South Pointe Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 5725 South Ross, Oklahoma City, Oklahoma 73119
- CMS Provider Number
- 375365
- Inspections on file
- 32
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at South Pointe Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility did not provide or document advance directive information for several residents, as required. The DON confirmed that the process previously involved only asking about advance directives and recording DNR orders if present, without completing the necessary acknowledgement forms for all residents.
Three residents' assessments were not accurately coded to reflect their current clinical status, including a missed wound, an incorrectly documented feeding tube, and unreported falls. Staff interviews confirmed that the MDS assessments did not match the residents' actual conditions as documented in progress notes and incident reports.
The facility did not provide in-between meal snacks to residents on one hall, as required by policy. Observations showed that no snacks were distributed, and two residents confirmed they did not receive their afternoon snack. The DON acknowledged that snacks were not being offered or distributed at the scheduled time.
Kitchen staff were observed using gloved hands to touch multiple surfaces and then directly handle plated food, including pushing food together and placing rolls on plates, instead of using serving utensils as required. This practice affected all residents who received meals from the kitchen.
Three residents were not offered or did not have documentation of being offered the pneumococcal vaccine as required by facility policy. The Infection Preventionist confirmed that the process for offering and documenting vaccines was not followed for these individuals, resulting in missing records and unadministered vaccines.
The facility did not respond to or provide rationale for grievances raised by residents during council meetings over a six-month period. Issues such as requests for lawn furniture, concerns about food temperatures, and missing laundry items were not addressed, despite facility policy requiring responses to resident concerns.
The facility did not ensure that two residents had access to their personal funds outside of standard banking hours, despite policy and service agreements stating residents could make withdrawals at any time. One cognitively intact resident was unable to access funds for a family member, and a family member of another resident with severe cognitive impairment raised concerns about fund access. The BOM confirmed there was no process for accessing funds after hours.
The facility did not provide quarterly personal fund statements to two residents whose funds were managed by the facility, as required by policy. One resident, who was cognitively intact, reported being unable to access their money and filed a grievance, while a family member of another resident with severe cognitive impairment raised concerns about fund access. The new BOM confirmed that the required statements had not been distributed following the departure of the previous responsible employee.
A contracted laborer provided services without a completed background check, as the HR specialist was unaware of their presence and did not receive the necessary contract agreement or background information. This lapse was attributed to poor communication among administrative staff. At the time, 176 residents were in the facility.
A resident with multiple mental health diagnoses reported being slapped by a staff member during care. The incident was not reported to the Oklahoma State Department of Health within the required two-hour timeframe, as facility policy and federal regulations mandate. The DON confirmed the delay in reporting.
A resident with a history of liver abscess and chronic kidney disease had a physician order for daily abdominal girth measurements, but staff inconsistently documented the actual measurement values, often only recording checkmarks or initials on the TAR. Staff were unclear about notification parameters and did not routinely enter measurement values, resulting in incomplete monitoring as required by the physician's order.
The facility did not obtain laboratory tests as ordered for two residents: one requiring quarterly A1C monitoring for dialysis and another needing monthly Keppra level checks for seizure management. Staff were unable to explain the missed labs, and there was no policy in place to ensure compliance with lab orders.
A resident receiving dialysis did not have a required A1C lab test completed as ordered, and the physician was not promptly notified of the missing result. Staff were unaware of how the lab was missed, and the DON confirmed there was no policy in place for laboratory services.
A resident with anxiety disorder and intact cognition was physically and verbally assaulted by a medication delivery person after intervening in an altercation between the delivery person and a CMA. The incident was witnessed by an LPN, and the resident subsequently reported feeling unsafe, but no interventions were implemented to address these concerns, and required reporting procedures were not followed.
The facility failed to provide adequate supervision and enforce smoking safety protocols, resulting in two residents smoking without staff oversight—one of whom suffered third-degree burns after a fire started in their room. Smoking assessments were not completed as required, and staff interviews confirmed that residents previously kept their own smoking materials and smoked unsupervised, contrary to facility policy.
The facility did not maintain an adequate supply of towels for bathing, with residents and staff reporting frequent shortages and only a small number of towels available for use. Shower beds and chairs were observed to be unclean and in disrepair, with debris, broken parts, and makeshift fixes present. Additionally, a shower hose was missing and broken tiles were found in a shower room, with maintenance issues not consistently reported or addressed. There was no policy in place for maintenance, cleanliness, or towel supply.
