Sherwood Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 2416 West 51stsouth, Tulsa, Oklahoma 74107
- CMS Provider Number
- 375556
- Inspections on file
- 21
- Latest survey
- April 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sherwood Manor Nursing Home during CMS and state inspections, most recent first.
A CNA engaged in a verbal and physical altercation with a resident, including yelling, threatening, and throwing milk at the resident, resulting in a scratch on the resident's forehead. The incident was witnessed by a CMA and an LPN, who attempted but failed to de-escalate the situation. The event was captured on video and reported to authorities, highlighting a failure to ensure residents are free from abuse.
A resident with schizoaffective disorder and bipolar type did not receive multiple consecutive doses of prescribed antipsychotic medications due to unavailability, with staff failing to notify the physician or follow facility policy. During this period, the resident exhibited worsening behavioral symptoms, including delusions, agitation, and threats, resulting in emergency room visits and psychiatric admission.
A resident with a diagnosis of schizoaffective disorder, bipolar type, was prescribed lithium and had a physician order for a lithium level lab test. The test was not requested or completed, as staff either did not see the option in the lab portal or mistakenly believed it would be included in a CBC. The DON was unaware of the omission and noted that audits to ensure labs were obtained had not been conducted recently.
A resident at risk for pressure ulcers was not properly assessed or monitored, resulting in a significant wound that went unreported to the physician for several days. The resident's family discovered the wound, which was emitting a foul odor, and the resident was eventually transferred to the hospital. The facility failed to follow protocols for skin integrity monitoring and communication.
The facility failed to secure chemicals in a shower room and nursing supply closet, leaving hazardous materials accessible. A resident with diabetes and renal disease was observed smoking unsupervised with a cigarette in their mouth, but the incident was not reported or documented. Additionally, a resident using bed rails lacked proper assessment and consent, as the facility did not routinely perform these evaluations.
The facility failed to maintain infection control during various procedures, including blood glucose monitoring, medication administration, wound care, and catheter care. An LPN did not wear gloves or disinfect the glucometer between uses, and CMAs handled medications with bare hands. Additionally, hand hygiene lapses were observed during wound and catheter care, with catheter bags touching the floor. The DON confirmed the need for proper handwashing and surface sanitization.
A facility failed to update a care plan for a resident with a stage four pressure ulcer. The resident's clinical record lacked documentation of the wound or wound care. The MDS coordinator admitted the omission, affecting one resident among 73 in the facility.
A resident with non-pressure wounds on their toes received unauthorized Betadine treatment from an LPN without obtaining physician orders. The LPN failed to notify the wound physician or document the new wounds, assuming the treatment would be ordered. The DON confirmed that nurses must obtain physician orders for wound treatments, which was not done in this case.
A resident with end-stage renal disease and cardiac issues did not have daily weights recorded as ordered by the physician. The facility's failure was due to unclear responsibilities between the restorative aide, charge nurse, and MDS coordinator, resulting in weights being recorded only 19 times out of 35 opportunities.
A facility failed to administer enteral formula as ordered for a resident with a gastrostomy. The resident was prescribed Nutren 1.5 at 60 ml/hr, but was observed receiving 50 ml/hr on multiple occasions. An LPN and the DON confirmed the discrepancy after reviewing the electronic clinical record and the formula label, but could not explain the error. Nurses were expected to verify the correct formula and rate on each shift.
A facility failed to conduct and document pre and post dialysis assessments for a resident with end-stage renal disease, despite having a care plan and physician's order for dialysis three times a week. Staff interviews revealed a lack of awareness and documentation of necessary assessments, as the facility was new to admitting residents requiring dialysis.
A facility failed to assess and inspect bed rails for entrapment risks for a resident who used them for repositioning. An LPN revealed that the last assessment was done months ago, despite monthly reassessment requirements. A maintenance worker stated they only addressed issues reported by staff and did not routinely check bedrails. The DON mentioned bed rails were used only upon resident request.
The facility failed to report abuse allegations to state agencies within the required time frame for two residents. One resident, with Parkinson's disease, had an abuse allegation against a CNA reported three days late. Another resident, with cognitive impairments, was involved in a possible exploitation incident reported two days late. The administrator was unaware of the two-hour reporting requirement.
A resident with Parkinson's disease and physical debility was left exposed during incontinent care when a CNA exited the room without using the privacy curtain. The LPN confirmed the exposure, as the privacy curtain was not utilized despite the door being closed.
A resident with Parkinson's Disease and physical debility experienced inadequate assessment and monitoring of a pressure ulcer due to inconsistent and incomplete documentation. The facility's policy requires detailed assessments, but records lacked necessary details about the ulcer's location and condition. The DON acknowledged the discrepancies and the need for proper monitoring.
