The Lodge At Brookline
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 5301 North Brookline, Oklahoma City, Oklahoma 73112
- CMS Provider Number
- 375574
- Inspections on file
- 25
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at The Lodge At Brookline during CMS and state inspections, most recent first.
A deficiency occurred when staff failed to immediately initiate CPR for a resident with a full code status who was found unresponsive and without vital signs. Instead of starting CPR, staff moved the resident, cleaned them, and delayed resuscitative efforts while checking code status and waiting for supervisory direction. This delay resulted in the resident not receiving timely basic life support as required by physician orders and facility policy.
Surveyors found that appropriate care was not consistently provided for residents with bowel or bladder continence or incontinence, including improper catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to resident care.
Two residents with PEG tubes did not have physician orders for tube care transcribed or completed. One resident's PEG site was observed without gauze, with dark residue and red droplets, while another had old gauze left in place and dark residue at the site. Both residents were dependent on staff and had moderately impaired cognition, and staff confirmed that proper daily care was not consistently provided.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with multiple severe pressure ulcers and significant mobility limitations did not consistently receive or have documented turning and repositioning every two hours as required by facility policy and care plan. Staff reported the resident was often resistive to turning due to discomfort, and documentation of these interventions was frequently incomplete, making it impossible to verify that pressure ulcer prevention measures were consistently implemented.
A resident with a newly placed PICC line did not have documented site assessments or dressing changes as required by facility policy, and nursing staff were unclear about documentation procedures. Only heparin flushes were recorded, and neither the DON nor the administrator could find evidence of proper PICC line care during the time the line was in place.
A resident did not receive their prescribed oxycodone for several days due to delays in medication reordering and communication issues between staff and the physician. During this period, the resident was given tramadol, which they reported was ineffective for their pain. Staff interviews indicated confusion about the timing and process for medication refills, and the DON acknowledged a breakdown in communication that led to the lapse in pain management.
The facility did not have grievance forms available in the designated location as per policy. Grievance information indicated forms should be in a binder on the front lobby table, but none were found. A CNA was unaware of their location, and the social services director confirmed they were incorrectly kept in their office.
A resident with amyotrophic lateral sclerosis was admitted with a noninvasive ventilator, but the MDS assessment failed to reflect this. The DON, responsible for MDS completion, acknowledged the oversight despite the resident confirming the ventilator's presence since admission.
A facility failed to include the use of a noninvasive ventilator in a resident's care plan, despite the resident having a diagnosis of amyotrophic lateral sclerosis and being admitted with the device. The ventilator was observed at the bedside, and the resident confirmed its use at bedtime. The DON acknowledged the oversight, stating the ventilator had been in use since admission but was not documented in the care plan.
A facility failed to obtain a physician order for a noninvasive ventilator for a resident with amyotrophic lateral sclerosis. The resident used the device at bedtime, but no order was documented until after surveyor observation. The DON confirmed the absence of a prior order.
A facility failed to provide an accessible emergency call cord in a resident's bathroom. The resident, who relies on a wheelchair, reported falling and being unable to reach the emergency call system. The bathroom had a red emergency switch by the toilet, but it lacked a string, making it inaccessible to someone on the floor. A CNA confirmed the absence of the string, and the administrator acknowledged the pull string should be positioned near the toilet.
The facility failed to secure medication carts on hall 400, as observed on three occasions. Despite a policy requiring locked storage, carts containing medications, insulin, and needles were found unlocked and unattended. An LPN admitted to leaving the cart unlocked and was unsure of the policy.
The facility failed to maintain appropriate dishwasher temperature and sanitization levels, with observed wash temperatures below the required 165 degrees and no sanitizer reaction. The CDM acknowledged the issue and called maintenance, who advised contacting the company for repairs. The facility used a three-compartment sink to ensure proper sanitization until repairs were made.
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices and open wounds, as there was no signage or PPE available. Staff were unaware of the new policy, and infection control practices were not followed, as observed in multiple instances, including improper handling of a glucometer and unbagged linen.
A facility failed to ensure a resident with malignant neoplasm of the lungs and end-stage renal disease was offered the choice to formulate an advance directive. The Executive Director could not locate the acknowledgment despite multiple requests, and no policy was provided by the time of the survey exit.
The facility failed to maintain privacy and confidentiality of residents' medical records. An LPN left a cart unlocked with a laptop open, exposing a resident's information, and admitted to not following policy. Another LPN left a laptop open displaying a resident's treatment record. Additionally, a new LPN applied cream to a resident's legs in the hallway, failing to ensure privacy. The Executive Director was informed of these findings.
