Shanoan Springs Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Chickasha, Oklahoma.
- Location
- 2500 South 12th Street, Chickasha, Oklahoma 73018
- CMS Provider Number
- 375362
- Inspections on file
- 19
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Shanoan Springs Nursing And Rehabilitation during CMS and state inspections, most recent first.
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 was transferred to the hospital due to respiratory symptoms, but the facility did not send the signed advance directive with the transfer. Although the face sheet and medication list were provided, hospital staff had to request the advance directive after the transfer, and staff confirmed it should have been sent.
An LPN failed to don gown and gloves before administering enteral medications to a resident on enhanced barrier precautions, despite facility policy and signage indicating the requirement for PPE during high-contact care activities. The resident had a traumatic brain injury and required assistance with personal care, and the administrator confirmed that PPE should be used for residents with devices such as PEG tubes.
The facility failed to maintain food safety and hygiene standards, with staff observed not washing hands after handling trash, improperly labeling and storing food, and neglecting hand hygiene while serving meals. The kitchen and storage areas were unclean, and staff did not use sanitizer when cleaning surfaces. The Dietary Manager and administrator acknowledged these lapses, indicating a systemic issue in adhering to professional standards.
The facility failed to ensure residents were offered the opportunity to formulate advance directives and accurately display code status. Three residents were not properly assisted in creating advance directives, and one resident's code status was incorrectly posted as full code despite having a DNR order. The social service director and DON acknowledged these oversights.
The facility failed to serve meals at an appetizing temperature, with food items such as pork chops, peas, and mac and cheese being served cold. A resident complained about cold food, and a test tray confirmed the issue. The Dietary Manager acknowledged the oversight in not checking food temperatures before service.
The facility failed to maintain proper infection control practices, with catheter tubing observed dragging on the floor for two residents, posing an infection risk. Additionally, wound care was not performed hygienically, and the facility lacked a comprehensive water management program to prevent Legionella growth. Staff interviews confirmed lapses in infection control protocols and incomplete documentation of water management activities.
The facility failed to protect residents from abuse and neglect, as evidenced by two incidents involving cognitively impaired residents. One resident was physically and verbally abused by a CNA during a shower, while another ingested disinfectant left unattended by a dietary aide. Both residents had dementia and required supervision, highlighting the facility's failure to ensure a safe environment.
A resident with cognitive impairment reported that a nurse used inappropriate language towards them. The incident was initially reported to a CMA, who did not escalate it immediately, advising the resident to speak to the nurse instead. The following day, the CMA informed the ADON, who notified the DON but did not complete an incident report. The facility's policy requires immediate notification of the Administrator or DON, which was not followed, leading to a delay in reporting the incident.
The facility failed to ensure accurate assessments for two residents. One resident's psychiatric medication reduction was incorrectly documented due to a discrepancy in consultation dates, while another resident's MDS assessment omitted several wounds, only noting two pressure ulcers. The DON acknowledged the need for corrections.
A facility failed to refer a resident with a new mental health diagnosis for a PASRR level II evaluation. The resident, transferred from another facility, had a PASRR level I assessment that did not include the new diagnosis of psychosis with risk of hallucinations and delusional paranoia. Despite a significant change assessment indicating severe cognitive impairment and a diagnosis of psychotic disorder, no referral for a PASRR level II evaluation was made.
A facility failed to administer nutritional supplements as recommended for a resident with a gastric tube. The resident, with a traumatic brain injury, had a physician's order for enteral feeding four times a day. A dietitian recommended increasing this to five times a day, but the recommendation was not communicated to the physician due to staff oversight in reviewing emails. As a result, the resident did not receive the necessary nutritional support.
A facility failed to follow physician's orders for changing oxygen tubing for a resident with chronic obstructive pulmonary disease and respiratory failure. The tubing, which was supposed to be changed twice a month, had not been replaced since early March, as confirmed by observations and the treatment administration record. The DON acknowledged the oversight.
