Tuscany Village Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 2333 Tuscany Blvd, Oklahoma City, Oklahoma 73120
- CMS Provider Number
- 375536
- Inspections on file
- 38
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Tuscany Village Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and diagnoses including obstructive uropathy and non-Alzheimer dementia had physician orders for weekly weights, a milk/soy protein supplement, and sodium bicarbonate. Over multiple occasions, the resident refused the ordered protein supplement, a scheduled weight, and sodium bicarbonate, with these refusals documented in nurses' notes. However, there was no documentation that the resident's family or physician were notified of these refusals, despite facility policy and staff statements indicating that such refusals should be communicated and recorded. The DON confirmed that the record lacked evidence of required notifications.
Two residents with urinary catheters did not receive appropriate assessment, orders, and monitoring. One resident with a suprapubic catheter had no admission documentation of the catheter, no physician order specifying catheter type or diagnosis, and no catheter-related focus or interventions in the care plan, even though staff and a representative confirmed the catheter was present on admission and throughout the stay. Another resident with an indwelling catheter was observed with thick off-white material filling the catheter tubing into the drainage bag; staff described this as sometimes normal, and the DON noted the tubing was very cloudy with sediment and not secured to the leg, despite acknowledging it should be secured.
A resident with a tracheostomy, severe cognitive impairment, COPD, and documented need for suctioning received regular tracheostomy suctioning without a corresponding physician order, contrary to facility policy requiring care in accordance with standard practice guidelines. The baseline care plan and admission assessment both indicated the need for suctioning and tracheostomy care, but a review of physician orders showed no order for tracheostomy suctioning. The DON confirmed that an order should have been in place, and an LPN reported suctioning the resident’s tracheostomy after the family requested suctioning and stated that the resident was suctioned regularly.
A resident with obstructive uropathy and severe cognitive impairment was admitted with an indwelling catheter and received a regular diet, but the physician orders and treatment records documented suprapubic catheter care and enteral tube feeding. An LPN and the DON confirmed there was no physician order for the actual catheter type in use and that the enteral feeding order was erroneous, resulting in medical records and orders that did not accurately reflect the resident’s catheter type or nutritional status.
A resident with severe cognitive impairment, obstructive uropathy, and a suprapubic catheter was admitted with physician orders for catheter changes as needed, output monitoring each shift, and catheter care every shift, and treatment records showed catheter care was being provided. However, the comprehensive care plan created after admission addressed only activities and did not include any focus, goals, or interventions for catheter care or ADLs, despite the resident’s dependence for transfers and need for assistance with self-care. A resident representative confirmed the catheter was present throughout the stay, a CNA reported there was no documentation directing catheter care, and both the DON and MDS coordinator later acknowledged that the comprehensive care plan was incomplete and had been missed.
Two residents who required assistance with ADLs did not consistently receive scheduled baths, and refusals or completed baths were not properly documented. One cognitively impaired resident, scheduled for twice‑weekly showers, only received showers on two occasions during a two‑week period, with no refusals recorded and family reporting showers occurred only after complaints. Another resident with intact cognition but significant physical impairments and physician‑ordered twice‑weekly baths did not receive a bath on a scheduled day, despite an LPN initialing the MAR as if the bath occurred, while the TAR and nurses’ notes showed no bath or refusal. Staff interviews revealed that showers were not completed for all residents, that aides cited insufficient staffing, and that required documentation and notification procedures for bath refusals were not followed.
A resident with severe cognitive impairment, septicemia, renal failure, and IV access had a physician order for weekly IV midline dressing changes on day shift, or sooner if the dressing became compromised. Review of the MAR showed a scheduled dressing change was missed without a documented reason, and a family grievance later reported the IV dressing had not been changed since admission and was dated nearly two weeks earlier. Nursing staff told the family the dressing change was missed because the resident was at dialysis when it was scheduled, and documentation and interviews with the DON and regional nurse consultant confirmed there was no record of the ordered IV dressing change being completed as required.
A resident with multiple medical conditions experienced a significant change in condition and received a new medication order. In both cases, documentation showed that the spouse and hospice company were notified, but there was no evidence that the designated HealthCare contact, the resident's daughter, was informed as required by policy. Staff interviews confirmed the omission.
