Southern Pointe Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Colbert, Oklahoma.
- Location
- 101 Sherrard Drive, Colbert, Oklahoma 74733
- CMS Provider Number
- 375469
- Inspections on file
- 25
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Southern Pointe Living Center during CMS and state inspections, most recent first.
A resident with diabetes and hemiplegia, identified as being at increased risk for pressure ulcers, was not properly assessed or monitored for skin integrity. Required weekly skin assessments were not documented, and no evidence of wound care or physician notification was found prior to the resident's hospital transfer, where multiple unstageable pressure injuries were discovered. Staff interviews confirmed the lack of documentation and inservices addressing skin assessments, resulting in a deficiency for neglect.
A resident with diabetes and hemiplegia, identified as being at increased risk for pressure ulcers, was not properly assessed or monitored for skin integrity over a two-week period. Upon hospital admission, multiple unstageable pressure injuries and a deep tissue injury were discovered, despite facility policy requiring regular skin assessments and reporting. The facility did not document or communicate these wounds prior to transfer, and the family was not informed of any skin issues.
The facility failed to develop comprehensive care plans for two residents, one related to nutrition and the other to elopement risk. One resident experienced significant weight loss without a nutrition care plan, while another, identified as an elopement risk, eloped from the facility before an elopement risk care plan was initiated.
The facility failed to follow physician orders for three residents, leading to deficiencies in care. One resident's meal intake was not properly documented, and two residents with diabetes had high blood sugar levels without the required physician notification. The DON confirmed these lapses in adherence to prescribed care plans.
The facility failed to follow the pureed diet menu for three residents, omitting cornbread from their meal despite it being listed on the menu. The dietary manager acknowledged the mistake, citing nervousness as the cause.
The facility failed to ensure accurate resident assessments for two residents. One resident's significant change assessment did not correctly document the contraindication date for a GDR of medications. Another resident's discharge assessment incorrectly classified a fall with a hand fracture as a minor injury instead of a major injury.
The facility failed to notify OHCA of a new diagnosis of Bipolar disorder for a resident who already had serious mental illness diagnoses. This oversight was confirmed by a corporate nurse.
The facility failed to complete a PASRR I screening for a newly admitted resident diagnosed with Schizoaffective disorder. The resident later received additional diagnoses of major depressive disorder and bipolar disorder. A PASRR I was eventually completed but did not document the resident's serious mental illness. The corporate nurse confirmed the PASRR I was completed late and could not be found on admission.
A resident with dementia and mood disorder, identified as an elopement risk, eloped from the facility due to inadequate assessment and monitoring. The care plan did not include an elopement risk plan, and the elopement risk assessment was not completed as per policy. The resident was later found and transferred to a geri-psych facility.
The facility failed to conduct pain assessments for two residents, leading to unmanaged pain despite visible discomfort and complaints. The DON and MDS coordinator acknowledged the lack of required pain assessment components and were unaware of the residents' unrelieved pain.
The facility failed to complete a Medication Regimen Review (MRR) within the required time frame for a resident with severe cognitive impairment and multiple psychotropic medications. The physician's response to the MRR exceeded the 30-day policy requirement.
The facility failed to ensure that a resident did not receive psychotropic medication unless for a specific diagnosed condition. The resident, with severe cognitive impairment, received multiple psychotropic medications without appropriate diagnoses. Both the DON and the pharmacist acknowledged the need for diagnosis clarification.
A resident with chronic conditions and cognitive intactness was denied the right to receive a visitor of their choice due to the administrator's concerns about the visitor's past employment at the facility. The resident's right was eventually restored after intervention by the resident council president and the ombudsman.
Failure to Assess and Monitor Skin Integrity Resulting in Neglect
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes mellitus type II and hemiplegia was not properly assessed or monitored for skin integrity, despite being at increased risk for pressure ulcers. Upon admission, the resident had no documented skin issues, and a quarterly assessment confirmed no skin concerns while indicating a Braden score of 16, which placed the resident at increased risk for pressure injury development. However, there was no documentation of weekly skin assessments or monitoring between late January and early February, and no evidence that the resident received treatment for pressure ulcers or injuries during this period. The facility's policies required regular skin assessments and prompt reporting of any changes in skin integrity, but these procedures were not followed. Certified Nursing Assistant (CNA) documentation did not indicate any skin issues, and there was no record of staff conducting or documenting the required weekly skin assessments. Additionally, there was no documentation of wound care or physician notification regarding any skin breakdown prior to the resident's transfer to the hospital. When the resident was transferred to the hospital for altered mental status and slurred speech, a hospital wound consult identified multiple unstageable pressure injuries and a deep tissue injury that had not been previously documented by the facility. Interviews with facility staff confirmed that no wounds were documented prior to the resident's readmission, and no inservices had been conducted to address the lack of skin assessments. This failure to assess, monitor, and document the resident's skin condition resulted in neglect and a deficiency related to the resident's right to be free from neglect.
