Stigler Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Stigler, Oklahoma.
- Location
- 1402 Northwest 7th Street, Stigler, Oklahoma 74462
- CMS Provider Number
- 375497
- Inspections on file
- 26
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Stigler Nursing & Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean environment when a room was observed with 3 to 4 inches of baseboard pulled away from the wall near the bathroom door and a moderate amount of black, mold-like substance on the wall under and around the baseboard. A housekeeper reported the black substance had been present for the entire three months they had worked there and that attempts to clean it had been unsuccessful. The maintenance supervisor also stated the substance looked like mold and acknowledged that spackling was used to reattach the baseboard and cover the area, which did not remove the suspected mold but only concealed it.
A resident with dementia, identified as at risk for elopement, managed to leave the facility without staff knowledge and was returned by a community member. Despite multiple indications of the resident's exit-seeking behavior, the facility failed to implement adequate monitoring or revise the care plan. Additionally, treatment carts were observed unlocked and unsupervised, indicating a lapse in safety protocols.
The facility did not maintain RN coverage for eight consecutive hours daily, as required. Timecards showed insufficient RN coverage on several dates, and a staff member confirmed the absence of an RN on two specific days, unaware that the RN was clocking out early.
A facility failed to create a comprehensive care plan for a resident with multiple pressure ulcers. The resident, who had conditions such as paraplegia and diabetes, had pressure ulcers on various parts of the body, but these were not included in the care plan. An LPN admitted to overlooking the wounds during an audit of new physician's orders.
A facility failed to ensure accurate wound care assessments for a resident with multiple wounds, including paraplegia and pressure ulcers. The resident's wounds were inaccurately documented as suspected deep tissue injuries (SDTI) instead of unstageable. An LPN noted the inaccuracies, and the facility had recently eliminated the dedicated wound care nurse position.
The facility failed to update the comprehensive care plans for four residents, leading to discrepancies between physician's orders and the care plans. Issues included unrecorded oxygen therapy, outdated shower schedules, missing CPAP documentation, and unupdated tube feeding orders.
A resident with dementia and other conditions was abused by a CNA who sprayed water in their face during a shower. The incident was reported but not investigated or notified to the state agency promptly. The abusive CNA was later rehired without proper screening, and the family expressed concerns about the rehiring.
The facility failed to provide hot water for approximately a month, affecting residents' ability to receive safe and comfortable care. Despite multiple repairs and the purchase of new commercial water heaters, the issue persisted, leading to cold shower temperatures and residents refusing to bathe.
The facility failed to ensure residents received scheduled bathing, affecting four residents who either required total assistance or supervision with ADLs. Issues with cold water and missing documentation were identified, with the COO acknowledging problems with the facility's water heaters.
The facility failed to report an abuse incident within the required two-hour timeframe and a final report within five days. A CNA reported another CNA for spraying a resident in the face with a shower nozzle, but the DON did not file a state reportable within the required timeframe, and the administrator only reported the incident nearly two months later. The abusive CNA was initially terminated but later seen working at the facility again.
Failure to Address Suspected Mold and Damaged Wall in Resident Room
Penalty
Summary
The facility failed to maintain a clean environment as part of its infection prevention and control program when surveyors observed a damaged wall and apparent mold-like substance in one resident room. During observation of room [ROOM NUMBER], 3 to 4 inches of baseboard were found pulled away from the bottom of the wall next to the bathroom door, with a moderate amount of black substance present on the wall under and around the baseboard. A housekeeper who had worked at the facility for three months stated the black substance looked like mold, reported it had been present the entire time they had worked there, and stated they had tried to clean it off several times but it would not come off. Later, the maintenance supervisor also stated the black substance looked like mold and explained that spackling had been used to adhere the baseboard back to the wall and around the skirting. The maintenance supervisor acknowledged that the spackling did not remove the suspected mold but only covered it up, and stated that the substance should have been cleaned off the wall. The report identifies 54 residents residing in the facility but does not provide specific medical histories or conditions for the resident(s) occupying the affected room.
