNA did not follow the facility's standards, resulting in their termination.
A facility failed to notify a resident's representative of a transfer to another facility for therapy. The resident had mild intellectual disabilities and a fractured left femur, requiring moderate assistance. The administrator assumed the receiving facility had contacted the representative, which was not documented in the resident's record.
A CNA mentally abused a resident with dementia and psychosis by making distressing comments about Indians harming children. Despite attempts by other staff to deescalate the situation, the CNA continued the psychological torment, causing the resident significant distress. The incident was reported and the CNA was subsequently terminated.
A facility failed to prevent a staff member from working outside their scope of practice by attempting a blood draw on a resident with vascular dementia and cerebrovascular disease. The ADON observed but did not stop the SSD, who was no longer certified as a phlebotomist, from performing the procedure. The DON later confirmed that the ADON should have intervened.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident with a known history of assaultive behavior. Documentation in the medical record showed that one resident had multiple prior incidents of physically assaulting staff, including hitting, scratching, and beating staff members with objects. Despite these repeated behaviors, there was no consistent monitoring or behavioral intervention plan in place for this resident, except for a brief four-day period in March. Staff interviews confirmed that there was no ongoing order to monitor the resident's behavior, and monitoring was only done if an incident was observed and documented in a progress note. On one occasion, the resident with a history of assaultive behavior kicked another resident in the lower left leg while both were in the dining area. The assaulted resident had a moderate cognitive impairment, as indicated by a recent assessment. Staff were unaware of any prior incidents of this resident harming other residents before this event, and there was no evidence of proactive measures to prevent such incidents. The facility's policy committed to protecting residents from abuse by anyone, including other residents, but this was not effectively implemented in this case.
Failure to Thoroughly Investigate Resident-to-Resident Assault
Penalty
Summary
The facility failed to conduct a thorough investigation following a resident-to-resident physical assault. According to progress notes, one resident was kicked in the leg by another resident while in the dining area. The facility's investigative documentation showed that only the two residents involved and staff on duty at the time were interviewed. There was no evidence that other residents were interviewed to determine if the resident who committed the assault had harmed anyone else. The Director of Nursing confirmed that they had not considered interviewing additional residents as part of the investigation, despite facility policy requiring all reports of abuse to be thoroughly and promptly investigated.
Unauthorized Access to EHR by Former Employees
Penalty
Summary
The facility failed to safeguard resident medical records against unauthorized use, as evidenced by two incidents involving former employees accessing the electronic health record (EHR) system after their employment had ended. The first incident involved an LPN who resigned on 02/27/24 but accessed the EHR system on 03/01/24, viewing multiple areas of a resident's documentation. The administrator was aware that the LPN was in the facility on the day of resignation but assumed they were there to speak with a survey team. The LPN's access to the EHR system was only terminated after their resignation. The second incident involved another LPN who left the facility on 03/21/24 but accessed the EHR system on 04/01/24 and 04/02/24, viewing several pages of the facility's records, including multiple residents' medication administration records (MARs). The administrator acknowledged that the EHR system allowed offsite access, which was not regularly monitored for unauthorized use unless there was a suspicion or complaint. This lack of regular checks contributed to the unauthorized access by the former employees.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents, leading to multiple incidents of falls and injuries. Resident #1, who had diagnoses including dementia, anxiety, and heart failure, experienced eight falls over a period of time. Despite having a care plan with 11 interventions, the resident continued to fall, resulting in injuries such as skin tears and a significant head injury that led to hospitalization. The care plan for Resident #1 had not been updated since July 2022, and the resident ultimately died after a severe fall that caused a right orbital floor fracture and significant swelling and laceration to the forehead, eye, and cheek. The facility's failure to update the care plan and implement effective interventions contributed to the resident's repeated falls and injuries. Resident #5, who had diagnoses including hypertension and emphysema, also experienced multiple falls. The care plan for Resident #5 had not been updated with new fall interventions since July 2022, despite the resident having several falls. The MDS coordinator and the DON acknowledged that the care plans were not updated regularly and did not reflect the residents' current conditions and treatments. The facility's inadequate care planning and failure to follow policies and procedures for fall prevention contributed to the residents' falls and injuries.
