The Lakes
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 5701 West Britton Road, Oklahoma City, Oklahoma 73132
- CMS Provider Number
- 375396
- Inspections on file
- 22
- Latest survey
- December 18, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Lakes during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and at risk for falls sustained a closed head injury after rolling out of bed during peri care. The incident occurred when a CNA provided care alone, despite the resident's care plan requiring two-person assistance. The facility's policy on resident safety was not consistently followed, leading to the accident.
A resident with severe cognitive impairment was not protected from sexual abuse when another resident was witnessed placing their hand on the resident's crotch. The incident was reported as abuse, but a specific safe survey was not conducted, and there was a delay in separating the residents.
A facility failed to update the PASARR for a resident with new diagnoses of anxiety, psychosis, and recurrent depression. Despite the facility's policy requiring coordination with the Medicaid PASARR program for mental disorders, no new screening was conducted after the initial assessment in 2018. Interviews with the MDS Coordinator and DON confirmed the oversight, acknowledging the need for a new PASARR due to the resident's serious mental health conditions.
The facility failed to develop comprehensive care plans for three residents, resulting in deficiencies in addressing their medical needs. One resident's care plan lacked documentation for IV antibiotics, another's did not address visual impairment despite broken glasses, and a third's did not include antipsychotic medication use for a psychotic disorder. MDS coordinators acknowledged these omissions.
A resident admitted with a pressure ulcer on the right heel did not receive timely wound care due to a lack of treatment orders and delayed physician notification. The admitting nurse failed to contact the physician, resulting in a three-day delay before treatment orders were obtained. The facility's policies for admission and physician notification were not followed, leading to a lapse in wound care protocol.
A resident with chronic pain and diabetes did not receive properly labeled and administered medications. The insulin label did not reflect a recent order change, and the LPN failed to clean the site before applying a new lidocaine patch, contrary to facility policy. The DON confirmed the correct procedures were not followed.
A long-term care facility failed to maintain an effective infection prevention and control program. The facility did not adhere to its Legionella water management policy, lacked proper enhanced barrier precautions for a resident with a wound, and failed to ensure hand hygiene and equipment cleaning practices. An LPN was observed not washing hands between resident interactions and using the same gloves for multiple tasks, increasing the risk of cross-contamination.
The facility failed to document the administration of the pneumococcal vaccine for two residents, despite signed consents. The facility's policy requires offering the vaccine within thirty days of admission, but there was no record of administration. The DON confirmed the lack of documentation and stated that no vaccines had been administered to these residents.
A resident was admitted with multiple health issues, including an unstageable eschar on the right heel. The admitting LPN failed to notify the physician of the wound or obtain treatment orders, contrary to facility policy. The physician was only informed days later by the ADON, highlighting a lapse in communication and adherence to procedures.
A facility failed to accurately code the MDS for a resident with spondylosis and peripheral vascular disease. An admission assessment incorrectly documented the presence of an indwelling catheter, which was later identified as a system error by an MDS coordinator. The coordinator admitted to multiple inaccuracies and the need for better attention to detail.
A resident was discharged after a respite stay without a completed discharge summary. The facility's policy requires documentation of the resident's destination, discharge details, teaching, medications, a brief summary, and who picked them up. An LPN confirmed the absence of the summary, despite a communication note indicating the resident's discharge and awareness of involved parties.
A resident with chronic respiratory failure did not receive proper oxygen care, as the facility failed to change oxygen tubing weekly and administered oxygen at an incorrect flow rate. Staff were unaware of specific orders, and the DON confirmed the protocol was not followed.
An LPN was observed leaving a treatment cart unlocked and unattended while preparing for wound care, contrary to the facility's policy requiring carts to be locked when not in use.
A resident with severe cognitive impairment and a history of elopement was able to leave the facility unsupervised, resulting in an Immediate Jeopardy situation. The resident was found at a local church with bruising after reportedly falling. The facility failed to document 1:1 supervision and did not adequately address the resident's elopement risk in their care plan. Staff interviews revealed a lack of awareness and training regarding elopement procedures, and the facility's door alarm system was ineffective.
The facility failed to implement its abuse policy for three residents, leading to deficiencies in handling allegations of abuse. A resident with cognitive impairment was involved in an incident with another resident, but the facility did not document required interviews or additional monitoring. Another resident reported rough handling during a transfer, resulting in a fracture, but the facility did not conduct a thorough investigation. The lack of documentation and adherence to policy raises concerns about resident safety.
