The Oaks Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Poteau, Oklahoma.
- Location
- 1501 Clayton Avenue, Poteau, Oklahoma 74953
- CMS Provider Number
- 375166
- Inspections on file
- 23
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Oaks Healthcare Center during CMS and state inspections, most recent first.
A facility failed to coordinate with a contracted hospice provider regarding a resident's code status change to DNR. The hospice provider did not notify the facility or provide the signed DNR document, resulting in the resident being transferred to the hospital as a full code and receiving interventions inconsistent with the updated code status. Facility staff were unaware of the change until after the hospital transfer.
The facility failed to maintain the dignity of two residents with dementia by not providing clean clothing and appropriate dining assistance. One resident was observed with food debris on their clothing and blanket, while another was assisted with their meal by a CNA who stood, contrary to facility protocol. Staff admitted to not following proper procedures, impacting the residents' dignity.
A facility failed to maintain a medication error rate below five percent, resulting in a 6.9% error rate. A CMA administered albuterol sulfate without waiting the required one minute between puffs and gave two sprays of aller-flo fluticasone in each nostril, contrary to the physician's order. The DON and CMA supervisor expected adherence to medication administration protocols, but the supervisor had not trained the CMA involved, contributing to the errors.
The facility failed to secure medications on two medication/treatment carts, with one LPN repeatedly leaving the 300 hall cart unattended and unlocked. The 400 hall cart was also found unlocked and unattended. Despite the facility's policy requiring carts to be locked, staff interviews revealed inconsistent adherence to this protocol.
The facility failed to ensure proper hand hygiene in the kitchen and did not cover food delivered to residents on the C hall. Staff were observed not washing hands upon entering the kitchen and handling food without proper hygiene. Additionally, meal trays were delivered with uncovered items, contrary to facility policy.
The facility failed to ensure proper infection control, as staff did not use PPE during care for two residents, and catheter bags were in contact with the floor. Clean laundry was transported without covers, and the facility had not implemented a water management program to prevent waterborne pathogens. Staff were unaware of EBP requirements due to missing signage.
The facility failed to provide education and offer influenza and pneumococcal immunizations to two residents, one with coronary artery disease and another with diabetes mellitus. Documentation was missing, and the corporate nurse acknowledged the oversight, noting that a previous infection preventionist was responsible for this task.
The facility failed to provide COVID-19 vaccine education and offer to four residents, as there was no documentation of these actions. A resident with dementia, another with coronary artery disease, and two with diabetes mellitus were not documented as having received the necessary education or vaccine offer. The infection preventionist responsible for these tasks could not locate the required documentation.
A facility failed to assess a resident for self-administration of medication. The resident, diagnosed with chronic obstructive pulmonary disease, was observed self-administering Albuterol without a documented assessment in their clinical record. The facility's policy requires an interdisciplinary team to determine the appropriateness and safety of self-administration, which was not followed. The LPN and DON confirmed the oversight.
A facility failed to notify a resident's guardian about the resident's suicidal ideation, despite the resident expressing a desire to die due to frustration. The resident, diagnosed with major depressive disorder, schizophrenia, and anxiety, was placed under one-on-one observation, but no documentation of guardian notification was found. Staff were aware of the situation, but communication and documentation were lacking.
A facility failed to assess and monitor a dialysis port for a resident with renal failure, as required by their care plan. Despite the facility's policy on hemodialysis access care, there was no documentation of pre and post-dialysis assessments for several months. Interviews revealed that the facility did not perform necessary assessments before or after dialysis sessions, and monitoring of the central catheter was not documented, leading to a deficiency in care.
A facility failed to obtain physician-ordered labs for a resident with multiple health conditions, including diabetes and end-stage renal disease. Although the medication administration record indicated that the labs were completed, the clinical record lacked the lab reports. An LPN admitted the labs were not completed despite documentation stating otherwise.
A facility improperly discharged a resident with Alzheimer's and other conditions due to the use of authorized electronic monitoring in their room. The facility's policy allows discharge only under specific conditions, but the discharge was initiated citing misuse of surveillance cameras, which is against the Nursing Home Care Act. The DON admitted the facility could meet the resident's needs and was unaware of the legal requirements regarding video surveillance.
