The Wolfe Living Center At Summit Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrah, Oklahoma.
- Location
- 18501 Northeast 63rd Street, Harrah, Oklahoma 73045
- CMS Provider Number
- 375472
- Inspections on file
- 17
- Latest survey
- April 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Wolfe Living Center At Summit Ridge during CMS and state inspections, most recent first.
A resident with Alzheimer's, dementia, and severely impaired cognition was not accurately assessed for wandering behavior on the MDS, despite documentation in progress notes and an elopement risk assessment indicating wandering and elopement risk during the assessment period. The ADON confirmed the MDS coding did not reflect the resident's actual behavior.
A resident who was at risk for elopement left the facility without triggering a door alarm and was found outside by staff. Although immediate interventions such as frequent visual checks and door alarm monitoring were started, the care plan was not updated to reflect the incident or these new interventions, as confirmed by the ADON.
A facility failed to include a resident's Power of Attorney (POA) in their clinical record, despite the resident having a cognitive communication deficit and atrial fibrillation. The resident's Advance Directives Acknowledgement form indicated a POA existed, but it was not documented as required by the facility's policy. The Social Service Director confirmed the oversight and noted that the resident's family was contacted to provide the missing document.
The facility failed to provide advance beneficiary notices (ABNs) to two residents discharged with skilled days remaining. The MDS coordinator confirmed the ABNs were not signed, and the BOM admitted to not issuing them, leaving residents uninformed of potential liability for non-covered services.
The facility failed to implement its abuse policy, resulting in deficiencies related to two residents. Allegations of abuse were not thoroughly investigated, reported to the OSDH within the required timeframe, or coordinated with the QAPI program. In one case, a resident with cerebral palsy was allegedly pushed aggressively by a CNA, and in another, a resident with cerebral infarction was allegedly handled roughly. The facility did not document thorough investigations or assessments for harm, and the QAPI program did not address these issues.
A facility failed to report an abuse allegation within the required timeframe. A resident with cerebral palsy and cognitive deficits was allegedly pushed aggressively by a CNA, leading to scratches on the CNA's arm. The incident was reported to the DON immediately but not to the state agency until the next day, exceeding the two-hour reporting requirement.
A facility failed to investigate an abuse allegation involving a resident with cerebral palsy and cognitive deficits. A CNA allegedly pushed the resident aggressively, leading to scratches on the CNA's arm. The DON witnessed the incident but did not conduct a thorough investigation or safe surveys with other residents, as required by facility policy.
A resident with chronic kidney disease and osteoarthritis did not receive scheduled bathing assistance, as required for hygiene and skin health. Despite being scheduled for specific days, records showed inconsistencies, and the resident reported staff failed to assist after requests. Interviews revealed discrepancies in documentation and adherence to the bathing schedule.
A facility failed to implement wound care orders for a resident with a venous ulcer. The resident's treatment plan included Medihoney and alginate, but these were not documented as implemented. Interviews revealed confusion over the orders, with staff unable to show that the treatments were carried out. Despite some improvement in the wound, the facility did not adhere to the specified care orders, leading to a deficiency.
A facility failed to document side effect monitoring for a resident on anticoagulant therapy, despite policy requirements. The resident, with schizoaffective bipolar type and cognitive communication deficit, was prescribed Eliquis 5 mg twice daily. The ADON confirmed the absence of monitoring documentation in the resident's records.
Inaccurate MDS Coding for Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when the Minimum Data Set (MDS) was not properly coded. The resident, who had diagnoses of Alzheimer's, dementia, and severely impaired cognition, was assessed on a quarterly MDS with no wandering behavior documented in section E0900 for the seven-day look-back period. However, a progress note from the same assessment reference date indicated the resident had wandered or paced three times during a shift, and an elopement risk assessment identified the resident as at risk for elopement, noting aimless or non-goal-directed wandering. Upon review, the Assistant Director of Nursing (ADON) confirmed that the MDS section E0900 was not accurately coded, as the resident had indeed exhibited wandering behavior during the look-back period.
