Shawnee Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shawnee, Oklahoma.
- Location
- 1202 West Gilmore, Shawnee, Oklahoma 74804
- CMS Provider Number
- 375246
- Inspections on file
- 26
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Shawnee Care Center during CMS and state inspections, most recent first.
A resident with bipolar and depressive disorders did not receive a physician-ordered gradual dose reduction of olanzapine, as staff continued to administer the higher 20 mg dose for 11 days after the order was changed to 15 mg. The error occurred because the CMA did not verify the updated order before medication administration, resulting in the resident receiving the incorrect dosage.
A resident with chronic pain and paraplegia went six days without prescribed morphine due to the facility's failure to secure a physician to authorize refills after the previous physician's departure. During this period, the resident's pain increased, and staff did not consistently assess or document pain levels. Additionally, the resident's request for a pain management specialist referral was not communicated or acted upon, resulting in a lack of appropriate pain management services.
After the resignation of the facility's medical director, the facility did not secure a replacement physician, leaving 39 residents without physician supervision. Several residents and families were unaware of who would provide medical care, and one resident experienced a delay in receiving pain medication due to the absence of a physician to write prescriptions.
The facility did not have a registered nurse assigned as the DON after the previous DON left employment, as confirmed by staffing records and statements from the corporate nurse consultant. At the time, 49 residents were living in the facility.
The facility did not have a medical director in place after the previous physician resigned, leaving 49 residents without the required oversight for medical care and policy implementation. Despite advance notice of the resignation, no new contract or replacement was established, and staff confirmed the absence of an active medical director following the departure.
Two residents in the assisted dining room, requiring assistance with eating, experienced a delay in meal service and were left in a cold environment without immediate staff intervention. Despite complaints about the cold, staff did not promptly address the issue, resulting in a meal service delay of over an hour and a half. The infection preventionist acknowledged the dignity issue, and the administrator and Corporate Nurse Consultant were informed.
The facility failed to provide residents access to their trust account funds during nights and weekends. The business office manager, the only person able to access these funds, worked Monday through Friday, limiting residents' access to their money. The facility's policy did not address fund access outside regular business hours, affecting residents' ability to obtain money on weekends.
The facility did not notify a Medicaid recipient when their trust account balance exceeded the $2,000 resource limit by $874.59. The business office manager confirmed the lack of notification and documentation, which was discovered during a review of the trust account ledger.
The facility did not close resident trust accounts and convey funds within the required 30 days for three residents who had expired. Despite the policy, accounts remained open for 131, 228, and 243 days. The business office manager stated they were trained to wait 90 days before closing accounts.
The facility failed to maintain a surety bond with adequate coverage for the resident trust account, which had balances exceeding the bond's $20,000 coverage. The business office manager confirmed the discrepancy and acknowledged the absence of a system to ensure the bond matched the account balance.
The facility failed to ensure proper documentation of advance directives and DNR forms. A resident with vascular dementia and malignant neoplasm did not have an advance directive acknowledgment, while another resident with dementia, hypertension, and anemia had an invalid DNR form due to the absence of their name. The corporate nurse confirmed the documentation errors.
A resident with a history of falls and cognitive deficits experienced two falls in the shower. The facility failed to notify the family immediately after the incidents, with one notification delayed by 24 hours. The corporate nurse consultant confirmed that families should be notified the same day as the fall, but this protocol was not followed.
The facility failed to develop comprehensive care plans for two residents, one with an indwelling urinary catheter and another requiring anticoagulant and diuretic therapy. The care plans lacked documentation for catheter maintenance, infection prevention, and necessary therapies, leading to deficiencies in addressing the residents' medical needs.
A facility failed to update the care plan for a resident with a pressure ulcer. The resident, diagnosed with a stage III sacral pressure ulcer, dementia, and a fracture, was documented as at risk for pressure ulcers but the care plan did not reflect the actual ulcer or its treatment. Despite receiving wound care, the care plan was not updated, as confirmed by an LPN and a corporate RN.