A resident with severe cognitive impairment was assaulted by another resident after dining services, resulting in a chokehold incident. Witnesses reported that the aggressor was agitated by noises made by the victim during meal service. The facility's failure to provide comprehensive staff training on de-escalation and resident-to-resident behaviors contributed to the incident.
A facility failed to provide a written summary of grievance investigations to a resident's POA, despite having a policy requiring such documentation. The facility only communicated verbally, which was confirmed by the administrator, contradicting their grievance policy.
A facility failed to report an allegation of abuse involving a CNA and a resident to the OSDH. The incident was reported to the administration as a rumor, and the administrator conducted an informal inquiry but did not report it to the state due to uncertainty about its validity. This inaction violated the facility's abuse policy, which requires reporting all suspected abuse to appropriate agencies.
The facility failed to investigate an alleged abuse incident involving a resident and a CNA. Despite reports of inappropriate behavior, the facility did not conduct a thorough investigation or document findings. The administrator did not report the incident to the OSDH, citing uncertainty about the nature of the allegation.
A facility failed to update a resident's care plan with a physician's order. The resident, diagnosed with dementia and stage 3 chronic kidney disease, had a specialist's order to drink water and avoid coke and tea. This order was not added to the care plan, and the DON was unsure why it was overlooked.
A facility failed to implement a physician's order for a resident with dementia and stage 3 chronic kidney disease. The order, faxed by a Urologic Specialist, instructed the resident to drink water and avoid coke and tea, but it was neither documented nor executed. The DON acknowledged the oversight without an explanation.
Failure to Coordinate Hospice Code Status Communication
Penalty
Summary
The facility failed to coordinate care with a contracted hospice service provider for a resident who was admitted to hospice services. Despite the resident and their family previously declining to change the resident's cardiac code status from full code, a Do Not Resuscitate (DNR) document was later signed by the resident's guardian outside the facility, with a hospice representative as a witness. However, the facility was not notified of this change, nor was a copy of the signed DNR provided to the facility by the hospice provider. Subsequently, the resident experienced a decline in condition, exhibiting sluggishness and audible secretions, and was transferred to the emergency room as a full code. During transport, the resident was intubated, sedated, and paralyzed by emergency medical technicians. It was only after this event that the facility staff became aware of the signed DNR document and updated the resident's code status in the medical record accordingly. Interviews with facility staff revealed that there was no established process for ensuring timely communication of code status changes from the hospice provider to the facility. The hospice provider's representative admitted to not notifying the facility of the DNR status change and was unsure of the standard procedure for such notifications. Facility staff also indicated that without direct communication or documentation from the hospice provider, they could not update the resident's code status, especially when the resident or family was unavailable for care plan meetings.
Failure to Maintain Resident Dignity in Clothing and Dining Assistance
Penalty
Summary
The facility failed to maintain the dignity of two residents, both diagnosed with dementia, by not providing clean clothing and appropriate dining assistance. One resident was observed on multiple occasions with food debris on their clothing and blanket, indicating a lack of attention to personal cleanliness after meals. Despite being severely impaired in cognition, the resident was left in the common area with food debris, and staff admitted to not knowing why the resident was not cleaned up. Another resident, also severely impaired in cognition, was assisted with their meal by a CNA who stood while feeding them, contrary to the facility's protocol. The CNA expressed a preference for standing, while the LPN and DON confirmed that staff should sit to maintain the resident's dignity during meals. This inconsistency in following proper dining assistance procedures further contributed to the failure in maintaining resident dignity.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 6.9% during the observation of medication administration. Specifically, a Certified Medication Aide (CMA) administered medications to a resident without adhering to the proper procedures. The CMA administered two puffs of albuterol sulfate inhalation aerosol to the resident without waiting the required one minute between puffs, as per the manufacturer's instructions. Additionally, the CMA administered two sprays of aller-flo fluticasone in each nostril of the resident, contrary to the physician's order, which specified one spray in each nostril twice a day. The Director of Nursing (DON) and the CMA supervisor both expressed expectations that medications be administered according to the five rights and prescriber orders. However, the CMA supervisor admitted that they had not trained CMA #1, as this staff member was hired before their tenure at the facility. The supervisor monitored medication administration from a distance to ensure compliance, but this oversight did not prevent the errors observed. These actions and inactions contributed to the facility's failure to maintain the required medication error rate.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure the security of medications on two of its medication/treatment carts, specifically on the 300 hall and 400 hall. Observations revealed that the 300 hall medication/treatment cart was left unattended and unlocked multiple times by an LPN while they entered various rooms. This occurred on several occasions within a short time frame, indicating a pattern of non-compliance with the facility's policy. The policy, dated April 2007, clearly states that the nurse must secure the medication cart during the medication pass to prevent unauthorized entry. Additionally, the 400 hall medication/treatment cart was also found to be unlocked and unattended. Interviews with the staff, including LPNs and the DON, confirmed that the carts were expected to be locked when unattended. However, one LPN admitted to not locking the cart when moving from room to room, only securing it when finished on the hall. The DON mentioned that they randomly checked the carts to ensure compliance, but the observations suggest that these checks were not effective in preventing the deficiency.
