Westhaven Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Stillwater, Oklahoma.
- Location
- 1215 South Western, Stillwater, Oklahoma 74074
- CMS Provider Number
- 375417
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Westhaven Nursing Home during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, dependent on staff for transfers and wheelchair use, was allegedly yanked from a wheelchair and dropped forcefully onto a couch by a CNA after being described as combative with care. A family member and an RN both believed the CNA’s actions were abusive. Although the facility’s abuse policy required immediate reporting of suspected abuse to the Administrator or DON, the RN delayed reporting the allegation until the following morning, resulting in a failure to promptly report the suspected abuse.
A resident with dementia, severely impaired cognition, and dependence on staff for transfers and wheelchair use was allegedly abused by a CNA during a night shift. The RN who witnessed or became aware of the abusive behavior did not know the facility’s abuse procedure, did not remove the CNA from duty, and delayed reporting the allegation to the DON until the following morning, allowing the CNA to complete the shift. This response conflicted with the facility’s abuse policy, which required suspension of an employee during an abuse investigation.
A resident admitted with malnutrition, GI hemorrhage, and dysphagia, and receiving tube feeding, experienced an 8.66% weight loss over about one month, as shown by weight records. Despite this, the admission MDS documented that the resident had not lost 5% or more body weight in the prior month. An LPN reported the resident was placed on five daily bolus feedings of Jevity 1.5 for a few days, and the MDS coordinator later acknowledged that the admission assessment should have reflected a weight loss greater than 5% in one month.
A resident with malnutrition, GI hemorrhage, dysphagia, and a feeding tube experienced significant weight loss over about one month, but the care plan was not updated to reflect this change or add specific interventions. The existing care plan only noted the need for tube feeding and periodic RD evaluation, despite physician orders for multiple daily bolus feedings of Jevity 1.5. During interviews, an LPN reported the resident received five bolus feedings daily for a few days, and the MDS coordinator acknowledged that the care plan should have documented the greater than 5% monthly weight loss and included measures to prevent further loss.
Surveyors found that daily nurse staffing information was consistently posted on a bulletin board down a hallway rather than in a prominent, easily visible area such as the main lobby or front entrance. The DON and administrator acknowledged that the posting location was not readily visible to all residents and visitors unless they already knew where to look, despite dozens of residents residing in the facility at the time.
Surveyors identified that the facility failed to remove expired medications and medical supplies from a medication supply room and a medication cart, despite a policy requiring constant review and rotation to prevent expiration. In the supply room, multiple expired wound care dressings and an opened Tubersol vial without an open date were found, and another Tubersol vial remained beyond the 30-day use period. On one hall’s medication cart, an expired box of Naloxone nasal spray was present. Nursing staff and the DON acknowledged that these expired items should have been removed and that opened vials should have been properly dated and discarded within the required timeframe.
A CNA failed to remove soiled gloves or perform hand hygiene after providing perineal care to a resident, then proceeded to handle clean items such as blankets and a bed remote, contrary to facility policy requiring glove removal and handwashing before touching clean areas.
The facility did not complete discharge summaries for three residents who were discharged. A review of their records showed the absence of these summaries, and the DON confirmed the oversight.
A facility did not ensure a pharmacy's medication regimen review recommendation was sent to a physician for a resident with diabetic neuropathy. The resident was prescribed Gabapentin 600 mg TID, but a review suggested a dose reduction due to renal function. No documentation showed the recommendation was acted upon, and the DON could not find the physician's response.
The facility failed to implement a 14-day stop date for as-needed lorazepam for a resident with anxiety and did not act on a Medication Regimen Review request for dose reduction of psychotropic medications for another resident with anxiety and depression. The oversight in medication management was acknowledged by staff, and the Director of Nursing could not locate a physician's response to the review request.
The facility failed to remove expired medications and supplies from the medication storage room, as observed during a tour with the DON. Expired items included Ipratropium Bromide and Albuterol Sulfate, collection and transport swab packets, Milk of Magnesia, and Narcan nasal spray. Additionally, a bottle of Lantus insulin was found opened and undated. The DON acknowledged the oversight.
A resident with Alzheimer's and dementia developed a new pressure ulcer, but the facility failed to notify the physician as required. The wound was documented and treated with calazime, but there was no record of physician notification. The DON confirmed the oversight during a wound care observation.