Handrails in two shower rooms were found to be loose, wiggling, or hanging off the wall, with exposed screws and metal coverings. CNAs reported the issues to nursing staff, who were responsible for submitting maintenance requests, but the maintenance supervisor was unaware of the problems and no repairs were underway. Staff avoided using affected areas due to safety concerns.
A resident with anxiety disorder and chronic embolism, who was cognitively intact, witnessed a med-delivery person verbally abuse a staff member and attempted to intervene. An LPN observed the med-delivery person make a threatening gesture toward the resident, called 911, and notified the DON and the resident's family. Despite these actions, the incident was not reported to the OSDH as required by policy, and the DON confirmed no report was made.
A resident with anxiety disorder and chronic embolism was involved in a confrontation with a med-delivery person, during which an LPN witnessed the med-delivery person verbally abusing a staff member and making a physical gesture toward the resident. Although 911 was called and the incident was reported to the DON and the resident's family, the care plan was not updated to address the altercation or provide interventions to help the resident feel safe.
A resident with severe cognitive impairment was injured after being pushed by another resident, resulting in a fractured hip requiring surgery. The incident occurred when a CNA, who was present, failed to intervene due to fear of being hit, despite the facility's policy requiring adequate supervision. The facility lacked a specific dementia care policy, and the incident was recognized as neglect by the DON and administrator.
The facility failed to report allegations of abuse involving two residents to the OSDH as required by their policy. An incident report documented that a CNA was reported to have been rough with a resident, leading the resident to feel abused. Despite this, there was no documentation that an incident report was filed with OSDH or that local law enforcement was notified. The investigation included resident interviews, but the facility did not properly investigate negative responses, and there was a lack of communication and documentation regarding follow-up actions.
The facility failed to protect residents from abuse and conduct thorough investigations into abuse allegations. Incidents included physical altercations between residents and rough handling by a CNA. The facility did not document law enforcement notifications or QAPI reviews, as required by their Abuse Prevention policy.
A facility failed to administer and document wound care as ordered for a resident with diabetes and a diabetic wound. The resident had physician's orders for daily wound care on the left ankle and heel, but the Treatment Administration Record (TAR) was blank on specific dates, indicating non-compliance. The DON confirmed that the treatments were not documented or completed as required.
The facility did not ensure residents had access to the grievance procedure, as there was no signage indicating the grievance official or available forms in resident units. Residents were unaware of how to file a grievance, and the DON and Social Services Director confirmed that the grievance procedure information was not posted for resident access.
The facility failed to follow the menu and provide adequate portion sizes during a meal service. A resident did not receive the correct portions or pureed garlic bread as required by their meal card. The dietary aide and CDM acknowledged the inadequacy of the portions served and the failure to adhere to the menu.
The facility did not follow its abuse prevention policy by failing to report suspected abuse incidents involving two residents with significant medical histories. An LPN, aware of the abuse by a CNA, did not notify the DON or administration, leading to their termination. The CNA was also terminated for sleeping on the job.
The facility did not thoroughly investigate abuse allegations involving two residents. A CNA reported another CNA's abusive behavior to an LPN, but no action was taken. The investigation only included interviews with the directly involved staff, and the DON admitted that more staff should have been interviewed.
The facility failed to provide ADL care according to the plan of care for three residents, resulting in multiple missed care opportunities for bed mobility, personal hygiene, toilet use, and bowel and bladder elimination. CNAs confirmed that the blanks in the documentation indicated that the care was not provided.
The facility failed to maintain the cleanliness of the ice machine in the kitchen, as black, brown, and white slimy residue and particles were observed. Maintenance staff confirmed the presence of food particles and noted that the machine was supposed to be cleaned every 30-40 days. The Area Director acknowledged the issue and indicated a need to review the cleaning frequency.