A resident with multiple diagnoses, including hemiplegia and muscle weakness, was admitted to hospice care as documented by certification and physician's order. However, the significant change MDS assessment did not indicate the resident's hospice status, and the MDS coordinator confirmed the assessment was not accurately coded to reflect this change.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident with multiple medical conditions, including hemiplegia and muscle weakness, did not have required documentation of intake, output, or meal percentages for a week prior to a hospital stay. Facility policy required documentation of meal consumption in the EHR, but records for this period were missing, and the regional nurse consultant confirmed the absence of both the documentation and a specific policy for eating or intake and output.
An LPN in a facility used disinfectant wipes, not intended for skin use, to clean two residents' skin before blood sugar testing and insulin administration, contrary to the facility's policy requiring alcohol swabs. The LPN acknowledged the correct procedure, highlighting a deviation from established protocols.
The facility failed to ensure staff competency with the new EMR system, affecting three staff members. A medication was not administered to a resident because the CMA was unaware of how to verify orders using the new system. Both the CMA and an LPN reported not receiving training on the EMR. The corporate nurse confirmed that in-service sheets did not show attendance for these staff members, and the AD also demonstrated a lack of knowledge about the system.
The facility failed to administer medications as ordered for five residents. Observations showed that a CMA and an LPN did not administer medications according to physician orders, with issues such as missing medications, incorrect dosages, and unauthorized administration. Staff interviews revealed problems with medication availability and adherence to procedures, contributing to these deficiencies.
The facility experienced a medication error rate of 23.68%, significantly above the acceptable threshold. Errors included missed doses of hydrocodone/acetaminophen, lisinopril, amlodipine, and clindamycin, as well as incorrect administration of Vitamin B12 and gabapentin. Staff interviews revealed issues with medication availability and adherence to the MAR.
The facility failed to maintain infection control practices during the handling of soiled linen and hand hygiene. An LPN transported a soiled incontinent pad without bagging it, and a CNA did not change gloves or perform hand hygiene during incontinent care, placing soiled items on the floor instead of in a bag.
The facility failed to provide adequate treatment and services for a resident with a stage 3 pressure ulcer, resulting in the worsening of the wound. Despite physician orders for bi-weekly treatments and a care plan requiring frequent repositioning, the resident received only one wound care treatment over a two-week period, and staff did not document turning or repositioning efforts.
The facility failed to ensure that two residents experiencing pain received appropriate treatment. One resident, who had a hip fracture, was not properly assessed for pain during care, and another resident experienced delays in receiving prescribed pain medication. The staff did not follow the facility's pain management policy, resulting in prolonged pain and discomfort for the residents.
The facility failed to hold a care plan meeting and include a resident's representative for a resident with chronic kidney disease and chronic pain. The meeting was missed due to the responsible LPN not working and no one covering for them.
The facility failed to ensure accurate resident records, as one resident's clinical record contained hospital records belonging to four other residents. The Records Management policy requires consistent and logical maintenance of records, but the process failed, leading to incorrect documents being included in the resident's record.
The facility failed to ensure dishware was clean, as 32 blue-handled coffee cups were found with white residue and contaminants. Both a cook and the Corporate Dietary Manager confirmed the presence of debris inside the cups. The Administrator identified that 114 residents received nutrition from the kitchen.
The facility failed to maintain proper infection control during incontinent care for two residents and did not ensure staff wore required PPE before entering a COVID-19 positive room. CNAs did not change gloves as required, and a CMA entered a COVID-19 positive room without appropriate PPE.
A CNA failed to provide thorough incontinent care for a resident with hemiplegia and hemiparesis by not cleaning the labia, contrary to the facility's perineal care policy. The CNA acknowledged the omission, stating they did not wipe the labia because the resident had just voided.
Failure to Notify Family and Physician of Resident's Repeated Refusals of Care
Penalty
Summary
The facility failed to notify a resident's family and physician of repeated refusals of ordered care and treatment. Facility policy on Refusal of Care and Treatment, dated 02/16/23, required staff to notify the physician when a resident refused ordered treatment or procedures and to notify the resident's responsible party unless the resident chose otherwise. Resident #8 had physician orders dated 10/08/25 for weekly weights for four weeks, a milk/soy protein supplement of 60 milliliters twice daily, and sodium bicarbonate 650 milligrams twice daily. An admission assessment dated 10/14/25 documented that the resident had severely impaired cognition with a BIMS score of 3 and diagnoses of obstructive uropathy and non-Alzheimer dementia, and that the resident did not reject care during the seven-day look-back period. Subsequent nurses' notes from 10/2025 through 11/2025 showed multiple refusals of ordered care by Resident #8, including repeated refusals of the protein supplement health shake on several dates, refusal to be weighed on one date, and refusals of both the protein supplement and sodium bicarbonate on multiple dates. The resident representative stated they were not notified of these refusals. CNA #4 and LPN #6 each stated that when a resident refused care, the nurse should document the refusal and notify both the family and the physician. When shown the nurses' notes, the DON acknowledged there was no documentation that the family or physician had been notified of Resident #8's refusals of care and confirmed that such notification should have occurred and been documented in the nurses' notes.