Failure to Implement Background Check Policy
Penalty
Summary
The facility failed to implement its policy and procedures to ensure that applicants' employment history and references were checked, and that registry checks were completed prior to employment. The facility's Background Check Policy mandates that background checks, including prior employment verification, reference checks, license verification, and criminal background checks, be completed before the first day of assigned work. However, the business office manager admitted that they did not typically document checking references or employment history and were trained to complete registry checks after the first day of employment. This was confirmed during a review of employment records, which revealed that none of the 19 records reviewed had documentation of verified previous employment or contacted references, and one record lacked documentation of registry checks. Additionally, seven records did not have OSDH background check letters, and one CNA's registry checks were completed two days after their first day of employment. The administrator confirmed that the business office manager was responsible for completing and documenting employment history checks and reference checks, and ensuring that registry checks were completed prior to employment. Despite this responsibility, the business office manager failed to adhere to the facility's policy, resulting in incomplete and undocumented background checks for several employees. This lapse in procedure was identified during a survey, highlighting the facility's failure to ensure the safety and compliance of its hiring practices.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility staff failed to report allegations of abuse to their administrator within the timeframe indicated in state regulations for four residents. The facility's abuse reporting and investigation policy, dated September 2022, required that suspicions of abuse, neglect, exploitation, misappropriation of resident property, or injury of an unknown source be reported immediately to the administrator and other officials according to state law. However, the incidents involving Residents #1, #2, #3, and #7 were not reported within the required timeframe. For instance, the incident involving Resident #1, who had diagnoses including dementia, anxiety, and heart failure, was reported to the social services director the day after the alleged incident. Similarly, the incidents involving Residents #2 and #3, both with severely impaired cognition, were reported to local law enforcement but not immediately to the administrator. The incident involving Resident #7, who had dementia and psychosis, was reported six days after it occurred. The administrator confirmed that they were informed of the incidents involving Residents #1, #2, #3, and #7 well after the required reporting timeframe. Specifically, the administrator learned about the incident involving Resident #1 the day after it occurred, and the incident involving Resident #7 six days after it occurred. The Director of Nursing (DON) acknowledged that the staff had not been following the policy regarding the timely reporting of abuse allegations. This failure to adhere to the facility's abuse reporting policy resulted in a deficiency in meeting state regulations for reporting allegations of abuse within the specified timeframe.
Failure to Revise Care Plans for Falls
Penalty
Summary
The facility failed to revise resident care plans related to falls for three of seven sampled residents reviewed for abuse and neglect. Resident #1, who had diagnoses including dementia, anxiety, and heart failure, experienced eight falls between specific dates, three of which resulted in injuries such as skin tears and a fracture. Despite these incidents, the care plan for Resident #1 had not been updated since July 2022. The MDS coordinator and DON acknowledged that the care plan had not been revised to reflect the resident's condition and falls, and the DON admitted to not attending care plan meetings or being aware of their responsibility to do so. Resident #5, with diagnoses including hypertension and emphysema, had multiple falls documented, yet no new fall interventions had been added to their care plan since a specific date. Similarly, Resident #6, who had mild intellectual disabilities and anxiety, experienced falls, including one resulting in a broken femur, but their care plan had not been updated with new interventions since a specific date. The MDS coordinator admitted that interventions should have been added but were not, and the DON described the facility's care planning as inadequate, with the MDS coordinator not following the care planning policy and procedures.
Failure to Administer Showers as Ordered
Penalty
Summary
The facility failed to ensure showers were given as ordered for two residents. Resident #5, who had diagnoses including hypertension and emphysema, was documented as severely impaired for daily decision making and required moderate assistance with ADLs. In February 2024, Resident #5 received two showers and refused two, but on nine other scheduled shower days, either did not receive a shower or it was not documented. Resident #6, with diagnoses including mild intellectual disabilities and anxiety, was moderately impaired for daily decision making and required partial assistance. In February 2024, Resident #6 received two showers and refused three, but on eight other scheduled shower days, either did not receive a shower or it was not documented. CNA #8 confirmed the discrepancies in shower documentation. The administrator acknowledged that the charge nurse should ensure showers are administered as ordered, but ultimately the DON and administrator were responsible.