Deficiency in Hand Hygiene and Food Covering Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed in the kitchen, as observed during a survey. Dietary aide #2 was seen entering the kitchen, touching their pants, and beginning work without washing their hands. Similarly, the dietary manager put on gloves without prior handwashing, and dietary aide #1 started preparing meal trays without washing their hands. Dietary aide #2 was also observed touching their face, donning gloves, preparing food, and removing gloves without washing hands. The facility's policy on preventing foodborne illness requires employees to wash their hands whenever entering or re-entering the kitchen, and it specifies that antimicrobial hand gel cannot replace handwashing in foodservice areas. Despite this policy, staff did not adhere to these guidelines, as confirmed by the dietary manager and dietary aide #2. Additionally, the facility did not ensure that food delivered to residents on the C hall was adequately covered. Meal trays were delivered with uncovered cake on saucers, and cook #1 confirmed that while main plates were covered, small bowls or saucers were not. The dietary manager stated that uncovered food items were protected by the cart, and staff were instructed to push the cart down the hall to each room rather than carrying uncovered food. This practice did not align with the facility's standards for food safety and hygiene, as observed during the survey.
Infection Control Deficiencies in PPE, Laundry, and Water Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by several observations and interviews. Two residents, one with diabetes and another with dementia, were not provided with appropriate PPE during care. An LPN was observed providing wound care without a gown, and CNAs did not wear gowns during catheter care. Additionally, the facility did not have EBP signage outside the residents' rooms, leading to staff being unaware of the need for PPE. Furthermore, catheter bags and tubing for two residents were observed in contact with the floor, contrary to the facility's policy. The facility also failed to maintain infection control in the transportation of clean laundry, as clothing racks were not covered during transport, exposing them to potential contamination. The laundry supervisor and administrator acknowledged the lack of covers for clothing racks. Additionally, the facility had not implemented a water management program to prevent the spread of waterborne pathogens, as the maintenance supervisor had not assessed the water system for potential growth areas of bacteria. The administrator confirmed that the Legionella Water Management Program policy had not been implemented, although some educational classes had begun.
Failure to Provide Immunization Education and Offer
Penalty
Summary
The facility failed to ensure that residents were provided education and offered influenza and pneumococcal immunizations, as evidenced by the cases of two residents. Resident #88, who was admitted with a diagnosis including coronary artery disease, did not have documentation in their clinical record indicating they had been educated or offered these immunizations. Similarly, Resident #17, admitted with a diagnosis including diabetes mellitus, also lacked documentation of being educated or offered the immunizations. The corporate nurse and infection preventionist acknowledged the absence of documentation for these residents, noting that a previous infection preventionist was responsible for this task but could not locate the necessary records.
Failure to Provide COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to ensure that residents were provided education and offered the COVID-19 vaccine, as evidenced by the lack of documentation for four residents. Resident #78, who was admitted with dementia, Resident #88 with coronary artery disease, Resident #17 with diabetes mellitus, and Resident #49, also with diabetes mellitus, were not documented as having received education or an offer for the COVID-19 immunization. The Director of Nursing identified a total of 87 residents in the facility, but the clinical records for these four residents did not show any evidence of the required education or vaccine offer. A corporate nurse and infection preventionist confirmed that the previous infection preventionist was responsible for these tasks but could not locate the necessary documentation for the affected residents.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, specifically for Resident #35, who was observed self-administering Albuterol Sulfate HFA Aerosol Solution. Resident #35 had a diagnosis of chronic obstructive pulmonary disease and was cognitively intact for daily decision-making, as per the annual assessment. However, there was no documented assessment for self-administering an inhaler in the resident's electronic clinical record. The facility's policy, dated December 2016, requires an interdisciplinary team to determine if it is clinically appropriate and safe for residents to self-administer medications, including a specific skill assessment. The LPN and DON acknowledged that the assessment had not been completed, which was contrary to the facility's policy.