The facility failed to report an alleged abuse incident involving two residents to APS and law enforcement. One resident with cognitive impairment allegedly slapped another resident with severe dementia. Staff were unaware or did not report the incident, and the administrator admitted to not notifying authorities, contrary to facility policy.
A resident with multiple wounds did not receive the required weekly wound assessments. Despite having a pressure ulcer and other wounds, the facility only documented complete assessments on two occasions, failing to provide consistent weekly evaluations as confirmed by the DON.
A facility failed to provide medical records within the required timeframe for a resident with multiple diagnoses, including a pressure ulcer and diabetes. The resident's legal representative requested the records, but the facility's policy allowed up to five business days, conflicting with the regulatory requirement of two working days. The records were mailed late, and the family confirmed they had not received them within the expected timeframe.
Failure to Prevent Resident Fall During Peri Care
Penalty
Summary
The facility failed to prevent a fall resulting in a closed head injury for a resident diagnosed with vascular dementia and Alzheimer's disease. The resident was dependent on staff for bed mobility, repositioning, turning, and transfers, and was at risk for falls. During peri care, the resident rolled out of bed and sustained a head injury. The incident occurred while a CNA was providing care alone, despite the resident's care plan indicating a need for total assistance. The CNA reported that the resident was slippery due to a bowel movement, and there were no bed rails to prevent the fall. The facility's policy emphasized resident safety and supervision to prevent accidents, yet the staff was not consistently following the care plan requirements for two-person assistance during peri care. Observations and interviews revealed inconsistencies in staff understanding and implementation of the required assistance level for the resident. The CNA involved in the incident was informed that the resident required only one-person assistance, contrary to the care plan and other staff practices. Additionally, there was no documentation of staff education on the need for two-person assistance following the incident.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically sexual abuse, as evidenced by an incident involving two residents. Resident #2, who had severe cognitive impairment due to dementia and senile degeneration of the brain, was involved in an incident where Resident #4 was witnessed placing their hand on Resident #2's crotch while they were sitting in the TV area. This incident was observed by Housekeeper #1, who reported that it took five to eight minutes to get help to separate the two residents. The facility's policy defines sexual abuse as any non-consensual sexual contact, and the incident was reported as abuse to the Department. The administrator, who also served as the abuse coordinator, acknowledged that the incident could be considered sexual abuse. However, it was noted that a specific safe survey related to this incident was not completed, although a safe survey for a different incident had been conducted earlier. The report highlights a lapse in the facility's response to the incident, as the immediate separation of the residents was delayed, and a specific assessment of the situation was not conducted promptly. Resident #2 was unable to answer questions regarding the situation due to their cognitive impairment, and no injury was noted.
Failure to Update PASARR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with a new diagnosis of a serious mental health condition had an updated Pre-Admission Screening and Resident Review (PASARR) completed. The resident, who had been initially assessed in 2018, was diagnosed with anxiety, psychosis, and recurrent depression after the initial PASARR was completed. Despite these new diagnoses, the facility did not conduct a new PASARR to determine if a Level Two assessment was necessary. The facility's policy requires coordination with the Medicaid PASARR program for individuals with mental disorders, but this was not adhered to in this case. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the facility was aware of the requirement to complete a PASARR upon admission and with the onset of new psychological diagnoses. Both staff members acknowledged that the resident's serious mental health diagnoses warranted a new screening, which was not conducted. The oversight was identified during a review of the resident's medical records, which documented the new diagnoses and the absence of an updated PASARR since the initial assessment in 2018.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific medical needs. One resident with metabolic encephalopathy, chronic kidney disease, and a urinary tract infection required IV antibiotics and a midline or PICC placement. However, the care plan did not include documentation or interventions for the IV or antibiotic treatment, despite the resident completing their antibiotic course. The MDS coordinator acknowledged that the IV and antibiotic were not included in the care plan, which was a deviation from the norm. Another resident with anxiety disorder, essential hypertension, and impaired vision had a care plan that did not address their visual function, even though their CAA summary triggered this need. The resident reported broken glasses, which were observed to be taped and missing a lens. Additionally, a resident with a psychotic disorder and severe cognitive impairment was prescribed Seroquel for insomnia and delusions, but their care plan did not address the antipsychotic medication use or interventions for their condition. The MDS coordinator confirmed that the antipsychotic medication was not included in the care plan, despite being coded on the resident assessment.