Two residents did not receive bathing according to standards of care. One resident, with cerebral infarction and hemiplegia, reported insufficient CNA availability on shower nights, resulting in only a partial bath in June. Another resident, with metabolic encephalopathy and morbid obesity, also reported missed showers, with documentation showing only a partial bath in June. The corporate nurse confirmed these deficiencies.
The facility failed to perform weekly skin assessments and wound care per physician orders for a resident with a stage III sacral pressure ulcer, and also failed to obtain weekly weights for another resident with morbid obesity and hypertensive heart disease. The corporate RN and nurse confirmed these deficiencies.
A resident with a stage III sacral pressure ulcer, dementia, and a fractured femur had an indwelling urinary catheter placed without a physician order. The facility failed to document catheter maintenance or infection prevention interventions. The resident was unaware of the catheter's purpose, and the corporate RN acknowledged the lack of necessary documentation.
A resident with abnormal weight loss and muscle wasting did not receive snacks between meals and at bedtime as ordered, and weekly weights were not documented. The resident experienced a significant weight loss of 16.13% over several months. The corporate nurse could not confirm the provision of snacks or completion of weekly weights.
A resident with acute respiratory disease and asthma was observed with oxygen tubing that had not been changed as per physician orders, which required weekly changes. Despite being cognitively intact and experiencing shortness of breath, the resident's tubing was dated several weeks prior, indicating non-compliance with the care plan. The corporate RN confirmed the tubing should have been changed weekly.
The facility experienced consistent delays in meal service due to insufficient nursing staff to assist with both meal service and resident care. Meals were served late, with some residents waiting over an hour and a half, causing anxiety among them. The dietary manager and CNAs confirmed that staffing issues were the primary cause of these delays.
The facility failed to implement enhanced barrier precautions for residents with pressure ulcers and urinary catheters, as required by their infection control policy. Observations showed that staff only used gloves during care, and there was no PPE available near residents' rooms. Staff were unfamiliar with the enhanced barrier precautions, and the corporate nurse confirmed they were not in place.
A resident with heart failure and a need for personal care assistance was repeatedly observed with their call light out of reach, placed inside a bedside dresser drawer. The DON confirmed that the call light should be accessible to the resident at all times.
A facility failed to refer a resident with a new mental health diagnosis of delusions to OHCA for a PASRR Level II evaluation. The resident, admitted with heart failure, chronic pain, depressive disorders, and anxiety, had a PASRR Level I completed. However, after the new diagnosis, there was no documentation of notification to OHCA, as confirmed by the corporate nurse.
The facility failed to thoroughly investigate abuse allegations involving three residents. In one case, a resident alleged a dismissive comment by a Certified Medication Aide, but no employee statements were documented. Another resident reported rough handling by a Certified Nurse Aide, but the investigation lacked interviews with other residents and the alleged perpetrator. A third resident's claim of rough handling was not fully investigated as the alleged perpetrator had quit. The Corporate Nurse Consultant and Administrator acknowledged the investigations were incomplete.
A resident with multiple falls and diagnoses including vascular disturbance and anxiety did not have a resident-centered fall prevention plan. Despite experiencing five falls, the care plan was not reviewed or revised, and it was reported that no fall prevention plan was in place.
The facility failed to ensure medication was not set up and left sitting on top of the medication cart. An LPN was observed to have four medication cups containing one pill each and one cup containing an unknown amount of crushed medication sitting on top of the cart. The medication cups were not labeled or dated, and there was no staff observed near or around the cart. The LPN stated that she had memorized whose medications were in the cups and confirmed that medications are not supposed to be set up before the time to administer and should not be left unattended on top of carts.
The facility failed to post nurse staffing information in an area accessible to residents and visitors. This deficiency was observed on multiple occasions, and the corporate nurse consultant confirmed that the information should have been posted daily.