A resident with severe cognitive impairment and a traumatic brain injury was observed with bed rails on both sides of their bed without a documented physician order or care plan. Although a consent was signed by the resident's representative, the DON stated it was not signed at the time of the request, indicating a deficiency in the facility's documentation and consent process.
The facility failed to ensure monthly drug regimen reviews and timely physician responses for two residents. One resident's medications were not reviewed or addressed by a physician for several months, while another resident's MRR request for a gradual dose reduction was not timely responded to by the physician. These actions did not comply with the facility's policy, affecting medication management.
The facility did not adhere to the planned menu, affecting meal service for residents. A resident requiring pureed meals did not receive a pureed roll, and another resident supposed to receive finger foods was not served the pork chop as indicated on the menu. Additionally, four meals were served without rolls, contrary to the menu plan.
The facility failed to properly dispose of kitchen garbage, affecting 48 residents. Staff were observed placing trash in a shopping cart outside the kitchen instead of taking it directly to the trash receptacle. The DM confirmed this practice, acknowledging that trash should be taken directly to the bin. A small bag of trash was later observed unattended in the cart.
A resident with intellectual disabilities and a need for assistance with personal care was not provided with scheduled showers as required. Despite being scheduled for four shower opportunities, the resident was only showered twice. The ADON confirmed that the staff should have informed the nursing staff if the resident refused or if they were unable to shower the resident.
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 Send Advance Directive During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident's advance directive was sent with them during a transfer to the hospital. According to facility policy, advance directive information should be communicated to the receiving provider when a resident is transferred or discharged. In this case, a resident experiencing labored breathing and coughing up thick green phlegm was transferred to the hospital. Although the face sheet and medication list were sent, the signed advance directive was not included. Hospital staff subsequently had to call the facility to request a copy of the advance directive, confirming that it was not provided at the time of transfer. Interviews with the DON and an LPN confirmed that the advance directive should have been sent but was omitted.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident requiring enhanced barrier precautions. During observation, an LPN entered the room of a resident with a traumatic brain injury and a need for assistance with personal care to administer medications via enteral tube, but did not don gown and gloves as required by the facility's Enhanced Barrier Precautions policy. The policy specifies that gown and glove use is necessary during high-contact resident care activities, and the medication administration policy also lists PPE as required equipment. The LPN acknowledged that the signage outside the resident's room indicated the need for enhanced barrier precautions and admitted that gown and gloves should have been worn prior to administering the medication. The administrator confirmed that PPE is required for direct care of residents with devices such as PEG tubes.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. On the initial tour of the kitchen, a staff member was seen handling trash and then returning to food preparation without washing their hands. Additionally, numerous food items in the refrigerator and freezer were not labeled or dated, and some were left open to air. The kitchen and storage areas were found to be unclean, with debris and dirt present, and scoops were improperly left in dry ingredient bins. During a subsequent tour, further violations were noted, including staff failing to use sanitizer when cleaning surfaces and neglecting hand hygiene after touching potentially contaminated items. Staff members were observed entering the kitchen and handling food without washing their hands or wearing hair nets. The Dietary Manager acknowledged these lapses, stating that proper procedures were not being followed, such as labeling food items and maintaining cleanliness. In the dining area, staff were seen serving meals without performing hand hygiene between residents and balancing meal plates against their clothing. The administrator confirmed that nursing staff should use hand sanitizer between residents and wash their hands after every few meals served. These observations indicate a systemic failure in maintaining food safety and hygiene standards, potentially compromising resident safety.
