Sequoyah Manor, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Sallisaw, Oklahoma.
- Location
- 615 East Redwood, Sallisaw, Oklahoma 74955
- CMS Provider Number
- 375173
- Inspections on file
- 22
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sequoyah Manor, Llc during CMS and state inspections, most recent first.
Two residents were involved in separate resident-on-resident altercations in which one resident was struck on the head and another had their glasses knocked off, with both victims assessed as having no injuries. The aggressors and victims had differing cognitive statuses, including severe cognitive impairment, moderate cognitive impairment, Alzheimer’s disease, and intact cognition. CNAs witnessed both incidents, one of which was captured on camera, and the events were documented on incident reports and in nursing notes. Interviews with an LPN and the DON described that some residents were placed in memory care due to family concerns about confusion and elopement, and that behavioral concerns and resident altercations were ongoing topics of attention.
A resident with dementia and moderate cognitive impairment, who required set-up assistance with eating and drinking, was not consistently supervised while consuming hot coffee. This lack of supervision led to the resident spilling coffee and sustaining a second-degree burn on the inner thigh. Staff interviews confirmed that supervision and assistance with hot liquids were not provided prior to the incident.
A resident with dementia and moderate cognitive impairment, who required set-up assistance with eating and drinking, suffered a burn injury after spilling coffee due to the lack of care plan interventions addressing assistance with hot liquids. Facility staff confirmed the care plan should have included measures for hot beverage safety.
An IJ situation was identified in a memory care unit due to unsecured hazardous materials, including bug spray and bleach wipes, accessible to wandering residents. The facility's failure to adhere to policies on chemical safety and storage led to this deficiency, with staff unaware of the risks posed by unlocked storage areas.
The facility failed to provide baseline care plan summaries to three residents or their representatives, as required by policy. The baseline care plans for residents with Alzheimer's, obstructive and reflux uropathy, and Parkinson's disease lacked signatures and documentation of summary provision. The MDS coordinator confirmed the absence of documentation in the electronic health records.
The facility's medication error rate was 7.41%, exceeding the acceptable threshold of less than five percent. A resident received levothyroxine after their morning meal instead of before, and another resident received only one drop of Refresh eye drops in each eye instead of two. The DON attributed these errors to staff non-compliance.
A cook in the facility failed to maintain sanitary food handling practices by not changing gloves or washing hands between tasks while preparing meals for 64 residents. This was against the facility's policy on preventing foodborne illness, which requires gloves to be discarded after each task and hands to be washed between handling different food items and surfaces. Both the cook and the DM acknowledged the oversight.
The facility failed to ensure proper infection control during catheter care and medication administration. A resident with a catheter did not receive care with the required gown usage by CNAs, and another resident's catheter care lacked hand sanitation between glove changes. Additionally, a CMA did not sanitize hands during medication administration for four residents. The DON confirmed the expectations for infection control practices.
A resident with an indwelling urinary catheter was repeatedly observed with their catheter bag visible from the hallway, not covered by a dignity bag as required by the facility's policy. The resident expressed a desire for privacy, and both a CNA and an LPN confirmed the expectation to use privacy bags. The DON also stated that staff should cover catheter bags to maintain dignity.
A facility failed to ensure accurate assessments for a resident with hypertension, leading to a deficiency. The resident was documented as having a fall with major injury, but reviews of state-reported incidents and the electronic clinical record showed no evidence of such a fall. The resident confirmed they had not experienced a fall, and the MDS coordinator acknowledged the assessment was inaccurately coded.
A facility failed to develop a comprehensive care plan for a resident with a history of transient ischemic attack and range of motion impairment. The resident's care plan did not document their upper extremity impairment, despite an observation of a contracted right hand. The MDS coordinator admitted to missing the development of a care plan for the resident's limited range of motion, and the DON confirmed that such a plan should have been implemented.
A resident with a history of stroke and a contracture in their right hand did not receive appropriate range of motion (ROM) services. The care plan lacked documentation of the resident's ROM impairment, and no interventions were in place to address the contracture, despite facility policy requiring treatment to prevent further decrease in ROM. Observations and staff interviews confirmed the absence of necessary interventions.
A facility failed to maintain infection control for a resident with an indwelling urinary catheter. Observations showed the catheter tubing and bag were often on the floor, and the resident reported discomfort due to the catheter not being secured. Staff confirmed the absence of securement devices and inadequate documentation of catheter care, despite facility policies requiring these measures.
The facility failed to accurately assess bedrail use for two residents. One resident with hemiplegia was observed with half side rails, despite orders for quarter rails. Another resident with falls and altered mental status also had half side rails, contrary to the physician's order for quarter rails. The DON and MDS coordinator were unaware of the discrepancies.
