Wewoka Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wewoka, Oklahoma.
- Location
- 1400 West First Street, Wewoka, Oklahoma 74884
- CMS Provider Number
- 375303
- Inspections on file
- 44
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 13 (6 serious)
Citation history
Health deficiencies cited at Wewoka Healthcare Center during CMS and state inspections, most recent first.
A resident with chronic pain and other conditions had an order for PRN oxycodone/APAP, with pharmacy records showing 120 tablets delivered, but facility documentation only accounted for a fraction of the medication and contained unexplained discrepancies between the controlled drug count sheet and the MAR. Staff reported forged signatures on the narcotic count sheet and stated that concerns were brought to the administrator and ADON, yet the administrator later denied being informed, and required reporting to state authorities and law enforcement, as outlined in the facility’s abuse and misappropriation policy, did not occur. Nursing staff, including a CMA, an LPN, and the ADON, described limited follow-up and unclear responsibility for reconciliation of controlled substances, resulting in a failure to implement and follow policies and procedures to prevent, detect, and report misappropriation of controlled narcotic medications.
The facility failed to prevent misappropriation of controlled medications for two residents with chronic pain and major depressive disorder. Pharmacy records showed full quantities of oxycodone/APAP and hydrocodone/APAP were delivered, but internal documentation, including receiving logs, narcotic count sheets, and MARs, did not account for all tablets. One resident reported taking only a single dose and then refusing further medication, while a CMA reported their signature had been forged on narcotic count sheets, with another staff member stating this was reported to administration despite the administrator denying awareness. For the second resident, reconciliation of count sheets and packing slips revealed missing tablets and an absent count sheet, and a search of locked medications did not locate the unaccounted doses.
The facility failed to maintain an effective system for receiving, documenting, and reconciling controlled narcotics, resulting in missing oxycodone/APAP and hydrocodone/APAP for two residents with chronic pain and major depressive disorder. Pharmacy records showed full quantities of controlled medications were delivered, but medication cards and count sheets for significant portions of these drugs could not be located, and the receiving logs did not reflect the deliveries. For one resident, the controlled drug count sheet showed doses documented as given that were not recorded on the MAR, while the resident reported taking only one dose and a CMA reported their signature had been forged on the count sheet. For the other resident, reconciliation of count sheets and packing slips revealed 30 tablets unaccounted for, with incomplete count sheets for the month. Staff interviews showed inconsistent reconciliation practices and acknowledged a period without a full-time DON during which these discrepancies occurred.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of mouse droppings, chewed wall material, dead roaches, and live roaches in the kitchen, dining room, and a resident room, including inside an ice machine and a room refrigerator. A resident with dysphagia, hemiplegia, chronic pain, suprapubic catheter status, and an open buttocks wound, who was bed/chair bound and required moderate assistance with all ADLs, was found to have dead roaches and mouse droppings in the room and bathroom areas. The facility’s pest sighting log documented ongoing mice and roach activity in resident rooms and the dining room over several months and showed a preventive treatment date, but did not show that each recorded pest sighting was treated, despite a written policy stating the building would be kept free of insects and rodents.
A resident with traumatic brain injury, mood disorder, and intact cognition exhibited escalating behaviors including yelling, cursing, hoarding medications, attempting self-harm, threatening staff, and expressing suicidal intent, leading to an emergency discharge and police transport to a hospital. An immediate written discharge notice was completed and given to the resident, but the LPN who prepared the transfer packet sent only a face sheet, diagnosis list, and medication list, omitting the discharge notice. The administrator had assumed all discharge documents were sent, and the hospital case manager later confirmed the hospital did not receive the discharge notice until they contacted the facility about returning the resident, showing the facility failed to provide the required immediate written discharge notice to the receiving hospital.