Failure to Implement Physician-Ordered Gradual Dose Reduction of Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses of bipolar disorder and recurrent depressive disorders did not receive a physician-ordered gradual dose reduction of olanzapine, an antipsychotic medication. The physician had ordered the olanzapine dosage to be decreased from 20 mg daily to 15 mg daily, following a pharmacist's recommendation for a gradual dose reduction. However, the medication administration records and pill blister card review revealed that the resident continued to receive the higher 20 mg dose for 11 days after the order change. The error was discovered when it was noted that the first 15 mg dose was not administered until 12 days after the order was written. The Certified Medication Aide (CMA) responsible for administering the medication stated they were unaware of the dosage change and continued to give the previous 20 mg dose, failing to verify the current physician order against the medication card prior to administration. The Director of Nursing (DON) confirmed that the resident received the incorrect dosage for 11 days, as the CMA had not checked the updated order. The resident was moderately cognitively impaired, had no symptoms of depression or behaviors at the time, and had been receiving both antipsychotic and antidepressant medications.
Failure to Provide Timely Pain Medication and Specialist Referral
Penalty
Summary
The facility failed to ensure that a resident requiring narcotic pain management had uninterrupted access to prescribed medications and appropriate specialist care. The resident, who had diagnoses including anxiety, depression, paraplegia, and chronic pain, was admitted with orders for morphine extended release and oxycodone for chronic pain. After admission, the resident received 11 doses of morphine, but then went without the medication for six days due to the facility's inability to refill the prescription. This lapse occurred because the resident's attending physician ended their service on April 30th, and the facility had not secured a replacement physician to continue care and authorize prescriptions. During the period without morphine, the resident's pain increased, with self-reported pain levels rising from a manageable five to as high as seven or eight out of ten. The resident attempted to obtain the medication by visiting the emergency room multiple times, but was unable to receive a prescription there, as the ER would not provide PRN medications. Facility staff, including nurses and medication aides, confirmed that there was confusion regarding who was responsible for ordering the narcotic medication and that pain levels were not consistently assessed or documented during this period. The medication administration record reflected the missed doses, and staff interviews revealed a lack of clarity about the resident's attending physician and the process for medication refills. Additionally, the resident requested a referral to a pain management specialist, but this request was not acted upon. The social service director, who was responsible for arranging outside services, was not informed of the resident's request, and no referral was made. Communication breakdowns among staff, lack of physician coverage, and inadequate documentation and monitoring of pain contributed to the resident experiencing increased pain and a gap in pain management services.
Failure to Ensure Physician Supervision After Medical Director Resignation
Penalty
Summary
The facility failed to ensure that residents were under the care of a supervising physician after the resignation of the previous medical director and primary physician. Physician #1 provided written notice of resignation in February, stating they would continue services through the end of April. Despite this advance notice, the facility did not secure a replacement physician by the time Physician #1 ceased providing care on April 30. As a result, 39 residents, including all six sampled residents, were left without physician supervision. Multiple residents and family members reported not knowing who their new physician would be, and some residents confirmed they had not seen a physician since Physician #1's departure. One resident reported running out of prescribed morphine and experiencing increased pain due to the inability to obtain a new prescription in the absence of a supervising physician. The corporate nurse consultant confirmed that there was no physician available for these residents after April 30, which led to delays in necessary medical care and prescriptions.
Failure to Designate a Director of Nursing
Penalty
Summary
The facility failed to have a registered nurse designated as the director of nursing (DON), as required. Observations on May 12, 2025, showed that the posted nurse staffing did not list a DON, and the facility's employee and key staff lists also lacked a registered nurse in this role. Review of time cards confirmed that the previous DON, an RN, ended employment on April 1, 2025, and no replacement had been designated since then. The corporate nurse consultant confirmed that the facility had not assigned anyone to the DON position following the previous DON's departure. At the time of the survey, 49 residents were residing in the facility.