The facility failed to adhere to prescribed menus and portion sizes, as observed during a survey. A cook was unsure of the correct portion size for breaded chicken, serving 1.5 ounces instead of the required three ounces. The DM was unaware of the correct weight and substituted corn for peas and carrots due to a shortage. The entire meal served was actually the menu for the next day, and sandwich bread was used instead of buns due to a shortage. The administrator stated that dietary staff should follow recipes and menus, with changes approved by a dietitian.
The facility failed to regularly inspect bed frames and side rails for two residents, leading to discrepancies between physician orders and observed conditions. One resident with hemiplegia was observed with incorrect side rails, while another with hemiparesis had a side rail in the wrong position. Conflicting statements from staff revealed a lack of awareness about the requirement for regular inspections.
A facility failed to report an allegation of abuse involving a resident to local law enforcement within the required time frame. The incident, involving a housekeeper, occurred in the afternoon, but law enforcement was not notified until the following day. The ADON admitted to forgetting the notification, despite knowing it should have been done within two hours, as per facility policy.
A resident with cerebral palsy was verbally abused by another resident with bipolar disorder, but the incident was not reported to the administrator or investigated as required by the facility's abuse policy. The facility's policy, which stated a 24-hour reporting timeframe for abuse allegations, was outdated and not aligned with the current two-hour requirement, highlighting the need for policy revision.
A resident with intellectual disabilities was verbally abused by another resident with bipolar disorder, but the incident was not reported or investigated as required. The LPN documented the event but failed to notify the administrator, and both the ADON and DON were unaware of the incident despite regular reviews of progress notes.
The facility failed to ensure person-centered care plans for two residents. One resident's care plan did not document the representative's preference to redirect male residents, despite staff awareness. Another resident's care plan lacked details on behaviors to monitor after a new Depakote order, following verbal abuse incidents. The MDS coordinator and DON acknowledged these oversights.
Failure to Protect Residents From Abuse During Resident-on-Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse when resident-on-resident altercations occurred. In the first incident, a certified nursing assistant (CNA) witnessed one resident strike another resident on the top of the head. Documentation showed the resident who was struck was assessed and found to be free of injury. The resident who committed the act had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment, while the resident who was struck had a BIMS score of 12, indicating moderate cognitive impairment. The incident was reported on an OSDH incident report form, and nursing notes documented the aggressor’s status and supervision level following the event. In the second incident, another CNA witnessed a resident knock the glasses off another resident’s face. The resident whose glasses were knocked off was assessed and found to be free of injury and had an Alzheimer’s diagnosis and was described as unaware of their own actions. The resident who committed the act had a BIMS score of 15, indicating they were cognitively intact. The incident was captured on camera and documented on an OSDH incident report form. Interviews with an LPN and the DON indicated that the cognitively intact resident had been placed in memory care due to family concerns about elopement and that the other involved residents had varying levels of cognitive impairment and behavioral concerns. These events formed the basis of the finding that the facility failed to protect residents from abuse.
Failure to Supervise Resident with Dementia Results in Burn from Hot Liquid
Penalty
Summary
The facility failed to provide adequate supervision to prevent burns from hot liquids for a resident with dementia and moderate cognitive impairment. The resident had a BIMS score of 12, indicating moderate impairment in daily decision-making, and required set-up assistance with eating and drinking. Despite this, the resident was not always supervised while drinking coffee. On one occasion, the resident spilled coffee on themselves, resulting in a second-degree burn with a reddened area and blister on the right inner thigh. Interviews with staff confirmed that prior to the incident, the resident was not consistently assisted or supervised with hot liquids or meals. The resident's need for increased assistance had been noted, but supervision practices had not been adjusted accordingly before the burn occurred. Documentation and staff statements indicated that changes to supervision and assistance were only implemented after the incident.
Failure to Update Care Plan for Hot Liquid Assistance
Penalty
Summary
The facility failed to develop and implement a care plan addressing the need for assistance with hot liquids for a resident with dementia and moderate cognitive impairment. The resident, who required set-up assistance with eating and drinking, experienced an incident where they spilled coffee on themselves, resulting in a reddened area and a blister on their right inner thigh. Despite documented evidence of the resident's decline and increased need for assistance, the medical record did not include any care plan interventions related to hot liquids. Facility staff, including an LPN, the ADON, and the minimum data set coordinator, acknowledged that the care plan should have been updated to address this need.