Failure to Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a staff member. During a breakfast pass, a CNA engaged in a heated verbal and physical altercation with a resident in the hallway. The CNA was observed yelling, threatening, and ultimately throwing both a glass of milk and a nearly full gallon of milk at the resident. The incident was witnessed by a CMA and an LPN, who attempted to intervene and de-escalate the situation but were unsuccessful. The CNA continued to act aggressively, including pushing the CMA away and swinging at the resident after slipping and falling. The resident involved had a medical history that included unspecified dementia and schizoaffective disorder, bipolar type. Following the altercation, the resident was found to have a scratch on their forehead, and their glasses were found on the floor with the nose piece stuck in their hair. The incident was captured on facility video surveillance, which confirmed the sequence of aggressive actions by the CNA and the unsuccessful attempts by other staff to protect the resident. The facility's abuse and neglect policy strictly prohibits any kind of abuse against residents. However, after the incident, it was noted that the DON did not provide education on abuse to staff, and the administrator did not come to the facility on the day of the incident. The event was reported to the Oklahoma State Department of Health, and the resident was sent to the hospital for evaluation. The deficiency was identified as the facility's failure to ensure residents were free from abuse.
Failure to Provide Ordered Antipsychotic Medications for Resident with Serious Mental Illness
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, bipolar type, was not provided with their ordered antipsychotic medications, specifically risperidone and Seroquel, for multiple consecutive days following admission. The resident did not receive 12 consecutive doses of risperidone and five consecutive doses of Seroquel due to the medications not being available in the facility. Documentation in the medication administration record repeatedly noted that the medications were "waiting on pharmacy" or "on order," and there was no evidence that the physician was notified about the unavailability of these vital medications. Staff interviews revealed that certified medication aides (CMAs) and nurses were either unaware of the medication orders or did not document notifications to the charge nurse or pharmacy regarding the missing medications. The DON and administrator were not made aware that the medications were unavailable, and the physician confirmed they had not been notified nor had they ordered the medications to be placed on hold. The facility's existing policy required physician notification if three consecutive doses of a vital medication were withheld, refused, or not available, but this protocol was not followed in this case. During the period when the resident was not receiving their prescribed antipsychotic medications, they exhibited escalating behavioral symptoms, including delusions, hallucinations, agitation, and threats toward staff, which ultimately led to emergency room visits and in-patient psychiatric treatment. The failure to ensure the availability and administration of ordered medications for a resident with a serious mental illness constituted a deficiency in providing necessary behavioral health care and services as required.
Failure to Obtain Physician-Ordered Lithium Level Lab Test
Penalty
Summary
The facility failed to ensure that laboratory tests ordered by a physician were obtained for a resident with schizoaffective disorder, bipolar type, who was prescribed lithium. A physician order for admission labs, including a lithium level, was documented, but review of the resident's records and lab order summary showed that the lithium level was neither requested from the lab company nor completed during the resident's stay. An LPN reported not seeing an option to order a lithium level in the lab portal, and the DON was unaware of why the test had not been entered, noting that a staff member mistakenly believed the lithium level would be included in a CBC. The DON also stated that random audits were conducted to ensure labs were obtained as ordered, but the last audit had been conducted over two months prior.
Failure to Monitor and Report Pressure Ulcer
Penalty
Summary
The facility failed to adequately assess, monitor, and intervene for a resident at risk for pressure ulcers, leading to an Immediate Jeopardy situation. A resident, who was totally dependent on staff and at increased risk for pressure ulcer development, was admitted with no initial skin concerns documented. Despite a physician's order for weekly skin assessments, no issues were noted until a family member discovered a wound on the resident's coccyx, which was emitting a foul odor. The wound was significant, measuring 11cm x 13cm with a necrotic bed, and was not reported to the physician until several days later. The delay in notifying the physician and implementing appropriate treatment contributed to the severity of the wound. The Director of Nursing (DON) was informed of the wound by an LPN, who mistakenly believed they had notified the physician and the family, but had not. The physician was eventually notified, and treatment was ordered, but the resident was transferred to the hospital at the family's request. This incident highlights the facility's failure to follow protocols for skin integrity monitoring and timely communication with medical professionals and family members.