The facility failed to accurately code Resident Assessments for two residents. One resident was incorrectly documented as taking anticoagulants without physician orders, while another was inaccurately recorded as receiving insulin injections. An LPN confirmed the inaccuracies, and the Executive Director stated that the policy required accurate MDS coding.
A facility failed to complete a baseline care plan within 48 hours for a resident admitted with hemiplegia, malnutrition, gastrostomy, and chronic pain. The comprehensive care plan was delayed, being created only after the required timeframe. Interviews with an LPN and the Executive Director confirmed the oversight, which was against the facility's policy.
A resident with epilepsy, end-stage renal disease, and cirrhosis fell while attempting to move from a chair to bed without assistance. Although a nurse's note indicated that neurological checks were initiated, no documentation was found. The interim DON and an LPN could not locate the records, and the LPN admitted that checks should have been completed, revealing a failure to follow best practices.
The facility did not update and post the required daily staffing information, missing details such as the facility name, resident census, and hours worked by RNs, LPNs, CMAs, and CNAs. Observations on two occasions revealed these omissions, and the ED confirmed the absence of necessary information.
A facility failed to administer medication as ordered for a resident with systemic lupus erythematosus, hypertension, and diabetes mellitus. A physician's order required Aquaphor application twice daily for ten days, but the treatment was not documented on the TAR for the specified period. An LPN confirmed the lack of documentation and was unaware of the resident's foot issues until observing redness and dryness.
A facility failed to ensure a call light was within reach for a dependent resident, who was observed in pain and unable to call for assistance. The call light was found hanging between the bed and the wall, out of reach. A CNA acknowledged the issue, stating it might have been moved during wound care. The facility's policy requires call lights to be accessible, which was confirmed by the Executive Director.
The facility failed to prevent cross-contamination during finger stick blood sugar tests. An LPN did not wash hands or sanitize the glucometer before or after use on multiple residents. Another LPN cleaned the glucometer but did not wash hands. Both LPNs were unaware of infection control protocols, leading to potential cross-contamination risks.
A facility failed to address and document grievances regarding missing clothing and medical equipment for a resident with severe protein-calorie malnutrition and end-stage renal disease. The resident's family complained about a missing wheelchair, purse, and clothes, but there was no documentation in the clinical record about the resolution of these grievances. Both the administrator and social service director acknowledged the complaints but admitted there was no documentation on how they were handled.
A facility failed to complete a discharge summary with a recapitulation of stay for a resident discharged with diagnoses including protein calorie malnutrition, diabetes mellitus, and cachexia. The discharge instruction form only noted that the resident went home with their daughter and medications were provided, lacking a complete summary of the resident's stay. The administrator confirmed that the discharge instructions form was the only document used as a discharge summary, which did not include a full recapitulation of the resident's stay.
Failure to Timely Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to initiate cardiopulmonary resuscitation (CPR) immediately for a resident with a full code status who was found unresponsive and without vital signs. The resident had a physician's order indicating full code status and had been admitted with diagnoses including bladder cancer, stage 3 kidney disease, and absence of a kidney. On the day of the incident, the resident was last observed sitting up in bed and later was found by a family member to be unresponsive, not breathing, and with open mouth and eyes. The family member alerted staff, who responded to the room. Upon entering the room, staff, including CNAs and LPNs, checked for vital signs and found none. Instead of immediately initiating CPR, staff moved the resident onto the bed, cleaned the resident, and put on a gown and brief. Multiple staff members, including nurses and CNAs, were present, but CPR was not started right away. There was confusion among staff regarding the resident's code status and who was responsible for initiating CPR. Some staff waited for direction from a supervisor, and others were occupied with checking for code status in binders or the electronic health record. According to interviews, there was a delay of several minutes before CPR was initiated, and 911 was called only after this delay. Staff interviews revealed inconsistent understanding of the process for identifying code status and when to begin CPR. Some staff believed only nurses should initiate CPR, while others were unsure of their roles during a code. The delay in starting CPR was attributed to waiting for confirmation of code status and for instructions from supervisory staff. The resident ultimately did not receive timely CPR as required by facility policy and physician orders, and was later pronounced deceased by emergency medical services.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the cited deficiency.