A facility failed to ensure safe medication administration when a resident was observed with two medication cups left on their bedside table while eating breakfast. Despite the policy requiring staff to stay with residents until medications are swallowed, an RN left the medications with the resident, who intended to take them later, violating the facility's guidelines.
A facility failed to implement Enhanced Barrier Precautions (EBP) during incontinent and indwelling catheter care for a resident. Despite a policy requiring gowns and gloves for high-contact activities, staff did not wear gowns while providing care. The CNA and CMA involved were unsure if EBP should be used during such care, indicating a lack of adherence to infection control protocols.
Failure to Immediately Report Alleged Abuse of a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an allegation of abuse was immediately reported as required by its policy. The facility’s undated “Patient Abuse” policy stated it was strictly prohibited for any employee to fail to immediately report an incident of patient abuse to the Administrator or DON. Resident #1, admitted on 01/25/26, had severely impaired cognition with a BIMS score of 03, diagnoses including dementia, and was dependent on staff for transfers and required substantial/maximal assistance for wheelchair use. An incident report dated 02/12/26 documented an allegation of abuse that occurred on 02/11/26 at approximately 11:00 p.m., when RN #1 observed CNA #1 behave in an abusive manner toward Resident #1. Family member #1 reported they had been called to the facility around 10:30 p.m. to 11:00 p.m. because Resident #1 was being combative with care and requested the resident be transferred to a couch where they had been sleeping recently. Family member #1 stated CNA #1 yanked the resident up from the wheelchair and dropped them down on the couch with force, and they felt the CNA’s actions were abusive. RN #1 stated they had asked CNA #1 to transfer Resident #1 from the wheelchair to the couch in the common area, and that CNA #1 was mad and aggressively transferred the resident. RN #1 stated they and family member #1 both felt the CNA’s actions were abusive, but RN #1 did not report the incident to the DON until 6:00 a.m. the next morning, rather than immediately. The administrator stated they reported the abuse allegation and started an investigation as soon as they were made aware of the incident by RN #1, and the DON stated the incident should have been reported to them or the administrator immediately by RN #1.
Failure to Immediately Remove Alleged Perpetrator After Abuse Allegation
Penalty
Summary
The facility failed to immediately protect a resident from potential further abuse after an allegation against a CNA. An admission assessment for Resident #1, who had dementia, severely impaired cognition with a BIMS score of 03, and was dependent on staff for transfers and wheelchair use, documented the resident’s condition. An incident report showed that on 02/11/26 at approximately 11:00 p.m., an allegation of abuse by CNA #1 toward Resident #1 occurred, but RN #1 did not report the allegation to the DON until 6:00 a.m. on 02/12/26. During this time, CNA #1 was not removed from duty and was allowed to continue working, as confirmed by a timesheet showing CNA #1 clocked out at 6:15 a.m. on 02/12/26. The facility’s undated Patient Abuse policy stated that to protect the resident during an abuse investigation, the employee would be suspended during the investigation process. RN #1 stated they did not send CNA #1 home after witnessing the abusive behavior and did not know the facility’s abuse procedure, waiting until the next morning to report the allegation. The DON stated CNA #1 should have been sent home immediately and should not have been allowed to finish the shift. This sequence of events demonstrates that the facility did not follow its own abuse policy and failed to immediately remove the alleged perpetrator from resident care after an abuse allegation involving Resident #1.
Inaccurate MDS Assessment of Significant Weight Loss
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for one resident when the admission MDS did not reflect a significant weight loss that had occurred prior to and at the time of admission. Record review showed the resident, admitted with malnutrition, gastrointestinal hemorrhage, and dysphagia and requiring nutrition via feeding tube, weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26, with an admission assessment weight of 195 pounds on 01/23/26. This represented an 8.66% weight loss between 12/24/25 and 01/23/26. However, the admission MDS documented that the resident had not experienced a weight loss of 5% or more in the last month. During interview, an LPN reported the resident had been placed on five daily bolus feedings of Jevity 1.5 for a few days, and the MDS coordinator, after reviewing the weight summary, acknowledged that the admission assessment should have indicated a weight loss of over 5% in one month.