Deficiencies in Chemical Security, Smoking Safety, and Bed Rail Assessment
Penalty
Summary
The facility failed to ensure that chemicals were secured in one of the three halls observed for storage of chemicals. During observations, it was noted that the door to a shower room was left open, despite a sign instructing it to be kept closed. Inside, unsecured chemicals such as Xpress detergent disinfectant, Derma daily moisturizing lotion, and Senegence hand sanitizer were found. Additionally, the nursing supply closet was observed to be unsecured, containing items like wound cleanser and shaving cream, which were also labeled to be kept out of reach of children. Staff acknowledged that these areas were supposed to be locked, but they were not. The facility also failed to properly assess a resident for safe smoking practices. A resident with diabetes and end-stage renal disease was observed smoking unsupervised, with a cigarette hanging from their mouth while their eyes were closed. Although the resident was previously assessed as a safe smoker, the incident was not reported or documented by the staff member who witnessed it. The social services director and DON were unaware of the incident until informed by the surveyor, indicating a lapse in communication and monitoring. Furthermore, the facility did not conduct proper assessments or obtain necessary consents for the use of bed rails for a resident with type two diabetes. The resident was observed using bed rails without an order, consent, or assessment documented in their clinical record. The DON admitted that assessments and consents for bed rails were not routinely performed, highlighting a gap in the facility's protocol for ensuring resident safety regarding bed rail use.
Infection Control Deficiencies in Medication and Care Procedures
Penalty
Summary
The facility failed to maintain infection control during blood glucose monitoring and insulin administration for two residents with diabetes mellitus. An LPN was observed not wearing gloves while obtaining blood glucose and administering insulin. The glucometer was not disinfected between uses, contrary to the manufacturer's instructions and facility policy. The LPN admitted to forgetting to don gloves and incorrectly using alcohol pads instead of the required sanitizing wipes for disinfection. Infection control lapses were also noted during medication administration. A CMA was observed handling medication with bare hands, failing to don gloves or sanitize hands, which is against the facility's policy. Another CMA transferred medication between cups with bare hands, acknowledging the mistake. The DON confirmed that gloves should be used when handling pills to prevent contamination. The facility did not ensure proper infection control during wound care and catheter care. An LPN failed to wash hands between glove changes during wound care for two residents. Additionally, catheter care for a resident was performed without sanitizing hands between glove changes, and the catheter bag was observed touching the floor. The DON stated that handwashing is required between glove changes and that surfaces should be sanitized before placing supplies, even when using wax paper.
Failure to Update Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a care plan was reviewed and updated for a resident with a significant medical condition. The resident was admitted with a diagnosis of a stage four pressure ulcer in the sacral region. Upon review of the resident's clinical record, it was found that there was no documentation of the wound or any wound care in the care plan. The MDS coordinator acknowledged that the wound care had not been documented in the care plan, despite believing it had been added. This oversight occurred for one resident out of the 73 residing in the facility.
Unauthorized Wound Treatment Without Physician Orders
Penalty
Summary
The facility failed to ensure that treatments for non-pressure wounds on a resident's toes were ordered by a physician. The resident had non-pressure wounds on the right third toe and left second toe, as documented in their care plan. However, the wound care provided, specifically the application of Betadine, was not authorized by a physician. LPN #1 applied Betadine to the wounds without obtaining the necessary orders, assuming that the wound physician would have ordered it. This action was taken without notifying the wound physician or documenting the new wounds in the progress notes or wound log. LPN #1 admitted to not following the protocol of notifying the DON and obtaining physician orders for the newly identified wounds. The DON confirmed that the nurses were required to notify the physician and obtain treatment orders for any identified wounds. Despite the resident's care plan and the facility's policy requiring physician authorization for wound treatments, LPN #1 did not adhere to these procedures, leading to the deficiency. The physician later confirmed that they did not recall giving an order for Betadine for the resident's wounds.
Failure to Obtain Daily Weights as Ordered
Penalty
Summary
The facility failed to ensure that daily weights were obtained for a resident as per the physician's order. The resident in question had end-stage renal disease and cardiac issues, necessitating close monitoring of their weight. The physician's order, dated August 1, 2024, required daily weights to be taken during the day shift starting August 2, 2024. However, a review of the electronic clinical record and paper weight logs from August 2, 2024, to September 5, 2024, showed that weights were only recorded 19 times out of 35 opportunities. The deficiency was attributed to a lack of clarity and communication regarding the responsibility for obtaining daily weights. The Director of Nursing (DON) indicated that the restorative aide was responsible for obtaining and documenting the weights, which were then provided to the MDS coordinator for entry into the electronic record. If the restorative aide was unavailable, the charge nurse was supposed to obtain or assign a CNA to take the weights. However, the MDS coordinator stated they only monitored weekly and monthly weights, not daily ones, leading to confusion about who was responsible for ensuring daily weights were recorded as ordered.