Failure to Manage Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that residents were offered the opportunity to formulate an advance directive or implement their choice to do so. Three residents were affected by this deficiency. One resident, with diagnoses including atrial fibrillation and COPD, had an advance directive acknowledgment form signed but lacked an actual advance directive in their records. The social service director admitted to not discussing the advance directive with the resident, instead relying on the resident's POA. Another resident, diagnosed with COPD and PVD, expressed interest in creating an advance directive, but the care plan incorrectly documented that they already had one. The DON later removed this incorrect documentation. A third resident, with PVD and dementia, also expressed interest in an advance directive through their POA, but no follow-up was conducted by the social service department. Additionally, the facility failed to post the correct code status information for a resident with multiple sclerosis and dementia. Despite having a physician's order for a DNR, the resident's room displayed a green name tag indicating full code status. The DON acknowledged the oversight after checking the charts and doorframes but missed correcting this resident's code status. These deficiencies highlight lapses in the facility's processes for managing advance directives and ensuring accurate code status information is displayed.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing temperature, affecting the quality of food provided to residents. On April 17, 2024, during the noon meal service, the pork chops were initially removed from the oven at a temperature of 184 degrees Fahrenheit and placed on the steam table without checking the temperature of other food items. The meal service began at 12:01 p.m., but the steam table was not checked for temperature before service. At 12:20 p.m., the Dietary Manager (DM) acknowledged that the food should have been temped before serving, and a pork chop on top of the stack was found to be at 106 degrees Fahrenheit. Additionally, a resident complained about receiving cold food on April 15, 2024. On April 17, 2024, a test tray was taken to the north hall, and the temperatures of the food items were recorded. The pork chop was 115 degrees Fahrenheit, the peas were 105 degrees Fahrenheit, the mac and cheese noodles were 107 degrees Fahrenheit, and the apple dessert was 81.5 degrees Fahrenheit, all of which were cold to taste. The test meal was also missing a roll. The DM stated that there had been no complaints of cold food but agreed that the food should have been served at a palatable temperature.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations and interviews. One resident with a suprapubic catheter was repeatedly observed with the catheter tubing dragging on the floor, which poses a significant infection control risk. Despite the care plan indicating the need for enhanced precautions due to the resident's increased risk of infection, staff did not consistently ensure the catheter tubing was kept off the floor. Interviews with staff confirmed that the catheter tubing should not have been dragging on the floor, highlighting a lapse in adherence to infection control protocols. Another resident with a catheter was also observed with the catheter tubing dragging on the floor, including instances where the tubing touched the sole of the resident's shoe. This further indicates a systemic issue with catheter management and infection control practices within the facility. The infection preventionist acknowledged that the catheter tubing should not have been in contact with the floor, underscoring a failure to implement proper infection control measures. Additionally, the facility did not implement a comprehensive water management program to prevent the growth of Legionella and other waterborne pathogens. The facility's documentation was incomplete, lacking evidence of a detailed water system diagram or regular team meetings to address water management. The infection preventionist and administrator were not fully aware of the program's status, and the maintenance staff admitted to a lack of documentation for routine cleaning activities. This indicates a significant oversight in maintaining a safe water system, as required by the facility's policy.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by two separate incidents involving residents with cognitive impairments. In the first incident, a certified nursing assistant (CNA) placed their hand over a resident's mouth and nose on three occasions during a shower, and verbally abused the resident by telling them to shut up. This incident was reported by a hospitality aide who witnessed the abuse, and another staff member heard the resident screaming. The resident involved had dementia with behavioral disturbances and required extensive assistance with activities of daily living. In the second incident, a resident with dementia and Alzheimer's disease, who was severely impaired in cognition and required supervision with eating, ingested Purell Surface Disinfectant. The disinfectant was left unattended on a cart in the dining room by a dietary aide, allowing the resident to access it. The resident was seen with the bottle pointed towards their mouth, and the incident was reported by another resident. The dietary aide did not witness the ingestion but found the resident with the bottle in hand. The resident's care plan noted poor impulse control and the need for interventions to mitigate behaviors. Both incidents highlight the facility's failure to ensure a safe environment for residents, particularly those with cognitive impairments. The facility did not adequately supervise or control access to potentially harmful substances, nor did it prevent or promptly address abusive behavior by staff. These deficiencies were identified through observations, record reviews, and interviews conducted during the survey.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe for a resident diagnosed with atrial fibrillation, COPD, and chronic pain. The resident, who was moderately impaired with cognition and required assistance with most activities of daily living, reported that a nurse used inappropriate language towards them. The incident was initially reported by the resident to a CMA on a Sunday night, but the CMA did not escalate the report immediately, believing the resident might exaggerate the situation. Instead, the CMA advised the resident to speak directly with the nurse involved. The following day, the CMA reported the incident to the Assistant Director of Nursing (ADON), who then informed the Director of Nursing (DON) and a DON from a sister facility. However, the ADON did not complete an incident report. The facility's policy requires immediate notification of the Administrator or Director of Nursing Services in cases of suspected abuse, but this protocol was not followed, resulting in a delay in reporting the incident to the Administrator until two days later.
