Stillwater Creek Skilled Nursing And Therapy
Inspection history, citations, penalties and survey trends for this long-term care facility in Stillwater, Oklahoma.
- Location
- 1215 West 10th Street, Stillwater, Oklahoma 74074
- CMS Provider Number
- 375178
- Inspections on file
- 22
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Stillwater Creek Skilled Nursing And Therapy during CMS and state inspections, most recent first.
A facility failed to notify a physician when a resident with multiple health issues left AMA with all medications. The administrator confirmed no documentation of physician notification, and a corporate nurse consultant stated there was no policy for handling AMA situations.
The facility failed to notify the physician when a resident's fingerstick blood sugar results exceeded 501 on multiple occasions, despite the requirement to do so. Interviews and record reviews confirmed the absence of documentation for physician notification, constituting a deficiency in care.
A resident with quadriplegia and existing pressure ulcers developed new pressure ulcers due to the facility's failure to ensure heel lift boots and other pressure-relieving devices were in place as per the care plan. Staff admitted to noticing the absence of these devices but did not take appropriate action.
The facility failed to obtain proper physician orders for continuous oxygen and did not ensure that oxygen tubing and humidifier bottles were changed and dated as required for two residents with COPD. Observations revealed discrepancies in oxygen flow rates and undated tubing and humidifier bottles, with residents indicating a need for continuous oxygen.
The facility failed to ensure ongoing assessment for a resident on dialysis, missing required checks for AVF thrill and bruit, monitoring for trauma or infection, and timely dressing changes as per physician orders. Documentation inconsistencies were confirmed by the ADON and a corporate nurse consultant.
A facility failed to administer medications according to physician orders for a resident with diabetes, coronary artery disease, and hypertension. The MAR and insulin administration records documented multiple instances of late or missed doses, and blood pressure medications were given despite readings being out of prescribed parameters. Staff confirmed these discrepancies, leading to a deficiency in pharmaceutical services.
The facility failed to monitor for side effects related to the use of Warfarin for a resident with hemiplegia and hemiparesis following cerebral infarction. The resident was administered Warfarin from September through January without documented monitoring for side effects until January.
The facility failed to monitor behavior and side effects for a resident on psychotropic medication and did not limit PRN antianxiety medications to 14 days for another resident. One resident with dementia was prescribed quetiapine without proper monitoring, and another resident with anxiety received Ativan without a required stop date, exceeding the 14-day limit.
The facility failed to obtain laboratory studies as ordered for a resident with hypokalemia. Despite orders to repeat a CMP on a specific date, the facility was unable to locate documentation for the repeat lab.
The facility failed to complete a significant change assessment for a resident who experienced declines in ADLs, including range of motion impairments and increased dependency on assistance for daily activities. The corporate MDS coordinator acknowledged the oversight.
The facility failed to update the care plan with smoking interventions for a resident with heart failure and type two diabetes mellitus. Despite the resident being identified as a smoker and having signed a smoking contract, the care plan lacked necessary interventions and safety measures. Interviews confirmed the oversight, which was against the facility's Smoking Policy and Procedure.
The facility failed to ensure a timely response to a pharmacist's recommendation for a gradual dose reduction of medications for a resident with bipolar disorder, insomnia, and depression. The recommendation was made in a monthly medication review, but the facility did not document a response until nearly two months later, when the physician declined the GDR.
Failure to Notify Physician of Resident Leaving AMA
Penalty
Summary
The facility failed to notify the physician when a resident left against medical advice (AMA). The resident, who had diagnoses including alcohol abuse, psychoactive substance abuse with intoxication, chronic heart failure, anxiety, depression, and anemia, left the facility under the care of a friend with all medications in their possession. A late entry progress note documented the resident's departure on 11/25/24, but there was no evidence that the resident's physician was informed of this event. During an interview on 03/04/25, the administrator confirmed the absence of documentation regarding physician notification. Additionally, a corporate nurse consultant indicated that the facility lacked a policy or procedure for handling situations where a resident leaves AMA.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician when a resident's fingerstick blood sugar (FSBS) results were greater than 501, as required by the physician's order. The resident, who had diagnoses including heart failure and type two diabetes mellitus, had multiple instances where FSBS readings exceeded 501. Specifically, on five separate occasions, the FSBS readings were 528, 501, 545, 556, 501, and 544, but there was no documentation indicating that the physician had been notified of these elevated results. The facility's policy required consultation with the resident's physician in such events, but this was not adhered to in these instances. Interviews with facility staff, including an LPN and a corporate nurse consultant, confirmed that there was no documentation in the resident's clinical health record or progress notes indicating that the physician had been notified of the elevated FSBS results. The corporate nurse consultant reviewed the January and February Medication Administration Records (MAR) and confirmed the absence of documentation for physician notification on the specified dates. This failure to notify the physician as required by the facility's policy and the physician's order constitutes a deficiency in the care provided to the resident.
