Sienna Extended Care & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Midwest City, Oklahoma.
- Location
- 9221 Harmony Drive, Midwest City, Oklahoma 73130
- CMS Provider Number
- 375534
- Inspections on file
- 31
- Latest survey
- April 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sienna Extended Care & Rehab during CMS and state inspections, most recent first.
The facility did not ensure that the most recent state survey results were readily accessible to residents, family members, or legal representatives, as required by policy and resident rights. Despite posted notices indicating availability, the survey results could not be located by staff or administration, and the binder intended for these documents was empty. Residents reported never seeing the survey results and described barriers when requesting access.
The facility maintained resident trust account balances that exceeded the coverage amount of its surety bond, with account balances surpassing $40,000 while the bond covered only $25,000. The DON identified 11 residents with funds in the account. The administrator acknowledged the discrepancy and attributed it to an increased number of residents, stating that the facility relied on FDIC insurance for additional protection.
Residents repeatedly voiced grievances about dietary services, including food shortages, meal delays, and reduced portions, and reported feeling that their complaints led to retaliation, such as further reductions in food variety and quantity. Despite ongoing complaints documented in resident council meetings, issues remained unresolved, and staff were unclear on procedures for addressing allegations of retaliation.
Two residents had inaccurate MDS assessments: one resident's quarterly assessment failed to indicate ongoing hospice care, and another's annual assessment did not reflect regular dialysis treatments, despite supporting documentation and staff confirmation.
Staff failed to adhere to infection prevention protocols by not wearing required gowns and gloves during care of a resident on enhanced barrier precautions, and by improperly handling soiled linen and neglecting hand hygiene between resident care activities. These lapses occurred despite clear facility policies and the presence of infection control signage and supplies.
A resident with severe cognitive impairment experienced unauthorized charges to their debit card, with funds deposited into a CNA's cash app account. The facility did not conduct interviews with other residents or staff after being notified of the misappropriation, and the only related inservice had occurred prior to the incident. The CNA was terminated after the allegation was reported, and the incident was reported to authorities.
The facility did not ensure timely reporting of suspected abuse and misappropriation of property, failing to notify APS and the state agency as required. In two cases involving missing money and a missing phone, residents and their families reported the incidents, and police were involved, but there was no documentation of required notifications to APS or timely state reporting. Staff interviews revealed a lack of awareness of reporting requirements.
Three residents with non-pressure skin conditions did not receive weekly skin assessments as ordered by their physicians. In each case, required documentation was missing for extended periods, and staff interviews revealed confusion about responsibility for completing assessments. Observations included a resident with an untreated open wound and another with persistent dry, flaky skin, with no recent assessments or treatment orders documented.
A resident with COPD did not receive oxygen therapy as ordered, with the concentrator set at 2 liters per minute instead of the prescribed 5 liters. Nursing staff failed to verify the flow rate during checks, despite facility policy requiring adherence to physician orders.
The facility allowed the maintenance supervisor, who is not authorized to administer medications, to access medication storage rooms containing residents' medications without the presence of licensed nursing staff. Staff interviews confirmed that maintenance, nurses, and medication aides all had access, contrary to facility policy that restricts access to only qualified personnel.
The facility did not ensure that the dietary manager obtained certification as a certified dietary manager within the required timeframe. The DM, employed since 2011, had not completed the necessary certification or alternative qualifications, and this was confirmed by both the DM and the administrator. Most residents received meals from the cafeteria overseen by the uncertified DM.
The facility did not provide required dementia management training to staff caring for residents with dementia. An LPN who had been at the facility for a year reported not receiving such training, and there was no documentation of dementia care in-services for staff during the relevant period. Two residents with severe cognitive impairment and behavioral issues were among those affected, and the facility had no mandatory requirement for staff dementia training.