Failure to Prevent Elopement and Secure Treatment Carts
Penalty
Summary
The facility failed to prevent the elopement of a resident diagnosed with dementia, who was identified as being at risk for elopement. The resident, who had a history of exit-seeking behavior, managed to leave the facility without staff knowledge and was returned by a community member. Despite multiple progress notes indicating the resident's attempts to leave the facility, the staff did not implement adequate monitoring or environmental interventions to prevent elopement. The care plan for the resident was not revised to address the risk, and there was no consistent plan in place to monitor and prevent further elopement. Additionally, the facility did not complete a baseline care plan for the resident upon admission, and the 72-hour portion of the wander risk assessment was incomplete. The facility's documentation was lacking, as evidenced by missing hourly resident check forms for several dates, indicating a failure to consistently monitor the resident. Observations revealed that the resident continued to wander the halls and approach the front door without staff intervention, further highlighting the lack of adequate supervision. Furthermore, the facility failed to ensure that treatment carts were locked and supervised. On multiple occasions, treatment carts were observed unlocked and unsupervised, posing a potential safety risk. Staff members acknowledged that the carts should be locked when not in use, but this practice was not consistently followed, indicating a lapse in adherence to safety protocols.
Removal Plan
- A notification sign will be placed on front door and service door to alert visitors and vendors to not let anyone out without notifying/asking facility staff first.
- All staff In-Serviced on elopement risk policy, ensuring that identified elopement risk residents are redirected away from doors, properly performing 1:1 monitoring, and location of list of wandering/elopement risk residents and to check list at beginning of shift.
- MDS Coordinator in-serviced on completion of care plans on all new admissions to include but not limited to potential for risk of elopement.
- HR/BOM in-serviced on all newly hired personnel will be educated on elopement policy, location of list of at risk for elopement residents with an acknowledgement page.
- Nursing Administration In-Serviced on reviewing elopement risk resident list/any new admissions and updating list accordingly during clinical meeting.
- DON/Designee will report any negative findings to QAPI.
- Any employee that can't be reached for In-Service will be inactive and taken off of schedule until education is provided.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days a week, as required. A review of timecards from June 16, 2024, to July 31, 2024, revealed that RN coverage was not provided for the full eight hours on multiple dates, including June 16, June 17, June 28, July 2, July 3, July 4, July 10, July 13, July 17, July 18, July 27, and July 28, 2024. On August 1, 2024, at 1:15 p.m., a staff member acknowledged that there was no RN in the building on July 27 and July 28, 2024, and admitted to being unaware that the RN on shift was clocking out before completing the required eight hours.
Failure to Develop Comprehensive Care Plan for Resident with Wounds
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple wounds. The resident had diagnoses including paraplegia, end-stage renal disease, hepatitis C, diabetes, and pressure ulcers located on the coccyx, left heel, outer right ankle, outer right foot, and spinous process lower. Despite these conditions, the resident's care plan did not address the pressure ulcers. An LPN acknowledged missing the wounds during an audit of new physician's orders, indicating that the wounds should have been included in the care plan.
Inaccurate Wound Care Assessments
Penalty
Summary
The facility failed to ensure accurate wound care assessments for a resident with multiple wounds. The resident, who had diagnoses including paraplegia, end-stage renal disease, hepatitis C, diabetes, and pressure ulcers, was documented to have a suspected deep tissue injury (SDTI) on the spinous process lower and the coccyx. However, the wound care assessments were inaccurate regarding the staging of these wounds. An LPN reported that the wounds documented as SDTI should have been classified as unstageable. The facility had a dedicated wound care nurse, but the position was recently eliminated, which may have contributed to the inaccuracies in wound documentation.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to update the comprehensive person-centered care plans to reflect the residents' current needs for four of the 15 sampled residents. Resident #2's care plan did not include oxygen therapy despite physician's orders and the resident's use of oxygen since 07/31/23. The MDS coordinator confirmed that the oxygen therapy was not captured on the MDS and was not included in the care plan. Resident #19's care plan was not updated to reflect the change in shower schedule, leading to the resident refusing showers due to the late timing. The MDS coordinator acknowledged that the care plan had not been updated to reflect the new shower schedule but stated it would be updated now. Resident #30's care plan did not document the use of a CPAP machine for sleep apnea, despite physician's orders and the resident's use of the machine. The MDS coordinator was unaware of the CPAP order and confirmed that it was not captured on the MDS or the care plan. Resident #46's care plan did not reflect the change from Osmolyte to Jevity for tube feeding, nor did it include the use of a protector around the G-tube site. The MDS coordinator and IP nurse both acknowledged that the care plan should have been updated with the new orders and the use of the protector but had not been done so.