Failure to Maintain Appropriate Catheter Orders, Assessment, and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate assessment, orders, and care for residents with urinary catheters. For one resident with a suprapubic catheter, the admission assessment did not document the presence of a catheter, and physician orders lacked a specific order for the catheter type and supporting diagnosis, despite orders for suprapubic catheter care, catheter changes as needed, and monitoring of output each shift. The treatment administration record showed ongoing suprapubic catheter care, but the comprehensive care plan contained no focus or interventions for catheter care, and the catheter was not included on the baseline or comprehensive care plan. The resident had severe cognitive impairment, obstructive uropathy, and non-Alzheimer dementia, and was known by staff and the resident representative to have a catheter upon admission and throughout the stay. Staff, including an LPN and the DON, acknowledged that there was no physician order specifying the catheter type, even though they stated such an order was required to guide care. For another resident with an indwelling catheter, surveyors observed the catheter tubing filled with a thick off-white substance extending from the resident’s body into the drainage bag. The physician order directed that the catheter be changed as needed or when clinically indicated. The resident had severe cognitive impairment with a BIMS score of 0, diagnoses of cerebral palsy and traumatic brain injury, and was dependent on staff for all needs. An LPN stated that catheters should be changed if there were signs of infection, but noted the resident did not have a fever and described the thick off-white substance as sometimes normal. The DON described the catheter tubing as stained and very cloudy with sediment and was unsure if this appearance was normal for the resident, and also noted the catheter tubing was not secured to the resident’s leg, despite acknowledging it was advised to secure the catheter to prevent pulling against the bladder wall.
Failure to Obtain Physician Order for Tracheostomy Suctioning
Penalty
Summary
The facility failed to obtain a physician’s order for tracheostomy suctioning for one resident who required this care. The facility’s Tracheostomy Care policy dated 03/02/23 stated that staff would provide care and suctioning for residents with a tracheostomy in accordance with standard practice guidelines. A baseline care plan for Resident #1 dated 01/14/26 documented that the resident had a tracheostomy and required suctioning, and an admission assessment dated 01/21/26 showed the resident had severely impaired cognition with a BIMS score of 07, required suctioning and tracheostomy care, and had a diagnosis of chronic obstructive pulmonary disease. However, a review of physician orders from 01/14/26 through 01/27/26 showed no order for tracheostomy suctioning. The DON confirmed that Resident #1 should have had a physician order for tracheostomy suctioning and that no such order was present. An LPN reported that on 01/26/26 the resident’s family stated the resident needed to be suctioned; the resident was not in distress and was suctioned via the tracheostomy after eating and after the family left, and the LPN stated the resident’s tracheostomy was suctioned regularly despite the absence of a physician order. This deficiency centers on the provision of tracheostomy suctioning without a corresponding physician order, despite documented care needs and facility policy requiring care in accordance with standard practice guidelines.
Inaccurate Physician Orders for Catheter Type and Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate physician orders and medical records for a resident with an indwelling catheter and no enteral feeding. Facility policy on care and removal of indwelling catheters required staff to evaluate the need for catheter removal by validating the record and physician’s order. For this resident, physician orders dated 10/08/25 included directions to change a suprapubic catheter as needed, monitor output every shift, provide suprapubic catheter care every shift, and administer enteral tube feeding twice a day. The treatment administration record for the same period showed the resident received care for a suprapubic catheter. However, the resident’s annual assessment dated 10/14/25 documented that the resident had a catheter in place, not a suprapubic catheter, and that the resident did not have a tube feeding device and instead ate with supervision or touching assistance. The resident had diagnoses of obstructive uropathy and non-Alzheimer dementia, with severely impaired cognition (BIMS score of 3), and was later discharged for a short-term hospital stay. During interviews, the resident’s representative stated the resident had a catheter upon admission and throughout the stay and was not receiving enteral tube feeding. An LPN confirmed that residents admitted with catheters should have orders specifying the catheter type and size, acknowledged that this resident had a catheter upon admission, and identified that there was no physician order for a catheter, only for suprapubic catheter care, and that the resident was on a regular diet rather than enteral tube feeding. The DON similarly confirmed the resident had a catheter upon admission, that the orders incorrectly specified suprapubic catheter care and lacked an order for the actual catheter, and that the resident was on a regular diet and not nothing by mouth, identifying the enteral tube feeding order as an error. These findings show the resident’s physician orders were inaccurate and inconsistent with the resident’s actual catheter type and nutritional status.
