Wagoner Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Wagoner, Oklahoma.
- Location
- 205 North Lincoln Avenue, Wagoner, Oklahoma 74467
- CMS Provider Number
- 375369
- Inspections on file
- 20
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Wagoner Health & Rehab during CMS and state inspections, most recent first.
The facility failed to ensure that meals were served at a palatable, appetizing temperature for multiple cognitively intact residents receiving in-room meal service. A test tray showed undercooked, lukewarm fried potatoes, lukewarm turnip greens, and cold, dry cornbread. A resident reported that food delivered to their room was always cold and did not taste good. Another resident stated that their food arrived cold, had tasted bad for a long time, and that potatoes served at a recent lunch were undercooked and crunchy. A third resident, who ate all meals in their room, reported that their food was almost always cold upon arrival, while 48 residents in total were identified as receiving meals from the kitchen.
Surveyors found that dietary staff, including a dietary aide and the Dietary Manager, repeatedly entered the kitchen and began work without performing required hand hygiene, despite a facility policy mandating handwashing upon kitchen entry. Over several closely spaced observations, the dietary aide was seen multiple times starting work without washing hands, and the Dietary Manager was also observed doing the same. The infection preventionist reported that dozens of residents received meals prepared in this kitchen during the period in question.
A resident with emphysema and heart failure had an order for oxycodone 10 mg PO every six hours. Facility policy required two staff signatures when wasting narcotic medications, but documentation on the controlled drug record showed that one oxycodone tablet was wasted with only a single staff signature. An LPN and the infection preventionist both stated that two staff members must sign when a narcotic is wasted, confirming that the documented wasting did not follow facility policy, in a setting where multiple residents were receiving medications.
A resident with a PEG tube, identified as at risk for infection and placed on Enhanced Barrier Precautions (EBP), had a care plan and door signage indicating that EBP should be used during care. The facility’s EBP policy required staff to don gown and gloves for high-contact care of residents with indwelling medical devices, including feeding tubes. An LPN was observed performing PEG tube care for this resident without wearing a gown, contrary to the posted EBP sign, the resident’s care plan, and facility policy. The LPN later acknowledged a gown should have been worn, and the infection preventionist confirmed that gowns are required when providing care to residents on EBP, noting that multiple residents in the facility were on EBP.
The facility did not update care plans with new fall prevention interventions after three residents experienced falls, despite existing policies requiring timely review and revision. One resident with heart failure and neuropathy, another with atrial fibrillation and a fall history, and a third with dementia and Alzheimer's each had falls that were not followed by care plan updates, as confirmed by the DON and facility records.
A scoop was left in a bulk flour container and the handwashing sink in the kitchen did not have hot water, contrary to facility policy and professional standards. Meals prepared under these conditions were served to 46 residents, as confirmed by the dietary manager and corporate nurse manager.
The facility did not ensure that competency and skills checks were completed upon hire and annually for several LPNs and CNAs. Employment files lacked documentation of these required assessments, and facility leadership confirmed that competencies had not been completed in over a year.
The facility did not ensure that dietary menus were reviewed and approved by the dietician as required by policy. A menu for one week lacked documentation of dietician approval, and both the dietary manager and social services director confirmed that the approval had not occurred.
Staff did not consistently use enhanced barrier precautions during wound care and urinary catheter care, including failure to wear gowns and improper glove use. In several cases, staff relied on personal knowledge or verbal communication instead of signage to identify when precautions were needed. Additionally, clean laundry was transported uncovered to resident rooms, contrary to infection control protocols.
A resident with atrial fibrillation was inaccurately coded on their admission assessment as having received an anticoagulant, despite medication records showing no such administration. The MDS coordinator confirmed the error during an interview.
Surveyors identified that two residents did not have comprehensive care plans addressing their specific needs. One resident with severe cognitive impairment used a half bed rail for mobility, which was not documented in the care plan as required by facility policy. Another resident with congestive heart failure, dependent on staff for daily activities and using supplemental oxygen, also lacked care plan documentation for both ADL assistance and oxygen use. The MDS coordinator confirmed these omissions.
A resident with severe cognitive impairment was observed using a half bed rail without documented assessment for entrapment risk or consideration of alternatives, and no informed consent was obtained. Staff confirmed that only an outdated assessment was on file, and facility policy requiring annual assessment and consent was not followed.
Surveyors found that multiple medication and treatment carts were left unlocked and unattended in several areas of the facility on repeated occasions. Staff, including LPNs, admitted to forgetting to lock the carts, and the DON confirmed that the expectation was for all carts to be secured when not in use. The facility's policy required all drug and biological storage compartments to be locked when unattended, but this was not consistently followed.