Failure to Appoint Medical Director After Resignation
Penalty
Summary
The facility failed to designate a physician to serve as medical director responsible for the implementation of resident care policies and coordination of medical care after April 30, 2025. According to facility policy, physician services must be under the supervision of a medical director, who also ensures residents receive adequate services appropriate to their needs. The only contract for medical director services was with a physician who provided written notice of resignation in February, stating services would end on April 30, 2025. No new contract or replacement physician was identified after this date. The corporate nurse consultant confirmed that there was no active medical director or signed contract in place after April 30, 2025, affecting the care oversight for the 49 residents residing in the facility at that time.
Failure to Provide Dignified Meal Service in Assisted Dining Room
Penalty
Summary
The facility failed to provide meals in a dignified manner for residents in the assisted dining room, specifically affecting two residents who required assistance with eating. Resident #28, diagnosed with dementia and other conditions, and Resident #47, with a diagnosis including malignant neoplasm of the prostate and cognitive communication deficit, were observed waiting for their morning meal in the assisted dining room. Both residents, along with others, complained about the cold temperature in the room, but no staff were present to address their concerns. Resident #28 repeatedly asked for a jacket, and despite the presence of a certified nurse aide and an infection preventionist, the complaints were not immediately addressed. The infection preventionist eventually acknowledged the complaints and attempted to adjust the temperature and provide blankets, but this occurred after a significant delay. The meal service was delayed by over an hour and a half past the scheduled time, with Resident #28 receiving their meal at 9:05 a.m. and Resident #47 at 9:15 a.m. The infection preventionist admitted that the delay and the residents being cold were dignity issues. The administrator and Corporate Nurse Consultant #1 were informed of the situation and agreed that it was a dignity issue for the residents to wait that long and be cold.
Lack of Access to Trust Account Funds on Weekends
Penalty
Summary
The facility failed to ensure that residents had access to their trust account money during nights and weekends, affecting three residents reviewed for this issue. The business office manager identified 24 residents with money in the trust account. The facility's resident trust policy did not address access to funds outside of regular business hours. During an initial tour, a sign was observed indicating that banking hours for obtaining money from the trust account were limited to Monday through Friday from 1:00 p.m. to 3:00 p.m., with no documented availability during evenings or weekends. Residents reported that they could only access their funds when the business office manager was present, which was Monday through Friday from 8:00 a.m. to 5:00 p.m., leaving them without access on weekends. The business office manager confirmed that they were the only person able to access the funds for residents and only worked during these hours.
Failure to Notify Medicaid Resident of Trust Account Balance
Penalty
Summary
The facility failed to provide necessary notifications to a Medicaid recipient resident regarding their trust account balance. Specifically, the facility did not inform Resident #1 when their trust account balance reached $2,874.59, which is within $200 of the $2,000 resource limit for Medicaid recipients. The business office manager confirmed that they had not provided the required notification to the resident, and there was no documentation to indicate that such a notice had been given. This oversight was identified during a review of the trust account ledger and subsequent interview with the business office manager.
Failure to Close Resident Trust Accounts Timely
Penalty
Summary
The facility failed to ensure that resident trust accounts were closed and funds conveyed within 30 days for three residents who had expired and were no longer in the facility for over 30 days. The business office manager identified five residents with open trust accounts despite being gone from the facility for over 30 days. The facility's policy stated that funds must be returned to the resident or the resident's estate within 30 days if the resident leaves the home or passes away. However, the trust accounts for three residents remained open well beyond this period, with one account open for 131 days, another for 228 days, and a third for 243 days after the residents had expired. The business office manager mentioned that they were trained by corporate to wait 90 days before closing out trust accounts and conveying the funds to the family.
Insufficient Surety Bond Coverage for Resident Trust Account
Penalty
Summary
The facility failed to secure a surety bond with sufficient coverage for the resident trust account balance. The business office manager identified 24 residents who had money in the trust account and were current residents. A review of the current surety bond for the resident trust account showed that the bond had coverage of $20,000. However, the resident trust account monthly bank statements documented account balances of $26,681 and $32,329.75 for two consecutive months. On a specific date, the business office manager confirmed that the surety bond was only for $20,000 and acknowledged that there was no system in place to ensure the surety bond was sufficient for the account balance.