Failure to Transcribe and Complete Physician Orders for PEG Tube Care
Penalty
Summary
The facility failed to ensure that physician orders for PEG tube care were transcribed and completed for two residents with PEG tubes. For one resident, observation revealed that the PEG site had no gauze, dark residue around the insertion site, and red droplets on the clamp. There were no physician orders in place for PEG tube care for this resident, who was blind, had moderately impaired cognition, and was dependent on staff for all activities of daily living. The Director of Nursing (DON) confirmed that the site was not clean and that daily care should have been provided, especially in the presence of drainage. For another resident, the PEG tube site was observed with old gauze labeled with a previous date and shift, and dark residue was present under the gauze at the site entrance. Similarly, there were no physician orders for PEG tube care for this resident, who also had moderately impaired cognition, chronic kidney disease stage 5, and was dependent on staff for all activities of daily living. An LPN confirmed that care was documented as completed, but new gauze was not available, so the old gauze was left in place.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Consistently Document and Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions to promote pressure ulcer healing were consistently implemented for a resident with multiple pressure ulcers. Facility policies required turning and repositioning of residents at risk for pressure ulcers at least every two to three hours, with documentation of these interventions. Wound care provider notes specified that the resident should be turned every two hours using a foam wedge. However, review of the resident's ADL records over several months revealed numerous undocumented opportunities for turning and repositioning, with significant numbers of blanks in the records for this task. The resident's care plan also indicated the need for staff assistance with transfers and repositioning due to severe mobility limitations. Interviews with staff confirmed that the resident was immobile, contracted, and unable to turn independently, requiring substantial assistance. Staff reported that the resident was sometimes resistive to turning due to discomfort, and repositioning was attempted as much as the resident would allow. Despite these efforts, the Director of Nursing acknowledged that, due to the incomplete documentation, there was no way to verify that the resident was turned every two hours as required. The resident had multiple stage three and four pressure ulcers and deep tissue injuries, all present upon admission, and required ongoing wound care interventions.
Failure to Document and Provide PICC Line Care
Penalty
Summary
The facility failed to provide proper care and documentation for a resident with a peripherally inserted central catheter (PICC) line. According to the facility's policy, central line sites should be assessed with each infusion and at least daily, and dressings should be changed at least every seven days or sooner if compromised. The resident was discharged from the hospital with a newly placed tunneled PICC line and required intravenous antibiotics. However, there was no physician's order for central line care, and the medication administration records (MAR/TAR) for October and December did not document any central line care or dressing changes. Progress notes also lacked documentation of daily site assessments or dressing changes from the time of readmission until the line was discontinued. Interviews with nursing staff revealed uncertainty about documentation practices for PICC line care, with one LPN stating they were unfamiliar with the charting system and did not know where or if dressing changes were documented. The DON confirmed that dressing changes should be recorded on the nurse's treatment sheet, but only heparin flushes were documented. Neither the DON nor the administrator could locate any records of site assessments or dressing changes while the central line was in place, despite facility policy and staff statements that such care should occur regularly.
Failure to Provide Timely Pain Medication Due to Reordering and Communication Lapses
Penalty
Summary
The facility failed to ensure that a resident received their prescribed pain medication, oxycodone, as ordered by the physician. According to the facility's policy, medications are to be administered in a safe and timely manner, with reordering procedures in place to prevent interruptions. Documentation showed that the resident's supply of oxycodone ran out, and there was a gap of several days before the medication was available again. During this period, the resident was given tramadol instead, which they reported was ineffective for their pain. The resident stated they had to wait three to four days without their prescribed oxycodone. Staff interviews revealed that medication reordering was supposed to occur when a four to five day supply remained, but there was confusion and lack of documentation regarding when the refill was requested. The LPN involved was unsure of the exact timing of the request and noted difficulty obtaining the necessary prescription due to the physician being out of the office for a holiday. The DON confirmed that the request was not made until the medication had already run out and acknowledged that there was a breakdown in communication between the facility and the physician, resulting in the resident not having access to their prescribed narcotic.
Grievance Forms Not Available in Designated Location
Penalty
Summary
The facility failed to ensure grievance forms were available in the designated location as per their policy. During a tour of the facility, it was observed that grievance information was posted at the entrance, indicating that grievance forms could be found in a binder on the table in the front lobby. However, upon inspection, no grievance forms or binder were present on the table. A CNA was unaware of the location of the grievance forms, and the social services director confirmed that the forms were supposed to be on the table in the front lobby, as per the grievance policy, but were instead located in their office.