Failure to Develop Comprehensive Care Plan for Resident With Suprapubic Catheter
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for one resident with a suprapubic catheter. Facility policy required a comprehensive care plan with measurable objectives and timeframes to be developed within seven days after completion of the comprehensive MDS, considering all triggered Care Area Assessments and other identified needs. For this resident, physician orders dated at admission directed suprapubic catheter changes as needed, monitoring of catheter output every shift, and catheter care every shift, and the treatment administration record showed ongoing suprapubic catheter care throughout the month. However, the comprehensive care plan initiated shortly after admission contained only an activities focus and did not include any focus, goals, or interventions related to catheter care or other ADLs. The resident’s admission assessment documented severe cognitive impairment with a BIMS score of 3, diagnoses of obstructive uropathy and non-Alzheimer dementia, and the presence of a catheter, with urinary continence not rated due to catheter use. The assessment also showed the resident required varying levels of assistance for eating, bathing, dressing, and was dependent for bed transfers, but these needs were not reflected in the comprehensive care plan. A resident representative confirmed the resident had a catheter upon admission and throughout the stay. A CNA reported there was no documentation directing catheter care, although they stated they checked and provided care for all catheters every two hours. The DON and the MDS coordinator both acknowledged on review that the comprehensive care plan for this resident was incomplete, containing only an activities focus and omitting catheter care and ADLs, and that the comprehensive care plan had been missed.
Failure to Provide and Accurately Document Scheduled Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing and to document refusals or completed baths for two residents who required assistance with activities of daily living. Facility policy required staff to provide bathing services per standard practice and to document refusals in the record. For one resident with severely impaired cognition, a BIMS score of 7, and no history of rejecting care, CNA flow sheets showed showers only on two Sundays within a two‑week period, despite the resident being scheduled for showers on Tuesdays and Fridays. Interdisciplinary progress notes contained no documentation of shower refusals, and the resident’s family member reported the resident only received showers after they complained to staff. For a second resident with intact cognition (BIMS 14), polyneuropathy, anxiety disorder, depression, and bilateral upper and lower extremity impairments, assessments showed the resident required substantial to maximum assistance with showers/baths and personal hygiene and was dependent for tub/shower transfers and non‑ambulatory. Physician orders specified bath days twice weekly on first shift. The TAR for a specific month showed the resident did not receive a bath on one scheduled bath day, while the MAR for the same date was initialed by an LPN as if a bath had been given. Nurses’ notes for that date contained no documentation of a bath being provided or refused. Multiple staff interviews confirmed that scheduled showers were not consistently completed for all residents and that there were no bath sheets for the second resident over several days at the end of the month. A CNA reported the second resident stated they had not had a shower for two weeks and that aides told the resident there was not enough staff to bathe all residents. Nursing staff, including CNAs, LPNs, the ADON, and the DON, described a process in which CNAs should notify nurses of refusals, and nurses should document refusals and notify family and physicians, but review of the electronic health record and bath documentation showed no evidence that this process was followed for the missed bath date. The second resident stated they did not receive a bath over several consecutive days and reported being told by aides that staffing shortages prevented all residents from being bathed.