Failure to Assess and Monitor At-Risk Resident for Pressure Ulcers
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident at risk for pressure ulcers was properly assessed and monitored to prevent the development of pressure ulcers. The resident, who had a history of diabetes mellitus type II and hemiplegia following a cerebral infarction, was admitted without any skin concerns and was identified as being at increased risk for pressure ulcers based on a Braden score of 16. Despite this risk, there were no documented skin assessments for the resident between late January and early February. On February 10th, the resident was transferred to the hospital for altered mental status and slurred speech, with no documentation of skin concerns at the time of transfer. However, upon hospital admission, multiple unstageable pressure injuries and a deep tissue injury were identified on the resident's buttock and coccyx. The facility's own policy required regular assessment and monitoring of skin integrity, as well as prompt reporting of any changes, but these procedures were not followed for this resident. Interviews confirmed that there was no documentation of wounds prior to the resident's hospital admission, and the family was not informed of any skin issues by the facility. The hospital documented the pressure ulcers as present on admission, indicating that the facility failed to identify and report these injuries prior to the resident's transfer.
Failure to Develop Comprehensive Care Plans for Nutrition and Elopement Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, one related to nutrition and the other related to elopement risk. Resident #22, who had diagnoses including muscle wasting, atrophy, hypokalemia, and vitamin deficiency, experienced significant weight loss from 241 pounds to 205 pounds without being on a physician-prescribed weight loss program. Despite the resident's admission assessment and quarterly assessment indicating nutritional concerns, no nutrition care plan was developed. The resident reported stomach pain after breakfast and a lack of appetite, contributing to the weight loss, but expressed no concern about the weight loss itself. The MDS coordinator confirmed that no nutrition care plan was in place for this resident. Resident #50, diagnosed with dementia and mood disorder, was identified as an elopement risk upon admission. Despite this, no elopement risk care plan was initiated. The resident eloped from the facility through a torn window screen and was later found and transferred to a geri-psych facility. Upon returning to the facility, an elopement risk care plan was finally initiated. RN #2 confirmed that the elopement risk care plan was not started until after the resident's return from the geri-psych facility, despite the initial identification of the elopement risk.
Failure to Follow Physician Orders for Three Residents
Penalty
Summary
The facility failed to follow physician orders for three residents, leading to deficiencies in care. Resident #22, who had diagnoses including muscle wasting and atrophy, hypokalemia, and vitamin deficiency, had a physician order to document meal and fluid intake. However, the meal percentage documentation was incomplete for several days in March and April, as confirmed by the Director of Nursing (DON). This lack of documentation indicates a failure to adhere to the prescribed care plan for the resident's nutritional monitoring. Resident #1, diagnosed with diabetes, had a physician order for insulin administration based on blood sugar levels, with instructions to notify the physician if blood sugar exceeded 350. On multiple occasions in February and March, the resident's blood sugar levels were above 350, but there was no documentation that the physician was notified. Similarly, Resident #34, also diagnosed with diabetes, had a physician order for insulin administration with a requirement to notify the physician if blood sugar was above 350. On three occasions in March, the resident's blood sugar exceeded 350, but there was no documentation of physician notification. The DON confirmed that the nurses failed to call the physician as required by the orders.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to ensure that menus were followed for one meal service for residents on a pureed diet. On 04/03/24, during meal preparation, the dietary manager (DM) pureed cherry cobbler, cabbage, sausage, and potatoes but did not include cornbread, which was listed on the menu. The menu specified that residents on a pureed diet should receive a #10 scoop of cornbread. The DM acknowledged the omission of cornbread, attributing it to nervousness. This deficiency affected three residents who required pureed meals.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate resident assessments for two of the twelve sampled residents. One resident with diagnoses including COPD, Bipolar disorder, Schizoaffective disorder, and dementia had a significant change assessment that did not accurately document the contraindication date for a gradual dose reduction (GDR) of medications. The corporate nurse consultant identified that the contraindication should have been dated earlier. Another resident with osteoporosis fell and sustained a left hand fracture, but the discharge assessment incorrectly documented the fall as a minor injury instead of a major injury. The MDS Coordinator was unsure about the classification of the injury according to the RAI manual.
Failure to Notify OHCA of New Mental Health Diagnosis
Penalty
Summary
The facility failed to notify the Oklahoma Health Care Authority (OHCA) of a new diagnosis of serious mental illness for a resident. The resident was admitted with diagnoses including Schizoaffective disorder and major depressive disorder. A PASRR I assessment completed did not document the resident's serious mental illness. Later, the resident received a new diagnosis of Bipolar disorder, unspecified, but OHCA was not contacted regarding this new diagnosis. This failure was confirmed by a corporate nurse.