A facility failed to ensure medications were administered as ordered for a resident with sepsis and cellulitis. The MAR showed missed doses of ceftriaxone sodium and normal saline flushes. The DON and LPNs confirmed that blanks on the MAR indicated the medication was not given.
Failure to Make State Survey Results Accessible to Residents
Penalty
Summary
The facility failed to make the most recent state survey results readily accessible to residents, family members, and legal representatives, as required. Although a framed notice was posted outside the dining room indicating that survey results were available on a table at the north end of the main entrance, the surveyor did not find any survey results on the indicated table. The facility's policy stated that the most recent survey results should be maintained in a 3-ring binder in an area frequented by most residents, such as the main lobby or activity room. However, when the activity director and administrator were asked about the location of the survey results, neither could locate them, and the binder produced by the administrator was empty. Interviews with the resident council revealed that they had never seen the state survey results and that staff questioned their reasons when they requested to view them. The activity director, responsible for the resident council, was also unaware of the survey results' location. The facility's own Resident's/Patient's Rights form stated that residents have the right to examine the last state survey, and denial of this right could result in penalties. Despite these policies and notices, the survey results were not accessible as required at the time of the survey.
Resident Trust Account Balances Exceeded Surety Bond Coverage
Penalty
Summary
The facility failed to ensure that the total amount of resident funds held in the facility trust account did not exceed the coverage provided by the facility's surety bond. Record review showed that the trust account balances at several points in time were significantly higher than the $25,000 surety bond, with balances reaching over $40,000. The Director of Nursing identified 11 residents with funds in the trust account. During interviews, the administrator acknowledged that the surety bond was intended to protect resident funds but stated that the facility relied on the bank's FDIC insurance for additional protection, considering the surety bond as redundant. The administrator also noted that an increase in the number of residents likely contributed to the higher account balances, and admitted that the facility should have monitored the account amounts more closely.
Failure to Protect Residents' Right to Voice Grievances Without Retaliation
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal and did not promptly resolve grievances raised by the resident council. Resident council meeting minutes over several months documented repeated complaints about dietary issues, including being out of requested food items, food not being served as ordered, meals being late, and dissatisfaction with the quality and temperature of meals. Despite meetings with the dietary manager and assurances that issues were resolved, the same complaints persisted in subsequent meetings, and documentation of how issues were resolved was often incomplete or missing. Residents reported that after voicing complaints, particularly about receiving greens daily, the facility reduced the variety and quantity of food items, such as cutting breakfast bacon portions. Residents expressed that this reduction felt retaliatory, stating that complaining led to negative consequences, including longer wait times for meals and incomplete orders. Interviews with the activity director confirmed that dining complaints were ongoing and that the process for addressing retaliation was unclear, as they were unaware of any established procedure for residents who felt retaliated against.
Inaccurate Coding of Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents. For one resident who began hospice services, the quarterly Minimum Data Set (MDS) assessment did not reflect their hospice status, despite documentation in the hospice contract and care plan indicating ongoing hospice care. The MDS coordinator confirmed that the assessment was coded incorrectly. For another resident requiring dialysis three times a week due to renal failure, the annual MDS assessment inaccurately indicated that the resident had not received dialysis in the facility during the assessment period, despite care plans and physician orders confirming regular dialysis treatments. The MDS coordinator acknowledged the inaccuracy in the assessment coding for this resident as well.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to follow evidence-based practices (EBP) for infection prevention and control during the care of a resident on enhanced barrier precautions. A certified nursing assistant (CNA) provided care to a resident with a PEG tube, who was on EBP, without donning a gown as required by facility policy. The CNA assisted the resident with toileting, changing clothing, and stripping bedding without wearing a gown, despite EBP signage and the availability of gowns and gloves at the room entrance. The CNA later acknowledged not following the EBP process, and the Director of Nursing confirmed that residents with PEG tubes require both gown and gloves for care activities under EBP. Additionally, the facility did not ensure proper handling of dirty linen and hand hygiene between resident care activities. A CNA was observed transporting unbagged soiled clothing through the hallway while wearing gloves, contrary to facility policy, and did not wash or sanitize hands between setting up meal trays for different residents. The CNA admitted to not knowing the hand hygiene policy and was observed performing multiple tasks for residents without appropriate hand hygiene. The administrator later clarified that dirty linen should be bagged, gloves should not be worn in the hallway, and hand hygiene is required between residents.