Failure to Secure Hazardous Materials in Memory Care Unit
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified in a locked memory care unit due to the facility's failure to secure chemicals away from wandering residents. An unlocked closet was found with gauze stuffed in the door latch, preventing it from closing. This closet contained hazardous items such as bug spray, paint, and personal care items labeled to be kept out of reach of children. At the time of the observation, three residents were seen wandering aimlessly in the hall, and it was noted that five out of nine residents on the unit wandered independently. The Director of Nursing (DON) was unaware of the issue with the lock and acknowledged the presence of hazardous items that should have been secured. Further observations revealed that a soiled linen closet on another hall was also unlocked and contained a container of bleach wipes, which were labeled to be kept out of reach of children. The facility's policy on hazardous areas and chemical safety required such items to be stored securely and away from resident access. Despite these policies, multiple areas within the facility were found to have unsecured hazardous materials, posing a risk to residents, particularly those who wandered. Interviews with staff, including Certified Nursing Assistants (CNAs) and the DON, confirmed that there was a lack of awareness and adherence to the facility's policies regarding the storage of hazardous materials. The CNAs reported that they were the only staff assigned to the memory unit, which limited their ability to monitor wandering residents effectively. The DON admitted that chemicals should be locked and stored properly, and the failure to do so was a significant oversight that contributed to the deficiency.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that a copy of the baseline care plan was provided to the resident and/or resident representative for three of the 19 sampled residents. The facility's policy, dated March 2022, requires that a written summary of the baseline care plan be provided in a language that the resident or representative can understand. However, for Resident #2, diagnosed with Alzheimer's disease, the baseline care plan dated 04/29/24 did not have a signature from the resident or representative, and there was no documentation in the clinical record indicating that the summary was provided. Similarly, Resident #15, with diagnoses including obstructive and reflux uropathy, had a baseline care plan dated 04/27/24 that lacked a signature and documentation of the summary being provided. The resident stated they did not think they received the summary upon admission. For Resident #29, diagnosed with Parkinson's disease, the baseline care plan dated 03/12/24 also lacked a signature and documentation of the summary being provided. The MDS coordinator confirmed that there was no documentation in the electronic health records indicating that the summaries were provided to the residents or their representatives.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 7.41% for two of the 27 residents reviewed for medication administration. One incident involved a resident who received levothyroxine 125 mcg after their morning meal, contrary to the physician's order to administer it before the meal. Another incident involved a resident who was supposed to receive two drops of Refresh eye drops in both eyes four times daily, but only received one drop in each eye. The errors were attributed to staff non-compliance, as stated by the Director of Nursing (DON).
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner, as observed during a meal service for 64 residents. A cook, identified as [NAME] #1, was seen handling a resident's menu sheet, obtaining a clean plate, using various serving utensils, and reaching into a bag of sandwich bread to obtain slices of bread, all while wearing the same pair of gloves. The cook also placed a slice of cheese on breaded chicken using their gloved hand without changing gloves or washing hands between tasks. This was contrary to the facility's policy on preventing foodborne illness, which requires gloves to be discarded after completing a task and hands to be washed between handling raw meats and ready-to-eat foods, as well as between handling soiled and clean dishes. Both the cook and the Dietary Manager (DM) acknowledged that the gloves should have been changed and hands washed to prevent cross-contamination.
Infection Control Deficiencies in Catheter Care and Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during catheter care and medication administration. For Resident #15, who had a diagnosis of malignant neoplasm of the prostate, CNAs #5 and #4 did not wear gowns as required for catheter care, despite the resident being on enhanced barrier precautions. CNA #5 admitted to not doing anything different for Resident #15, while CNA #4 acknowledged forgetting to wear gowns. LPN #1 confirmed that staff should wear gloves and gowns for catheter care, and the DON stated that staff were educated to use enhanced barrier precautions for residents with devices. For Resident #4, who had paraplegia and urinary retention, CNA #2 did not sanitize their hands between glove changes during catheter care, although they claimed to have used hand sanitizer. RN #1 stated that hand hygiene should be performed between glove changes to maintain infection control. Additionally, during medication administration for four residents, CMA #1 failed to sanitize their hands before and after checking blood pressure and administering medications. The DON confirmed that staff were expected to sanitize their hands between each resident during medication administration.