Failure to Provide Timely Wound Care for Admitted Resident
Penalty
Summary
The facility failed to provide appropriate wound treatment for a resident admitted with a pressure ulcer. Upon admission, the resident had a right heel wound with eschar, which was documented as unstageable and measured 3 cm x 3 cm. Despite the presence of this wound, there were no documented treatment orders for the right heel at the time of admission. The resident's baseline care plan noted the wound and associated pain but did not include any specific treatment interventions for the wound. The deficiency was further compounded by the lack of timely communication with the attending physician. The admitting nurse, LPN #3, did not contact the physician to obtain treatment orders after completing the admission assessment. It was not until three days later that the ADON notified the physician and obtained the necessary treatment orders. During this period, the resident did not receive any treatment for the wound, as confirmed by the Treatment Administration Record (TAR), which showed the first treatment was administered three days post-admission. Interviews with the resident and staff revealed that the resident was aware of the untreated wound and that treatments only began a week after admission. The DON acknowledged that the facility's policies for admission and physician notification were not followed, resulting in a delay in wound care. This oversight led to the resident going without necessary treatment for three days, highlighting a significant lapse in the facility's wound care protocol.
Medication Labeling and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and administration of medications for a resident with chronic pain and type two diabetes mellitus. The insulin label for the resident did not reflect a recent change in the order, as the Lantus pen was labeled for 45 units, while the current order was for 55 units. The LPN acknowledged the discrepancy and mentioned the need to coordinate with the pharmacy to update the label. Additionally, the facility had a procedure for using a sticker to indicate changes in medication orders, but this was not applied to the resident's Lantus pen. Furthermore, the facility did not adhere to the standards of practice for administering topical medications. The LPN failed to clean the site before applying a new lidocaine patch to the resident's thigh, contrary to the facility's policy, which requires cleaning and drying the area and rotating the application site. The LPN admitted to not cleaning the area and only slightly moving the patch's location. The DON confirmed the correct procedure, which includes verifying the order, checking expiration, and cleaning the application site, was not followed.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies identified during the survey. The facility did not adhere to its water management program to prevent the growth of Legionella and other waterborne pathogens. The maintenance supervisor was unaware of the requirements outlined in the facility's Legionella policy, and there was no documentation to confirm that Legionella monitoring had been completed. This lack of awareness and documentation indicates a significant oversight in the facility's infection control measures. Additionally, the facility did not follow enhanced barrier precautions (EBP) for a resident with a wound. The resident had an unstageable wound with eschar on their right heel, and the facility's policy required the use of personal protective equipment (PPE) such as gowns and gloves during wound care. However, an LPN was observed performing wound care without wearing a gown, and there was no signage indicating the need for EBP for the resident. The Assistant Director of Nursing (ADON) acknowledged that the policy was not followed, which compromised the infection control protocols for residents with wounds. The facility also failed to ensure proper hand hygiene and equipment cleaning practices. An LPN was observed not washing or sanitizing their hands between resident interactions and using the same gloves for multiple tasks and residents. The LPN also did not clean the pulse oximeter or nebulizer canister after use, contrary to the facility's policies. These actions increased the risk of cross-contamination and infection spread among residents. The Director of Nursing (DON) confirmed that staff were expected to follow hand hygiene protocols and clean equipment after each use, highlighting a gap between policy and practice.
Failure to Document Pneumococcal Vaccine Administration
Penalty
Summary
The facility failed to provide documentation that the pneumococcal vaccine was administered to two of the five sampled residents reviewed for immunizations. According to the facility's Pneumococcal Vaccine policy, residents should be assessed for eligibility and offered the vaccine series within thirty days of admission. Resident #62 was admitted to the facility, and although the pneumococcal consent was signed on December 4, 2023, there was no documentation of the vaccine being administered. Similarly, Resident #69 was admitted, with the consent signed on May 2, 2024, but again, there was no documentation of vaccine administration. The Director of Nursing (DON) confirmed on November 21, 2024, that they could not locate any documentation indicating that either resident received the pneumococcal vaccine. The DON, who started at the facility in September of the same year, stated that they had not administered any vaccines to these residents.