Failure to Educate and Offer Advance Directives to Residents
Penalty
Summary
The facility failed to ensure that residents were educated about and offered the opportunity to create an advance directive, as required. Record review for five sampled residents revealed that no advance directive information had been provided or documented in their electronic health records. The Director of Nursing (DON) confirmed that, prior to March, the facility's practice was to only ask residents about advance directives and document a Do Not Resuscitate (DNR) order in the chart if one existed, rather than completing an advance directive acknowledgement form for all residents. This resulted in multiple residents not having documented evidence of being informed about or offered the opportunity to establish an advance directive.
Inaccurate Coding of Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments were accurately coded to reflect the current status of three residents. For one resident with dementia, heart failure, and COPD, a new open wound was documented in a progress note, but the corresponding quarterly MDS assessment did not indicate the presence of any wounds. Staff interviews confirmed that the wound should have been captured in the assessment. Another resident with severe intellectual disabilities and a history of metabolic acidemia had their feeding tube removed and was not on tube feeding as of a specific date, yet the quarterly assessment inaccurately documented the presence of a PEG tube. Staff confirmed the resident was no longer on tube feeding at the time of the assessment. A third resident with dementia and mobility issues experienced two documented falls within a month, as shown in incident reports. However, the quarterly assessment for this resident indicated no falls had occurred since admission or the previous assessment. Staff interviews acknowledged that the assessment should have included both falls. These discrepancies between clinical documentation and MDS assessments demonstrate a failure to ensure accurate resident assessments.
Failure to Provide Scheduled Snacks to Residents
Penalty
Summary
The facility failed to provide in-between meal snacks to residents on Hall 3, as required by their policy and in accordance with residents' needs and preferences. Observations on Hall 3 revealed that no snacks were offered or distributed to residents during the scheduled snack time. Two residents on Hall 3 reported not receiving their afternoon snack when asked. The Director of Nursing confirmed that snacks were not being offered or distributed to the residents at that time. The facility's policy states that nursing is responsible for distributing snacks delivered by nutritional services, but this was not carried out as observed and reported.
Failure to Minimize Infection Risk During Meal Service
Penalty
Summary
The facility failed to serve the noon meal in a manner that minimized the risk of infection and cross-contamination for all 174 residents who consumed meals prepared in the kitchen. During observation, a cook was seen plating food from the steam table while wearing gloves, but touched various surfaces such as the counter, shelving, and utensils that had also been handled by other staff. The cook then used the same gloved hands to manipulate food on the plates, including pushing food together and placing a roll directly onto the plates. The dietary manager confirmed that staff were expected to use serving utensils and tongs for plating food, not their gloved hands.
Failure to Offer and Document Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that pneumococcal vaccines were offered to three out of five sampled residents reviewed for vaccines. According to the facility's policy, all residents should be offered the pneumococcal vaccine upon admission, and documentation should be maintained regarding whether the vaccine was accepted or declined. However, record review showed that there was no documentation indicating that three residents had been offered the pneumococcal vaccine at the time of their admission. Interviews with the Infection Preventionist (IP) confirmed that the process involved sending letters to families of residents unable to make decisions for themselves and directly asking those who could. The IP also stated that immunization status and decisions were to be documented in the clinical record. Despite this, there was no documentation for the three residents in question, and it was confirmed that at least one resident was due for another pneumococcal vaccine, while another had not received the vaccine at all.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address grievances and concerns raised by residents during resident council meetings over a six-month period. According to the facility's own policy, residents and their representatives are entitled to present concerns or grievances and receive responses from facility authorities. However, review of resident council meeting minutes revealed that no rationale or responses were provided by staff for concerns raised during this time. The administrator confirmed that issues such as requests for lawn furniture, concerns about food temperatures, and missing items in laundry rooms had been brought up by the resident council since November 2024, but acknowledged that the facility had not been addressing these grievances as required.