A resident with intact cognition and multiple psychiatric and medical diagnoses was receiving several psychotropic medications, including Quetiapine and Trintellix. During a pharmacist’s monthly medication regimen review, the pharmacist requested gradual dose reductions for these medications. The physician marked that dose reductions were contraindicated but did not document any clinical rationale, despite facility policy requiring such documentation when GDR is declined. Nursing staff noted the physician’s response but did not obtain or document a rationale, and the ADON later confirmed the absence of this required documentation while also noting that many residents in the facility were on psychotropic medications.
Multiple incidents occurred in which a resident physically struck other residents, including one with intact cognition and another with hemiplegia, resulting in injuries such as a bruise and a small tear. In another case, a resident with moderate cognitive impairment was hit on the head during a dining room altercation. Staff and LPNs witnessed or responded to these events, but the facility did not prevent the physical abuse.
The facility did not ensure timely reporting of suspected abuse incidents to the State Agency, including a physical altercation between two residents that resulted in injury. Initial reports were submitted late, and final investigation reports were either not sent within the required timeframe or not successfully transmitted, as confirmed by fax logs and the State Agency's records. These failures involved multiple residents and reflected noncompliance with required abuse reporting protocols.
A resident with cognitive and mental health diagnoses reported being held down and subjected to unwanted kissing by another resident. The incident was not promptly reported or thoroughly investigated, and the affected resident experienced ongoing fear and isolation as the perpetrator continued to approach them in common areas. Facility staff failed to ensure immediate protection and proper documentation as required by policy.
A resident with full code status was found unresponsive, but staff were initially unable to confirm the code status because it was not listed in the electronic health record. This led to a delay in starting CPR, as staff had to consult the Kardex to verify the resident's wishes. CPR was eventually initiated, but EMS records indicated that resuscitation efforts were not started prior to their arrival, highlighting a delay in providing basic life support.
A resident with schizoaffective disorder, psychosis, and depression exhibited repeated threats of self-harm and aggression toward others, including physical assaults on staff and another resident. Despite these behaviors, the resident was not placed on behavior monitoring, did not receive a psychiatric evaluation or medication reconciliation, and lacked appropriate care plan interventions. Staff confirmed that no special monitoring or interventions were in place after re-admission, and the facility environment was not equipped to manage the resident's mental health needs.
A resident with a history of schizoaffective disorder, hallucinations, and depression threatened to harm themself and others while exhibiting aggressive behavior and reporting auditory hallucinations. Although the resident was placed on one-on-one monitoring and emergency services were contacted, there was no documentation that the physician or psychiatric provider was notified of the incident, as confirmed by staff interviews and record review.
A resident with severe cognitive impairment was inappropriately touched by another cognitively intact resident in a common area. Staff intervened immediately, but the incident had already occurred. The affected resident was unable to recall the event due to their condition, and facility policies required protection from such abuse and consent based on decision-making ability.
A resident with a history of physical aggression assaulted another severely cognitively impaired resident, causing injury that required emergency care. Facility staff did not immediately implement required one-on-one supervision for the aggressor or update care plans with new interventions after each incident, and failed to document witness statements, all in violation of facility policy.
A resident with a history of physical aggression assaulted another resident, resulting in injury and hospital evaluation. The facility did not conduct a thorough investigation, failed to document witness statements, did not immediately implement required one-on-one safety measures, and did not update the care plan with new interventions or coordinate with QAPI as required by policy.
A resident with severe cognitive impairment and neuropsychiatric conditions was physically assaulted by another resident, resulting in visible injuries and an ER visit. The facility did not document any witness statements from staff or other residents, and the administrator acknowledged that a thorough investigation was not completed, contrary to facility policy.
Two residents with cognitive impairment and behavioral health diagnoses were able to leave the facility unsupervised, with one found walking on a road and another located miles away in a construction zone, both without proper documentation or notification to leadership. Staff interviews revealed confusion about elopement risk identification and inconsistent communication. Additionally, an unwitnessed fall involving another resident was not documented, despite evidence of the incident.
A resident with multiple medical conditions and full dependence for ADLs was found to have roaches on their body, mouse droppings in their room, and a mouse trap near their bed. Despite repeated pest sightings documented in the facility's log and complaints from the resident, there was no evidence that the pest issues were addressed after being reported. Staff confirmed ongoing pest problems in the room.