Inaccurate Resident Assessments for Psychiatric and Wound Care
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents. The first resident had multiple psychiatric diagnoses, including anxiety disorder, major depressive disorder, bipolar disorder, and schizophrenia. A quarterly assessment inaccurately documented a gradual dose reduction (GDR) attempt for antipsychotic medication on a date that was not correct. The MDS coordinator, new to the position, found a discrepancy in the date of a psychiatric consultation note, which was signed and dated differently. The Director of Nursing (DON) confirmed that the psychiatrist had made medication changes that the attending physician did not approve, leading to an incorrect date on the MDS for medication reduction. The second resident had several diagnoses, including a stage 3 pressure ulcer, peripheral vascular disease (PVD), and lymphedema. The care plan documented multiple wounds, but the quarterly assessment only noted two unhealed stage 3 pressure ulcers, omitting other wounds. A wound progress note later detailed additional wounds, including a non-pressure wound and a lymphedema wound, which were not captured in the MDS assessment. The DON acknowledged the need for a correction in the wound section of the MDS assessment, as it failed to include all the resident's wounds.
Failure to Refer for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with a new mental health diagnosis for a PASRR level II evaluation. The resident, who was transferred from another facility, had a PASRR level I assessment dated 06/30/10, which documented diagnoses including multiple sclerosis, neurogenic bladder, paraplegia, sebaceous cysts, and a syndrome. Upon admission, the resident had additional diagnoses, including dementia with agitation, delusional disorder, cognitive communication deficit, and dementia with behavioral disturbances. A significant change assessment later documented severe cognitive impairment and a diagnosis of psychotic disorder. The care plan was revised to include a diagnosis of psychosis with risk of hallucinations and delusional paranoia. However, the Director of Nursing confirmed that the diagnosis of psychosis was not documented on the PASRR level I, and no referral for a PASRR level II evaluation was made.
Failure to Administer Recommended Nutritional Supplements
Penalty
Summary
The facility failed to ensure that nutritional supplements were administered as recommended for a resident with a gastric tube, leading to a deficiency in maintaining the resident's health. The resident, who was admitted with a diffuse traumatic brain injury and other conditions requiring personal care assistance, had a physician's order for enteral feeding with TwoCal HN four times a day. However, a dietitian later recommended increasing the feeding to five times a day. This recommendation was not communicated to the physician, as the facility staff, including the ADON and DON, did not review the dietitian's email containing the updated feeding instructions. Consequently, the resident did not receive the recommended nutritional support.
Failure to Follow Oxygen Tubing Change Orders
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen tubing care maintenance for a resident who was dependent on supplemental oxygen due to chronic obstructive pulmonary disease and respiratory failure. The physician's order specified that the oxygen tubing should be changed on the 5th and 20th of each month during the night shift. However, observations made on multiple occasions in April 2024 revealed that the resident was using oxygen tubing dated 03/06/24, indicating that the tubing had not been changed as per the physician's order. The treatment administration record for April 2024 also lacked documentation of any tubing changes since 03/06/24. The Director of Nursing confirmed that the tubing should have been changed on the 5th of April 2024.