Deficiencies in Advance Directive and DNR Documentation
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate an advance directive and that DNR forms were filled out correctly. One resident, admitted with vascular dementia and malignant neoplasm of uterine adnexa, did not have an advance directive acknowledgment in their record. The administrator confirmed the absence of this acknowledgment. Another resident, with diagnoses of dementia, hypertension, and anemia, had a DNR form in their chart that lacked the resident's name, rendering it invalid. The corporate nurse confirmed the form was not filled out correctly.
Failure to Notify Family of Resident Falls
Penalty
Summary
The facility failed to notify the family of a resident about falls that occurred on two separate occasions. The resident, who had diagnoses including abnormalities of gait, a history of falling, and cognitive communication deficit, experienced a fall on 05/17/24 while in the shower. Despite the incident being documented in an incident report and a nursing progress note, there was no record of the family being notified of this fall. A second fall occurred on 05/27/24, again while the resident was in the shower. Although a nursing progress note dated 05/28/24 indicated that the family had been notified of the event, this notification did not occur until 24 hours after the fall. The corporate nurse consultant confirmed that families should be notified immediately after a fall once the resident is stabilized, and that this notification should be documented in the progress notes on the same day as the fall. However, the family was not notified in a timely manner for either incident.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident, diagnosed with a stage III sacral pressure ulcer, dementia, and a fractured right femur, had an indwelling urinary catheter placed due to wounds on the coccyx. However, the care plan did not document the presence of the catheter, its maintenance, or infection prevention interventions. Despite being cognitively intact and dependent on toileting, the resident was observed with the catheter attached to their wheelchair, unaware of the reason for its placement. Another resident, admitted with metabolic encephalopathy, acute kidney failure, morbid obesity, and generalized anxiety disorder, had physician orders for Eliquis and Toresemide. The care plan lacked documentation for activities of daily living, diuretic therapy, and anticoagulant therapy, despite the resident requiring limited assistance with showers and baths. The corporate nurse confirmed that these aspects were not care planned, indicating a failure to address the resident's comprehensive care needs.
Failure to Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to update the care plan for a resident with a pressure ulcer, leading to a deficiency. The resident, who had diagnoses including a stage III sacral pressure ulcer, dementia, and a fracture of the right femur, was documented in a quarterly assessment as cognitively intact and requiring partial to moderate assistance with mobility. Initially, the care plan noted the resident was at risk for pressure ulcers but did not document the presence of an actual ulcer or its treatment. Despite a later assessment indicating the presence of a stage II pressure ulcer, the care plan remained unchanged. Observations confirmed the resident had wounds on their tailbone and received wound care, which was not reflected in the care plan. Both an LPN and a corporate RN acknowledged that the care plan should have been updated to include the pressure ulcer and its treatment.
Failure to Provide Scheduled Bathing for Residents
Penalty
Summary
The facility failed to ensure that residents were bathed according to standards of care, affecting two residents. Resident #31, who was admitted with diagnoses including cerebral infarction and hemiplegia, reported that there were not enough CNAs available on her scheduled shower nights, leading her to take showers during the day. Her care plan, last revised in May, indicated she required extensive assistance from one person for bathing. However, documentation showed she only received a partial bath in June, with no further bathing recorded until early July. The corporate nurse confirmed that the resident did not receive showers according to standards of care. Resident #35, admitted with conditions such as metabolic encephalopathy and morbid obesity, also reported not receiving showers as scheduled. Her care plan, revised in May, lacked documentation of activities of daily living. Observations in early July found her in her wheelchair, and a review of her ADL documentation revealed she only received a partial bath in June, with no other showers documented until July. The corporate nurse acknowledged that the resident did not receive showers per standards of care and that her activities of daily living were not care planned.