A resident with Medicaid coverage and intact cognition was not notified when their trust account balance exceeded the $200 threshold below the Medicaid resource limit, as required. Documentation and interviews confirmed the lack of notification, and the BOM was unaware of the notification requirement.
Multiple residents were found living in unsanitary and uncomfortable conditions, including mold under a sink, cracked and stained flooring, pest infestations, soiled linens, and damaged walls. Staff and administration acknowledged the presence of these issues, and residents reported that their concerns about cleanliness and pests were not addressed.
A resident with dementia and impaired decision-making was found on the floor after an unwitnessed fall. An LPN took a photo of the resident, exposing their bottom, before providing assessment or care, and did not document the incident in the health record. The facility's policy prohibits taking demeaning or privacy-violating photos, and the incident was reported to the state health department.
A treatment cart was found unlocked and unattended near the nurses station, with an insulin pen for a resident stored inside. Facility policy requires all medications to be securely stored and accessible only to authorized personnel. An LPN confirmed the cart should have been locked and attended at all times.
A call light was found not working in one of the shower rooms, as observed and confirmed by staff. The administrator confirmed that call lights are expected to be operational in all shower rooms, but the maintenance supervisor reported no work orders had been submitted for this issue.
A resident with multiple diagnoses began receiving Cipro, an antibiotic, without a documented physician's order or entry in the MAR. Despite this, the medication was administered, as indicated by a count sheet. A CMA admitted to not documenting the administration, and the ADON confirmed that medications not listed on the MAR should not be given.
The facility did not maintain a consistent temperature log for the medication refrigerator, with missing entries for several days across multiple months. The responsibility for maintaining these logs was assigned to the night shift nurses, as confirmed by the DON.
A facility failed to update a fall care plan for a resident with rheumatoid arthritis, omitting the intervention of a low bed with a fall mat despite it being implemented. The MDS coordinator was unaware of this change due to a lack of communication processes.
The facility did not conduct scheduled activities for residents, as observed and reported by residents and staff. The activity calendar listed events like Dominoes and Bingo, but these were not held at the scheduled times. Residents expressed dissatisfaction with the lack of activities and the absence of an activity director. Staff acknowledged the issue, with discussions about sharing activity responsibilities but no implementation.
The facility failed to ensure safety in the smoking area, resulting in a resident with schizophrenia smoking without a proper assessment and another resident with depression receiving a burn hole in their jacket due to overcrowding. Staff confirmed the lack of assessments and supervision, and the administrator acknowledged the overcrowding issue.
A facility failed to develop a comprehensive care plan for a resident with schizophrenia, specifically regarding their smoking habits. Despite the resident's assessment documenting tobacco use, no care plan was completed by the required date. The resident was observed smoking with staff assistance, but there was no care plan addressing this behavior. The MDS coordinator admitted to being behind on care plans, leading to this omission.
A resident with psychotic disorders exhibited adverse behaviors, such as aggression and inappropriate urination, which were documented in nursing progress notes but not in the TAR. An LPN confirmed the omission, indicating a failure to maintain accurate medical records.
The facility failed to notify mental health physicians of resident-to-resident abuse incidents involving two residents with mental health diagnoses. Despite multiple aggressive incidents, there was no documentation of physician notification, and interviews confirmed the oversight.
A facility failed to accurately assess a resident's adverse behaviors, despite documented instances of aggression and inappropriate actions. The resident, diagnosed with hallucinations and psychotic disorders, exhibited behaviors such as urinating in inappropriate places and physical aggression. However, the MDS assessment did not reflect these behaviors, and several sections were incomplete or inaccurately documented. The MDS Coordinator acknowledged the inaccuracies after reviewing the resident's records.
