Shady Rest Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pryor, Oklahoma.
- Location
- 210 South Adair, Pryor, Oklahoma 74361
- CMS Provider Number
- 375334
- Inspections on file
- 25
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Shady Rest Care Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility failed to provide consistent food portions to residents, as observed during an afternoon meal service. A staff member used tongs instead of the correct serving spoon for fried potatoes, leading to varied portion sizes. The staff member admitted to not having the correct measuring spoons, and the Administrator was unaware of this issue.
The facility failed to employ a director of food services, leaving the position of Dietary Manager vacant for four to five months. The administrator was ordering food, and the dietician visited infrequently. The absence of a dietary manager was confirmed by staff and the administrator, who stated that the last manager was terminated and not yet replaced.
A resident with benign prostate hyperplasia and depression repeatedly requested the removal of a urinary catheter due to discomfort. Despite multiple documented requests over nearly a month, the facility did not honor the resident's right to refuse treatment, resulting in a deficiency. The DON acknowledged the resident's right to refuse treatment, yet no action was taken to address the resident's requests.
The facility did not replace a broken window pane in a resident's room, instead covering it with Styrofoam and tape. Two residents reported the issue, and the maintenance supervisor cited a lack of funds for the delay. The corporate nurse acknowledged the inadequacy of the temporary fix.
A facility failed to include the use of psychotropic medications in a resident's care plan. The resident, diagnosed with bipolar and anxiety disorders, was prescribed clonazepam, fluoxetine, and trazodone. Interviews with the DON and ADON confirmed that these medications should have been addressed in the care plan.
A facility failed to ensure a resident's attending physician participated in care plan conferences, as required by policy. The resident, with chronic obstructive pulmonary disease and chronic kidney disease, did not have their attending physician present at a quarterly care plan meeting. The ADON confirmed the medical director, acting as the attending physician, had not attended any care plan meetings for the resident since early 2024, despite policy requirements.
The facility did not ensure that dryer lint screens were routinely cleared in the laundry room, as required by their policy. The Dryer Lint Log for August 2024 indicated that the screens were cleared only 17 out of 84 times. The housekeeping supervisor reported that the second shift did not clear the screens, and the third shift often forgot to document the clearing. The facility had a census of 34 residents.
A resident was transferred to a hospital without notifying their responsible party, as required by the facility's policy. The resident requested hospital transfer, but there was no documentation of notification to the family. A family member later complained about not being informed, and the DON confirmed the lack of notification.
A facility failed to complete an admission MDS assessment within the required 14-day timeframe for a resident. The facility's policy requires timely assessments, but the admission MDS was still in process and not completed on time. This was confirmed by the ADON, with the facility census reported as 34 residents.
A facility failed to monitor side effects for a resident receiving psychotropic medications, including clonazepam, fluoxetine, and trazodone, despite having a policy in place for such monitoring. Interviews with the DON and ADON confirmed the lack of side-effect monitoring, and the corporate nurse noted that 23 residents were on psychotropic medications.
A resident with a pork allergy was repeatedly served pork products, such as bacon and sausage, despite their allergy being documented in their EHR. The facility's policy required that allergies be noted on meal cards and checked by staff, but this was not followed, resulting in the resident being exposed to allergens.
Two residents with significant medical conditions experienced excessively hot room temperatures, with measurements of 88.5 and 86.1 degrees Fahrenheit. Despite multiple reports to staff, the issue persisted for one to three months. CNAs confirmed the heat problem, but the administrator claimed to be unaware until recently.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Inconsistent Food Portions Served to Residents
Penalty
Summary
The facility failed to provide the correct amount of food to residents in accordance with the facility menu. During an observation of the afternoon meal service, it was noted that the amount of fried potatoes served to residents varied and did not adhere to the specified serving size of one half cup as documented in the facility's Spring/Summer 2024 Diet Spreadsheet. The staff member responsible for serving the food, identified as [NAME] #1, used tongs instead of the appropriate serving spoon for the fried potatoes, resulting in inconsistent portion sizes. Upon interview, [NAME] #1 admitted that they did not have the correct size of serving spoon for the fried potatoes and were unaware of how long the facility had been without the necessary measuring spoons. The facility's food portion policy, dated 01/02/23, required that food portions served match those written on the menus. The Administrator was unaware of the missing spoons and acknowledged the importance of providing residents with the correct amount of each food item.
Facility Lacks Dietary Manager
Penalty
Summary
The facility failed to employ a director of food services, which is a requirement for the food and nutrition service. The facility's resident roster indicated that 34 residents were residing in the facility. A review of the facility's staff document revealed that the position of Dietary Manager was vacant, with no name associated with the title. During an interview, a staff member confirmed that the facility did not have a dietary manager at the time, stating that the last person in that role had left four or five months prior to the survey. The facility administrator was handling food ordering, and the dietician was visiting only once or twice a month. The administrator also confirmed that the last dietary manager was terminated and that they had not yet found a replacement, leaving the duties of the dietary manager unfulfilled.
Failure to Respect Resident's Right to Refuse Treatment
Penalty
Summary
The facility failed to respect a resident's right to refuse treatment, specifically regarding the removal of a urinary catheter. The resident, who had diagnoses including benign prostate hyperplasia and depression, repeatedly expressed a desire to have the catheter removed. This request was documented multiple times in nurse notes over a period of nearly a month, indicating the resident's consistent discomfort and desire for the catheter's removal. Despite the resident's repeated requests, the catheter was not removed, and the resident continued to express discomfort and dissatisfaction with the situation. The Director of Nursing acknowledged that the resident has the right to refuse treatment, yet the facility did not act on the resident's requests, leading to a deficiency in honoring the resident's rights as outlined in the facility's policy on resident rights and refusal of treatment.