Failure to Perform Ordered IV Midline Dressing Change
Penalty
Summary
The facility failed to provide a physician-ordered IV midline dressing change for one resident receiving IV therapy. A physician’s order dated 07/09/25 directed that the resident’s IV midline dressing be changed on the day shift weekly on Friday, or sooner if the dressing became damp, loose, soiled, or if problems at the site required further inspection. The MAR for 07/11/25 showed the IV midline dressing change was missed, with no documented reason. The resident’s admission assessment dated 07/12/25 documented severe cognitive impairment with a BIMS score of 07, dependence in ADLs, and active IV access, with diagnoses including septicemia and renal failure. The resident’s care plan dated 07/28/25 indicated the resident was on IV therapy for infection and that medications and treatments were to be administered as ordered. A grievance form dated 07/16/25 documented that the resident’s family reported the IV dressing had not been changed since admission, and that the dressing present at that time was dated 07/03/25. Family reported being told by nursing staff that the dressing change had been missed because the resident was at dialysis when it was scheduled, and that it would be changed that day. A nurse progress note dated 07/18/25 stated the IV dressing change was not performed because it had been changed on 07/16/25. During interviews, the DON stated the resident had been out of the facility for an appointment and that the dressing change should have been done upon return, and the regional nurse consultant confirmed there was no documentation that the IV dressing change was performed before 07/16/25.
Failure to Notify Responsible Party of Change in Condition and New Medication Order
Penalty
Summary
The facility failed to ensure that responsible parties were notified in two separate instances for one resident. In the first instance, a resident with a history of hemiplegia, hemiparesis, cerebral infarction, muscle weakness, and bipolar disorder experienced a significant change in condition, including vomiting, inability to keep food, water, and medication down, increased confusion, and hallucinations. The physician ordered the resident to be sent to the emergency room, and documentation showed that the resident's spouse, who was also the roommate, was notified. However, there was no documentation that the designated HealthCare contact, the resident's daughter, was notified as required by facility policy. In the second instance, a new physician's order for alprazolam was issued for the same resident to address anxiety. Documentation indicated that the resident and the hospice company were notified of the new medication order, but again, there was no documentation that the HealthCare contact was informed. Interviews with staff confirmed that the daughter was listed as the HealthCare contact and should have been notified in both cases, but there were no notes indicating that this notification occurred.
Inaccurate Coding of Significant Change MDS Assessment
Penalty
Summary
The facility failed to accurately code a significant change Minimum Data Set (MDS) assessment for one resident. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and bipolar disorder. Documentation showed the resident was admitted to hospice care, with a hospice certification and physician's order confirming the start of hospice services. However, the significant change MDS assessment did not reflect the resident's hospice status, as the section for hospice care was not marked. The MDS coordinator confirmed that the assessment was related to the resident's transition to hospice but acknowledged that hospice was not coded on the MDS, resulting in an inaccurate assessment.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency were not provided in the report.
Failure to Document ADL Intake and Output for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure that activities of daily living (ADL) documentation was completed for one of three sampled residents reviewed for ADLs. Specifically, for a resident with diagnoses including hemiplegia, hemiparesis, muscle weakness, cerebral infarction, and bipolar disorder, there was no documentation of intake and output or meal percentages for a seven-day period leading up to a hospital stay. The resident was assessed as cognitively intact with a BIMS score of 15. Review of facility policy indicated that staff were required to document percentage consumed in the electronic health record (EHR), but no such documentation was found for the specified period. The regional nurse consultant confirmed that all available ADL documentation had been provided and acknowledged the absence of a generalized ADL policy, as well as the lack of a specific policy for documenting eating or intake and output.
Improper Use of Disinfectant Wipes for Blood Sugar Testing and Insulin Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed during blood sugar testing and insulin administration for two residents. On April 1, 2025, an LPN was observed using disinfectant wipes, which were not intended for use on skin, to clean the fingers of two residents before obtaining blood sugar levels. Additionally, the LPN used the same type of disinfectant wipe to clean the skin on a resident's abdomen before administering insulin. The disinfectant wipes' container and Safety Data Sheet explicitly stated they were not safe for skin contact. The facility's policy required the use of alcohol swabs for these procedures. The LPN acknowledged the correct procedure involved using alcohol swabs, indicating a deviation from established protocols.