The facility failed to update care plans with interventions to protect vulnerable residents from abuse and prevent further potential abuse. Two residents were assaulted by others, and a resident with psychotic disorders exhibited abusive behavior without preventative interventions documented in their care plan. The MDS Coordinator acknowledged the need for updates, highlighting a lapse in adherence to the facility's abuse policy.
The facility did not employ a full-time DON and failed to ensure RN coverage for eight consecutive hours daily. The administrator and interim DON confirmed the absence of a full-time DON since May, with timecard reports showing insufficient RN coverage on 20 days in both August and September.
The facility failed to consistently implement COVID-19 isolation procedures for residents who tested positive, as required by their policy. Despite being in outbreak status, there was no signage indicating positive cases, and staff were unclear about which residents were in isolation and for how long. Some residents were removed from isolation after only five days, contrary to the 10-day policy, leading to a deficiency identified by surveyors.
The facility did not designate a qualified infection preventionist for its infection prevention and control program. The administrator identified the ADON as the infection preventionist, but there was no certification documentation. The interim DON, who had the certification, was on vacation, and the ADON had been handling duties without being formally assigned. The ADON attempted to manage COVID procedures but did not fulfill all required duties.
A resident with intact cognition missed a scheduled court hearing due to the facility's failure to communicate the hearing details to the appropriate staff. Despite informing the facility upon admission, the resident's attendance was not facilitated, leading to a delay in their guardianship proceedings.
A resident, dependent on staff for bathing due to conditions like edema and morbid obesity, did not receive scheduled baths as per the facility's shower schedule. The resident was supposed to be bathed three times a week, but there was no documentation of completed baths in the EHR. The resident reported receiving only three baths since admission. A CNA confirmed that bath completions and refusals should be documented, but the ADON found no such records.
The facility failed to investigate an alleged abuse incident involving two residents, one with cognitive communication deficit and another with aphasia and dementia. A witness reported seeing one resident force the other into a room and undress them. Despite discrepancies in staff accounts and police involvement, the incident was not documented in medical records or reported to the state health department.
A facility failed to prevent physical abuse of a resident who was severely cognitively impaired and dependent on staff for most ADLs. A CNA witnessed another CNA grab the resident's groin with force and yell at the resident during care, being rough during incontinent care. The facility's investigation substantiated the allegation of abuse.
A facility failed to report an alleged abuse incident within the required two-hour timeframe. A CNA witnessed potential abuse by another CNA towards a resident and reported it to the ADON. However, the incident, which occurred in the evening, was not reported to the OSDH until the following morning, exceeding the mandated reporting period.
The facility failed to maintain kitchen sanitation and food safety, affecting 74 residents. Observations included grease and food debris accumulation, warm hamburger meat in dirty water, and numerous cockroaches. Open garbage cans without lids and undated food packages were found, with a lack of temperature documentation for refrigerators and freezers. Staff shortages contributed to the unclean kitchen, and the DM was unaware of the conditions due to sick leave.
The facility failed to maintain an effective pest control program, with numerous cockroaches observed in the kitchen and dining areas. Staff and residents reported ongoing issues, including a resident finding a cockroach in their breakfast. The Dietary Manager acknowledged the problem, noting it remained a major concern despite some improvement.
A resident with a supra-pubic catheter experienced chronic pain due to the facility's failure to ensure a scheduled urology surgery was completed. The appointment was canceled because of transportation issues and lack of paperwork, and it was not rescheduled promptly due to inconsistent social services staffing. The interim DON admitted the oversight, and the resident expressed frustration over the continued need for the catheter.
The facility failed to ensure food was palatable and served at appetizing temperatures, as required by their policy. Observations revealed that food items were served below the required 135 degrees F, and residents reported dissatisfaction with the meals, describing them as cold and unappetizing. The Dietary Manager acknowledged the lack of temperature documentation and the oversight in maintaining proper food temperatures.
The facility did not cover garbage containers in the kitchen, contrary to their policy, leading to pest presence. Open garbage cans filled with food waste were observed, and the DM acknowledged the need for lids to prevent contamination and pests.