Failure to Notify Physician of Wound on Admission
Penalty
Summary
The facility failed to notify the attending physician of a wound without a treatment order for one of the sampled residents with wounds. The resident was admitted with multiple diagnoses, including acute respiratory failure, Parkinson's disease, acute kidney failure, atrial fibrillation, a displaced bimalleolar fracture of the left lower leg, and a disorder of the skin and subcutaneous tissue. Upon admission, the resident's summary documented surgical wounds, bruises, skin tears/cuts, and other open lesions on the foot. A skin and wound progress note indicated the resident had an unstageable eschar on the right heel, measuring 3 cm x 3 cm, which was present upon admission. However, there was no documentation that the physician had been notified of this wound or that any treatment orders had been obtained. The admitting nurse, an LPN, acknowledged that they reviewed orders from a previous facility but did not contact the physician regarding the wound before leaving for the day. The physician was not notified until several days later when the Assistant Director of Nursing (ADON) contacted them. The Director of Nursing (DON) confirmed that it was the facility's expectation to notify the physician of any wounds upon admission and to obtain necessary treatment orders. This oversight resulted in a failure to adhere to the facility's policy for notifying physicians of clinical problems, as outlined in their guidelines and admission assessment procedures.
Inaccurate MDS Coding for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one of the sampled residents. The resident in question had diagnoses including spondylosis and peripheral vascular disease. An admission assessment documented that the resident had an indwelling catheter. However, during an interview, an MDS coordinator stated that the resident did not have a catheter and attributed the error to the system auto-populating incorrect information. The coordinator acknowledged the need for a correction and admitted that this was not the only instance of inaccurate coding, indicating a lack of attention to detail in the MDS assessments.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged after a respite stay. The resident was discharged on September 3, 2024, after staying at the facility since August 26, 2024. A communication note documented that the resident was picked up by transport to be taken home, with the resident's wife, Hospice, ADON, and PA being aware, and personal belongings and medications were given to the transport. However, there was no documentation of a discharge summary being completed. An LPN stated that they did not see the summary and explained that the facility's policy required documentation of the resident's destination, discharge details, any teaching, medications, a brief summary, who picked them up, and details of the stay.
Failure to Ensure Proper Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring that oxygen tubing was changed and that oxygen was administered as ordered. The resident, who had chronic respiratory failure with hypoxia and hypercapnia, was observed using oxygen via nasal cannula at an incorrect flow rate of four liters instead of the prescribed two liters. Additionally, the oxygen tubing and humidifier bottle were not changed as per the facility's protocol, with the humidifier bottle dated from several months prior and the tubing lacking a date sticker. Staff interviews revealed inconsistencies in the understanding and implementation of oxygen administration protocols. LPNs were unaware of the specific orders for changing the tubing and did not consistently monitor the oxygen flow rate. The Director of Nursing confirmed that the facility's protocol required weekly changes of oxygen tubing and adherence to physician orders for oxygen flow rates. However, these protocols were not followed, leading to the deficiency in care for the resident.
Failure to Secure Treatment Cart
Penalty
Summary
The facility failed to ensure that treatment carts were secured when not in use, as observed during a survey on hall 500. The facility's policy, dated April 2007, mandates that all drugs and biologicals must be stored in a safe, secure, and orderly manner, with compartments containing these items locked when not in use. On November 19, 2024, at 3:30 p.m., an LPN was observed preparing to perform wound care and walked away from an unlocked treatment cart, leaving it unattended as they proceeded towards the nurses' station. The LPN returned to the cart two minutes later and acknowledged that they had left it unlocked, contrary to the facility's policy requiring carts to be locked when unattended.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment, daily wandering behaviors, and a history of elopement. The resident, who had diagnoses including mood disorder, vascular dementia, parkinsonism, and repeated falls, was found at a local church after eloping from the facility. Upon assessment, the resident had bruising on their lower extremities and knees and reported falling but not hitting their head. The resident was sent to the emergency room for evaluation and returned to the facility with no new orders. The facility's documentation revealed significant lapses in monitoring and supervision. There was no documentation of 1:1 supervision being completed by staff on the day and evening shifts following the resident's return from the hospital. The resident's care plan, which was supposed to address their wandering and exit-seeking behaviors, did not document the resident's risk for elopement or their history of elopement. Additionally, behavior monitoring records for the months leading up to the incident showed inconsistencies, with some elopement behaviors documented but not consistently monitored or addressed. Interviews with staff indicated a lack of awareness and training regarding elopement risks and procedures. Staff members were unsure of the policy for identifying residents at risk for elopement and did not receive additional education following the incident. The facility's doors were supposed to be locked with a code, but there was a delay in relocking, and the alarm was not heard by staff when the resident eloped. The facility did not have an assessment tool for elopement risk, relying instead on behavior monitoring forms, which were not effectively utilized to prevent the incident.