Failure to Maintain Resident Dignity with Urinary Catheter
Penalty
Summary
The facility failed to ensure the dignity of a resident with an indwelling urinary catheter. The resident, who had diagnoses including obstructive and reflux uropathy, was observed multiple times with their urinary catheter bag visible from the hallway, not covered by a dignity bag as required by the facility's Dignity policy dated February 2021. The resident expressed a desire for their catheter bag to be covered, indicating that staff were supposed to keep it in a bag to prevent it from being seen. Both a CNA and an LPN confirmed that catheter bags should be placed in privacy bags to maintain dignity. The Director of Nursing also stated that staff were expected to use privacy bags to cover catheter bags to uphold the resident's dignity.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure accurate assessments for a resident, leading to a deficiency. A resident with a diagnosis of hypertension was documented in a quarterly assessment as being moderately impaired in cognition for daily decision-making and having experienced a fall with major injury since the prior assessment. However, a review of state-reported incidents and the electronic clinical record did not reveal any evidence of such a fall. Furthermore, the resident themselves confirmed they had not experienced a fall with major injury. The MDS coordinator acknowledged that the clinical record review showed no fall with major injury, indicating that the assessment dated 10/30/24 was inaccurately coded.
Failure to Develop Comprehensive Care Plan for Resident with Range of Motion Impairment
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident with a history of transient ischemic attack and range of motion impairment. The resident's significant change assessment documented impairment to one side of their upper body and both sides of their lower body. However, the care plan, revised later, did not include the resident's upper extremity impairment. During an observation, the resident was found in bed with a contracted right hand, which they stated had been contracted since a stroke years ago. The MDS coordinator acknowledged missing the development of a care plan addressing the resident's limited range of motion. The DON confirmed that a care plan should have been developed to include interventions for the resident's right hand contracture.
Failure to Provide ROM Services for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) services to a resident with limited ROM, specifically to one resident who had a contracture in their right hand. The resident had a history of transient ischemic attack and had been experiencing a contracture since a stroke several years ago. Despite this, the care plan did not document the resident's ROM impairment in the upper extremity, and there were no interventions in place to address the contracture. Observations and interviews revealed that the resident's right hand was contracted, and the facility typically applied hand rolls for residents with contractures. However, the electronic clinical record lacked any interventions for the resident's condition. Both the MDS coordinator and the DON confirmed that there were no interventions in place for the resident's contracture or limited ROM, indicating a failure to adhere to the facility's policy on providing treatment and services to prevent further decrease in ROM.
Inadequate Catheter Care and Infection Control
Penalty
Summary
The facility failed to maintain infection control standards for indwelling urinary catheters, as evidenced by the improper handling and documentation of catheter care for a resident with obstructive and reflux uropathy. Observations revealed that the resident's catheter tubing and drainage bag were frequently in contact with the floor or fall mat, contrary to the facility's policy which mandates that these items be kept off the floor to prevent infection. Additionally, the resident reported discomfort due to the catheter not being secured, and staff confirmed that securement devices were not used because they were unavailable on their hall. Further investigation showed that catheter care was not documented in the resident's clinical record as required by the care plan, which specified catheter care every shift. Interviews with CNAs and the LPN indicated a lack of adherence to the facility's policy regarding the use of securement devices and proper documentation. The DON acknowledged the absence of documentation and was unaware of the lack of securement devices for the resident's catheter, despite having them available in the facility.
Inaccurate Bedrail Assessment for Two Residents
Penalty
Summary
The facility failed to ensure that residents were accurately assessed for bedrails, as evidenced by the cases of two residents. Resident #30, who had diagnoses including pain and left-sided hemiplegia, was observed with half side rails in the up position, despite a physician's order and consent form indicating the use of quarter side rails. The discrepancy was noted by the Director of Nursing (DON) and the MDS coordinator, who were unaware of why the resident had half side rails instead of the ordered quarter rails. Similarly, Resident #48, with diagnoses including falls and altered mental status, was also observed with half side rails, contrary to the physician's order and consent form that specified quarter side rails for bed mobility and repositioning. The DON and MDS coordinator acknowledged the inconsistency but could not explain why the resident had half side rails instead of the quarter rails documented in the physician's order and consent form.
Failure to Follow Prescribed Menus and Portion Sizes
Penalty
Summary
The facility failed to follow the prescribed menus for residents, as observed during a survey. On the evening of December 18, 2024, the cook preparing the pureed diet was unsure of the correct portion size for the breaded chicken, which was supposed to weigh three ounces per serving according to the recipe. Instead, the chicken weighed only 1.5 ounces. The Dietary Manager (DM) was unaware of the required weight and only knew that the menu called for one piece of chicken. Additionally, the vegetable for the evening meal was supposed to be peas and carrots, but corn was substituted due to a lack of the specified vegetables. The entire meal served was actually the menu planned for the following day, indicating a switch in the menu schedule. Furthermore, sandwich bread was used instead of a bun for the breaded chicken sandwich because all buns had been used during lunch. The DM confirmed this substitution. The facility administrator acknowledged that dietary staff should adhere to recipes and menus, and any changes or substitutions should be approved by a dietitian.