Failure to Provide Resident Access to Personal Funds During Non-Banking Hours
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds during non-banking hours, as required by their own policy and resident agreements. The policy stated that residents or their legal guardians could request withdrawals from their trust fund accounts at any time. However, the process in place only allowed residents to access their funds through the receptionist, who was available from 8:00 a.m. to 5:00 p.m. daily, including weekends. Outside of these hours, the funds were locked in a safe and there was no process for residents to access their money. This deficiency was identified for two residents. One resident, who was cognitively intact, reported being unable to obtain money from their personal funds to give to a family member and had filed a grievance. Another resident, who was severely cognitively impaired, had a family member express concerns about whether the resident was receiving their money. The Business Office Manager confirmed that there was no process for residents to access their funds outside of the designated hours.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements of personal funds to two of three sampled residents whose funds were managed by the facility. According to the facility's own policy, residents or their legal guardians are to be informed of internal audits and receive quarterly statements regarding their trust accounts. Record review showed that the signature page for the quarterly trust fund statements was left blank for both residents, indicating they did not receive or acknowledge receipt of these statements. One resident, who was cognitively intact, reported being unable to access their personal funds and had filed a grievance about the issue. The other resident, who had severely impaired cognition, had a family member express concerns about whether the resident was receiving their money. Interviews with the new Business Office Manager (BOM) revealed that the previous employee responsible for the trust fund statements had left, and the BOM had not yet completed or distributed the required quarterly statements. The BOM acknowledged that the statements had not been provided and that they were in the process of preparing them, with the deadline for distribution approaching. At the time of the survey, the facility had not ensured that residents or their representatives received the mandated quarterly statements for their personal funds.
Failure to Perform Background Check for Contracted Laborer
Penalty
Summary
The facility failed to perform a background check for a contracted laborer who provided services to residents. Record review showed that the employee file for the contracted laborer did not contain proof that a background check had been completed. During an interview, the HR specialist admitted they were unaware that the contracted laborer was working in the facility until recently and confirmed that the laborer had not returned the required contract agreement or provided information necessary for a background check. The HR specialist also stated they did not know when the contracted laborer began working in the facility, attributing this to a lack of communication among administrative staff and limited presence outside the office. A total of 176 residents were identified as residing in the facility at the time of the deficiency.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with diagnoses including major depressive disorder, seizures, suicidal ideations, and bipolar disorder within the required two-hour timeframe to the Oklahoma State Department of Health. According to the facility's policy, any reasonable suspicion of a crime, such as abuse, must be reported immediately but no later than two hours if abuse or serious bodily injury is suspected. An incident report documented that the resident complained of being slapped on the buttocks by a staff member during incontinent care. Although the incident was reported internally at 5:00 a.m., the report was not faxed to the state health department until 2:37 p.m. the same day, exceeding the mandated reporting window. The Director of Nursing confirmed that the report was not submitted within the required timeframe.
Failure to Document and Follow Physician Orders for Abdominal Girth Measurement
Penalty
Summary
The facility failed to ensure that physician-ordered daily abdominal girth measurements were properly completed and documented for a resident with a history of liver abscess and stage three chronic kidney disease. Although there was a standing order for daily abdominal girth measurement, documentation in the nurse progress notes showed inconsistent recording of measurement values, with several days missing entries between documented measurements. The Treatment Administration Record (TAR) only contained staff initials and checkmarks indicating completion, but did not include the actual measurement values. Staff reported that the system did not provide a field for entering the measurement value on the TAR unless it was manually added, and this was not routinely done prior to the survey. Interviews with staff revealed confusion regarding the parameters for when to notify the physician about changes in abdominal girth, as the order did not specify thresholds for notification. The LPN stated that they measured the resident's abdomen daily but did not have a value to compare the measurements to, and the DON acknowledged that without daily documentation of the measurement values, staff would not be able to identify increases in girth size. The resident confirmed that staff were monitoring their abdomen due to previous liver issues, but the lack of consistent documentation and clear parameters led to a failure in following the physician's order as intended.
Failure to Obtain Ordered Laboratory Tests for Residents
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered for two residents. For one resident with diagnoses including renal dialysis and atrial fibrillation, the physician ordered an A1C test to be performed every three months, but the required test for February was not completed, with the last available result from November. Staff interviews revealed uncertainty about how the lab was missed and indicated there was no policy in place. For another resident with a seizure diagnosis and a physician's order for monthly Keppra level monitoring over three months, only the first month's lab was completed, with no documentation of the required tests for the following two months. Facility staff confirmed that these labs were not obtained as ordered.