Failure to Update Care Plan After Elopement Incident
Penalty
Summary
The facility failed to review and revise the care plan for a resident following an elopement incident. According to facility policy, comprehensive care plans are to be updated by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and with any new or changed interventions. An incident report documented that a resident was found ambulating across the parking lot after leaving the building through an ambulance door without the door alarm sounding. Immediate interventions, including 15-minute visual checks on the resident and hourly checks on door alarms, were initiated. However, the resident's care plan, which already listed a risk for elopement, was not updated to reflect the incident or the new interventions. The ADON confirmed that the care plan did not include the elopement event or the additional monitoring measures implemented after the incident.
Failure to Document Resident's Power of Attorney
Penalty
Summary
The facility failed to ensure that a resident's Power of Attorney (POA) was included in their clinical record, which is a requirement for maintaining accurate and complete documentation of advance directives. This deficiency was identified during a review of the clinical records for a resident diagnosed with cognitive communication deficit and atrial fibrillation. The resident's Advance Directives Acknowledgement form indicated that they had a POA for medical or health care decisions, but the clinical record did not contain a copy of this document. The facility's policy on Residents' Rights Regarding Treatment and Advance Directives mandates that any advance directives, including POAs, should be documented and communicated to the staff upon admission. However, the Social Service Director (SSD) confirmed that the facility did not have a copy of the resident's POA, although the resident's family was contacted to provide it. The SSD explained that during the admission process, they review advance directives with the resident or family and request a copy of the POA if one exists. The absence of the POA in the resident's clinical record indicates a lapse in following the facility's policy and ensuring that the resident's rights and preferences are documented and respected.
Failure to Provide Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide advance beneficiary notices (ABNs) to two residents who were discharged with skilled days remaining. According to the facility's policy, ABNs should be issued when services are terminated, and the beneficiary wishes to continue receiving care that is no longer considered medically necessary. However, for two residents, the facility did not provide these notices. Resident #140 was admitted on Medicare Part A services and discharged home with skilled days remaining, yet no ABN was provided. Similarly, Resident #141 was discharged home with skilled days remaining without receiving an ABN. Interviews with facility staff revealed that the MDS coordinator confirmed the ABNs for these residents were not signed, indicating they were not provided. The Business Office Manager (BOM), responsible for completing the ABNs, admitted to not issuing them, stating they were left on their desk and not attended to. This oversight resulted in the residents not being informed of their potential liability for services not covered by Medicare.
Failure to Implement Abuse Policy and Conduct Thorough Investigations
Penalty
Summary
The facility failed to implement its abuse policy effectively, resulting in several deficiencies. The policy required the prevention of abuse, neglect, and exploitation, as well as the investigation of allegations and coordination with the QAPI program. However, the facility did not conduct a complete and thorough investigation into the allegations of abuse involving two residents. The incidents were not reported to the OSDH within the required two-hour timeframe, and there was no documentation of a physical or psychosocial assessment of the residents involved. In the case of Resident #1, who had cerebral palsy, dysphagia, and cognitive communication deficit, an allegation was made that a CNA pushed the resident aggressively. The incident was not reported to the OSDH within two hours, and there was no documentation of a thorough investigation or assessment of the resident for harm. The QAPI program did not address the abuse allegations, and the facility's staff, including the DON and administrator, admitted to not following the policy requirements for reporting and investigating abuse. Similarly, for Resident #23, who had cerebral infarction and other conditions, an allegation was made that a CNA was rough during a shower. The investigation was incomplete, and the QAPI program did not address the abuse allegations. Interviews with staff revealed that the CNA was terminated, but there was no documentation of a thorough investigation or assessment of the resident. The facility's failure to follow its abuse policy and procedures led to deficiencies in handling these serious allegations.