Thunder Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Moore, Oklahoma.
- Location
- 2120 North Broadway, Moore, Oklahoma 73160
- CMS Provider Number
- 375331
- Inspections on file
- 30
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Thunder Care And Rehabilitation during CMS and state inspections, most recent first.
Two residents were not protected from neglect and verbal abuse. One, fully dependent and cognitively impaired, was left unattended outside for over an hour due to poor staff communication. Another, also fully dependent, was subjected to yelling and foul language by a CNA during personal care, with the incident confirmed by witnesses.
The facility did not maintain an effective pest control program, as evidenced by repeated findings of cockroaches and a report of bed bugs in resident rooms and common areas. Multiple residents and a CNA confirmed the presence of pests, and inspection reports documented ongoing pest activity despite interventions. The administrator noted that resident hoarding contributed to the problem and that pest control services were called as needed, but pest issues persisted.
A resident with a history of stroke and significant physical impairments was not assessed or documented after a fall from bed. The incident was not reported or recorded by staff present, and the required post-fall evaluation and notifications were not completed, resulting in a lack of timely medical assessment.
A resident with hypothyroidism did not receive two scheduled doses of levothyroxine as ordered by the physician, with no documented reason for the missed administrations. The quality coordinator confirmed the medication should have been given according to the order.
The facility did not ensure that residents were protected from all forms of abuse and neglect, resulting in a deficiency related to resident safety and well-being.
Two residents with significant medical needs did not receive any of their scheduled showers over a six-day period, as confirmed by both their reports and missing bath documentation. Both residents stated they were supposed to receive showers three times weekly but had not received any, and the ADON could not locate the required bath records for the month.
The facility did not follow its abuse policy by failing to report an allegation of abuse within the required two-hour window. A resident with bipolar disorder and anxiety was involved in inappropriate behavior toward another resident and a staff member. Although the incident was recognized and the resident was redirected, the required incident form and notification to the state health department were not completed within the mandated timeframe.
A resident with a history of bipolar disorder and anxiety was involved in inappropriate physical contact with another resident and a staff member. The incident was not reported to the OSDH within the required two-hour window, as mandated by facility policy, and the DON confirmed that proper reporting procedures were not followed.
A resident with bipolar disorder and anxiety was reported to have inappropriately grabbed another resident's hand and later attempted to grab a staff member. Despite the facility's policy requiring investigation of all abuse allegations, the DON confirmed that no investigation was conducted into these incidents.
A resident with bipolar disorder and anxiety engaged in inappropriate physical contact with another resident and a staff member. Although the incident was documented and the care plan was revised to include the event, no new interventions were added to address the behavior, as confirmed by record review and interviews.
A resident with an indwelling urinary catheter did not have a physician order or care plan documentation for the catheter, and there was no record of catheter care or infection prevention interventions. Staff were unsure why the catheter remained in place and could not confirm if regular care was provided, resulting in a failure to ensure appropriate catheter management.
A resident with severe cognitive impairment was provided bed rails without a required safety assessment. Facility policy mandates a thorough evaluation before bed rail use, but staff confirmed that this was not completed prior to installation.
The facility did not include the required resident census and actual hours worked on the posted daily nurse staffing schedules for two consecutive days. The administrator was unaware of the requirement to post this information, and the deficiency was identified while 127 residents were present in the facility.
A resident did not receive prescribed morning medications within the facility's scheduled administration window, as all medications were given after the designated time. Facility policy required timely administration, and the DON confirmed the medications were administered late.
A nurse failed to wear a gown while providing wound care to a resident with a stage four pressure ulcer, contrary to the facility's Enhanced Barrier Precautions policy, which requires both gown and glove use for residents with wounds. No EBP signage was present near the resident's room, and both the nurse and DON acknowledged the lapse.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident who was cognitively intact. The impaired resident frequently wandered into other residents' rooms, including the abuser's room, where inappropriate sexual behavior was observed by staff. Despite these observations, the facility failed to identify the incidents as sexual abuse and did not adequately implement its abuse policy, leading to a deficiency in protecting the resident.
A facility failed to implement its abuse policy when a cognitively impaired resident was found in a compromising situation with another resident. Despite multiple observations of inappropriate behavior, the incidents were not recognized or investigated as potential abuse. The facility's administrator and DON were not fully informed, and the abuse protocol was not followed, leading to a deficiency.
A facility failed to notify a resident's representative of a medication change, which involved the application of permethrin cream. The resident, diagnosed with cerebral palsy and other conditions, had no documentation in their record indicating that their representative was informed of the new order. An LPN could not recall if they had notified the representative.