Failure to Notify Physician of Missing Lab and Lack of Lab Policy
Penalty
Summary
The facility failed to notify the physician of missing laboratory results and did not have a policy in place for laboratory services. Specifically, a resident with a diagnosis of renal dialysis had a physician order for an A1C test to be performed every three months, with the next test due in February 2025. The laboratory result for February was not found in the records, and the last available A1C result was from November 2024. Staff, including an LPN and the DON, were unaware of how the lab was missed, and the physician was only notified of the missing lab on April 24, 2025. Additionally, the DON confirmed that there was no existing policy for laboratory services at the facility.
Failure to Protect Resident from Abuse by Medication Delivery Person
Penalty
Summary
A deficiency occurred when a resident with anxiety disorder and intact cognition was not protected from mental and physical abuse by an individual delivering medications to the facility. The incident began when the medication delivery person entered through a door after being let in by a certified medication aide (CMA). The delivery person verbally abused the CMA, using profanities and aggressive language. The resident intervened, asking the delivery person to stop, at which point the delivery person physically assaulted the resident by swinging at and striking them in the face. The incident was witnessed by an LPN, who observed the confrontation and the physical act of aggression. Following the assault, the resident reported feeling unsafe and expressed concerns that a similar incident could happen again. The resident did not know the identity of the delivery person but indicated that the administrator and DON would have that information. The police were called, and charges were pressed against the delivery person. Despite the resident's expressed fear and request for increased security, there was no evidence that interventions were put in place to address the resident's ongoing feelings of insecurity after the incident. The facility's abuse prevention policy required protection of residents from abuse by anyone, including outside agency staff. However, the incident was not reported on a state incident report form, and the DON was not aware of the resident's continued feelings of being unsafe. There was a lack of follow-up or implementation of measures to ensure the resident's sense of safety, and the required documentation and reporting procedures were not completed as outlined in facility policy.
Removal Plan
- Trauma informed questionnaire completed for Resident #12 by Social Services. Resident #12 provided with a notebook for journaling and agreed to meet with social services and speak to a psychology service.
- Social Services educated on psychosocial health regarding abuse incidents by the DON. Any residents who do not feel safe will have follow up completed by social services regarding obtaining a referral to psychology services and report findings to DON/LNHA.
- All door codes changed by the Maintenance Director. Signage placed stating 'After 5pm, please go to Unit 400 door and ring doorbell for assistance.'
- Facility staff educated on the new process by Department Heads. Staff will be educated prior to working their next shift.
- Resident safe surveys completed by department heads.
- Social Services to follow up with Resident #12 5 times a week for one month to ensure no signs of fearfulness.
Failure to Supervise Smoking and Enforce Safety Protocols Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for residents who smoked, resulting in a serious incident involving a resident who sustained third-degree burns. One resident, who had diagnoses including unspecified lack of coordination and muscle weakness, was found with a wound dressing on fire in their room. The resident had a history of requiring substantial assistance for personal hygiene and mobility, and their care plan indicated the need for supervised smoking and that smoking materials should be locked up. Despite this, the resident was able to access cigarettes and a lighter in their room, leading to a fire that caused significant injury and required emergency medical attention. Another resident was observed smoking unsupervised in the designated outdoor area, using their own cigarettes and matches, and stated they smoked whenever they wanted. There was no smoking safety evaluation in this resident's clinical record, and staff were unaware that the resident was a smoker. The facility's policy required supervision during smoking and completion of smoking assessments on admission, but these procedures were not consistently followed. Staff interviews confirmed that, prior to the incident, residents often kept their own smoking materials and smoked without supervision, and that the smoking policy was not enforced. Additionally, a review of records revealed that smoking assessments were not completed as required on admission and at quarterly intervals for some residents who smoked. Staff acknowledged lapses in completing these assessments and in enforcing the smoking policy. The lack of supervision and failure to follow established protocols directly contributed to the unsafe conditions and the resulting injury.
Removal Plan
- Complete a smoking safety evaluation for Resident #4 by the DON.
- Educate Resident #4 on the smoking policy, procedures, and smoking times.
- Complete an ad hoc QAPI by the DON.
- Complete a smoking safety evaluation for Resident #7 by Social Services.
- Educate Resident #7 on smoking policy, procedures, and smoking times by Social Services.
- Search resident rooms by Social Services and Unit Managers to ensure no residents have lighters, matches, cigarettes, or vape. Add any items found to the smoking cart.