Failure to Update Care Plan for Significant Weight Loss in Tube-Fed Resident
Penalty
Summary
The facility failed to update and implement a comprehensive care plan to address significant weight loss for one resident who received nutrition via a feeding tube. Record review showed the resident weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26, an 8.66% loss between 12/24/25 and 01/23/26, yet the existing care plan dated 12/29/25 only reflected that the resident required tube feeding and included an intervention for the registered dietitian to evaluate quarterly and as needed, with no update documenting the significant weight loss or additional interventions. A physician’s order dated 01/17/26 directed bolus feedings of Jevity 1.5 five times daily, and the admission MDS documented diagnoses including malnutrition, gastrointestinal hemorrhage, and dysphagia, with tube feeding required and no prior 5% or greater weight loss in the last month. During interview, an LPN stated the resident was placed on five bolus feedings daily for a few days, and the MDS coordinator, after reviewing the weight summary, acknowledged the care plan should have reflected the resident’s greater than 5% monthly weight loss and included interventions to prevent further weight loss. This deficiency involved the facility’s inaction in revising the care plan despite documented significant weight loss and existing clinical information indicating the resident’s nutritional risk, as well as reliance on assessments for weight information without ensuring that the care plan was updated to address the change in condition.
Failure to Post Daily Nurse Staffing Information in a Prominent Location
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a prominent location readily accessible to residents, staff, and visitors. On two separate observations, the daily nurse staffing information sheet was found posted on a bulletin board partway down hall 4, rather than in a clearly visible area such as the main lobby or front entrance. During these observations, the posting was not clearly visible to all visitors and residents. The DON acknowledged that the daily nurse staffing information sheet was not posted in the main lobby area and would not be visible to all residents and visitors who did not know where it was located, stating it had always been kept down hall 4 on the bulletin board. The administrator similarly confirmed that the daily nurse staffing information sheet was not posted at the front entrance and was not visible to all residents and visitors who did not know where to look. At the time of the survey, the DON identified that 62 residents resided in the facility. These observations and interviews demonstrate that the facility did not comply with the requirement to post nurse staffing information in a prominent, readily accessible place for all residents, staff, and visitors.
Expired Medications and Supplies Not Removed From Storage and Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure expired medications and medical supplies were removed from storage areas and a medication cart, as required by professional standards and the facility’s own policy on expired medications. In the medication supply room, multiple wound care products were observed to be past their expiration dates, including several packages of IoFlex iodophor foam dressings, Maxorb II alginate wound dressings, Sorbalgon calcium alginate dressings, Tegaderm film dressings, Zetuvit Plus silicone border dressings, and an Optifoam heel foam non-adhesive dressing. Additionally, one Tubersol vial was opened and dated, and another Tubersol vial was opened with no date indicating when it was opened, contrary to expectations that such vials be dated and discarded after 30 days. On a medication cart for one hall, surveyors observed a box of Naloxone hydrochloride nasal spray with an expiration date indicating it should already have been removed. Staff interviews confirmed that the expired medications and supplies should have been removed from the medication/storage room and that the Tubersol vial should have been dated and discarded after 30 days. Another staff member acknowledged that the Naloxone should have already been removed from the cart. The DON also stated that the expired medications and supplies should have been removed, confirming that the facility did not follow its policy to rotate and review medications on a constant basis to prevent expired items from remaining available for use.
Failure to Follow Infection Control Practices During Incontinent Care
Penalty
Summary
During an observation of incontinent care provided to one resident, two CNAs entered the resident's room to perform perineal care. CNA #1 was observed removing blankets and a pillow, assisting the resident to their side, and cleaning the perineal area with disposable wipes, using each wipe only once before discarding. After completing the cleaning, CNA #1 replaced the pillow, pulled up the blankets, and used the bed remote, all while still wearing the same gloves used during the perineal care. CNA #1 did not remove the soiled gloves or sanitize their hands before touching clean items and areas, contrary to the facility's perineal care policy, which requires glove removal and hand hygiene before handling clean items. CNA #1 later acknowledged not following the glove removal policy prior to touching clean areas.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete discharge summaries for three residents who were discharged from the facility. Resident #60 was discharged on August 22, 2024, Resident #67 on May 29, 2024, and Resident #69 on May 31, 2024. Upon review of their records, it was found that none of these residents had a discharge summary documenting their stay. The Director of Nursing (DON) confirmed on August 28, 2024, that the discharge summaries were not completed for these residents.