Failure to Perform Weekly Skin Assessments and Obtain Weekly Weights
Penalty
Summary
The facility failed to perform weekly skin assessments and wound care per physician orders for a resident with a stage III sacral pressure ulcer, dementia, and a fracture of the right femur. The resident was supposed to have weekly skin assessments every Friday as per a physician order dated December 28, 2023. However, the medical record showed that skin assessments were only documented on June 1 and June 21, 2024, with no additional assessments for June or July 2024. Additionally, the resident reported inconsistent wound care, and an LPN was observed applying santyl ointment without a corresponding physician order. The corporate RN confirmed that weekly skin assessments and wound care were not completed as ordered. Another resident, admitted with morbid obesity and hypertensive heart disease with heart failure, had a physician's order for weekly weights every Thursday. However, the resident's record showed weights were only documented sporadically on specific dates from February to June 2024, indicating that weekly weights were not consistently obtained. The corporate nurse acknowledged that the weekly weights were not being completed as required.
Lack of Physician Order and Documentation for Urinary Catheter
Penalty
Summary
The facility failed to ensure a physician order for an indwelling urinary catheter and did not provide necessary services to prevent urinary tract infections for a resident with a catheter. The resident, who had diagnoses including a stage III sacral pressure ulcer, dementia, and a fracture of the right femur, was documented as occasionally incontinent of bladder and wore adult undergarments for dignity. However, a nurse note indicated that an indwelling urinary catheter was placed, yet there was no physician order found in the medical record for this catheter. Additionally, there was no documentation related to urinary catheter maintenance or infection prevention interventions in the resident's medical record or care plan. The resident was observed with the catheter attached to their wheelchair and was unaware of the reason for its placement. The corporate RN confirmed that a physician order should have been documented and that interventions for catheter maintenance and infection prevention should have been recorded, but there was no documentation to verify that regular maintenance and monitoring had been completed.
Failure to Provide Snacks and Document Weights
Penalty
Summary
The facility failed to ensure that snacks were offered between meals and at bedtime as ordered, and that weekly weights were documented for a resident who experienced significant weight loss. The resident, who was admitted with diagnoses of abnormal weight loss and muscle wasting and atrophy, had a physician's order for a regular diet with thin liquids and a house supplement with meals. Additionally, there was an order to offer snacks between meals and at bedtime, and to document weekly weights on Thursdays. However, the resident's record lacked documentation of snacks being provided, and the corporate nurse could not confirm that the resident received them. Furthermore, the weekly weights were not completed as ordered, contributing to a significant weight loss of 16.13% from January to June.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to adhere to physician orders and best standard practices for changing oxygen tubing for a resident receiving oxygen therapy. The resident, who had diagnoses including acute respiratory disease, asthma, and nasal congestion, was observed wearing oxygen via nasal cannula with tubing dated 06/10/24, despite a physician order dated 06/26/23 that required the tubing to be changed weekly on Tuesdays. Observations on 07/07/24 and 07/08/24 confirmed the tubing had not been changed as per the order. The resident was cognitively intact and experienced shortness of breath with exertion, as documented in a quarterly assessment dated 03/18/24. The care plan reviewed on 04/16/24 also indicated the need for weekly tubing changes. The corporate RN acknowledged the oversight when informed of the observations, confirming the tubing should have been changed weekly per the physician's order.