Several residents reported that meals were often served lukewarm, bland, and unappetizing, with some foods missing expected components such as icing on desserts. Test tray observations confirmed that hot foods were not consistently hot and cold foods were not cold, particularly for those eating in their rooms. The dietary manager acknowledged these issues, indicating a failure to ensure food was palatable and served at appropriate temperatures.
A resident with severe cognitive impairment and Alzheimer's disease was found with a loose half bed rail on two occasions. Although facility policy required regular inspection of beds and related equipment, maintenance staff did not routinely monitor bed rails after installation and only addressed issues when reported by staff. The administrator was unaware that regular safety inspections were not being conducted.
The facility failed to maintain a functioning call light system in a resident's room. Staff interviews confirmed that the system should illuminate a light in the hallway when activated, but this did not occur during an observation. The maintenance supervisor indicated that call lights were tested weekly, but these tests were not documented.
Failure to Provide Palatable, Proper-Temperature Meals to Residents
Penalty
Summary
The facility failed to provide meals at a palatable, appetizing temperature for three cognitively intact residents who received meals in their rooms, as well as on a test tray sampled by surveyors. During a test tray observation, fried potatoes were found to be undercooked and lukewarm, turnip greens were lukewarm, and cornbread was cold and dry. One resident with a BIMS score of 15 reported that when they ate in their room the food was always cold and did not taste good. Another resident with a BIMS score of 15 stated that their food was cold by the time it was delivered to their room and that the food had tasted bad for a long time; this resident further reported that potatoes served at a recent lunch were undercooked, crunchy, and the entire meal was cold. A third resident with a BIMS score of 15, who ate all meals in their room, stated that the food was almost always cold by the time it arrived. The infection preventionist identified that 48 residents received meals from the kitchen at the time of the survey.
Failure of Dietary Staff to Perform Required Hand Hygiene Upon Kitchen Entry
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation and employee hygiene when two dietary staff members, a dietary aide and the Dietary Manager (DM), failed to wash their hands immediately upon entering the kitchen as required by facility policy. On multiple occasions within a short time frame, the dietary aide was observed entering the kitchen and beginning work without handwashing, specifically at 11:55 a.m., 11:59 a.m., 12:04 p.m., and 12:07 p.m. on the same day. The DM was also observed entering the kitchen at 12:00 p.m. and starting work without washing their hands. An undated facility policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” required staff to wash their hands when entering the kitchen, and the DM confirmed that staff were expected to wash their hands upon entry. The infection preventionist identified that 48 residents received meals from the kitchen during this period. No additional resident-specific medical histories or conditions were described in the report beyond the number of residents receiving meals from the kitchen.
Failure to Obtain Required Dual Witness Signatures for Wasted Narcotic Medication
Penalty
Summary
The facility failed to follow its Discarding and Destroying Medications policy requiring the signatures of at least two witnesses when wasting narcotic medications. Record review showed that a resident admitted on 08/20/24, with diagnoses including emphysema and heart failure, had a physician’s order dated 12/06/25 for oxycodone 10 mg by mouth every six hours. On the Controlled Drug Receipt/Record/Disposition Form for February 2026, an entry dated 02/13/26 at 6:00 a.m. documented that one 10 mg oxycodone tablet was wasted, but the form contained only one signature instead of the required two. During interviews, an LPN stated that when a narcotic medication is wasted a nurse must witness and sign off with the other employee, and the infection preventionist confirmed that two staff members are required to sign when a narcotic is wasted, demonstrating that the documented practice for this resident did not comply with facility policy. The infection preventionist identified that 48 residents in the facility received medications, indicating that the deficient practice occurred in a setting where multiple residents were receiving pharmaceutical services, although the documented failure to obtain two signatures for narcotic wasting was specifically identified for one resident receiving oxycodone.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during PEG tube care. Resident #7 had a care plan focus initiated on 05/09/25 indicating risk of infection due to the presence of a PEG tube and specifying that EBP was to be utilized when providing care. The facility’s EBP policy dated 04/29/24 required donning gown and gloves during high-contact resident care activities for residents with indwelling medical devices, including feeding tubes, and a sign on Resident #7’s door indicated the resident was on EBP. On 02/23/26 at 9:20 a.m., LPN #1 was observed providing PEG tube care to Resident #7 without wearing a gown, contrary to the posted EBP sign, the resident’s care plan, and the facility’s EBP policy. During interview at 9:25 a.m., LPN #1 acknowledged they should have worn a gown while providing PEG tube care, and on 02/24/26 at 3:35 p.m., the infection preventionist confirmed that gowns were to be used when providing care to residents on EBP. The infection preventionist identified that 23 residents in the facility were on EBP.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise the care plans for three out of four sampled residents after each experienced a fall, as required by their own policy and regulatory standards. For one resident with congestive heart failure and multifocal motor neuropathy, the care plan documented several previous falls and interventions, but after a non-injury fall while transferring from bed without assistance, no new intervention was added to the care plan. Another resident with atrial fibrillation and a history of falls had a care plan indicating risk for falls, but after a fall resulting in a major injury while ambulating, the care plan was not updated to reflect new interventions. The resident confirmed having fallen and sustaining a shoulder injury. A third resident with dementia and Alzheimer's disease had a care plan noting multiple prior falls and interventions, but following a minor injury fall while transferring from bed, the care plan was not revised to include additional interventions. The Director of Nursing confirmed that the care plans for these residents should have been updated to reflect new fall prevention interventions after each fall event. The facility's policy requires staff and practitioners to identify possible causes and implement pertinent interventions within 24 hours of a fall, and to re-evaluate and reconsider interventions if falls continue. Despite this, the care plans for the affected residents were not revised after their most recent falls, as documented in the facility's records and confirmed through staff and resident interviews.