A resident with cognitive impairment and obesity did not receive a proper bed bath due to CNAs reusing washcloths and failing to clean the peri area correctly. The CNAs reused washcloths due to a shortage and did not follow proper hygiene practices, particularly during the resident's menstrual cycle.
A facility failed to treat a resident with dignity and respect when a staff member grabbed the resident and took her back to her room after she attempted to hit the staff member. The resident had severe cognitive impairment and a care plan noting potential for physical and verbal behaviors.
Failure to Prevent Resident Neglect and Verbal Abuse
Penalty
Summary
The facility failed to protect two residents from neglect and abuse. One resident with spina bifida and quadriplegia, who was totally dependent on staff for care and had moderate cognitive impairment, was left unattended in the courtyard for over an hour. The resident had requested to go outside near shift change, and although staff came outside for smoke breaks, they did not check on the resident. The resident was only discovered and brought back inside during a routine two-hour check. Communication between CNAs was inadequate, as the CNA who took the resident outside claimed to have informed the next shift, but the receiving CNA stated they were not told the resident was outside and only found them during scheduled rounds. Another resident, who was totally dependent on staff for activities of daily living and was cognitively intact, experienced verbal abuse from a CNA. The resident requested assistance with personal hygiene, and the CNA responded by yelling and using foul language. The altercation escalated with both parties exchanging threats and inappropriate language. Witnesses confirmed the CNA's behavior, and the incident was substantiated as verbal abuse. The facility's policy required an abuse-free environment, but staff actions did not prevent or address the abuse and neglect in these cases.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented instances of cockroach activity and a report of bed bugs within resident rooms and common areas. Service Inspection Reports over a three-month period detailed repeated findings of cockroaches in various resident rooms, a broom closet, and the kitchen, with physical removal of pests occurring on each occasion. The reports also noted that some rooms required repeated treatments, and that cockroach activity was found behind appliances and underneath baseboards. Additionally, a resident reported that their room had been sprayed after finding a bed bug in their bed, and another resident stated they had seen cockroaches in their room about a week prior. A CNA confirmed the presence of cockroaches in the facility. During interviews, the administrator acknowledged that some residents hoarded items or kept belongings in cardboard boxes, which complicated pest control efforts. The administrator stated that pest control services were called whenever pests were found, but that the issue was ongoing and not always confined to the same areas. Despite the facility's pest control policy and ongoing interventions, the repeated findings of pests and resident and staff reports indicate that the pest control program was not effective in keeping the building free of insects and rodents as required.
Failure to Assess and Document Resident After Fall
Penalty
Summary
The facility failed to assess a resident after a fall, as required by policy. A resident with a history of stroke, cognitive intactness, and significant physical impairments was dependent on staff for all activities of daily living. The resident self-reported rolling out of bed and hitting their left ribs, later experiencing left-sided pain and coffee brown emesis, which led to transport to the emergency room. There was no documentation of the fall in the medical record, and the required assessment for injuries, including vital signs and documentation, was not completed at the time of the incident. Interviews revealed that two CNAs and an LPN were present when the resident was moved back to bed after the fall, but no incident report was filed, and the fall was not communicated to nursing staff until the resident reported it. The administrator confirmed that the staff involved did not follow facility procedures for post-fall assessment and documentation, resulting in a lack of timely evaluation and notification to the physician and family as required by policy.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one of three sampled residents reviewed for medication administration. Specifically, a resident with hypothyroidism had an active order for levothyroxine sodium oral tablet 150 mcg, which was to be started and continued until discharge. However, the July medication administration record showed that the medication was not administered on two consecutive days, with blank areas noted for those dates. The quality coordinator confirmed that there was no documented reason for the missed doses, and acknowledged that the medication should have been given according to the physician's order.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by anybody. This deficiency indicates that residents were not adequately safeguarded from potential or actual harm caused by others, as required by regulations. The report identifies a lapse in ensuring residents' safety and well-being from abuse and neglect, but does not provide specific details about the individuals involved or the circumstances of the incident.