Failure to Regularly Inspect Bed Rails and Frames
Penalty
Summary
The facility failed to ensure that beds and side rails were regularly inspected as part of a maintenance program for two residents who were reviewed for side rails. One resident had diagnoses including pain and left-sided hemiplegia, with a physician's order to use quarter side rails bilaterally for repositioning. However, the resident was observed with half side rails in the up position bilaterally. Another resident, diagnosed with hemiplegia and hemiparesis, had a physician's order to use one side rail for bed mobility and transfers, but was observed with a quarter side rail in the up position on the right side of the bed. The maintenance supervisor, housekeeping supervisor, and DON provided conflicting statements regarding who was responsible for conducting safety checks on resident beds and side rails. Ultimately, the maintenance supervisor admitted they were unaware of the requirement to regularly monitor and inspect the residents' beds and side rails for safety.
Failure to Timely Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to local law enforcement within the mandated time frame. The incident involved a housekeeper allegedly abusing a resident, which was documented to have occurred at approximately 2:15 p.m. on November 5, 2024. The facility's policy on abuse investigation and reporting requires that all alleged violations involving abuse be reported to various authorities, including law enforcement, within a specific time frame. However, the initial incident report did not document the notification of law enforcement, and the final report indicated that law enforcement was not notified until the following day at 10:53 a.m. The Assistant Director of Nursing (ADON) acknowledged conducting the investigation on the day of the incident but admitted to forgetting to notify law enforcement until the next day. The ADON was aware that the notification should have occurred within two hours of the allegation, as per the facility's policy. This oversight resulted in a failure to adhere to the established reporting time frames for suspected abuse, as outlined in the facility's policy dated July 2017.
Failure to Implement Abuse Policy and Outdated Reporting Timeframes
Penalty
Summary
The facility failed to implement its abuse policy for a resident with cerebral palsy and unspecified intellectual disabilities, who was verbally abused by another resident with bipolar disorder. The incident involved the abusive resident calling the other resident derogatory names in public areas, causing visible distress. Despite the incident being documented in a progress note by an LPN, the administrator was not notified, and no incident report was filed. The LPN admitted to notifying the ADON and the physician but failed to report the incident as verbal abuse or initiate an investigation. Additionally, the facility's abuse policy was outdated, stating a 24-hour timeframe for reporting allegations of abuse/neglect to the Oklahoma State Department of Health (OSDH), contrary to the ADON's understanding of a two-hour requirement. The DON confirmed the policy's 24-hour reporting timeframe and acknowledged the need for an update, as the policy had not been reviewed for the current year. The administrator also recognized the discrepancy and the necessity to revise the policy to align with current reporting requirements.
Failure to Report and Investigate Verbal Abuse Incident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving two residents. One resident, diagnosed with cerebral palsy and unspecified intellectual disabilities, was verbally abused by another resident with a diagnosis of bipolar disorder. The abusive behavior included being called derogatory names loudly in common areas, which visibly upset the victim. Despite the incident being documented in a progress note by an LPN, it was not reported to the administrator or investigated as required by the facility's policy. The facility's policy mandates immediate reporting of any suspected abuse to the administrator, but this protocol was not followed. The LPN involved acknowledged the failure to report the incident as verbal abuse. Additionally, the ADON and DON were unaware of the incident, despite regular reviews of event report progress notes. The administrator also confirmed they were not informed of the incident until much later, indicating a breakdown in communication and adherence to the facility's abuse reporting procedures.
Deficiencies in Person-Centered Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were person-centered for two residents. Resident #1, diagnosed with Rett's syndrome, had a care plan that did not document the preferences of their representative, specifically the request to redirect male residents from interacting with them. Despite the staff being aware of this preference, it was not included in the care plan. The MDS coordinator acknowledged the oversight, stating that the preference was known shortly after admission but was not added to the care plan. The DON confirmed that the preference was known before the last care plan meeting and should have been updated. Resident #2, diagnosed with bipolar disorder, had a care plan that did not address specific behaviors to monitor following a new order for Depakote. The resident had been verbally abusive to another resident, which led to the medication order. However, the care plan only noted the medication order without detailing the behaviors to be monitored. The MDS coordinator admitted to not reviewing the clinical record to determine the behaviors that warranted the medication, and the DON stated that the care plan should have been revised to reflect the reasoning for the order and the specific behaviors to monitor.
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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