Staff Competency with New EMR System Lacking
Penalty
Summary
The facility failed to ensure that staff were competent with the new Electronic Medical Records (EMR) system, affecting three staff members observed for competency. During a medication pass observation, a medication for a resident was not administered because the Certified Medication Aide (CMA) was unaware of how to verify if the medication had been ordered using the new EMR system. The CMA stated they had not received training on the new EMR and were unaware of how to check medication orders. Similarly, an LPN also reported not knowing how to order medication on the new EMR system. The corporate nurse indicated that a two-day training was conducted with key staff and nursing administration, who were then responsible for training the rest of the staff. However, in-service sheets did not show that the CMA, LPN, or the Activities Director (AD) attended the training sessions. During an interview, the AD asked the corporate nurse how to access care plans in the new system, further indicating a lack of training. The corporate nurse was unable to find additional in-service sheets to confirm that all staff had been trained, highlighting a gap in ensuring staff competency with the new EMR system.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered for five residents. Observations revealed that a CMA did not administer hydrocodone/acetaminophen to one resident and incorrectly administered Vitamin B12 without an order to another resident, while failing to administer thiamine and ferrous sulfate as prescribed. Another resident did not receive their prescribed lisinopril, and yet another resident did not receive their prescribed amlodipine and clindamycin. Additionally, an LPN administered only one capsule of gabapentin instead of two and failed to administer a potassium tablet due to an empty medication card. Interviews with staff revealed issues with medication availability and administration. A CMA stated that clindamycin was not in the facility and was unsure of the pharmacy's delivery timeline. An LPN acknowledged administering an incorrect dosage of gabapentin and not administering potassium due to an empty medication card. The corporate nurse explained the process for ensuring medications are administered per physician orders, including interfacing with the pharmacy through the EMR and faxing orders if necessary. However, the observations indicated lapses in following these procedures, leading to the deficiencies noted.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 23.68 percent. This deficiency was observed in the administration of medications to five residents. For instance, a Certified Medication Aide (CMA) did not administer hydrocodone/acetaminophen to one resident as ordered. Another resident was given Vitamin B12 without an order, while their prescribed thiamine and ferrous sulfate were not administered. Additionally, a resident did not receive their prescribed lisinopril, and another resident did not receive their ordered amlodipine and clindamycin. Further observations revealed that a Licensed Practical Nurse (LPN) administered only one capsule of gabapentin instead of the prescribed two and failed to administer a potassium tablet to a resident. The facility's Medication Administration policy requires medications to be administered according to prescriber orders, but this was not adhered to in these cases. Interviews with staff indicated issues such as medication unavailability and failure to follow the Medication Administration Record (MAR), contributing to the high error rate.
Infection Control Deficiency in Handling Soiled Linen and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices during the handling of soiled linen and hand hygiene during incontinent care for one of the sampled residents. On two separate occasions, staff members were observed not following the facility's infection control policies. An LPN was seen exiting a resident's room with a soiled incontinent pad without placing it in a bag before transporting it to the soiled utility room. This action was contrary to the facility's policy, which requires contaminated laundry to be bagged or contained at the point of collection. Additionally, a CNA was observed providing incontinent care to a resident without changing gloves after cleaning the resident. The CNA used the same soiled gloves to handle clean items, including a clean brief, incontinent pad, and draw sheet. Furthermore, the CNA placed soiled linen and wipes on the floor instead of in a plastic bag, and did not perform hand hygiene during the process. These actions were in violation of the facility's hand hygiene policy, which mandates handwashing after contact with soiled or contaminated articles.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate treatment and services to promote the healing of a pressure ulcer for a resident with multiple diagnoses, including Parkinson's disease and cognitive impairment. The resident's care plan required frequent turning and repositioning, as well as weekly skin inspections. Despite these requirements, the resident developed a stage 3 pressure ulcer on the sacrum, which worsened over time. Documentation revealed that the resident received only one wound care treatment between late April and early May, despite physician orders for bi-weekly treatments. Additionally, the facility staff did not document turning or repositioning efforts, relying instead on an informal understanding to make rounds every two hours. The DON confirmed that wound measurements were performed by hospice services, not facility staff. The deficiency was identified through observation, record review, and interviews. The resident's wound care was observed, and it was noted that the wound had increased in size. The DON acknowledged the lack of documentation for turning and repositioning and the missed wound care treatments. The facility's failure to adhere to the care plan and physician orders, as well as the lack of proper documentation and consistent wound care, contributed to the worsening of the resident's pressure ulcer.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to ensure that two residents experiencing pain received appropriate treatment. Resident #15, who had diagnoses including Parkinson's disease and cognitive communication deficit, fell and sustained a hip fracture. Despite the resident's cries of pain during incontinent care, CNA #1 did not notify the nurse and continued with the care. The DON later confirmed that CNA #1 was aware of the fall but did not stop to get the nurse when the resident expressed pain. Video surveillance showed the resident screaming in pain multiple times during care, but CNA #1 did not take appropriate action to address the pain. Resident #1, who had diagnoses including metabolic encephalopathy and anxiety disorder, experienced delays in receiving prescribed pain medication. The resident reported that it took 1.5 weeks to get their pain pills at the facility, and during this period, they were only offered Tylenol despite having a prescription for oxycodone. The DON confirmed that the resident's pain levels were documented as high as five on multiple occasions, but the resident only received Tylenol and not the prescribed oxycodone until the order was received on 02/29/24. The facility's failure to provide timely and appropriate pain management for both residents resulted in prolonged pain and discomfort. The staff did not follow the facility's Pain Management and Basic Comfort Measures policy, which required evaluating pain and providing appropriate interventions. The lack of communication and proper assessment by the staff contributed to the deficiencies in pain management for these residents.