Failure to Provide Scheduled Bathing for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living received scheduled bathing. Record review and interviews revealed that two residents missed all scheduled showers over a six-day period, despite both being cognitively intact and having medical conditions such as epilepsy, morbid obesity, hemiplegia, and hemiparesis following a cerebral infarction. Both residents reported not receiving their scheduled showers, which were supposed to occur three times per week. Additionally, the Assistant Director of Nursing was unable to locate the bath sheets for the relevant month, further indicating a lack of documentation and follow-through on scheduled care.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not reporting an allegation of abuse within the required two-hour timeframe. According to the facility's abuse policy, all incidents and allegations involving abuse or resulting in serious bodily injury must be reported within two hours. A behavior note documented that one resident reported another resident had grabbed their hand and placed it in the other resident's pants in the dining room. The resident who initiated the behavior was redirected and later attempted to grab a staff member while being fed, stating they wanted to play. This resident had diagnoses including bipolar disorder and anxiety. The Director of Nursing (DON) was notified of the incident, and the administrator instructed staff to return the resident to their room and continue monitoring behaviors. However, the DON acknowledged that an incident form should have been completed and the state health department notified within two hours, which did not occur.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe, as specified in their abuse policy. Record review showed that a resident with diagnoses including bipolar disorder and anxiety was involved in an incident where they inappropriately grabbed another resident's hand and placed it in their pants in the dining room. The same resident also reached for a staff member of the opposite sex during feeding, expressing a desire to play. Although the Director of Nursing (DON) acknowledged that an incident report should have been completed and OSDH notified within two hours, this was not done in accordance with facility policy.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving one of three sampled residents. According to the abuse policy, all allegations of abuse are to be investigated by the Administrator and the DON. Documentation showed that a resident was reported to have grabbed another resident's hand and placed it in their pants in the dining room, and later attempted to grab a staff member while voicing a desire to play. The resident involved had diagnoses including bipolar disorder and anxiety. Despite these incidents being reported, the DON confirmed that no investigation was conducted into the alleged abuse.
Failure to Revise Care Plan After Behavioral Incident
Penalty
Summary
The facility failed to ensure that a care plan was appropriately revised following a behavioral incident involving a resident. On 06/05/25, a behavior note documented that a resident with diagnoses of bipolar disorder and anxiety engaged in inappropriate physical contact with another resident in the dining room and later attempted similar behavior with a staff member. The resident was redirected and returned to their room. Although the care plan was revised the following day to note the incident, no new interventions were put in place to address the behavior. Review of records and interviews confirmed that the care plan should have been updated with specific interventions in response to the incident, but this was not done.
Failure to Document and Provide Appropriate Catheter Care
Penalty
Summary
A resident with a history of benign prostatic hyperplasia and moderate cognitive impairment was observed with an indwelling urinary catheter in place after returning from the hospital. The resident's care plan only referenced the use of disposable briefs for urinary incontinence and did not mention the presence of a catheter. There was no physician order for the indwelling catheter in the medical record, nor was there documentation of catheter care or infection prevention interventions. The resident was unaware of the reason for the catheter and could not confirm if regular catheter care was provided. Staff interviews revealed uncertainty regarding the necessity of the catheter and a lack of documentation for catheter care and maintenance. The LPN stated that catheter care is generally performed every shift but acknowledged that there was no way to verify if this was done due to missing documentation. The DON confirmed that a physician order specifying the medical diagnosis, catheter size, and care interventions should have been present, and that the resident had not been assessed for catheter removal. These omissions resulted in a failure to provide appropriate care and services for a resident with an indwelling urinary catheter.
Failure to Assess Resident Prior to Bed Rail Installation
Penalty
Summary
Surveyors found that the facility failed to assess a resident for the use of bed rails prior to their installation. Observations on two separate occasions showed that bed rails were up on both sides of the resident's bed. The facility's policy requires a comprehensive assessment of various risk factors before bed rails are used, including medical diagnosis, cognitive status, mobility, and risk of entrapment. Record review revealed that the resident had a severely impaired cognitive status, as indicated by a BIMS score of three. The administrator confirmed that no assessment was completed before the bed rails were put in place, despite the policy and the resident's condition.
