The Highlands At Owasso
Inspection history, citations, penalties and survey trends for this long-term care facility in Owasso, Oklahoma.
- Location
- 10098 N 123 E Ave, Owasso, Oklahoma 74055
- CMS Provider Number
- 375558
- Inspections on file
- 28
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at The Highlands At Owasso during CMS and state inspections, most recent first.
A cognitively impaired resident with cardiovascular comorbidities was given another resident’s medications when a CMA, unfamiliar with the residents, relied solely on the resident’s verbal confirmation of identity instead of using proper identification methods. The resident did not receive 11 of their own ordered medications and instead was administered multiple antihypertensives and other drugs, including amlodipine, lisinopril, and labetalol, that were not prescribed for them. Shortly after the error, the resident became diaphoretic, lethargic, cyanotic, and unresponsive, with EMS documenting sinus bradycardia, shallow respirations, and initiating cardiac arrest protocol. Hospital records showed treatment for wrong-medication administration, diagnoses of hypotension, bradycardia, and asystole, and the resident was later pronounced deceased; the medical director indicated that the erroneously administered labetalol and other antihypertensives, in combination with epinephrine given by EMS, could have contributed to an acute cardiac event.
A resident with severe cognitive impairment, dependent for most ADLs and requiring a mechanical lift with two-person assistance for transfers, was improperly positioned in a lift sling by two CNAs. During a transfer from bed to chair, staff failed to secure the resident’s back far enough on the sling, leaving inadequate trunk support and causing the resident to slip from the sling, fall to the floor, and hit the head. The resident, who was on blood thinners, complained of head pain and was later found to have a small subdural hematoma requiring hospitalization, demonstrating a failure to follow the facility’s safe lifting policy and the resident’s care plan.
A resident who had been receiving furosemide 60 mg PO daily in the hospital was admitted with discharge instructions to continue that dose, but the facility’s physician order was entered as only 40 mg PO daily. The resident, who had moderate cognitive impairment and was documented as receiving a diuretic, reported the dose discrepancy, and the ADON later confirmed that the hospital discharge order specified 60 mg daily and that a nurse had mistakenly entered the lower dose.
A cognitively intact resident with a stage II pressure ulcer to the coccyx had a physician’s order for zinc oxide 20% paste to be applied topically every shift, but the medication was left unsecured at the bedside instead of in a locked compartment. Nursing documentation later showed the resident was found mixing the zinc oxide paste into their oatmeal and confirmed ingesting some of it. Facility staff acknowledged that the topical medication had been inappropriately left unattended at the bedside and could not identify who was responsible.
A resident’s guardian requested dental assessment and denture fitting, but the clinical record contained no documentation of these services despite external e-mails confirming impressions, delivery of upper and lower dentures, and later adjustment with care instructions. The resident was observed with a denture cup at bedside and reported their dentures were in the cup, while the social service director acknowledged the absence of dental documentation in the record and was unable to explain the prolonged delay before the resident ultimately received dentures.
A facility failed to follow proper infection control practices during medication administration for a resident with chronic pain syndrome and hypertension. A CMA was observed handling oxycodone with bare hands before placing it into a medication cup, contrary to protocol. Both an LPN and the ADON confirmed that medications should not be touched with bare hands.
A resident with heart failure and anxiety disorder reported that their call light had not worked for several months, requiring them to rely on their roommate for assistance. An LPN was unaware of the issue until it was demonstrated, and the maintenance supervisor admitted that the wireless call system, which required batteries, had ongoing issues with no routine testing or scheduled battery replacement.
A resident with chronic conditions experienced a delay in receiving medications due to transcription errors and communication issues between the facility and pharmacy. The resident's hospital discharge instructions for Xanax were incorrectly transcribed, and medications were not delivered until three days post-admission. Staff interviews highlighted a lack of proactive communication with the pharmacy, resulting in medication administration delays.
The facility failed to serve meals at safe and appetizing temperatures, affecting 99 residents. A resident reported meals were never hot and often improperly cooked, while another resident found the meals inedible. The dietary manager claimed temperatures were checked, but a meal cart's gauge read 100°F, and a test tray showed shrimp at 92°F, cold and flavorless. The dietary manager acknowledged the issue.