Failure to Replace Broken Window Pane
Penalty
Summary
The facility failed to maintain a homelike environment by not replacing a broken window pane in a resident's room, instead covering it with Styrofoam and tape. This deficiency was observed in a room shared by two residents, who reported that the window had been broken by a previous roommate. Despite the residents' desire for the window to be fixed, the staff had only covered it with Styrofoam, which was not visible due to a curtain. The maintenance supervisor acknowledged the window had been broken the previous week but cited a lack of funds as the reason for not replacing the pane. The corporate nurse confirmed that using Styrofoam did not provide a homelike appearance and mentioned that funds had been provided to the maintenance supervisor to purchase materials for the repair.
Failure to Implement Comprehensive Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident diagnosed with bipolar disorder and anxiety disorder. The resident was prescribed clonazepam, fluoxetine, and trazodone, but the care plan did not address the use of these antidepressant and antianxiety medications. During interviews, both the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) acknowledged that psychotropic medication use should be included in the resident's care plan.
Physician Absence in Care Plan Conferences
Penalty
Summary
The facility failed to ensure the participation of a resident's attending physician in care plan conferences, as required by their policy. Specifically, the attending physician did not attend the care plan conference for a resident with chronic obstructive pulmonary disease and chronic kidney disease. The care conference information note for a quarterly assessment did not list the attending physician as an attendee. The Assistant Director of Nursing (ADON) confirmed that the medical director, who was the attending physician for the resident, had not participated in any care plan meetings for the resident since January 2024. Although the facility policy required the physician's presence during the care plan process, there was no documentation of the physician's attendance or involvement in these meetings.
Failure to Routinely Clear Dryer Lint Screens
Penalty
Summary
The facility failed to ensure that dryer lint screens were routinely cleared in the laundry room, as observed and reported. The facility's policy, dated February 11, 1995, required that lint screens be cleared at a minimum of every shift and as needed for build-up. However, a review of the Dryer Lint Log for August 2024 showed that the lint screens were cleared only 17 times out of 84 opportunities. During an interview, the housekeeping supervisor stated that the lint screens should be cleared at the end of every shift, but the second shift did not comply, and the third shift often forgot to document the clearing of the screens. The facility had a census of 34 residents at the time of the report.
Failure to Notify Family of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's responsible party when the resident was transferred to a hospital. This deficiency was identified for one of four sampled residents reviewed for hospitalizations. According to the facility's policy on a change in a resident's condition or status, a nurse is required to notify a resident's representative when the resident is transferred to a hospital. However, a progress note dated 07/30/24 documented that a resident requested to be sent to a hospital, and a medical transport was called, but there was no documentation indicating that the resident's representative was notified of the transfer. Subsequently, a progress note dated 07/31/24 recorded that a family member called the facility to complain about not being informed of the resident's hospitalization. The Director of Nursing (DON) confirmed that there was no documentation of notification to the emergency contacts, acknowledging that someone should have informed them.
Failure to Complete Timely Admission MDS Assessment
Penalty
Summary
The facility failed to complete an admission Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident. The facility's policy mandates that resident assessments be conducted and submitted in accordance with federal and state submission timeframes. However, for one resident, the admission MDS assessment was still in process and had not been completed on time. This was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged that the assessment was late. The facility census at the time was reported to be 34 residents.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were monitored for side effects, as evidenced by the case of Resident #139. This resident, diagnosed with bipolar disorder and anxiety disorder, was prescribed clonazepam, fluoxetine, and trazodone. However, a review of the electronic health record (EHR) revealed that there was no documentation of side-effect monitoring for these medications. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that side-effect monitoring was not in place for Resident #139, despite the facility's policy that all residents on psychotropic medications should be monitored for side effects. The corporate nurse reported that 23 residents in the facility were receiving psychotropic medications, highlighting a potential systemic issue.
Failure to Accommodate Resident Food Allergies
Penalty
Summary
The facility failed to provide food that accommodated resident allergies, specifically for a resident with a documented allergy to pork. The resident, who had diagnoses including congestive heart failure and depression, was observed eating breakfast with bacon on their plate, despite their electronic health record indicating an allergy to pork. The resident reported being served pork products on multiple occasions and had informed the staff about this issue. The facility's policy stated that residents with food allergies should be identified upon admission and offered substitutions, but this was not adhered to in practice. Staff members acknowledged that meal cards should list allergies and preferences, and these should be checked by both the person plating the meal and the person delivering it to the resident. However, this procedure was not followed, leading to the resident being served food containing allergens.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for two residents, both of whom had significant medical conditions. One resident, diagnosed with chronic kidney disease and obesity with alveolar hypoventilation, reported that their room had been too hot for about a month, with a measured temperature of 88.5 degrees Fahrenheit. The other resident, with chronic obstructive pulmonary disease and congestive heart failure, also reported discomfort due to excessive heat in their room, which was measured at 86.1 degrees Fahrenheit. Both residents had informed the administrator and other staff members about the issue multiple times. Certified Nursing Assistants (CNAs) confirmed that the area where these residents resided had been excessively hot for about one to three months. Despite these reports, the administrator stated they were only informed of the air conditioning issue on a recent Thursday and had arranged for contractors to address the problem. The administrator claimed to be unaware of the ongoing problem in that part of the building until it was reported to them, indicating a communication breakdown within the facility.
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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