Inappropriate Use of Bed Rails Without Proper Documentation
Penalty
Summary
The facility failed to ensure the appropriate use of side rails for a resident who was reviewed for side rails. The resident, who was admitted with diagnoses including diffuse traumatic brain injury and severe cognitive impairment, was observed lying on an air mattress with bed rails on both sides of the bed. However, the resident's electronic health record did not document a physician order for the use of bed rails, nor was there a care plan addressing their use. Although the resident's records contained a consent signed by the resident's representative for bed rails, the Director of Nursing stated that the representative had not signed a consent at the time the bed rails were requested. This indicates a lack of proper documentation and consent process for the use of bed rails, which is a deficiency in the facility's compliance with safety protocols.
Failure in Monthly Drug Regimen Review and Physician Response
Penalty
Summary
The facility failed to ensure that a consultant pharmacist conducted a monthly drug regimen review (MRR) for each resident, as required by their policy. Specifically, for two residents, the pharmacist did not review the medication regimen monthly, and the physician did not respond to the MRR requests within the time frame specified by the facility's policy. One resident, with diagnoses including anxiety disorder, major depressive disorder, bipolar disorder, and schizophrenia, had medications listed in a MRR dated September 2023, but there was no physician response found. Additionally, a MRR request in January 2024 for the same resident's medications was not addressed by the physician, and no MRR was found for February 2024. Another resident, diagnosed with generalized anxiety disorder, major depressive disorder, bipolar disorder, and dementia, had a MRR request in November 2023 for a gradual dose reduction (GDR) of Rilutek, which the physician disagreed with, but the response was not timely. Furthermore, the facility could not provide a MRR for January 2024 for this resident. These deficiencies indicate a failure to adhere to the facility's policy regarding timely MRRs and physician responses, potentially impacting the residents' medication management.
Failure to Follow Menus in Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed, resulting in discrepancies in meal service for residents. On April 17, 2024, the noon meal was supposed to include french onion pork chops, pork gravy, white cheddar mac and cheese, green peas, a wheat dinner roll, margarine, apple, milk, and coffee. However, during meal service, it was observed that four meals were served without rolls, and a resident who required pureed meals did not receive a pureed roll. Additionally, a resident who was supposed to receive finger foods was served butter noodles, white cheddar mac and cheese, and green beans, but not the pork chop as indicated on the menu. The dietary manager confirmed that the resident should have received a pork chop cut into finger food size. These observations indicate that the facility did not adhere to the planned menu, affecting the nutritional needs of the residents.
Improper Disposal of Kitchen Garbage
Penalty
Summary
The facility failed to properly dispose of garbage from the kitchen, affecting 48 residents who received services from the kitchen. On April 15, 2024, at 8:25 a.m., a staff member was observed removing trash from the kitchen garbage can and placing it in a shopping cart located outside by the storage building instead of taking it directly to the trash receptacle bin at the street. Later, at 9:03 a.m., the Dietary Manager (DM) confirmed that staff had been using the shopping cart to temporarily store trash before taking it to the trash receptacle, acknowledging that the trash should have been taken directly to the bin. On April 17, 2024, at 11:25 a.m., a small bag of trash was again observed unattended in the shopping cart outside by the storage room.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. A resident with a laceration without foreign body of the right eyelid and periocular area, who required assistance with personal care and had intellectual disabilities, was admitted to the facility. The care plan indicated that the resident required extensive assistance from one staff member for showering or bathing. A Medicare five-day assessment confirmed the need for substantial to maximal assistance with bathing. However, documentation revealed that the resident was only showered twice during their stay, despite being scheduled for four opportunities. The Assistant Director of Nursing (ADON) confirmed that the resident was on a 7 p.m. to 7 a.m. shower schedule and acknowledged that the staff should have informed the nursing staff if the resident refused or if they were unable to shower the resident. The documentation indicated that the resident did not receive showers as scheduled.
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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