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse immediately to the state agency, as required by their policy. The policy mandates that any alleged violations involving abuse or resulting in serious bodily injury must be reported to the Administrator, state agency, adult protective services, and other required agencies immediately, but not later than two hours after the allegation is made. In this case, an allegation was made that a CNA pushed a resident aggressively to the shower, and the incident was not reported to the state agency until the following business day, exceeding the two-hour reporting requirement. The resident involved had a history of cerebral palsy, dysphagia, and cognitive communication deficit, and was dependent on staff for showers and baths. The incident occurred when the CNA reported scratches on their arm inflicted by the resident after the shower. The DON witnessed the CNA pushing the resident roughly in a wheelchair but attributed it to the resident's weight. Despite the incident being reported to the DON immediately, it was not communicated to the state agency within the required timeframe, as the DON believed the delay was justified due to the resident not being harmed.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with cerebral palsy, dysphagia, and cognitive communication deficit. The incident involved a CNA allegedly pushing the resident aggressively to the shower, which was reported on an OSDH form. The resident, who had no history of aggression or violence, stated that the CNA made them feel uncomfortable. The CNA reported scratches on their arm inflicted by the resident after the shower. Another CNA witnessed the incident and reported it to the DON, who admitted to witnessing the CNA push the resident roughly but attributed it to the resident's weight. The facility's policy required identifying and interviewing all involved persons and providing complete documentation of the investigation. However, the DON did not conduct safe surveys with other residents or complete a thorough investigation. The administrator confirmed that the DON failed to complete the necessary safe surveys or conduct an investigation. Additionally, the ADON stated there was no documentation of an investigation being conducted, indicating a failure to adhere to the facility's abuse, neglect, and exploitation policy.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident received their scheduled baths or showers, as required for maintaining proper hygiene and preventing skin issues. The resident, who had diagnoses including stage 4 chronic kidney disease and bilateral primary osteoarthritis of the knee, required supervision or touching assistance for bathing. Despite being scheduled for bathing assistance on specific days, records showed inconsistencies, with some days marked as 'not applicable' and others lacking documentation of a bath or shower. The resident expressed difficulty in receiving assistance, stating that staff failed to show up after requests for help, and believed they had not been bathed for over a week. Interviews with CNAs and the ADON revealed discrepancies in the documentation and understanding of the bathing schedule. CNAs were instructed not to use 'not applicable' in records, yet it appeared in the documentation. Staff were expected to offer bathing assistance multiple times if initially refused by a resident, but there was no clear evidence that this protocol was followed. The ADON confirmed that the resident required limited physical help and was scheduled for bathing assistance on specific days, yet the facility's records and staff actions did not align with these requirements.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with a full thickness venous ulcer on the left posterior lower leg. The resident's wound care orders, dated 03/05/25, included cleansing with wound cleanser, applying collagen powder, and using a four-layer wrap weekly and as needed. However, subsequent wound care progress notes indicated changes to the treatment plan, including the addition of Medihoney on 03/12/25 and alginate on 03/19/25, which were not documented as implemented. Interviews with LPN #2 and ADON #1 revealed that the Medihoney and alginate treatments were not carried out, and there was confusion regarding the orders, as ADON #1 mentioned a verbal instruction to use calcium alginate instead of Medihoney. The resident was observed with ace wrap dressings on their legs, and there was no documentation of the Medihoney or alginate being applied as per the wound care physician's orders. The facility's clean dressing change policy emphasized the importance of following physician's orders to decrease the potential for infection. Despite the resident's wound showing some improvement, the lack of adherence to the specified wound care orders represents a deficiency in the facility's care practices.
Lack of Side Effect Monitoring for Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure proper side effect monitoring for a resident prescribed anticoagulant therapy. Resident #22, who was admitted with diagnoses including schizoaffective bipolar type and cognitive communication deficit, was prescribed Eliquis 5 mg twice daily. Despite the facility's policy requiring systematic medication management and monitoring for adverse consequences, there was no documentation of side effect monitoring in the resident's physician orders or Treatment Administration Record (TAR). During an interview, the Assistant Director of Nursing (ADON) confirmed that side effect monitoring should be documented on the TAR for residents on anticoagulant therapy. However, it was acknowledged that such monitoring was absent for Resident #22. This oversight was identified as a deficiency in the facility's adherence to its medication monitoring policy, specifically for residents receiving anticoagulant medications.
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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