The facility failed to maintain an effective pest control program, as evidenced by the presence of roach droppings, dead roaches, and live roaches in various areas during an environmental tour. The corporate administrator noted that the exterminator visited monthly but was unsure if recommendations were reviewed, indicating a deficiency in the pest control program.
A resident with Chronic Lymphocytic Leukemia was found with a large bruise on their arm, which they could not explain. Despite the facility's policy requiring prompt reporting of injuries of unknown origin, the incident was not reported until it was brought up as an abuse allegation. The regional administrator admitted the failure to notify the incident as required.
Fatal Medication Error Due to Failure to Correctly Identify Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically failing to correctly identify a resident before administering medications. A cognitively impaired resident with a history of atherosclerotic heart disease, hyperlipidemia, hypertension, and traumatic brain injury was admitted with orders that included amlodipine 5 mg for hypertension, to be held if systolic blood pressure was less than 115 or heart rate was less than 50. A quarterly assessment documented significantly impaired cognition with a brief mental illness score of 03, use of multiple psychotropic and other medications, and no indication that the resident rejected care. Vital signs taken the morning of the incident showed a blood pressure of 147/76 and pulse of 83 beats per minute. On the morning in question, a CMA administered medications intended for the resident’s roommate to this resident after asking the resident if they were the roommate and accepting the resident’s incorrect verbal confirmation as sufficient identification. The CMA reported being unfamiliar with the residents and relied on the resident’s verbal response rather than using other identification methods such as the photo in the health record, despite the resident’s known cognitive and hearing impairments. As a result, the resident did not receive 11 medications that were prescribed for them and instead received multiple medications prescribed for the roommate, including amlodipine 10 mg, lisinopril 40 mg, and labetalol 300 mg, all ordered with parameters to hold for low systolic blood pressure and/or low heart rate. Shortly after the medication error, nursing notes documented that the resident became diaphoretic, lethargic, pale, cyanotic around the lips, with labored breathing and unresponsiveness. EMS records indicated the facility reported that the resident had been given amlodipine, aldactone, aspirin, baclofen, cyanocobalamin, fluoxetine, glimepiride, labetalol, lamotrigine, lisinopril, metformin, and potassium chloride in error, and EMS found the resident lethargic with sinus bradycardia, shallow respirations, and initiated cardiac arrest protocol. Hospital records showed the resident was treated for having been administered the wrong medications and was diagnosed with hypotension, bradycardia, and asystole, and was pronounced expired later that morning. The medical director stated that labetalol 300 mg administered in error could have caused the resident to expire and that labetalol, amlodipine, and lisinopril all lower blood pressure, and further noted that epinephrine administered by EMS in the presence of labetalol could have caused an acute cardiac event. The resident’s representative stated the resident expired as a result of the medication administration error.
Removal Plan
- Conducted a QAPI meeting where the IDT reviewed the facility’s medication administration policies and procedures to ensure they would keep residents safe
- Provided in-service education by the DON and ADON for all staff administering medications covering medication administration policies and procedures, including correct resident identification during medication pass
- Implemented bi-weekly visual audits of staff administering medications to ensure compliance with medication administration policies and procedures
- Observed staff administering medications to verify they were identifying the correct resident during medication pass
- Verified medication aide certifications
- Completed medication aide skills check-offs
- Reviewed nursing licenses
- Suspended a medication aide
- Observed and interviewed medication aides and nursing staff across multiple shifts to confirm they had the skills and knowledge to correctly identify residents during medication pass and administer medications as prescribed
Improper Mechanical Lift Sling Positioning Leads to Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a mechanical lift in accordance with its own policy and the resident’s care plan. The facility’s Safe Lifting and Movement of Residents policy required that only staff with documented training use mechanical lifts and that residents be properly positioned in slings, with enough appropriate slings available. Resident #2’s quarterly assessment documented severe cognitive impairment with a BIMS score of 5 and dependence on others for most ADLs, including positioning and transfers. The resident’s care plan required the assistance of two or more staff members and the use of a mechanical lift for transfers. On 12/06/25, during a mechanical lift transfer from bed to chair, Resident #2 slipped from the sling and fell. A nurse’s progress note documented that the resident routinely received blood thinners, complained of head pain after the fall, and was transferred to the hospital. The progress note and state reportable incident indicated that two CNAs were present, witnessed the fall, and reported that the resident hit their head on the floor. The incident report stated that the CNAs were attempting to ambulate/transfer the resident in the lift and failed to secure the resident’s back far enough on the sling per facility policies and procedures, resulting in the resident falling from the top right of the sling and hitting their head on the ground. Further description from the ADON indicated that, upon reenactment of the transfer, it was immediately apparent that the CNAs had not properly positioned the sling, leaving the resident without trunk support. Because Resident #2 could not hold themselves up while in the sling, the improper sling positioning led to the resident falling from the sling. A subsequent nurse’s progress note documented that the resident sustained a small subdural hematoma requiring hospitalization. At the time of later observation on 01/07/26, the resident was noted sitting in a recliner, dressed, with the call light in reach, but the deficiency centers on the earlier transfer event in which staff failed to properly secure and position the resident in the mechanical lift sling as required by policy and the care plan.