Failure to Prevent New Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of new pressure ulcers for a resident with quadriplegia and existing pressure ulcers. Despite physician orders and a care plan requiring heel lift boots and floating heels with pillows, the resident was observed multiple times without any pressure-relieving devices in place. On one occasion, the resident's bare feet were pressed against the footboard of the bed, causing the toes to curl under from pressure. This lack of adherence to the care plan led to the development of new purple discolorations on the resident's right great toe and left great toe, as well as a new purple area on the right heel. Staff interviews revealed that both CNAs and nurses were responsible for ensuring the pressure reduction devices were in place. However, a CNA could not recall if the boots were in place the previous day, and an LPN admitted to noticing the boots were not in place but failed to take action or notify anyone. This inaction directly contributed to the resident developing new pressure ulcers, as documented in the nurse progress notes and observed by the wound nurse.
Failure to Obtain Proper Oxygen Orders and Change Tubing
Penalty
Summary
The facility failed to obtain proper physician orders for continuous oxygen and did not ensure that oxygen tubing and humidifier bottles were changed and dated as required for two residents. Resident #1, diagnosed with COPD, had a physician order to administer oxygen at 2 liters per minute as needed and to change the oxygen tubing and humidifier bottle monthly. However, observations revealed that the oxygen tubing and humidifier bottle were not dated, and the oxygen concentrator was set at 4 liters per minute without an order for continuous oxygen. The resident stated they needed oxygen most of the time but were unsure when the tubing and humidifier bottle were last changed. LPN #1 confirmed the absence of an order for continuous oxygen and noted the discrepancy in the oxygen flow rate settings. Similarly, Resident #9, also diagnosed with COPD, had a physician order for oxygen at 2 liters per minute as needed and to change the oxygen tubing and humidifier bottle monthly. Observations showed that the oxygen tubing and humidifier bottle were not dated, and the oxygen concentrator and portable oxygen tank were set at higher flow rates than ordered. The resident indicated they required oxygen continuously and pointed out that their oxygen tubing had never been changed, with the cannula showing discoloration. LPN #1 later confirmed that an order for continuous oxygen was obtained after noting the resident's increased need for oxygen.
Failure to Ensure Ongoing Assessment for Dialysis Resident
Penalty
Summary
The facility failed to ensure ongoing assessment of a resident on dialysis, specifically for Resident #54, who had diagnoses including end-stage renal disease (ESRD). Physician orders required the resident to undergo dialysis on specific days and mandated checks for arteriovenous fistula (AVF) thrill and bruit every shift, monitoring for signs and symptoms of trauma or infection every shift, and removal of the AVF dressing four hours post-dialysis. However, documentation revealed that out of 58 opportunities, the AVF was not checked for thrill and bruit 20 times, and out of 13 opportunities, the AVF dressing was not removed seven times as required by the physician's orders. This lack of documentation indicated a failure to follow the prescribed monitoring and care procedures for the resident's dialysis access site. The Assistant Director of Nursing (ADON) and a corporate nurse consultant confirmed that while they documented dialysis management in daily skilled nurses' notes, they did not consistently follow the physician's orders for monitoring each shift. The ADON acknowledged that the dialysis communication form used did not include documentation of the required checks for thrill and bruit, monitoring for trauma or infection, or dressing changes after dialysis. This inconsistency in documentation and adherence to physician orders led to the identified deficiency in providing appropriate dialysis care for Resident #54.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for one of the five sampled residents reviewed for unnecessary medications. The resident had diagnoses including diabetes, coronary artery disease, and hypertension. The physician orders included specific instructions for administering insulin glargine, insulin aspart, Victoza, amlodipine besylate, losartan potassium, and carvedilol. However, the Medication Administration Records (MAR) and insulin administration records for January, February, and March 2024 documented multiple instances where medications were administered late or not at all, and blood pressure medications were given despite the resident's blood pressure being out of the prescribed parameters. The resident confirmed that they often received their medications late, and staff interviews corroborated the findings of late administration and failure to hold medications as required by the physician orders. On specific dates, the resident's blood pressure readings were below the parameters set for holding the medications, yet the medications were still administered. Additionally, insulin and Victoza were frequently administered more than one hour after the prescribed times, and in some instances, doses were missed entirely. The staff acknowledged these discrepancies, with a Certified Medication Aide (CMA) and a Licensed Practical Nurse (LPN) confirming that the medications should have been held or were administered late. These actions and inactions led to the deficiency in providing pharmaceutical services according to physician orders, potentially compromising the resident's health and safety.