Inaccurate MDS Coding for Resident with Ventilator
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one of the six sampled residents. The resident in question had a diagnosis of amyotrophic lateral sclerosis and was admitted to the facility with a noninvasive ventilator. However, the significant change in status MDS assessment dated 09/26/24 did not reflect that the resident received noninvasive ventilator services. On 11/26/24, a noninvasive ventilator was observed on the resident's bedside table, although it was turned off. The resident confirmed on 11/27/24 that they were admitted with the ventilator. The Director of Nursing (DON), who was responsible for completing care plans and MDS assessments, acknowledged that the ventilator was not coded in the MDS assessment despite the resident having it since admission.
Care Plan Lacks Documentation for Noninvasive Ventilator Use
Penalty
Summary
The facility failed to ensure that a resident's care plan included the use of a noninvasive ventilator, which was necessary for one of the two sampled residents reviewed for respiratory services. The resident, who had a diagnosis of amyotrophic lateral sclerosis, was admitted to the facility with a noninvasive ventilator. However, the care plan dated 10/02/24 did not document the use of this device. On 11/26/24, the ventilator was observed on the resident's bedside table, turned off, and the resident confirmed its use at bedtime. The Director of Nursing (DON) acknowledged that the resident had the ventilator since admission and admitted that there was no care plan for its use, although it should have been included.
Lack of Physician Order for Noninvasive Ventilator Use
Penalty
Summary
The facility failed to ensure a resident had a physician order for the use of a noninvasive ventilator. The facility's policy required obtaining an order for devices such as CPAP, BiPAP, or AVAPS. A resident with amyotrophic lateral sclerosis was observed with a noninvasive ventilator at their bedside, which they used at bedtime. The resident stated they were admitted with the device. However, there was no physician order for its use and monitoring until after the surveyor's observation. The Director of Nursing confirmed the absence of a prior order upon reviewing the resident's hospice and electronic health records.
Inaccessible Emergency Call System in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that an emergency call cord was available in a resident's bathroom, specifically for one of the three sampled residents. The facility's policy on call lights, revised in October 2024, mandates that the call system must be accessible to residents at each toilet and bath or shower facility, and should be reachable by a resident lying on the floor. Resident #2, who has mobility issues and relies on a wheelchair, reported falling in the bathroom and being unable to reach the emergency call system. Upon inspection, it was observed that the bathroom had a red emergency switch by the side of the toilet, but it lacked a string, making it inaccessible to a resident lying on the floor. A CNA confirmed that the call switch did not have a string, and the administrator acknowledged that the pull string should be positioned on either side or in front of the toilet.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that medication carts were secured when not in use, as observed during three separate instances on hall 400. The Medication Storage policy, dated July 2024, mandates that all drugs and biologicals be stored in locked compartments. However, on September 3, 2024, at 12:42 p.m., a nurse cart was found unlocked and unattended, containing medications, insulin, and needles. An LPN acknowledged the cart was not locked, contrary to the policy. On September 4, 2024, at 7:59 a.m., the same LPN was seen leaving the medication cart unlocked while carrying medication cups. Upon returning, the LPN admitted to not locking the cart again. On September 6, 2024, at 9:39 a.m., another cart was observed unattended and unlocked, with similar contents. An LPN returned and admitted awareness of the unlocked cart but was unsure of the exact policy.
Dishwasher Temperature and Sanitization Deficiency
Penalty
Summary
The facility failed to ensure the appropriate dishwasher temperature and sanitization concentration levels were reached on a high temperature dishwasher. During a follow-up tour of the kitchen, it was observed that the dishwasher's wash temperature was 162 degrees, which is below the required 165 degrees for stationary rack, single temperature machines. Further testing showed wash and rinse temperatures of 167 and 159 degrees, respectively, and no reaction on the sanitizer strip, indicating improper sanitization. The Certified Dietary Manager (CDM) acknowledged the issue and attempted to address it by calling maintenance. Maintenance personnel noted that the pump did not switch on and advised contacting the company for repairs. The CDM confirmed they would use the three-compartment sink until the dishwasher was repaired, ensuring appropriate temperature and sanitization levels were maintained in the interim.