Incomplete Daily Nurse Staffing Information Posted
Penalty
Summary
The facility failed to post all required components of the daily nurse staffing information for two consecutive days. During observations, the daily staffing schedules displayed in a glass case on the North hall were found to be missing both the resident census and the actual hours worked, despite being dated for the respective days. The administrator confirmed that they were unaware that the census and actual hours worked were required to be included on the posted schedule. At the time of the survey, the facility had 127 residents.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident among those sampled for timely medication administration. Facility records indicated that the scheduled morning medication pass was from 7:00 a.m. to 11:00 a.m., and facility policy required medications to be administered in a safe and timely manner as prescribed. Physician orders for the resident included multiple medications to be given in the morning or twice daily. However, a medication administration audit showed that on a specific date, all of the resident's morning medications were administered after the scheduled window, between 12:28 p.m. and 12:32 p.m. The Director of Nursing confirmed that these medications were given late and should have been administered by 11:00 a.m.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse provided wound care to a resident with a stage four pressure ulcer without utilizing a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy. During the observation, the nurse wore gloves but did not don a gown, and there was no EBP signage near the resident's room. The facility's policy specifies that both gown and glove use are required during high-contact care activities for residents with wounds. The resident in question was severely cognitively impaired, as indicated by a BIMS score of three. Both the nurse and the Director of Nursing confirmed that a gown should have been worn during the wound care procedure.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The deficiency involved a failure to protect a resident from sexual abuse within the facility. Resident #1, who was severely cognitively impaired and had not been evaluated for the capacity to consent to a sexual relationship, was found in a compromising situation with Resident #2, who was cognitively intact. On multiple occasions, Resident #1 was observed entering Resident #2's room, and on one occasion, staff observed Resident #2 engaging in inappropriate sexual behavior with Resident #1. Despite these observations, the facility did not initially identify the incidents as sexual abuse. The facility's records showed that Resident #1 had a history of wandering and entering other residents' rooms, which was documented in progress notes and assessments. Despite this behavior, the facility's response was limited to redirecting Resident #1 and implementing 15-minute checks after the incident on December 11, 2024. The facility's abuse policy was not effectively implemented, as the incidents were not reported or investigated as abuse, and the staff did not receive adequate guidance on handling such situations. Interviews with staff revealed inconsistencies in the reporting and handling of the incidents. CNA #1 and CNA #2 provided detailed accounts of the inappropriate behavior they witnessed, but these details were not fully communicated to the administrator or documented in the facility's records. The administrator and DON were not fully aware of the extent of the incidents, and the facility's investigation was based on incomplete information. This lack of communication and failure to follow the abuse policy contributed to the deficiency in protecting Resident #1 from sexual abuse.
Failure to Implement Abuse Policy in Resident Interaction
Penalty
Summary
The facility failed to implement its abuse policy and procedure to identify and investigate an incident of sexual abuse involving two residents. Resident #1, who was severely cognitively impaired and had not been evaluated for the capacity to consent to a sexual relationship, was found in a compromising situation with Resident #2, who was cognitively intact. Despite multiple observations and reports of inappropriate behavior between the two residents, the facility did not recognize or investigate these incidents as potential sexual abuse. On several occasions, staff observed Resident #1 wandering into other residents' rooms, including Resident #2's room, where inappropriate contact was reported. On one occasion, a CNA observed Resident #2 on top of Resident #1, with Resident #2's hand down Resident #1's pants and engaging in inappropriate physical contact. Despite these observations, the facility categorized the incident as inappropriate behavior rather than abuse, and the abuse protocol was not implemented. The facility's administrator and DON were not fully informed of the details of the incidents, and the abuse policy was not followed. The administrator relied on reports from RN #1 and did not conduct a thorough investigation, including interviews with all involved staff and residents. The facility's failure to assess Resident #1's ability to consent and to recognize the incidents as potential abuse led to the deficiency.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to notify a resident's representative of a medication change, which constitutes a deficiency in communication and notification protocols. The resident in question was admitted with diagnoses including cerebral palsy, autistic disorder, and spastic quadriplegic cerebral palsy. A physician's order was issued for the application of permethrin external cream 5% to the resident's entire body, to be left on for eight hours before washing off. However, the resident's record lacked documentation indicating that the resident's representative was informed of this new medication order. During an interview, a licensed practical nurse stated they did not remember notifying the resident's representative about the medication change.
Improper Bed Bath and Hygiene Practices
Penalty
Summary
The facility failed to ensure a proper bed bath was provided to a resident with a diagnosis of obesity and moderate cognitive impairment, who was dependent on staff for bathing. During the observation of the bed bath, it was noted that the CNAs reused washcloths by dipping them back into the soapy and clean water basins, which is against proper hygiene practices. The CNAs did not have enough washcloths to continue the bath, leading to the reuse of washcloths, which were considered dirty and should have been discarded after each use. Additionally, the CNAs did not properly clean the resident's peri area, particularly between the labia, during the bed bath. The resident was on their menstrual cycle, and the improper cleaning was confirmed by the presence of a blood stain and a string of blood clot on the washcloth used. The CNAs acknowledged that they did not follow the correct procedure for cleaning the resident's peri area, which should have been done from top to bottom, including proper cleaning of female residents' peri areas.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by an incident involving a resident with diagnoses of intellectual disability disorders, bipolar disorder, and anxiety. The resident, who was severely impaired with cognition, was grabbed by a staff member and taken back to her room after she attempted to hit the staff member. This incident was documented in a state incident report and occurred despite the resident's care plan noting her potential for physical and verbal behaviors.
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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