Failure to Notify Guardian of Resident's Suicidal Ideation
Penalty
Summary
The facility failed to notify a resident's guardian about a significant change in the resident's condition, specifically regarding suicidal ideations. The resident, who had diagnoses including major depressive disorder, schizophrenia, and anxiety, expressed a desire to die out of frustration. Despite the resident's statements, the facility did not document any notification to the guardian, as required by their policy. The resident was placed under one-on-one observation, and the staff attempted to manage the situation internally without involving the guardian. Multiple staff members, including LPNs and the SSD, were aware of the resident's statements and the subsequent actions taken, such as contacting emergency services and placing the resident under observation. However, there was a lack of communication and documentation regarding the notification of the guardian. The corporate nurse confirmed that the resident had a guardian who should have been informed, but no documentation of such notification was found in the clinical record.
Failure to Monitor Dialysis Port for Resident
Penalty
Summary
The facility failed to properly assess and monitor the dialysis port for a resident who required dialysis services. The resident, diagnosed with renal failure, had a care plan indicating non-adherence to scheduled dialysis treatments. Despite this, there was no documentation of pre and post-dialysis assessments in the treatment records or progress notes for December 2024, January 2025, and February 2025. The facility's Hemodialysis Access Care policy outlined specific procedures for the care of central dialysis catheters, including keeping the site clean and dry, using sterile techniques for dressing changes, and documenting the condition of the catheter and any dialysis-related observations every shift. Interviews with the resident and facility staff revealed that the facility did not perform any assessments before or after the resident's dialysis sessions. An LPN mentioned reviewing dialysis papers upon the resident's return but admitted that monitoring of the central catheter was not documented. The corporate nurse acknowledged that the assessments and notes were not completed due to oversight by prior leadership. This lack of documentation and adherence to the facility's policy contributed to the deficiency in providing safe and appropriate dialysis care for the resident.
Failure to Obtain Physician-Ordered Labs for Resident
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered by the physician for a resident with multiple diagnoses, including diabetes, hyperlipidemia, congestive heart failure, and end-stage renal disease. The physician's order, dated June 3, 2024, required the resident to have a complete blood count, hemoglobin A1C, comprehensive metabolic panel, lipids, and liver function test every three months. Although the September 2024 medication administration record indicated that these labs were completed on September 3, 2024, and documented by an LPN, the clinical record did not contain the lab reports for that month. Upon review, the LPN acknowledged that the ordered labs for September 2024 had not been completed for the resident, despite having documented them as completed. The Director of Nursing confirmed that lab orders were supposed to be documented on the treatment record by the nurse when completed, but the discrepancy was not explained.
Inappropriate Resident Discharge Due to Electronic Monitoring
Penalty
Summary
The facility failed to comply with regulations regarding the discharge of a resident due to the use of authorized electronic monitoring in the resident's room. The facility's policy on transfer or discharge, dated March 2021, allows for discharge only under specific conditions, such as the resident's welfare, improvement in health, or failure to pay. However, the facility initiated the discharge of a resident diagnosed with Alzheimer's, dementia, cerebral infarction, stage three chronic kidney disease, depressive disorder, and hypertension, citing misuse of surveillance cameras and inability to meet the resident's needs as reasons. This action was contrary to the Nursing Home Care Act, which prohibits the removal of a resident due to authorized electronic monitoring. The Director of Nursing (DON) acknowledged that the facility could meet the resident's needs and that the family was dissatisfied with the care provided. The DON also admitted to being unaware of the requirement regarding video surveillance and the discharge of a resident. The resident's family had installed video surveillance with audio in the resident's room, and the facility expressed concerns about audio surveillance capturing conversations in the hallways. Despite these concerns, the facility's actions were not aligned with the legal requirements, leading to the inappropriate discharge of the resident.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving two residents. Resident #2, who had severe cognitive impairment and diagnoses including autistic disorder and hemiplegia, was involved in an altercation with Resident #1. The incident occurred after dining services when Resident #1 followed Resident #2, yelling and eventually putting Resident #2 in a chokehold. Multiple dietary aides witnessed the event, noting that Resident #1 was agitated by the noises Resident #2 made during meal service and subsequently stalked and physically assaulted Resident #2. The facility's policies on abuse prevention and neglect were not effectively implemented, as evidenced by the lack of comprehensive staff training on de-escalation techniques and resident-to-resident behaviors. Although an in-service was conducted on the day of the incident, it did not include all staff signatures, and several staff members, including a CMA, two LPNs, and the Infection Preventionist, confirmed they had not received the necessary training. This lack of training contributed to the facility's failure to protect Resident #2 from abuse by another resident.