Failure to Implement Enhanced Barrier Precautions and Adhere to Infection Control Practices
Penalty
Summary
The facility failed to implement enhanced barrier precautions for residents with indwelling devices and open wounds, as observed in two residents. One resident had a gastric tube, indwelling catheter, and multiple pressure ulcers, yet there was no signage indicating the need for enhanced barrier precautions, and no personal protective equipment (PPE) was available. A registered nurse acknowledged the absence of necessary precautions and PPE. Another resident, who was bedridden with a gastric tube, indwelling catheter, and pressure ulcers, also lacked enhanced barrier precautions signage. A licensed practical nurse admitted to not being aware of the enhanced barrier precautions policy and noted that gowns were stored on a different hall. Additionally, the facility's staff did not adhere to infection control practices after providing resident care. An LPN was observed performing wound care without wearing a gown, and another LPN was seen handling a glucometer and walking through the facility with gloves on, acknowledging the risk of cross-contamination. Furthermore, an LPN was observed carrying unbagged linen through the facility, contrary to the infection prevention policy. These observations indicate a lack of compliance with established infection control protocols and inadequate staff training on new policies.
Failure to Offer Advance Directive Formulation
Penalty
Summary
The facility failed to ensure that a resident was offered the choice to formulate an advance directive. This deficiency was identified during a review of records and interviews, where it was found that one of the twelve sampled residents, who had diagnoses including malignant neoplasm of the lungs and end-stage renal disease, did not have an advance directive acknowledgment on file. The Executive Director was unable to locate the acknowledgment despite being asked on two separate occasions. Additionally, no policy regarding advance directives was provided by the time of the survey exit.
Privacy and Confidentiality Breach in Resident Care
Penalty
Summary
The facility failed to maintain privacy and confidentiality of residents' personal and medical records, as observed during a tour. Two residents, including Resident #25 and an unidentified resident, had their privacy compromised during care provision. Additionally, protected health information for two residents, Resident #21 and Resident #40, was not secured. On one occasion, a cart on hall 500 was found unlocked with a laptop open, exposing Resident #21's information, while no nurse was present. LPN #4 admitted to not following the policy by performing a fingerstick blood sugar (FSBS) test in the lobby and acknowledged the need to lock the computer screen, which they subsequently did. Further observations revealed a laptop on the hall 400 treatment cart left open, displaying the treatment administration record (TAR) for Resident #40, with no staff nearby. LPN #3 admitted to leaving the laptop open and was unaware of the exact policy. Additionally, LPN #1 was observed applying cream to a resident's legs in the hallway, failing to ensure dignity and privacy. LPN #1, who was new to the facility, was unable to articulate the policy for maintaining privacy during point-of-care treatments. The Executive Director was informed of these findings.
Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to ensure accurate coding of Resident Assessments for two residents. Resident #21, who had diagnoses including gastrostomy, stage 4 pressure ulcers, osteomyelitis, and hepatitis C, was inaccurately documented as taking anticoagulants in the last 7 days on an Annual Resident Assessment. However, there were no physician orders for anticoagulant use, and the medication administration record for August confirmed that the resident was not taking anticoagulants. LPN #1 acknowledged the inaccuracy in the MDS coding. Similarly, Resident #34, with diagnoses of heart disease, end-stage renal disease, and COPD, was inaccurately documented as receiving insulin injections for 7 of the past 7 days on a Quarterly Resident Assessment. There was no physician order for insulin, and the medication administration record for June showed that the resident did not receive insulin. LPN #1 confirmed the MDS was coded inaccurately. The Executive Director stated that the policy required accurate MDS coding.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was completed in a timely manner for a resident, identified as #38, who was part of a sample of 13 residents reviewed for baseline care plans. The facility's policy required that a baseline care plan be developed within 48 hours of a resident's admission. Resident #38 was admitted with diagnoses including hemiplegia, malnutrition, gastrostomy, and chronic pain. However, a baseline care plan was not put into place within the required 48-hour timeframe. Instead, the comprehensive care plan was only created on June 26, 2024, well beyond the stipulated period. Interviews with LPN #1 and the Executive Director confirmed that the baseline care plan was not completed within the 48 hours as required by the facility's policy.