Failure to Implement Abuse Policy in LTC Facility
Penalty
Summary
The facility failed to implement its abuse policy for three residents, leading to deficiencies in handling allegations of abuse. Resident #5, who had moderate cognitive impairment, was involved in an incident where they allegedly slapped Resident #6, who had severe cognitive impairment due to dementia and Alzheimer's disease. The facility's policy required thorough investigations, including interviews with involved parties and witnesses, but there was no documentation of such interviews being conducted. Staff members were aware of the incident but did not witness it, and the facility did not document any additional monitoring or education for staff regarding the incident. Resident #2, with a history of osteoarthritis and fractures, reported leg pain and was found to have an acute displaced femur fracture. The resident believed they were handled roughly by staff during a transfer, but the facility did not document a thorough investigation into this allegation of abuse. The administrator acknowledged different stories about the incident but could not provide documentation of interviews or findings related to the allegation. The facility's failure to document a comprehensive investigation into the resident's claims of rough handling represents a significant oversight in adhering to their abuse policy. The facility's lack of documentation and failure to follow its abuse policy in these cases highlight deficiencies in their response to allegations of abuse. Despite the policy's requirement for prompt reporting and thorough investigation, the facility did not conduct or document necessary interviews with residents, staff, or witnesses. This lack of adherence to policy and documentation raises concerns about the facility's ability to protect residents from abuse and ensure their safety.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to Adult Protective Services (APS) and local law enforcement. Resident #5, who had a history of dysphagia following cerebral infarction and osteoporosis, was documented to have moderate cognitive impairment in June but was noted to have intact cognition by September. Resident #6, diagnosed with unspecified dementia, Alzheimer's disease, and a psychotic disorder with delusions, had severe cognitive impairment. An incident occurred where Resident #5 allegedly slapped Resident #6's hand, which was not witnessed by staff but was overheard by other residents. The facility's documentation indicated that the residents were separated, and staff were educated to monitor Resident #5 more closely. However, there was no documentation that the incident was reported to APS or law enforcement. Interviews with staff revealed a lack of awareness and action regarding the incident. CNA #1 and CNA #2 were unaware of any abuse incidents involving the two residents, while CMA #1 acknowledged awareness of the incident. LPN #1 stated that such incidents should be reported to the administrator and DON, and typically authorities would be called. The administrator and DON confirmed that APS and law enforcement were not notified. The administrator reviewed the incident report and admitted to not having a satisfactory explanation for the lack of reporting, despite the facility's policy requiring such actions.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure that wound and skin assessments were completed for a resident with multiple wounds. The resident was admitted with a pressure ulcer on the right heel, diabetes mellitus with polyneuropathy, congestive heart failure, cerebral infarction, and hemiplegia and hemiparesis. Initial documentation noted wounds on the right heel and great toe, but there was no additional documentation for the great toe. Subsequent notes on the resident's condition were not comprehensive assessments, as they lacked detailed descriptions and measurements of the wounds. The Director of Nursing, who also served as the wound nurse, confirmed that assessments should be conducted weekly, including measurements, stage, signs and symptoms of infection, drainage, and a full description. However, the only complete assessments documented were on two specific dates, with no weekly assessments recorded as required. This lack of consistent and thorough documentation of the resident's wounds and skin condition represents a deficiency in the facility's care practices.
Failure to Provide Medical Records Timely
Penalty
Summary
The facility failed to provide medical records within the required timeframe for a resident whose legal representative requested them. The resident, who had a diagnosis including a pressure ulcer, diabetes mellitus with polyneuropathy, congestive heart failure, cerebral infarction, and hemiplegia and hemiparesis, was admitted to the facility. The resident's spouse, who held power of attorney, requested the medical records on 07/30/24. However, the facility did not provide the records within the stipulated two working days. The facility's policy allowed up to five business days to fulfill such requests, which did not align with the regulatory requirement of two working days. The administrator acknowledged this discrepancy and noted that the records were sent to the corporate office and mailed out on 08/05/24, but they were unsure when the family received them. The family confirmed they had not received the records within the expected timeframe, highlighting a failure in the facility's process to comply with the regulation.
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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