Failure to Protect Resident from Abuse and Improper Rehiring of Abusive CNA
Penalty
Summary
The facility failed to ensure a resident was free from abuse, as evidenced by an incident involving a CNA who sprayed a resident in the face with water while the resident was screaming. The resident, who had diagnoses including dementia, major depression disorder, anxiety disorder, and cerebrovascular disease, was subjected to this abuse during a shower. The incident was witnessed by another CNA who reported it immediately to the DON. Despite the immediate termination of the abusive CNA, the facility did not conduct an investigation or notify the state agency until nearly two months later. Furthermore, the abusive CNA was rehired by the facility without proper screening or notification to the state agency. The administrator claimed to be unaware of the incident until it was reported to the state agency, and the DON admitted to not knowing the requirement to report abuse within two hours. The family member of the abused resident expressed concerns about the rehiring of the abusive CNA, especially given the CNA's pending charges for assault and battery in a separate incident. The facility's failure to promptly report the abuse and the rehiring of the abusive CNA without proper procedures highlight significant lapses in ensuring resident safety and compliance with regulatory requirements.
Failure to Provide Hot Water for Residents
Penalty
Summary
The facility failed to ensure hot water was provided for the residents for approximately a month. Multiple invoices document ongoing issues with the water heaters, including the replacement of various parts such as pipes, valves, thermostats, and connectors. Despite these efforts, the water heaters continued to malfunction, resulting in cold water temperatures in the showers. Observations confirmed shower temperatures as low as 90.3°F, and interviews with residents and staff corroborated the lack of hot water. One resident reported refusing to take showers due to the cold water, and another resident's representative stated that the resident had not been given a shower or bath in almost four weeks. The facility's Chief Operating Officer (COO) acknowledged the problem and mentioned that two new commercial water heaters had been purchased and were in the process of being installed. However, the installation was delayed due to the need for electrical upgrades. Maintenance staff confirmed that one water heater had been rewired and installed, and work was ongoing for the second unit. Despite these efforts, the deficiency persisted for an extended period, affecting the residents' ability to receive safe and comfortable care.
Failure to Provide Scheduled Bathing for Residents
Penalty
Summary
The facility failed to ensure residents received scheduled bathing for four residents sampled for activities of daily living (ADLs). Resident #1, who was severely cognitively impaired and required total assistance with ADLs, had no recent bathing documentation in their medical record. Resident #2, who was cognitively intact and independent with most ADLs, also had no recent bathing documentation. The resident reported refusing showers due to the water being ice cold, and a family member confirmed the resident had not been given a shower in almost four weeks. Resident #3, who had impaired cognition and required total assistance with bathing, similarly had no recent bathing documentation and reported not having showers as often as desired due to cold water. Resident #4, who was cognitively intact and required supervision with bathing, also had no recent bathing documentation in their medical record. The Chief Operating Officer (COO) acknowledged issues with the facility's water heaters, which were being replaced and rewired for commercial use. The Director of Nursing (DON) was unable to locate any bathing documentation for the four residents in question. The deficiency was further corroborated by interviews with the residents and their family members, who expressed concerns about the lack of proper bathing due to cold water. The maintenance staff confirmed that one water heater had been rewired and installed, while work on the second heater was ongoing. Despite these efforts, the lack of proper documentation and the residents' reports of inadequate bathing highlight a significant lapse in the facility's ability to provide essential care and assistance with ADLs as required.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to ensure all allegations of abuse were reported within the required two-hour timeframe and a final report within five days. Specifically, an incident involving a resident being sprayed in the face with a shower nozzle by a CNA was reported by another CNA to the charge nurse, ADON, and DON on the same day it occurred. However, the DON did not file a state reportable within the required two hours, and the administrator only faxed an incident report to the state agency nearly two months later. The DON admitted to not knowing about the two-hour reporting requirement, and the administrator claimed to have been unaware of the abuse until the later date when the report was finally filed. Additionally, the abusive CNA was initially terminated but was later seen working at the facility again, causing further concern among staff members who had reported the incident initially. The facility's policy on abuse and neglect requires the administrator to provide a written report of the results of all abuse investigations to the state survey and certification agency, local police department, and other relevant authorities within five working days of the reported incident. Despite this policy, the facility did not adhere to the required timelines for reporting the abuse incident involving the resident. The failure to report the abuse in a timely manner and the subsequent rehiring of the abusive CNA indicate significant lapses in the facility's adherence to its own policies and state regulations regarding abuse reporting and investigation.
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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