The facility did not follow the planned lunch menu, serving meat loaf instead of turkey pot pie without approval. The Dietary Manager was unaware of the substitution, and ingredients for the original meal were available. Additionally, a delay occurred when au gratin potatoes ran out, requiring mashed potatoes to be prepared for remaining residents.
Failure to Implement and Follow Policies for Controlled Narcotic Accountability and Misappropriation Reporting
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow policies and procedures to prevent and report misappropriation of a resident’s controlled narcotic medications. The facility had an undated Abuse Policy and Procedure stating residents have the right to be free from misappropriation of property and that the administrator would immediately report allegations to the Oklahoma State Department of Health and local police and conduct an immediate investigation. Resident #6 was admitted with diagnoses including chronic pain, hypertension, and major depressive disorder and had a physician’s order for oxycodone/APAP 10-325 mg, one tablet every six hours as needed, which was later discontinued. Pharmacy records showed 120 oxycodone/APAP tablets were delivered for this resident, but facility documentation only accounted for 30 tablets on the controlled drug count sheet, and the Medication Log of Receiving did not log the 12/15/25 delivery at all. The MARs for December and January showed only three documented doses, while the controlled drug count sheet reflected an additional 19 administered doses not documented on the MAR. Staff interviews revealed multiple failures to act on and report suspected misappropriation and documentation irregularities. CMA #1 reported that their name had been forged on the narcotic count sheet on multiple days and stated the resident did not request or take the medication beyond the first dose, and that they informed the administrator and were told it would be taken care of. Another CMA stated the issue was discovered during a cart count and that CMA #1 immediately reported it to the administrator. An anonymous staff member also stated they witnessed CMA #1 report the forged signatures to the administrator and ADON. However, the administrator later stated they were never informed of the issue and confirmed that neither the state agency nor law enforcement had been notified. LPN #1 acknowledged being told about the narcotic count sheet issue but did not follow up, believing it was the DON’s responsibility. The ADON stated they only ensured the count sheet and card matched before locking medications in the DON’s office and indicated RNs were usually responsible for reconciliation. The administrator stated reconciliation of the count sheet with the MAR should be done by the RN or charge nurse. LPN #2 denied administering any narcotics to the resident or signing the count sheet. Pharmacy staff confirmed that 120 tablets had been delivered, underscoring the discrepancy between delivered, documented, and administered doses and the facility’s failure to implement its own policies for reporting and investigating misappropriation of controlled medications.
Removal Plan
- Educate the administrator on policies and procedures that prohibit and prevent misappropriation of controlled medications
- Educate the administrator on investigating any allegations of misappropriation of controlled medications
- Ensure allegations of misappropriation of controlled medications are reported to the Oklahoma State Department of Health and law enforcement by the corporate administrator
- Re-educate all licensed nurses and CMAs on reporting requirements
- Re-educate all licensed nurses and CMAs on the controlled substance chain of command
- Re-educate all licensed nurses and CMAs on documentation requirements
Misappropriation and Poor Accountability of Controlled Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of controlled medications, resulting in unaccounted narcotics for two residents with chronic pain and major depressive disorder. For one resident, pharmacy records showed that 120 oxycodone/APAP tablets were delivered on 12/15/25, but facility documentation, including narcotic count sheets and medication logs, could only account for 30 of those tablets. The medication was not logged on the Medication Log of Receiving form, and the MAR for December 2025 and January 2026 showed only three documented doses administered. A controlled drug count sheet indicated 30 tablets received and 19 additional doses administered that were not reflected on the MAR. Staff interviews revealed discrepancies and possible forgery related to the controlled drug count sheet for this resident. One CMA reported that their name had been forged on the count sheet on multiple days and stated that the resident had only taken the first dose and then refused further doses because of how the medication made them feel. The resident confirmed they had not taken the oxycodone/APAP for approximately two months. Another CMA stated the issue was discovered during a cart count on 01/16/26 and that the first CMA immediately reported it to the administrator. However, the administrator stated they were never informed of the issue, and an anonymous staff member later reported witnessing the CMA report the forged signature to both the administrator and the ADON. Additional nursing staff indicated they did not administer narcotics to this resident and did not sign the count sheet. For a second resident with chronic pain and major depressive disorder, a physician’s order directed hydrocodone/APAP 7.5-325 mg three times daily. Pharmacy records showed that 90 tablets were delivered on 01/08/26, but the Medication Log of Receiving form did not show that this medication was logged in. When the resident’s controlled drug count sheets for several months were reconciled with packing slips, 30 tablets were found to be unaccounted for, and the ADON noted that one of the expected count sheets for January 2026 was missing. The DON reported that a search of all medications in lockup did not locate the missing hydrocodone/APAP. These documentation failures and missing medications for both residents constituted misappropriation of controlled substances.