Consistent Meal Service Delays Due to Staffing Issues
Penalty
Summary
The facility failed to ensure meals were served as scheduled for three residents in the assisted dining room. Observations revealed that breakfast, scheduled for 7:30 a.m., was delayed, with the first meal tray served at 8:20 a.m. in the main dining room and even later in the assisted dining area. Residents were observed waiting for their meals, with some experiencing delays of over an hour and a half. Interviews with residents and family members confirmed that meals were consistently served late, causing anxiety among residents. The dietary manager and CNAs attributed the delays to insufficient nursing staff available to assist with meal service and resident care simultaneously. The dietary manager noted that once the morning meal was delayed, it caused subsequent meals to be late as well. The infection preventionist mentioned that meal service was particularly late on weekends due to the need for nursing staff to assist residents before meals could be served.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program for enhanced barrier precautions for three residents reviewed for infection control. The Enhanced Barrier Precautions policy, dated 05/10/24, requires gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organism (MDRO) or those at increased risk of MDRO acquisition. However, observations and interviews revealed that these precautions were not implemented. For instance, a resident with a stage III sacral pressure ulcer was observed receiving wound care from an LPN who wore gloves but not a gown, and no personal protective equipment was available near the resident's room. The LPN and the infection preventionist both confirmed that enhanced barrier precautions had not been implemented in the facility. Additionally, two other residents with urinary catheters were observed without any indication or availability of PPE for enhanced barrier precautions. Staff members, including CNAs, reported only wearing gloves during catheter care and were unfamiliar with enhanced barrier precautions. The corporate nurse confirmed that the facility was not currently implementing these precautions. This lack of adherence to the infection control program highlights a significant deficiency in the facility's infection prevention and control practices.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call devices were within reach for a resident who required assistance with personal care and had a diagnosis of heart failure. The resident was observed multiple times throughout the day resting in bed with their eyes closed, and on each occasion, the call light was found to be out of reach, placed inside the top drawer of the bedside dresser. This was confirmed by the Director of Nursing (DON), who acknowledged that the call light should always be within the resident's reach.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with a new mental health diagnosis to the Oklahoma Health Care Authority (OHCA) for a Pre-Admission Screening and Resident Review (PASRR) Level II evaluation. This deficiency involved one resident who was admitted with diagnoses including heart failure, chronic pain, recurrent depressive disorders, and anxiety. A PASRR Level I was completed upon admission. However, after the resident received a new diagnosis of delusions, there was no documentation indicating that OHCA was notified of this change. The corporate nurse confirmed that OHCA had not been informed of the new mental health diagnosis.
Inadequate Abuse Investigation in LTC Facility
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving three residents. The first incident involved a resident who alleged that a Certified Medication Aide made a dismissive comment. The investigation lacked documented statements from other employees. The Social Service Director was unable to provide additional documentation when questioned about the investigation. In the second case, a resident alleged that a Certified Nurse Aide was rough and caused damage to a bed. The investigation did not include interviews with other residents or a statement from the alleged perpetrator. The Social Service Director and Director of Nursing did not complete the necessary interviews, and the Certified Nurse Aide was suspended without providing a statement. In the third case, a resident alleged rough handling by another Certified Nurse Aide, but the investigation lacked interviews with staff, including the alleged perpetrator, who had quit. The Corporate Nurse Consultant confirmed that the investigations were not thorough, and the Administrator acknowledged the deficiencies.
Failure to Implement Resident-Centered Fall Prevention Plan
Penalty
Summary
The facility failed to ensure a resident-centered fall prevention plan was completed for a resident with multiple falls. The resident, admitted with diagnoses including vascular disturbance with psychotic disturbance, anxiety, and altered mental status, experienced falls on five separate occasions. Despite these incidents, the care plan was not reviewed or revised after each fall. On 03/06/24, it was reported by the corporate nurse consultant that the resident did not have a fall prevention plan in place.
Unattended and Unlabeled Medications on Cart
Penalty
Summary
The facility failed to ensure medication was not set up and left sitting on top of the medication cart. On 03/06/24 at 5:16 a.m., the medication cart for the south hall was observed to have four medication cups containing one pill each and one cup containing an unknown amount of crushed medication sitting on top of the cart. The medication cups were not labeled or dated, and there was no staff observed near or around the cart. When asked, an LPN stated that she had memorized whose medications were in the cups and confirmed that medications are not supposed to be set up before the time to administer and should not be left unattended on top of carts.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all the residents and visitors. This deficiency was observed on multiple occasions: on 03/04/24 at 12:05 p.m., on 03/05/24 at 9:08 a.m., on 03/06/24 at 10:00 a.m., and on 03/07/24 at 10:30 a.m. The Assistant Director of Nursing (ADON) reported that 55 residents resided in the facility. The corporate nurse consultant confirmed that the staffing information should have been posted daily.
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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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