Improper Food Storage and Hand Hygiene Deficiency
Penalty
Summary
During an initial kitchen tour, a scoop was found left inside a bulk container of flour, and the handwashing sink was observed to lack hot water. The facility's policy on food receiving and storage requires compliance with safe food handling practices. The dietary manager confirmed that scoops should not be left in bulk containers and acknowledged the handwashing sink was not functioning properly. The corporate nurse manager reported that 46 residents received meals prepared in the kitchen during this time. These findings indicate that the facility did not adhere to professional standards for food storage and hand hygiene, as required by their own policies and regulatory guidelines.
Failure to Complete Required Staff Competency Checks
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had completed competency and skills checks both upon hire and annually, as required. Record review revealed that five employees, including two LPNs and three CNAs, did not have documentation of completed competency or skills checks in their employment files. The business office manager confirmed that there were no skills checks or competencies available for these staff members. Additionally, the Director of Nursing acknowledged that competencies should be completed upon hire and annually, but stated that they had not been completed in over a year. This deficiency was identified through review of employment files and interviews with facility staff, which confirmed the lack of required competency assessments for all reviewed employees.
Menus Not Reviewed or Approved by Dietician
Penalty
Summary
The facility failed to ensure that dietary menus were reviewed and approved by the dietician as required by policy. A review of a dietary menu for a specified week revealed no documentation of dietician approval. The dietary manager initially believed the menus had been approved by the dietician but was unable to provide documentation to support this. Additionally, the social services director confirmed that the menu had not been approved by the dietician. The facility's policy states that all menus are to be reviewed and approved by the dietician to meet residents' nutritional needs, but this process was not followed for the menu in question.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control
Penalty
Summary
The facility failed to ensure proper implementation of enhanced barrier precautions (EBP) and infection control practices during wound care and urinary catheter care, as well as during the transport of clean laundry. During wound care for a resident with a stage four pressure ulcer and severe cognitive impairment, an LPN did not wear a gown as required by the facility's EBP policy, and there was no signage indicating the need for EBP near the resident's room. The LPN believed that only gloves were necessary for wound care, and the facility did not utilize signage to indicate when EBP was required. In multiple instances of urinary catheter care, staff did not follow EBP protocols. One CNA wore multiple pairs of gloves at once and failed to change gloves during care, based on misinformation from an online video, and did not use a gown. Another LPN and two CNAs provided catheter care and flushing without wearing gowns, and the LPN failed to perform hand hygiene when changing gloves or after removing gloves. The staff relied on verbal communication or personal knowledge to determine when EBP was needed, rather than consistent signage or clear protocols. Additionally, the facility did not maintain infection control standards during the transport of clean laundry. The laundry staff was observed multiple times transporting clean clothes uncovered to resident rooms and was unaware that linens were supposed to be covered. The infection preventionist confirmed that clean clothes should be covered during transport.