- Complete a smoking assessment for all residents by the DON, Unit Managers, and Social Services.
- Educate residents that smoke on smoking policy and smoking times.
- Educate staff by the DON/LNHA on smoking policy, procedures, and rounding between smoking times.
- Do not permit residents to smoke without supervision.
- Do not allow staff to work until education is conducted.
- Educate all new employees on smoking policies and procedures prior to working.
- Complete random rounding between smoking times to ensure compliance.
- Bring monitored findings to the monthly QAPI for review.
Failure to Provide Adequate Towels and Maintain Clean, Safe Shower Facilities
Penalty
Summary
The facility failed to provide an adequate supply of towels for bathing, as evidenced by multiple observations and interviews with residents and staff. Residents reported not having towels available for several months, and staff confirmed frequent shortages, with as few as 11 towels available for the entire facility of 182 residents. During multiple walkthroughs, staff and the Director of Nursing were unable to locate sufficient towels in resident halls, shower rooms, or the laundry room, with only a handful of towels found throughout the building. Additionally, the facility did not ensure that shower beds were clean and in good repair. Residents and staff reported that shower chairs and beds were often unclean, with visible debris and substances present. Observations revealed shower beds with smeared substances, debris, and makeshift repairs such as a trash bag holding up a broken undercarriage. Staff stated that cleaning was supposed to occur after each use, but the observed conditions indicated this was not consistently done. Maintenance issues, such as broken shower beds and missing parts, were reported by staff but not always addressed in a timely manner. Further deficiencies included a missing shower hose in one shower room and broken or missing tiles in another, both of which had not been reported or repaired promptly. The maintenance supervisor was unaware of several issues until they were pointed out during the survey, and there was no policy in place regarding maintenance, cleanliness, or towel supply. These failures resulted in residents not having access to a safe, clean, and comfortable environment as required.
Loose and Unsecured Handrails in Shower Rooms
Penalty
Summary
The facility failed to ensure that handrails in two of seven shower rooms (Hall 100 and Hall 200) were firmly secured to the wall. Observations revealed that multiple handrails under the shower heads and on the back wall in these rooms were loose, wiggled easily, or were hanging off the wall, with metal coverings and screws exposed. Certified Nursing Assistants (CNAs) reported being aware of the loose handrails, with one stating it was frightening to use and another noting that the affected side of the shower was avoided for approximately two months due to the issue. CNAs indicated that they reported the problems to nursing staff, who were responsible for entering maintenance requests into the electronic notification system. Despite these reports, the maintenance supervisor stated there were no current repairs in progress and was unaware of the loose handrails until shown by surveyors. The maintenance supervisor acknowledged the danger posed by the loose handrails. The administrator confirmed that the facility did not have a specific policy on handrails and relied on state and federal regulations. At the time of the survey, 182 residents resided in the facility, and seven shower rooms were present.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the Oklahoma State Department of Health (OSDH). According to the facility's Abuse Prevention Policy, all suspected abuse must be reported. In this incident, a resident with anxiety disorder and chronic embolism and thrombosis, who was cognitively intact, witnessed a med-delivery person verbally abusing a staff member and intervened. An LPN observed the med-delivery person make a threatening gesture toward the resident's face, prompting the LPN to call 911 and notify the Director of Nursing (DON) and the resident's family. Law enforcement responded and took statements. However, there was no documentation that the incident was reported to the OSDH as required, and the DON confirmed that no such report was made.
Failure to Update Care Plan After Resident Involved in Altercation
Penalty
Summary
The facility failed to update the care plan for a resident following a significant incident involving a confrontation with a medication delivery person. The resident, who had diagnoses including anxiety disorder and chronic embolism and thrombosis of other specified veins, was observed by an LPN to intervene when the med-delivery person verbally abused a staff member. The situation escalated when the med-delivery person made a physical gesture towards the resident's face, prompting the LPN to call 911 and notify the DON and the resident's family. Despite this event, the resident's care plan was not updated to address the physical altercation or to include interventions to help the resident feel safe after the incident. Record review and staff interviews confirmed that the care plan did not reflect any changes or interventions related to the altercation. The facility's policy required that care plans be person-centered and updated for changes in events, such as falls or behavioral incidents. The MDS coordinator acknowledged that the care plan should have been updated in response to the altercation but confirmed that this was not done.