Failure to Prevent and Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to protect a resident from misappropriation of property by a staff member. A resident with severe cognitive impairment was found to have six unauthorized charges on their debit card, including four withdrawals deposited into a cash app account belonging to a CNA employed at the facility. The charges were discovered by the resident's family, who reported the incident to the facility and filed a police report. The resident's bank confirmed the cash app account was in the CNA's name, and the card was also used at a food establishment and a gas station. The facility's abuse, neglect, exploitation, and misappropriation prevention program required identification and investigation of all possible incidents of misappropriation. However, after being notified of the incident, the facility did not conduct interviews with other residents or staff regarding the misappropriation allegation. The DON stated that no additional residents were interviewed because they did not have similar bank cards, and no staff were interviewed in relation to the incident. The only documentation related to the investigation consisted of some statements, and the only inservice related to misappropriation was conducted prior to the incident. The CNA implicated in the misappropriation had not worked at the facility since before the incident was reported but remained on the PRN rotation until being terminated after the allegation surfaced. The facility was notified of the unauthorized charges after the resident had already been discharged. The administrator and DON confirmed that the incident was reported to the appropriate authorities, but no further internal investigation or interviews were conducted with other potentially affected individuals.
Failure to Timely Report Suspected Abuse and Misappropriation to Authorities
Penalty
Summary
The facility failed to ensure timely and proper reporting of suspected abuse, neglect, or misappropriation of resident property as required by policy and regulation. In two cases, allegations of misappropriation involving residents' personal property were not reported to Adult Protective Services (APS), and in one case, the initial report to the state agency was not made within the required two-hour timeframe. The facility's policy mandates immediate reporting of such suspicions to the administrator and appropriate authorities, including APS and the state licensing agency, but documentation and staff interviews revealed these steps were not consistently followed. One resident, with intact cognition and diagnoses including diabetes mellitus and angina pectoris, reported missing money on two separate occasions. The resident stated that the police were notified both times, and facility documentation confirmed that the administrator, family, and physician were also informed. However, there was no evidence that an initial incident report was filed with the state agency within two hours, nor was there documentation that APS had been notified. Staff interviews indicated a lack of awareness regarding the requirement to notify APS in cases of suspected abuse or misappropriation. In another instance, a resident's family reported a missing phone, which was last seen on the bedside table and later believed to have accidentally fallen into a waste basket. The police were involved, and the family, physician, and resident were notified. Despite this, there was no documentation of an initial facility-reported incident for this allegation, nor evidence that APS had been notified. The DON confirmed unawareness of the requirement to report such incidents to APS, contributing to the facility's failure to comply with mandated reporting protocols.
Failure to Complete Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to complete weekly skin assessments as ordered for three residents with non-pressure skin conditions. For one resident with peripheral autonomic neuropathy and protein-calorie malnutrition, the last documented skin assessment was several months prior to the survey, despite a physician's order for weekly assessments. Nursing staff confirmed that no recent skin evaluations were present in the medical record. Another resident with chronic obstructive pulmonary disease and moderate cognitive impairment was observed to have moderate white, dry flakes on the face and head. Although there was a physician's order for weekly skin assessments, the last documented assessment was several weeks prior. Nursing staff were unaware of any treatment orders for the skin condition and could not confirm how long the issue had been present. The DON acknowledged that weekly assessments were not being completed as ordered and that responsibility for these assessments had shifted among staff without proper follow-through. A third resident was observed with an open wound on the right lower leg. Although there was a physician's order for weekly skin assessments and documentation of findings, there were no weekly assessments recorded for over two months. The DON and nursing staff identified a system error that resulted in the failure to generate and complete the required assessments after the departure of the wound care nurse. Review of shower sheets completed by CNAs did not document the resident's current wound, and staff interviews confirmed a lack of proper skin assessment documentation during the relevant period.