Failure to Provide Written Grievance Summary
Penalty
Summary
The facility failed to provide a written summary or findings of a grievance investigation for a resident's representative, despite having a policy in place that requires such documentation. The grievance policy, which is posted in the common area, states that the resident or the person filing the grievance on behalf of the resident will be informed both verbally and in writing of the findings of the investigation and any corrective actions. However, in the case of a resident whose grievances were reviewed, the facility only provided verbal communication to the resident's Power of Attorney (POA) and did not issue a written summary as required. The deficiency was identified through a review of grievance reports and interviews. Two grievance reports were completed for the resident, with resolutions documented as a phone conversation and a one-to-one discussion with the POA. Despite these interactions, the POA reported not receiving any written responses to the grievances filed. The facility administrator confirmed that no written summaries were provided, believing that verbal follow-up was sufficient, which contradicts the facility's established grievance policy.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and a certified nursing assistant (CNA) to the Oklahoma State Department of Health (OSDH). The incident was initially brought to the attention of the facility's administration in April when a CNA reported hearing a rumor about inappropriate behavior between another CNA and a resident. Despite the report, the facility administrator did not report the incident to OSDH, as they were uncertain whether the situation was a true allegation of abuse or merely a rumor. The administrator conducted an internal inquiry by questioning the involved parties and other staff but did not consider this a formal investigation. The facility's abuse policy mandates that all suspected abuse be investigated and reported to the appropriate agencies. However, the administrator's uncertainty about the nature of the incident led to a failure to comply with this policy. The Director of Nursing (DON) and other staff were aware of the rumor, but no formal report was made to the state licensing agency. This inaction resulted in a deficiency as the facility did not fulfill its obligation to report the alleged abuse, as required by their own policy and state regulations.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident and a Certified Nursing Assistant (CNA). The facility's abuse policy mandates that all suspected abuse be investigated and reported to the appropriate agencies. However, there was no documented investigation regarding the incident involving the resident and CNA #2. The incident was initially reported as a rumor by CNA #1 and CNA #3, who mentioned inappropriate behavior involving CNA #2's breasts and the resident. Despite the report, the facility did not conduct a thorough investigation or document any findings. The Director of Nursing (DON) and the administrator were informed of the situation in April, but the administrator did not report the incident to the Oklahoma State Department of Health (OSDH) because they were uncertain if it was a true allegation of abuse or merely a rumor. The administrator admitted that their attempt to determine the nature of the incident was not a true investigation. Although an in-service on the facility's abuse policy was conducted for all staff, there was no documentation of the investigation or any formal report submitted regarding the alleged inappropriate behavior.
Failure to Update Care Plan with Physician's Order
Penalty
Summary
The facility failed to update the care plan of a resident with a physician's order, which was a deficiency identified during a survey. The resident in question had diagnoses including dementia and stage 3 chronic kidney disease. A physician's progress note from a Urologic Specialist, which was faxed to the facility, included an order for the resident to drink water and avoid coke and tea. However, this order was not incorporated into the resident's care plan. On July 11, 2024, the Director of Nursing (DON) acknowledged that the care plan had not been updated with the specialist's order and was unsure why the order was overlooked.
Failure to Implement Physician's Order for Resident
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with dementia and stage 3 chronic kidney disease. A progress note from a Urologic Specialist, which was faxed to the facility, included an order for the resident to drink water and avoid coke and tea. However, this order was neither documented nor executed for the resident. The Director of Nursing (DON) confirmed that the order was overlooked and could not provide an explanation for this oversight.
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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