Neglect in Resident Supervision Leads to Injury
Penalty
Summary
The facility failed to ensure residents were free from neglect, as evidenced by an incident involving two residents with severe cognitive impairments. Resident #3, who had diagnoses including dementia, depression, psychosis, and schizophrenia, took a water pitcher from the medication cart and poured it on Resident #2, who also had dementia and severe cognitive impairment. This led to Resident #2 forcefully pushing Resident #3 to the ground, resulting in a fractured hip that required surgery. The incident was observed by CNA #1, who did not intervene to prevent the altercation. The facility's Abuse Prevention policy defines neglect as the failure of an employee to provide necessary services to maintain the health and safety of residents, including adequate supervision to prevent injury. Despite this policy, CNA #1, who was present during the incident, did not take action to separate the residents. The CNA later stated they were afraid to intervene due to past experiences of being hit by residents and had only worked on the hall two other times. The DON acknowledged that CNA #1 should have intervened and that the incident constituted a neglectful act. The facility lacked a specific policy on dementia care, relying instead on the general abuse policy. The DON and the administrator both recognized the incident as neglect, with the administrator noting that CNA #1 appeared scared but did not inquire further. The incident highlights a failure in supervision and intervention, leading to serious injury to Resident #3.
Failure to Report Allegations of Abuse to Authorities
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the Oklahoma State Department of Health (OSDH) as required by their Abuse Prevention policy. The policy mandates that the Administrator or designee report any allegations of abuse, neglect, or misappropriation of resident property to the Department of Health. An incident report dated 09/01/24 documented that a CNA was reported to have been rough with a resident and failed to provide proper care, leading the resident to feel abused. Despite this, there was no documentation that an incident report was filed with OSDH or that local law enforcement was notified. The investigation into the allegations included interviews with ten residents, two of whom reported negative experiences. One resident expressed feeling unsafe due to their roommate's company, while another confirmed that staff were rough during care. The Director of Nursing (DON) and the Social Services Assistant (SSA) acknowledged that the investigation was not adequately followed up, and the SSA admitted to only completing a grievance form instead of a state reportable investigation. The facility did not properly investigate the negative responses from the resident interviews, and there was a lack of communication and documentation regarding the follow-up actions required by the facility's policy.
Failure to Protect Residents and Investigate Abuse Allegations
Penalty
Summary
The facility failed to protect residents from abuse and conduct thorough investigations into allegations of abuse involving several residents. The incidents involved physical altercations between residents and allegations of rough handling by a CNA. In one incident, a charge nurse responded to yelling and found two residents involved in a physical altercation, but there was no documentation of law enforcement notification or QAPI review. Another incident involved a resident reporting rough handling by a CNA, but again, there was no documentation of law enforcement notification or QAPI review. The facility's Abuse Prevention policy requires immediate investigation and protection of alleged victims, as well as reporting to law enforcement and review by the Interdisciplinary Team during QAPI meetings. However, the facility did not document law enforcement notifications or QAPI reviews for any of the incidents. The SSA and DON confirmed the lack of documentation and QAPI reviews for the incidents, indicating a failure to adhere to the facility's policy and regulatory requirements.
Failure to Administer and Document Wound Care
Penalty
Summary
The facility failed to ensure that medication and treatments were administered as ordered for a resident with diagnoses including type two diabetes mellitus and a diabetic wound. The resident had physician's orders for wound care on the left ankle and left heel, scheduled to be changed once daily on the day shift. However, the Treatment Administration Record (TAR) was blank on specific dates, indicating that the treatments were not documented as completed. The Director of Nursing (DON) confirmed that if treatments were not documented, they were not given, and acknowledged that the wound care orders were not followed.
Failure to Provide Access to Grievance Procedure
Penalty
Summary
The facility failed to ensure that residents had access to the grievance procedure and did not post information regarding the name of the grievance official. During a tour of the facility, it was observed that while there was a poster near the main dining room entrance with ombudsman contact information, resident rights, and the facility's senior management concern procedure, there was no signage indicating the person to contact for filing a grievance or available forms in the resident units. Interviews with residents revealed that they were unaware of who the grievance official was or how to file a grievance. The Director of Nursing (DON) stated that social services were responsible for grievances, but the Social Services Director confirmed that the grievance procedure and responsible official's information were not posted for resident access.