Failure to Conduct Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to conduct and monitor neurological checks after an unwitnessed fall involving a resident with diagnoses including epilepsy, end-stage renal disease, and cirrhosis of the liver. The incident occurred when the resident attempted to move from a chair to their bed without assistance, resulting in a fall. A nurse's note documented that a head-to-toe evaluation was performed, and no injuries were noted. The resident reported not hitting their head, and initial vital signs were recorded. Despite the nurse's note indicating that neurological checks were initiated, no documentation of these checks was found. Upon inquiry, the interim DON and LPN were unable to locate the neurological check records. The LPN initially stated that neurological checks were not initiated because the resident did not hit their head. However, the nursing note contradicted this by stating that checks were initiated. The LPN later acknowledged that the facility's policy did not specifically require neurological checks for unwitnessed falls unless there was a variance from the initial assessment. The LPN admitted that neurological assessments should have been completed, indicating a failure to adhere to best practices in monitoring the resident's condition post-fall.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the daily staffing information was properly updated and posted as required. During observations on two separate occasions, the staffing sheet displayed next to the nurses' station window lacked essential information, including the facility name, resident census, and the actual hours worked by RNs, LPNs, CMAs, and CNAs. On September 4th and September 6th, the posted staffing sheets were missing these critical details. When questioned, the Executive Director (ED) acknowledged that the staffing sheet did not contain the necessary information, which should have included each discipline for direct care, the shift, the date, and the resident census.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medication according to physician orders for a resident diagnosed with systemic lupus erythematosus, hypertension, and diabetes mellitus. A physician's order dated August 31, 2024, required the application of Aquaphor to the resident's body twice a day for ten days. However, the September Treatment Administration Record (TAR) lacked documentation of Aquaphor administration from September 1 to September 10, 2024, and indicated cessation of treatment from September 11 to September 30, 2024. On September 6, 2024, the resident's left foot was observed to be red, inflamed, and dry, with the resident reporting pain and mentioning a cream for the condition. An LPN confirmed the absence of documentation on the TAR, indicating the treatment was likely not administered. The LPN was unaware of any foot issues for the resident until observing the dryness and redness on the resident's foot, acknowledging a problem.
Inaccessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to ensure that emergency call cords were within reach for a dependent resident, leading to a deficiency. During an observation, it was noted that the call light for a resident who was dependent on staff for all activities of daily living (ADLs) was hanging between the head of the bed and the wall, making it inaccessible to the resident. The resident was observed moaning in pain and stated that they had to scream to get the staff's attention. A Certified Nursing Assistant (CNA) acknowledged that the call button was out of reach and mentioned that it might have been moved during wound care. The facility's policy requires that call lights be within reach of residents, and the Executive Director confirmed that call lights should be accessible to residents.
Inadequate Infection Control During Blood Sugar Monitoring
Penalty
Summary
The facility failed to prevent cross-contamination during the process of obtaining finger stick blood sugars for residents. Observations revealed that LPN #1 did not wash hands or use hand sanitizer before or after performing finger stick blood sugar tests and administering insulin to Resident #2. Additionally, the glucometer was not cleaned or disinfected before or after use, and it was used on multiple residents without proper sanitation. LPN #1 was unaware of the facility's policy regarding the cleaning of medical equipment and hand hygiene. Further observations showed that LPN #3, while cleaning and sanitizing the glucometer before use, did not wash hands or use hand sanitizer before obtaining a finger stick blood sugar reading from Resident #4. Interviews with the LPNs confirmed a lack of adherence to infection control protocols, as they admitted to not washing hands or sanitizing the glucometer as required. The facility's failure to implement proper infection prevention and control measures during these procedures was evident, potentially exposing residents to cross-contamination risks.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to address and document grievances related to missing clothing and medical equipment for one of the four sampled residents. The resident, who was admitted with severe protein-calorie malnutrition and end-stage renal disease, had family members who complained about a missing wheelchair, purse, and clothes. A handwritten social service note dated 04/23/24 documented these complaints, but there was no additional documentation in the resident's clinical record regarding the resolution of these grievances. The administrator and social service director both acknowledged receiving the complaints but admitted there was no documentation on how the grievances were handled.
Failure to Complete Discharge Summary with Recapitulation of Stay
Penalty
Summary
The facility failed to complete a discharge summary with a recapitulation of stay for a resident who was discharged. The resident was admitted with diagnoses including protein calorie malnutrition, diabetes mellitus, and cachexia. Upon review, it was found that the resident was discharged and went home with their daughter, as documented in the progress notes. However, the discharge instruction form only noted that the resident went home with their daughter and that medications were provided, lacking a complete summary of the resident's stay. The clinical record did not contain a discharge summary with a recapitulation of the resident's stay. When asked, the administrator confirmed that the discharge instructions form was the only document used as a discharge summary, which did not include a full recapitulation of the resident's stay.
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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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