Failure to Complete PASRR I Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to complete a PASRR I screening for a newly admitted resident diagnosed with Schizoaffective disorder. The resident was admitted on an unspecified date and did not have a PASRR I completed at the time of admission. The resident later received additional diagnoses of major depressive disorder and bipolar disorder. A PASRR I was eventually completed, but it did not document the resident's serious mental illness. The corporate nurse confirmed that the PASRR I was completed late and could not be found on admission.
Failure to Properly Assess and Monitor Elopement Risk
Penalty
Summary
The facility failed to ensure a resident at risk for elopement was properly assessed and monitored to prevent elopement. The resident, who had diagnoses including dementia and mood disorder, was identified as an elopement risk upon admission. However, the comprehensive care plan did not include an elopement risk care plan at that time. The resident eloped from the facility through a torn window screen and was later found and transferred to a geri-psych facility. Upon the resident's return, the elopement risk care plan was still not updated, and an elopement risk assessment had not been completed as per the facility's policy. RN #2 reported that they did not initiate an elopement risk care plan until after the resident returned from the geri-psych facility. Additionally, RN #2 was unsure if the elopement risk alert and the placement of a wander guard were done before or after the resident's elopement. There was no documentation provided regarding the wander guard, and the elopement risk assessment had not been completed since the resident's return. This lack of proper assessment and monitoring led to the resident's elopement from the facility.
Failure to Conduct Pain Assessments
Penalty
Summary
The facility failed to conduct pain assessments for two residents who were reviewed for pain management. Resident #10, who had diagnoses including pain, was observed multiple times experiencing significant knee pain. Despite the resident's complaints and visible discomfort, there were no pain assessments documented in the electronic health record (EHR). The resident's care plan indicated the need to monitor and record pain characteristics, but this was not followed. The Director of Nursing (DON) and MDS coordinator were unable to provide a pain assessment outside of the Minimum Data Set (MDS) and acknowledged the lack of required components in their assessments. Resident #24, with diagnoses including chronic pain, peripheral autonomic neuropathy, and peripheral vascular disease, also did not have any pain assessments in their clinical record. The resident reported that their current pain medication regimen was ineffective and requested more frequent administration, which was not addressed. The DON and MDS coordinator were unaware of the resident's unrelieved pain and acknowledged that their pain assessments did not meet the facility's policy requirements. The facility had only recently started performing pain assessments in March, which did not align with their established protocols.
Failure to Complete Timely Medication Regimen Review
Penalty
Summary
The facility failed to complete a Medication Regimen Review (MRR) within the required time frame for a resident diagnosed with bipolar disorder, major depressive disorder, and schizoaffective disorder. The MRR, dated 02/21/24, recommended discontinuing one of the two lorazepam orders. However, the physician did not respond to this request until 04/02/24, exceeding the 30-day time frame stipulated in the facility's policy. Additionally, a significant change assessment dated 03/06/24 documented that the resident was severely impaired with cognition, had inattention, and an altered level of consciousness, and received multiple psychotropic medications during the look-back period. The Director of Nursing (DON) confirmed that the physician's response was delayed beyond the policy's required time frame.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medication unless for a specific diagnosed condition. This was identified for one of five residents reviewed for unnecessary medication. The resident had diagnoses including bipolar disorder, major depressive disorder, and schizoaffective disorder. A significant change assessment documented severe cognitive impairment and fluctuating inattention and altered consciousness. The resident received multiple psychotropic medications, including risperidone, Vraylar, clonazepam, and lorazepam, without appropriate diagnoses. The DON and the pharmacist both acknowledged that the diagnoses for the antipsychotic medications needed to be clarified.
Failure to Honor Resident's Right to Choose Visitors
Penalty
Summary
The facility failed to ensure a resident's right to receive visitors of their choice. Resident #33, who had diagnoses including chronic pain syndrome, chronic kidney disease, and adjustment disorder with depressed mood, was cognitively intact and required supervision or touch assistance with most ADLs. The resident reported that their friend, who had been a supportive visitor during their hospital stay, was asked to leave the facility by staff on the administrator's orders. The administrator had informed the resident that the friend was not allowed to visit anymore, despite the resident's expressed desire to see them. The resident council president and the ombudsman were involved in addressing the issue, and the resident eventually regained the right to have their friend visit. Staff interviews revealed that the administrator had instructed CNA #1 to ask the friend to leave, citing the friend's previous employment at the facility and the circumstances of their departure as the reason. The DON was unaware of the specific reasons for the visitation restriction and did not have concerns about the friend visiting the resident. The administrator believed they were acting in the resident's best interest by preventing the visit, despite acknowledging the resident's right to choose their visitors.
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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