Failure to Use Gloves During Resident Care
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) used gloves while providing personal care to residents, leading to a breach in infection prevention and control protocols. Specifically, CNA #1 was observed using their bare hands to check the dryness of Resident #3's brief and to change the brief of Resident #2, making direct contact with the resident's bare buttocks. These actions were documented in handwritten statements by other CNAs and confirmed through interviews with staff members. Both residents involved had severely impaired cognition, with Resident #2 diagnosed with vascular dementia and cerebrovascular disease, and Resident #3 diagnosed with neurocognitive disorder with Lewy bodies and chronic obstructive pulmonary disease. Multiple staff members, including CNAs #5, #6, and #7, reported witnessing CNA #1's failure to don gloves during personal care tasks. The Director of Nursing (DON) acknowledged that nursing staff are aware of the requirement to wear gloves during resident care and confirmed that CNA #1 did not adhere to the facility's standards of practice and policy. As a result, CNA #1's employment was terminated. The facility's policy on standard precautions, dated September 2022, mandates the use of gloves in all resident care situations to prevent the spread of infectious diseases.
Failure to Notify Resident's Representative of Transfer
Penalty
Summary
The facility failed to ensure the resident's representative was notified of a transfer for one resident who was reviewed for notification of change. The resident had diagnoses including mild intellectual disabilities and a fractured left femur and was moderately impaired for daily decision-making, requiring moderate assistance from staff. A nurse's note documented that the resident had been transferred to another facility for therapy, but a review of the resident's record did not show that the resident's representative had been notified of the transfer. The administrator stated that they did not notify the resident's representative because they thought the facility the resident transferred to had contacted them. The administrator later acknowledged that the resident's representative should be notified and that it should be documented in the resident's chart.
Mental Abuse by CNA
Penalty
Summary
The facility failed to prevent a certified nurse aide (CNA) from mentally abusing a resident diagnosed with dementia and psychosis. The resident, who had moderately impaired cognition, made delusional statements about Indians harming children. On one occasion, CNA #13 antagonized the resident by asking if they were going to eat her babies, which caused the resident significant distress. Despite attempts by other staff members to deescalate the situation, CNA #13 continued to torment the resident, leading to the resident crying and becoming more agitated. Two other CNAs witnessed the incident and reported that CNA #13 made further distressing comments, such as claiming to be an Indian and suggesting that the resident's babies tasted good. The resident's distress escalated, and CNA #13 continued the psychological torment despite being asked to leave. The incident was reported to the facility administrator several days later, who then conducted an investigation and terminated CNA #13's employment.
Unqualified Staff Member Attempts Blood Draw
Penalty
Summary
The facility failed to prevent a licensed nurse from allowing a staff member to work outside their scope of practice by attempting a blood draw on a resident. The incident involved a resident with vascular dementia and cerebrovascular disease. The Assistant Director of Nursing (ADON) observed the Social Services Director (SSD) attempting to collect a blood sample from the resident using a phlebotomy set. Despite not giving the SSD directions to perform the blood draw, the ADON did not stop the SSD from proceeding. The SSD, who was no longer certified as a phlebotomist and had not been hired for that role, attempted the blood draw but was unsuccessful. The ADON then decided not to make another attempt as the resident required hydration. The Licensed Practical Nurse (LPN) also witnessed the SSD performing the blood draw with the ADON present in the room but did not intervene to stop the procedure. The SSD admitted to attempting the blood draw after the contract phlebotomist was unable to obtain a sample and the LPN requested assistance from the ADON. The SSD mentioned their past certification as a phlebotomist during their hiring process but had declined to perform such tasks at the facility. The Director of Nursing (DON) later stated that the ADON should have stopped the SSD from attempting the blood draw, as it was against the facility's policy regarding venipuncture. The facility's policy on obtaining blood specimens clearly outlines that only qualified personnel should perform such procedures to ensure safe and aseptic sampling of the resident's blood.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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