Incorrect Transcription of Hospital Furosemide Order
Penalty
Summary
The facility failed to ensure medications were administered as ordered when a resident did not receive the correct furosemide dose following hospital discharge. A hospital discharge medication list for Resident #16, dated 01/09/26, directed continuation of furosemide 60 mg by mouth daily, but the corresponding physician’s order entered at the facility on the same date specified only 40 mg by mouth daily. An admission assessment dated 01/16/26 documented that the resident had a BIMS score of 12, indicating moderate cognitive impairment, and was receiving a diuretic medication. On 01/22/26 at 10:00 a.m., the resident reported that they had been taking 60 mg of furosemide daily in the hospital and had only been receiving 40 mg daily since admission to the facility. At 12:20 p.m. the same day, the ADON confirmed that the hospital discharge order called for 60 mg daily, but the nurse had mistakenly entered an order for 40 mg daily. This discrepancy between the hospital discharge medication list and the facility physician’s order, along with the resident’s report and the ADON’s acknowledgment of a nurse’s entry error, demonstrates that the facility did not provide pharmaceutical services in accordance with the prescribed medication regimen for this resident.
Unsecured Topical Medication Left at Bedside and Ingested by Resident
Penalty
Summary
The deficiency involves the facility’s failure to secure and properly store medications, resulting in a cognitively intact resident having access to zinc oxide paste at the bedside. A physician’s order directed that zinc oxide 20% external paste be applied topically to the resident’s sacrum and buttocks every shift for skin integrity, and nursing documentation noted a stage II pressure ulcer on the coccyx with surrounding redness that was treated with zinc cream and a padded dressing. Despite this being a topical medication, it was left unattended at the resident’s bedside rather than stored in a locked compartment as required. A subsequent nurse’s progress note documented that when the nurse entered the resident’s room, the resident was observed mixing zinc oxide paste into their oatmeal and confirmed having eaten some of the mixture. The resident’s comprehensive assessment showed a BIMS score of 15, indicating they were cognitively intact, and noted the use of ointment or medication applied to body areas other than the feet. Facility staff, including the MDS coordinator and ADON, later acknowledged that zinc oxide paste had been left at the bedside and that it was inappropriate to leave medications unattended for this resident, and they were unable to determine which staff member had left the cream there.
Failure to Document and Timely Coordinate Denture Services
Penalty
Summary
The facility failed to provide medically appropriate dental services by not ensuring complete and timely documentation and follow-through of denture services for one resident. The resident was observed in bed with a denture cup at the bedside, and a social service progress note documented that the resident’s guardian had provided contact information and requested that the resident be assessed and fitted for dentures. However, review of the clinical record did not show that the resident had been assessed and fitted for dentures, despite this request. E-mails from the dental provider, supplied by the social service director, showed that impressions for upper and lower dentures were made, that the resident received upper and lower dentures with no adjustments initially needed, and that the dentures were later adjusted for comfort with instructions given on denture care. The resident stated their dentures were in their denture cup. The social service director, who began working at the facility months after the initial request, reported there was no documentation in the clinical record regarding these dental services, even though they found e-mail communications from the dental provider. The social service director also stated they did not know why the information was not included in the clinical record or why it took more than a year before the resident received dentures.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident diagnosed with chronic pain syndrome and hypertension. A physician's order required the resident to receive oxycodone 20 mg every 6 hours as needed for breakthrough pain. During an observation, a Certified Medication Aide (CMA) was seen administering the resident's oxycodone by punching the medication out of the card into their bare hand before placing it into a medication cup. The CMA later acknowledged that the medication should have been punched directly into the cup without being touched. Both a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) confirmed that medications should not be handled with bare hands and should be punched directly into the medication cup.