Missed Care Plan Meeting for Resident
Penalty
Summary
The facility failed to ensure a care plan meeting was held and a resident's representative was included for one of three sampled residents reviewed for representative inclusion in the plan of care. Resident #4, who had diagnoses including chronic kidney disease and chronic pain, had a Care Plan Conference on 07/31/23 and an Annual Resident Assessment completed on 10/10/23. A Nurse's Note dated 10/17/24 documented an email was sent to Resident #4's representative regarding setting up a care plan meeting. However, the next documented Care Plan Conference for Resident #4 was on 02/09/24, indicating a missed care plan meeting. LPN #1, responsible for care plan meetings, stated that the meetings were supposed to be every three months and acknowledged that a meeting was missed because it was scheduled when they were not working, and no one covered for them.
Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure resident records were accurate for one of three sampled residents reviewed for accurate records. The Records Management policy, revised on 06/01/17, mandates that records be maintained in a consistent and logical manner, meeting legal standards for protection, storage, and retrieval, and protecting the privacy of healthcare facility residents and patients. However, Resident #3's clinical record contained hospital records belonging to four other residents. Specifically, hospital records for Residents #14, #13, #11, and #12 were found in Resident #3's clinical record. Medical Records staff stated that they received resident information in a basket by the scanner, which the ADON reviewed to ensure orders were correctly entered before scanning. Despite this process, incorrect documents were included in Resident #3's record, indicating a failure in the record management system.
Unclean Dishware in Kitchen
Penalty
Summary
The facility failed to ensure dishware was clean during a kitchen observation. The Cleaning Dishes in Dish Machine policy, dated 08/01/18, required dishes to be inspected and put away if clean and dry, and to repeat the cleaning steps if dishes were not clean. On 01/26/24 at 2:54 p.m., 32 blue-handled coffee cups were observed in the clean dish area with white residue, small particles, and visible contaminants inside. Cook #1 acknowledged the presence of the white substance and stated it did not look clean. The Corporate Dietary Manager also confirmed the debris and residue inside the cups when shown the cups at 3:05 p.m. The Administrator identified that 114 residents received nutrition from the kitchen.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control during the provision of incontinent care for two residents and did not ensure staff donned appropriate PPE before entering a COVID-19 positive room. For Resident #8, a CNA did not change gloves during the entire process of providing incontinent care, including when handling clean and dirty items. The CNA also placed a dirty pad on the floor instead of disposing of it immediately. Similarly, for Resident #10, another CNA did not change gloves during the provision of incontinent care, resulting in the resident being left with a smear of fecal matter on their anal area. The CNA also failed to take the trash out of the room promptly. Both CNAs acknowledged their failure to change gloves as required by the facility's policy during their respective tasks. Additionally, the facility did not ensure that staff wore the required PPE when entering a COVID-19 positive room. A CMA entered Resident #11's room without wearing an N95 mask, gown, face shield, and gloves, despite the posted precautions indicating these were necessary. The CMA stated they believed the precautions only applied to direct care involving body contact. The DON confirmed that staff were required to wear full PPE in COVID-19 isolation rooms, indicating a lapse in adherence to the facility's infection control policies.
Failure to Provide Thorough Incontinent Care
Penalty
Summary
The facility failed to ensure thorough incontinent care for a resident diagnosed with hemiplegia and hemiparesis. The resident's care plan required perineal care with incontinent changes. During an observation, a CNA performed incontinent care but did not clean the resident's labia, only wiping the groin and buttocks. The CNA acknowledged the omission, stating they did not wipe the labia because the resident had just voided. This action was contrary to the facility's perineal care policy, which mandates cleaning the labia majora and washing downward from the pubic area toward the rectum in one smooth stroke.
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A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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