Failure to Administer Oxygen as Ordered for Resident with COPD
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of chronic obstructive pulmonary disease (COPD) did not receive oxygen therapy as ordered by the physician. The physician's order specified continuous oxygen via nasal cannula at 5 liters per minute, with titration to maintain oxygen saturation above 90%. However, observations revealed that the resident's oxygen concentrator was set to deliver only 2 liters per minute. Nursing staff confirmed the concentrator was set at 2 liters and acknowledged the order was for 5 liters, but did not verify the flow rate during their checks, only noting the resident's oxygen saturation was 93%. The facility's policy required staff to follow physician orders for oxygen administration, but this was not done in this instance.
Unrestricted Access to Medication Storage Rooms by Non-Qualified Staff
Penalty
Summary
The facility failed to ensure that access to medication storage rooms was limited only to qualified staff, as required by policy. During multiple observations, the maintenance supervisor was able to open medication storage rooms using their own key without the presence of licensed nursing personnel. On several occasions, the maintenance supervisor accessed these rooms alone or called for a nurse only after the room was already open. Both the medication storage room by the DON's office and the one on hall 500 contained numerous containers of residents' medications at the time of access. Interviews with staff confirmed that the maintenance supervisor, along with nurses and medication aides, had access to the medication storage rooms. The DON stated that the maintenance supervisor was allowed access due to the presence of a fire panel control in one of the rooms, but was supposed to be accompanied by nursing staff. Facility policy, however, specified that only licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications should have access to the medication supply. No controlled medications were reported to be stored in these rooms at the time.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the dietary manager (DM) completed the required certification as a certified dietary manager within three years of employment, as mandated by state regulations. The DM was hired on 11/22/2011 and, as of the time of the survey, had not obtained the certification. Documentation confirming completion of the certification was not available, and the DM confirmed during interview that although they had started the classes, they never completed them and did not possess any alternative qualifications accepted by regulation. The administrator acknowledged that the DM was expected to become certified within three years and believed the classes had been completed, but this was not substantiated by records or the DM's statements. At the time of the survey, the facility had 68 residents, with 66 receiving meals from the cafeteria managed by the uncertified DM.
Lack of Dementia Management Training for Staff
Penalty
Summary
The facility failed to provide dementia management education to staff members responsible for the care of residents with dementia. Specifically, one LPN who had been employed at the facility for a year reported not receiving any dementia management training during 2024 and 2025. Record review confirmed there was no documentation of staff in-service or training on dementia management for the period between April 2024 and April 2025. The Director of Nursing confirmed that no in-service training on dementia care had occurred during this time frame, and the administrator stated there was no mandatory requirement for all staff to participate in dementia management training. At the time of the deficiency, the facility had 18 residents diagnosed with dementia, including residents with severe cognitive impairment and behavioral issues such as yelling, throwing food, and disorganized thinking.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for one resident reviewed for intravenous medications. The resident had diagnoses including sepsis and cellulitis of the left upper arm. A physician's order dated 09/19/23 required ceftriaxone sodium injection solution to be administered intravenously once a day for eight days starting 09/20/23. Another order dated 09/20/23 required a normal saline flush every shift. The September Medication Administration Record (MAR) showed blanks on 09/25 and 09/26/23 for the ceftriaxone sodium and four blanks out of 21 opportunities for the flush. The Director of Nursing (DON) and two Licensed Practical Nurses (LPNs) confirmed that blanks on the MAR indicated the medication was not given and if it was not documented, it was assumed not to have been administered.
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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