Non-Functioning Call Light System for Resident
Penalty
Summary
The facility failed to ensure the call light system was functioning for a resident with heart failure and anxiety disorder. The resident reported that their call light had not worked for several months, and they relied on their roommate to activate their call light if they needed help. During an observation, the resident pressed the button to activate their call light, but the light outside their door did not illuminate. An LPN was shown the non-functioning call light and stated they were unaware of the issue and would inform maintenance. The maintenance supervisor acknowledged that call lights had been an ongoing issue in the facility, noting that the wireless call system required batteries. They admitted that there was no routine testing of the call system or scheduled replacement of the batteries, contributing to the deficiency.
Medication Transcription and Delivery Errors
Penalty
Summary
The facility failed to accurately transcribe admission orders and acquire medications within the required timeframe for a resident with chronic obstructive pulmonary disease, depressive episodes, and dementia with mood disturbance. The hospital discharge instructions indicated that the resident was to take alprazolam (Xanax) 1mg as needed every six hours, but the facility's admission orders incorrectly documented it as a routine medication. Additionally, the medications Xanax and Nuvigil were not delivered to the facility until three days after the resident's admission, resulting in a delay in administration. Interviews with facility staff revealed a lack of communication and verification processes between the facility and the pharmacy. The Certified Medication Aide (CMA) and Licensed Practical Nurse (LPN) stated that they often did not know a medication required a written script until it was not delivered. The facility's Director of Nursing (DON) confirmed the transcription error and acknowledged the delay in medication delivery. The staff relied on the pharmacy to notify them of any issues, which led to residents not receiving medications as ordered.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve hot foods at an appealing temperature, affecting 99 residents who ate meals prepared in the kitchen. On December 11, 2024, Resident #4 reported that meals served in their room were never hot and rarely warm, with some meals being either undercooked or overcooked. Resident #6 expressed that the meals tasted bad and suspected that the kitchen staff knowingly served inedible food. The dietary manager claimed that food temperatures were checked before serving and upon delivery to the residents' hall. However, an observation of the meal cart's temperature gauge showed it reading 100 degrees Fahrenheit, despite the heating dial being set to 145 degrees Fahrenheit. A test tray revealed that the temperature of popcorn shrimp was 92 degrees Fahrenheit, with the shrimp feeling cold, chewy, and covered in damp breading, lacking flavor. The dietary manager acknowledged the issue, stating that the food was hot when it left the kitchen.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations made during an environmental tour on the 400 hall. Roach droppings and dead roaches were found along baseboards, near and under the refrigerator, on glue traps located in the corners of the room, storage drawers, and closets. Live roaches were also observed in the corners nearest the bathroom door and near the heat/air unit in rooms 412 and another unspecified room. The corporate administrator acknowledged that the exterminator visited the facility monthly but was unsure if the administrator reviewed the recommendations left on the exterminator's invoices. Despite the exterminator's responsiveness to concerns, the presence of pests indicated a deficiency in the pest control program.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident diagnosed with Chronic Lymphocytic Leukemia of B-cell type. The resident was found with a large bruise on their right arm, which they could not explain. Initially, the resident did not report any pain, but later expressed discomfort, prompting a consultation with the wound nurse and an x-ray, which showed no fractures or abnormalities. Despite these findings, the facility did not immediately report the incident as an injury of unknown origin. The facility's policy required that all injuries of unknown source be reported promptly to local, state, and federal agencies. However, the incident was only reported as an abuse allegation after a family member inquired about the bruise, and the facility realized the reporting oversight. The regional administrator acknowledged the failure to notify the incident as an injury of unknown origin, indicating a lapse in following the established reporting procedures.
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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