Failure to Act on Pharmacy Recommendation for Medication Adjustment
Penalty
Summary
The facility failed to ensure that a Medication Regimen Review (MRR) pharmacy request was sent to the physician for action regarding a resident's medication. The resident, who had a diagnosis of diabetic neuropathy, was prescribed Gabapentin 600 mg three times daily. A MRR conducted on 06/11/24 recommended a dose reduction based on the resident's renal function, suggesting a maximum dosage of 700 mg twice daily. However, there was no documentation in the resident's clinical record indicating that the recommendation had been acted upon. The Director of Nursing (DON) was unable to locate the physician's response to the MRR pharmacy recommendation letter.
Failure to Implement Psychotropic Medication Protocols
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications. For one resident with a diagnosis of anxiety, the facility did not implement a 14-day stop date for as-needed lorazepam orders. The orders were documented with a re-evaluation date instead of a set stop date, leading to the continuation of the medication without proper review. This oversight was acknowledged by a corporate nurse who stated that the orders should have been entered with a set stop date. Another resident, diagnosed with anxiety and depression, was prescribed lorazepam and bupropion. A Medication Regimen Review (MRR) requested a gradual dose reduction of these medications, as per state and federal guidelines. However, the facility failed to act on this request, as the Director of Nursing (DON) could not locate a physician's response to the MRR. This inaction indicates a lapse in following up on medication reviews and ensuring appropriate medication management for the resident.
Expired Medications and Supplies Found in Medication Storage Room
Penalty
Summary
The facility failed to ensure the removal of expired medications and supplies from the medication storage room, as observed during a tour with the Director of Nursing (DON). Several expired items were found, including boxes of Ipratropium Bromide and Albuterol Sulfate with use-by dates ranging from April to November 2024, collection and transport swab packets expired since February 2024, and multiple bottles of Milk of Magnesia with use-by dates from March to August 2024. Additionally, a bottle of Lantus insulin was found opened and undated, and Narcan nasal spray boxes with expiration dates as far back as November 2013 were present. The DON acknowledged that the insulin should have been dated when opened and that expired medications and supplies should have been removed before their use-by dates.
Failure to Notify Physician of New Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician of a new pressure ulcer for a resident diagnosed with Alzheimer's disease and dementia. The resident developed an open area measuring 0.5 cm by 0.5 cm with red-tinged drainage, as documented in a progress note dated 07/27/24. The wound was cleaned, patted dry, and calazime barrier cream was applied, but there was no documentation indicating that the physician was notified of the new wound. On 08/27/24, during an observation of wound care, the Director of Nursing (DON) confirmed that the physician should have been notified on the day the wound was discovered, but there was no evidence of such notification.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for one of the six sampled residents reviewed for medications. During an observation, a resident was seen sitting in their room eating breakfast with two medication cups on their bedside table. One cup contained two white tablets, and the other contained 12-15 tablets/capsules. When questioned, RN #1 stated that the policy for administering medications involved checking the physician's orders, punching the medications out, initialing the MAR, and staying with the resident until they swallowed the medications. However, RN #1 left the medication cups on the resident's bedside table after the resident expressed a desire to take them after breakfast, contrary to the facility's policy and inservice education guidelines that medications should not be left in residents' rooms.
Failure to Implement Enhanced Barrier Precautions During Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during incontinent care and indwelling catheter care for one of the five sampled residents reviewed for infection control. The Director of Nursing identified nine residents with Foley catheters and 23 with EBP in place. An undated policy on EBP indicated that staff must wear gowns and gloves during high-contact resident care activities, such as changing briefs and urinary catheter care. An EBP sign was posted on the outside of the resident's door, instructing staff to wear gloves and a gown during transfers and urinary catheter activity. On the morning of the observation, a resident was seen sitting in a wheelchair with a lift sling under them, and a urinary drain bag was hooked under the wheelchair. Two staff members, a CNA and a CMA, cleaned their hands and donned gloves before transferring the resident to their bed using a lift. The CMA provided peri care and indwelling catheter care, while the CNA provided incontinent care. However, neither staff member wore gowns during these procedures. When asked about the EBP policy, the CMA mentioned that EBP should be used for residents with specific conditions but was unsure if it should be implemented during incontinent and urinary catheter care.
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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