Inaccurate Admission Assessment Coding
Penalty
Summary
The facility failed to ensure the accuracy of an admission assessment for one resident. The admission assessment, dated 03/07/25, indicated that the resident, who had a diagnosis of atrial fibrillation and a BIMS score of 15, had received an anticoagulant medication during the look back period. However, a review of the medication administration record and treatment administration record for March 2025 did not show that the resident had actually received an anticoagulant. During an interview, the MDS coordinator confirmed that the assessment had been coded inaccurately and acknowledged that the resident should not have been coded as having received an anticoagulant.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
Surveyors found that the facility failed to develop and implement comprehensive care plans for two of twelve sampled residents. In the first case, a resident with Alzheimer's disease and severe cognitive impairment was observed using a half bed rail for bed mobility on multiple occasions. Despite facility policy requiring the use of side rails to be addressed in the care plan, the resident's care plan did not document the use of the half side rail. The MDS coordinator confirmed that a care plan related to the use of the half bed rail had not been developed for this resident. In the second case, another resident with congestive heart failure, who was dependent on staff for several activities of daily living and used supplemental oxygen, was observed with an oxygen nasal cannula in place. The resident's care plan did not indicate the level of assistance required for activities of daily living or the use of supplemental oxygen. The MDS coordinator acknowledged that they were unaware of the resident's routine use of supplemental oxygen and had missed developing a care plan for both the oxygen use and the resident's ADL needs.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to complete required assessments and obtain informed consent for the use of bed rails for a resident. Observations on two separate occasions showed the resident in bed with a half bed rail in the up position. Documentation review revealed that the evaluation form for side rail use did not include an assessment for entrapment risk or consideration of alternatives prior to implementing the bed rail. The resident's annual assessment indicated a diagnosis of Alzheimer's disease with severe cognitive impairment, but there was no documentation of consent for the use of the bed rail. Interviews with staff confirmed that the resident used the bed rail for mobility and positioning, and that the only documentation completed was an assessment from several months prior. The DON acknowledged that no consent had been obtained and that alternatives to bed rail use had not been assessed or documented. Facility policy required both an assessment for entrapment risk and informed consent prior to bed rail use, but these steps were not followed for this resident.
Medication and Treatment Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that three of five medication and treatment carts in the facility were repeatedly left unlocked and unattended in various locations, including by the nurses station and in the front living room area. These observations occurred on multiple occasions over several days, with specific carts such as the North hall treatment cart, the [NAME] hall treatment cart, and the overflow treatment cart being found unsecured. Facility staff, including LPNs, acknowledged that the carts should have been locked when not in use but admitted to forgetting to do so. The Director of Nursing (DON) confirmed that staff were expected to keep the carts locked when unattended and recognized that surveyors had observed the carts unlocked and unattended multiple times. The facility's policy, dated 07/21/24, required that all compartments containing drugs and biologicals, including carts, be locked when not in use and not left unattended if open or accessible. Despite this policy, staff failed to consistently secure the carts, as evidenced by direct observations and staff interviews. No specific residents were identified as being directly affected in the report, and there was no mention of any adverse outcomes related to the unsecured carts.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable meals to residents, as evidenced by both direct observation and resident interviews. During test tray samplings, meals such as Dorito casserole and mixed vegetables were found to be lukewarm, bland, and not well seasoned, while banana cake was served dry and without icing. Multiple residents reported that hot foods were not served hot and cold foods were not served cold, particularly when meals were delivered to their rooms. Additionally, some residents described the food as bland and unappetizing, with one resident stating they only ate breakfast from the kitchen due to the poor quality of lunch and dinner meals. Assessments showed that the residents involved had varying levels of cognitive function, with most being independent in daily decision-making. The dietary manager acknowledged the issues, noting efforts to serve food quickly to maintain temperature and confirming that the banana cake should have included icing. These findings indicate that the facility did not consistently ensure meals were palatable, attractive, and served at safe and appetizing temperatures for the residents.
Failure to Monitor and Maintain Bed Rail Safety
Penalty
Summary
The facility failed to ensure that bed rails were properly monitored for safety for a resident who used a half bed rail. During two separate observations, the bed rail on the left side of the resident's bed was found to be loose when moved side to side and back and forth. The resident, who had a diagnosis of Alzheimer's disease and was severely impaired in cognition, confirmed that the bed rail was wiggly. The facility's policy required regular inspection of beds and related equipment by maintenance staff to identify risks, including potential entrapment hazards. Despite this policy, the maintenance supervisor stated that bed rails were not routinely monitored after installation and were only tightened if staff reported them as loose. The maintenance supervisor acknowledged the looseness of the bed rail upon observation and noted that it had been recently installed. The administrator confirmed that CNAs documented issues in the maintenance log if they noticed loose bed rails, but was unaware that maintenance staff were not conducting regular inspections for bed and bed rail safety.
Call Light System Malfunction in Resident Room
Penalty
Summary
The facility failed to ensure the call light system was functioning in one of six occupied resident rooms reviewed for call light functionality. The facility's policy, reviewed in July, stated that maintenance personnel were responsible for maintaining the nurse call system in good working order. During an observation, it was noted that when the call system in a specific room was activated, no light illuminated in the hallway or at the nurse's desk, indicating a malfunction. Interviews with staff, including an LPN and a CNA, confirmed that the call light system should illuminate a light in the hallway when activated. The maintenance supervisor stated that call lights were tested weekly, but these tests were not documented.
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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