Removal Plan
- Completed a full audit of all controlled substances by the on-site nurse consultant.
- Notified law enforcement and the physician.
- Educated the administrator on policies and procedures to prohibit and prevent misappropriation of controlled medications, investigate allegations, and report allegations to the Oklahoma State Department of Health and law enforcement.
- In-serviced all licensed nurses and CMAs that they are responsible for accepting medications from the pharmacy and signing verification of what was delivered.
- In-serviced all licensed nurses and CMAs to properly log controlled medications on narcotic count sheets, document administration on the MAR, verify count correctness at shift change, submit completed narcotic count sheets to the DON, and report any discrepancies to the administrator.
- Educated all licensed nurses and CMAs to turn in all medication receipts from the pharmacy, completed narcotic count sheets, and other drug records to the DON.
- Re-educated all licensed nurses and CMAs on controlled substance regulations and drug diversion.
- Provided ADON education on proper narcotic count procedures, documentation requirements, chain-of-custody, identifying and reporting drug diversion, reporting requirements for unusual occurrences, steps required when a discrepancy is found, and consequences of noncompliance.
Failure to Reconcile and Account for Controlled Narcotics for Two Residents
Penalty
Summary
The facility failed to maintain an effective system for the receipt, disposition, and reconciliation of controlled narcotic medications, resulting in unaccounted controlled drugs for two residents. Facility policy required a system for receipt, storage, administration, counting, reconciliation, investigation of discrepancies, and destruction of all controlled substances, including verification by two authorized staff upon delivery and documentation of the initial count. However, for one resident with chronic pain, hypertension, and major depressive disorder, a pharmacy packing slip showed that 120 oxycodone/APAP tablets were delivered, but count sheets and medication cards for 90 tablets could not be located. The controlled drug count sheet for this resident showed only 30 tablets received and documented 19 administered doses that were not recorded on the MAR. For this same resident, the Medication Log of Receiving did not reflect the oxycodone/APAP delivery, and the MAR for the relevant months showed only three administered doses, while the resident reported they had not taken the medication because they did not like how it made them feel and that the last dose was about two months prior. A CMA reported that their name had been forged on the narcotic count sheet on multiple days and stated the resident had only taken the first dose; this was reported to the administrator. Another CMA confirmed the issue was discovered during a cart count and that it was immediately reported to the administrator. Nursing staff, including an LPN, denied administering narcotics to this resident or signing the count sheet, and pharmacy staff confirmed the full quantity of 120 tablets had been delivered. For a second resident with chronic pain and major depressive disorder, a physician’s order prescribed hydrocodone/APAP three times daily, and a pharmacy packing slip showed 90 tablets were delivered. The Medication Log of Receiving did not show that this delivery was logged, and a count sheet and medication card for 30 tablets were missing. When the resident’s controlled drug count sheets and packing slips for several months were reconciled with the ADON, 30 hydrocodone/APAP tablets were found to be unaccounted for, and the ADON stated there should have been three count sheets for one month but only two were located. The administrator acknowledged the facility had been without a full-time DON for an extended period during the time these discrepancies occurred, and staff interviews indicated that reconciliation practices were limited to matching the count sheet and card, with RNs usually responsible for medication reconciliation.