Failure to Administer Enteral Formula as Ordered
Penalty
Summary
The facility failed to administer enteral formula as ordered by the physician for a resident who required tube feeding. The resident had a diagnosis that included attention to a gastrostomy and was ordered Nutren 1.5 continuous at 60 ml/hr according to the physician's order dated 07/02/24. However, observations on multiple occasions revealed that the resident was receiving Nutren 1.5 at 50 ml/hr instead of the prescribed 60 ml/hr. An LPN, upon reviewing the electronic clinical record and the label on the formula bag, confirmed the discrepancy and acknowledged the error. The Director of Nursing (DON) also reviewed the records and confirmed the resident was ordered 60 ml/hr, but could not explain why the resident was receiving 50 ml/hr. The DON stated that nurses on each shift were responsible for verifying the correct formula and rate were being administered.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre and post dialysis assessments for a resident with end-stage renal disease who required dialysis three times a week. The resident had a physician's order and a care plan indicating the need for dialysis on specific days, and staff were instructed to monitor for signs of infection, renal insufficiency, and the shunt access site. However, a review of the electronic clinical record revealed that these assessments were not documented. Interviews with staff, including an LPN and the DON, revealed that pre and post dialysis assessments were not performed or documented. The LPN mentioned monitoring for bleeding and nausea but did not document these observations. The DON acknowledged that they were supposed to check on the resident after dialysis, obtain vital signs, and implement any new orders from the dialysis center, but they were unaware that pre and post dialysis assessments were required. The administrator also noted that admitting residents who required dialysis was new to the facility, indicating a lack of awareness and preparation for the necessary care procedures.
Failure to Assess and Inspect Bed Rails for Entrapment Risks
Penalty
Summary
The facility failed to assess and inspect bed rails to identify any risks of entrapment for a resident who utilized bedrails. During an observation, the resident was seen lying in bed with the bed rails in the up position. An LPN stated that the resident used the bed rails to reposition themselves and that bed rails were supposed to be reassessed monthly, with documentation in the electronic clinical record. However, the last assessment for the resident was completed several months prior. A maintenance worker mentioned that they installed or removed bedrails based on orders and addressed any issues reported by CNAs or nurses, but did not routinely check them. The DON noted that bed rails were not usually utilized unless requested by a resident.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the required state agencies within the mandated time frame for two residents. Resident #1, diagnosed with Parkinson's disease and physical debility, was dependent on staff for hygiene and toileting. An allegation of sexual abuse against a CNA was documented on 06/15/24, but the CNA was not reported to the authorities until 06/18/24, three days after the incident. This delay in reporting violated the facility's policy, which requires immediate reporting within two hours of an abuse allegation. Similarly, Resident #2, who had major depressive disorder, dysphagia, intellectual disability, and cognitive impairment, was involved in an incident where possible exploitation was reported. The facility was notified on 06/13/24 about a video involving the resident and two staff members. However, the staff members were not reported to the authorities until 06/14/24, two days after the initial notification from the sheriff's office. The facility's administrator was unaware of the two-hour reporting requirement, which contributed to the delay in reporting these incidents.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care. The resident, who had diagnoses including Parkinson's disease and physical debility, required assistance with activities of daily living (ADLs) and was incontinent of bladder. On a specific date, an LPN and a CNA entered the resident's room to provide incontinent care. Although the door was closed, the privacy curtain was not used, leaving the resident exposed from the waist down when the CNA exited the room to obtain additional supplies. The LPN confirmed that the resident was exposed during this time.
Inadequate Pressure Ulcer Assessment and Monitoring
Penalty
Summary
The facility failed to implement its pressure ulcer policy effectively, resulting in inadequate assessment and monitoring of a new pressure wound for one of the residents. The facility's policy, revised in April 2018, requires a full assessment of pressure ulcers, including location, stage, and measurements. However, the documentation for the resident in question was inconsistent and incomplete, failing to provide necessary details about the pressure ulcer's location, size, and condition. The resident, who had diagnoses including Parkinson's Disease and physical debility, was documented to have various skin issues, including bruises, skin tears, and an unstageable ulcer. Despite these findings, the clinical records lacked comprehensive documentation of the pressure ulcer, with several assessments failing to mention the ulcer's location or provide a description. The inconsistency in documentation persisted over several days, with some assessments noting the presence of pressure ulcers without further details, while others did not mention them at all. The Director of Nursing (DON) acknowledged the discrepancies in the documentation and the lack of proper monitoring of the pressure wound. The DON admitted that the wound should have been measured and documented with each treatment, as per the facility's policy. The failure to maintain accurate and complete records of the resident's pressure ulcer care highlights a significant deficiency in the facility's adherence to its own clinical protocols.
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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