Inadequate Portion Sizes and Menu Non-Compliance
Penalty
Summary
The facility failed to ensure that the menu was followed and that adequate portion sizes were offered to residents during a meal service. The facility's policy on nutritional services menus, revised on 03/31/21, requires that menus be followed as reviewed and approved by a Registered Dietitian. However, during an observation on 08/12/24, it was noted that the menu for a regular/NAS lunch and a pureed lunch was not adhered to. Specifically, the portions served did not match the documented menu, which called for specific amounts of meat sauce, spaghetti noodles, Italian vegetable blend, and garlic bread. During the meal service, a resident expressed that they sometimes did not receive enough food. The dietary aide served meals with incorrect portion sizes, using tools that did not match the required serving sizes. The resident's meal card indicated a need for a regular diet with nectar thick fluids, puree, and double portions, but the resident did not receive the correct portions or the pureed garlic bread as required. The dietary aide and the CDM both acknowledged the inadequacy of the portions served and the failure to follow the menu, as well as the inability to determine the serving sizes of the tools used.
Failure to Report Abuse Incidents
Penalty
Summary
The facility failed to implement its abuse prevention policy by not immediately reporting suspected abuse incidents involving two residents. The policy, dated 10/21/22, requires that the Administrator and Director of Nursing (DON) be promptly notified of any suspected abuse. However, a State Incident Investigation Report dated 05/17/24 revealed that the DON was informed of an incident where a Certified Nursing Assistant (CNA) was abusive to two residents, but the Licensed Practical Nurse (LPN) who was aware of the issue did not report it to the DON or facility administration. The two residents involved had significant medical histories, including dementia, psychosis, cerebral infarction, insomnia, major depressive disorder, and anxiety. The LPN admitted to handling the allegation independently without notifying the DON, leading to their termination for not following the facility's abuse policy. Additionally, the CNA was terminated for sleeping on the job.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents. The facility's policy on Abuse Prevention mandates that any allegations of abuse, neglect, misappropriation of property, or mistreatment must be thoroughly investigated. An allegation was reported to the Oklahoma State Department of Health, indicating that a CNA accused another CNA of being abusive towards two residents. The allegation was initially reported to an LPN, but no action was taken. The investigation conducted by the facility included interviews with only the three staff members directly involved in the incident. The Director of Nursing acknowledged that they should have interviewed additional staff members who worked with those involved to ensure a comprehensive investigation.
Failure to Provide ADL Care According to Plan of Care
Penalty
Summary
The facility failed to ensure that activities of daily living (ADL) care was provided according to the plan of care for three residents. Resident #7, who required assistance with personal care, had multiple instances of missed care in April 2024, including bed mobility, personal hygiene, toilet use, and bowel and bladder elimination. CNA #3 confirmed that the blanks in the documentation indicated that the care was not provided. Similarly, Resident #8, who had a self-care performance deficit and required staff participation, had numerous missed care opportunities in February, March, and April 2024. CNA #2 confirmed that the blanks in the documentation meant the care was not done, indicating that the resident did not receive care per their plan of care. Resident #1, who also needed assistance with personal care, had significant gaps in ADL documentation for January 2024 and December 2023. The missed care opportunities included checks every two hours, bed mobility, personal hygiene, and toilet use. CNA #2 confirmed that the blanks in the documentation meant the care was not provided. The consistent failure to document and provide the required care as per the residents' care plans highlights a significant deficiency in the facility's adherence to its policies on turning and repositioning and incontinent care.
Ice Machine Cleanliness Deficiency
Penalty
Summary
The facility failed to ensure the ice machine in the kitchen was clean and free from debris. During an observation with the Dietary Manager and Maintenance staff, black, brown, and white slimy residue and particles were found at the right bottom corner of the machine, on the other side of the coils above the ice bin. Maintenance staff confirmed the presence of food particles and stated that the machine was supposed to be cleaned every 30-40 days, with the last cleaning having been done recently. The Area Director acknowledged that stagnant water could lead to slime and mold formation and indicated a need to review the cleaning frequency given the high usage of ice.
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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