Removal Plan
- The administrator and DON were in-serviced by the corporate administrator regarding the facility's controlled-substance reconciliation system, including mandatory reporting and record keeping requirements.
- All narcotic deliveries received would be verified against the pharmacy delivery receipt and signed into the controlled drug count sheets by a licensed nurse at the time of receipt.
- Delivery receipts would be attached to the unit's narcotic packet and routed to the DON by end of shift.
- The nurse consultant completed a full-scope audit of all units and verified medication availability for all residents with active orders.
- Access to controlled substances was restricted to licensed nurses only.
- CMAs would no longer receive or administer controlled substances.
- Medication storage for controlled substances was verified as double-locked and functional.
- End of shift dual signature counts by two licensed nurses were implemented.
- All licensed nurses and CMAs were re-educated by the ADON and LPN #4 on reconciliation, documentation, chain of custody, discrepancy escalation, and reporting expectations.
Failure to Maintain Effective Pest Control in Kitchen, Dining, and Resident Areas
Penalty
Summary
Failure to maintain an effective pest control program was identified based on multiple observations of mice and roach activity in food service and resident care areas. During a tour of the kitchen and dining room, surveyors observed a pile of mouse droppings mixed with chewed wall particles on the floor under the dishwasher, dead roaches along the baseboards in the kitchen and dining room, and dead roaches inside the ice machine. Live roaches were also seen crawling on the floors and walls around tables storing coffee cups and near the ice machine. On a later observation, live roaches were again seen around the ice machine and on the walls and floors in the dining room. The facility’s pest sighting log documented mice and roach sightings in resident rooms and the dining room over several months, and showed the last preventive treatment date, but did not document that every pest sighting recorded on the log was treated. In a resident room, surveyors observed dead roaches and mouse droppings on the floor and sticky traps in the closets and bathroom, as well as a live roach crawling inside the room refrigerator. The resident in that room had been admitted with dysphagia, hemiplegia, sequelae of cerebral infarction, chronic pain syndrome, suprapubic catheter status, and an open wound of the buttocks, and was care planned as bed/chair bound and requiring moderate assistance with all ADLs, with a BIMS score indicating intact cognition. The facility had a written pest control policy stating it would maintain an ongoing program to keep the building free of insects and rodents. Staff interviews confirmed awareness of a roach and mouse problem, and the pest sighting log and staff statements showed that pest activity had been ongoing and not consistently addressed in accordance with the facility’s stated pest control program.
Failure to Send Immediate Written Discharge Notice With Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide an immediate written notice of discharge to the receiving hospital when a resident was emergently transferred and discharged. The facility’s Emergency Transfer or Discharge policy required that, when an emergency transfer or discharge occurs, the receiving facility be notified that the transfer is being made and that a transfer form be prepared and sent with the resident. Resident #24 was admitted with traumatic brain injury with loss of consciousness and a mood disorder, was cognitively intact with a BIMS score of 14, and had documented behaviors including rejecting care and exhibiting physical and verbal behaviors. Nursing notes documented that the resident became increasingly upset, yelling and cursing at staff, hoarding medications, attempting to throw themself from the bed, attempting to hit staff, and threatening suicide if not allowed to leave. An immediate discharge written notice was completed, citing drastic violent episodes that endangered the health and safety of others and indicating that police intervention was required for removal. On the date of the incident, the LPN reported providing the immediate written discharge notice to the resident and explaining its contents, after which the resident discarded the notice. The resident was then transported to the hospital by police following threats of self-harm and continued requests to leave the facility. The administrator later stated they assumed all medical transfer forms, including the immediate discharge notice, had been sent with the resident. However, another LPN stated that only a face sheet, medical diagnosis list, and medication list were sent, and that a copy of the immediate discharge notice was not included with the transfer documentation. The hospital case manager confirmed that the hospital did not receive the immediate discharge notice at the time of transfer and only obtained it later when contacting the facility about discharging the resident back, demonstrating that the required immediate written discharge notice was not provided to the receiving hospital at the time of transfer.