Failure to Monitor Warfarin Side Effects
Penalty
Summary
The facility failed to monitor for side effects related to the use of Warfarin for a resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction. The resident had been administered Warfarin as ordered by the physician from September through January, but the clinical health record did not document any monitoring for side effects during this period. The resident's Treatment Administration Record (TAR) dated January 22 indicated that monitoring for side effects such as nose/gum bleeding, coughing or blood-tinged sputum, hematuria, black/tarry stools, vomiting of blood or coffee ground-like material, abnormal or excessive bruising, low blood pressure, change in cognition, and cyanosis should occur every shift for anticoagulation therapy. However, the Corporate Nurse Consultant confirmed that there were no orders to monitor for side effects until January 2024.
Failure to Monitor Psychotropic Medications and Limit PRN Antianxiety Medications
Penalty
Summary
The facility failed to ensure proper behavior and side effect monitoring for the use of psychotropic medications for one resident and did not limit PRN antianxiety medications to 14 days for another resident. Resident #127, who had a diagnosis of dementia with behavioral disturbances, was prescribed quetiapine fumarate at varying dosages over a period of time. However, there was no documentation of behavior and side effect monitoring from 03/04/24 through 03/12/24. The administrator confirmed that the monitoring was overlooked and not conducted as required by the facility's policy dated 10/25/21. Resident #9, diagnosed with an anxiety disorder, had a physician's order for Ativan oral tablet 0.5 mg every 12 hours as needed for anxiety. Despite a pharmacist's request to add a stop date to the PRN Ativan order in May 2023, the order continued without a stop date until August 2023. During this period, the resident received the medication multiple times each month, far exceeding the 14-day limit for PRN antianxiety medications. The corporate nurse consultant acknowledged that the 14-day stop date was not added to the order as required.
Failure to Obtain Ordered Laboratory Studies
Penalty
Summary
The facility failed to obtain laboratory studies as ordered for a resident diagnosed with hypokalemia. A lab result dated 06/20/23 indicated the resident had a low potassium level, and a new order was received to administer potassium and repeat a comprehensive metabolic panel (CMP) on 06/26/23. A nurse progress note on 06/23/23 documented a focused assessment related to labs and new orders to give potassium chloride (KCL) and repeat the CMP on 06/26/23. However, on 03/12/24, the missing labs were requested from the Assistant Director of Nursing (ADON), and by 03/15/24, the administrator confirmed that the facility was unable to locate documentation for the repeat lab on 06/26/23.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who experienced declines in activities of daily living (ADLs). An annual Minimum Data Set (MDS) documented that the resident had no functional impairments in range of motion and required minimal assistance with upper body dressing and supervision with walking. However, a subsequent quarterly MDS revealed that the resident had declined in range of motion, had impairments in both upper and lower extremities, and had become newly dependent on assistance for toileting hygiene, showering/bathing, upper and lower body dressing, and walking. The corporate MDS coordinator acknowledged that the significant change assessment had been missed and should have been completed.
Failure to Update Care Plan with Smoking Interventions
Penalty
Summary
The facility failed to update the care plan with smoking interventions for a resident diagnosed with heart failure and type two diabetes mellitus. Despite the resident having signed a smoking contract and being identified as a smoker in a smoking assessment, the care plan did not include any interventions or safety measures related to smoking. Interviews with the resident, the Administrator, and the corporate nurse confirmed that the resident was a smoker and that the care plan should have included smoking-related interventions. The facility's Smoking Policy and Procedure required physicians to update care plans and set goals for residents regarding smoking habits, but this was not done for the resident in question.
Failure to Respond Timely to Medication Regimen Review
Penalty
Summary
The facility failed to ensure a timely response to a medication regimen review for a resident diagnosed with bipolar disorder, insomnia, and depression. The resident had physician orders for Zoloft, Abilify, and Trazodone. A monthly medication review conducted on 12/18/23 by the pharmacist recommended a gradual dose reduction (GDR) of one of these medications. However, the facility did not document a response to this recommendation until 02/12/24, when the physician declined the GDR. According to a corporate consult RN, the facility should have escalated the issue to the medical director if there was no response within 30 days.
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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