Lack of Physician Rationale for Declined GDR of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a physician documented a clinical rationale when declining gradual dose reduction (GDR) requests for psychotropic medications, as required by facility policy and CMS guidance. The facility’s undated "Gradual Dose Reduction (GDR) Policy-Oklahoma Nursing Facility" stated that residents prescribed psychotropic medications should receive appropriate GDRs and non-pharmacologic interventions, and that the physician would document a rationale if a reduction was contraindicated. A consultant pharmacist completed a monthly medication regimen review on 12/31/25 for a resident admitted on 10/16/23 with diagnoses including paranoid schizophrenia, chronic pain, restless leg syndrome, paraplegia, major depressive disorder, obsessive compulsive disorder, hypertension, catheter status, and anxiety. The resident’s quarterly MDS dated 12/16/25 showed a BIMS score of 15, indicating intact cognition, and listed multiple medications, including Depakote for behavior management, Trazodone for sleep, Trintellix and Desvenlafaxine for depression, Meloxicam for arthritis, Olanzapine and Quetiapine for schizophrenia, Fesoterodine for neurogenic bladder, and several PRN medications. During the 12/31/25 medication regimen review, the consultant pharmacist requested consideration of a dose reduction in Quetiapine 300 mg at bedtime and Trintellix 20 mg daily, asking if a reduction in Quetiapine to 250 mg at bedtime was appropriate. On the review form, the physician checked "no, a reduction is contraindicated due to:" for both Quetiapine and Trintellix but did not document any rationale in the space provided. The Assistant Director of Nursing later verified that the GDR request for these medications was signed by the physician, that the physician had declined the dose reduction requests, and that no rationale was documented. The ADON also confirmed that the GDR request was noted by a nurse and there was no documentation that nursing staff sought or obtained a rationale from the physician for declining the GDR requests. The ADON identified that 47 residents in the facility were receiving psychotropic medications.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. In one instance, a resident with intact cognition and diagnoses including depression, schizophrenia, and bipolar disorder was physically struck on the arm by another resident who entered their room uninvited, resulting in a bruise. The incident was witnessed by staff and reported, with documentation indicating that the aggressor was moved and placed on one-to-one supervision. Another event involved a resident with hemiplegia and limited mobility who was confronted in their room by the same resident. Despite attempts to redirect the aggressor, a physical altercation ensued, resulting in a small tear on the resident's left arm. Staff and other residents reported hearing the commotion and observed the physical contact, with the aggressor swinging at the resident and making contact. A third incident occurred in the dining room, where a resident with moderate cognitive impairment and a history of physical and verbal aggression was struck on the head by the same resident during a verbal altercation. Staff intervened and separated the residents, and the affected resident was assessed for injuries, with no visible harm noted. These events demonstrate a pattern of resident-to-resident abuse that was not effectively prevented by the facility.
Failure to Timely Report and Document Abuse Allegations to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse incidents to the State Agency as required by its Abuse Prevention Program policy. Specifically, an incident involving a physical altercation between two residents resulted in one resident sustaining a small tear on the left arm. The incident occurred at 12:10 p.m., but the initial state reportable incident form was not submitted until 3:36 p.m., exceeding the two-hour reporting requirement. Additionally, there was no documentation that a final report was received by the State Agency within five business days for this incident. Interviews with staff and the administrator revealed inconsistencies regarding the time of notification and submission of reports, and the administrator acknowledged the report was not submitted in a timely manner if the incident occurred at the documented time. Further review identified another incident involving two residents in the dining room, which was reported initially, but the final incident report was not successfully transmitted to the State Agency. The administrator provided a fax transmission log indicating an unsuccessful attempt to send the final report, as denoted by a code indicating failed communication. The State Agency's database did not show receipt of the final report for this incident. These failures affected three residents and demonstrated noncompliance with both the facility's policy and state requirements for timely reporting and documentation of abuse allegations and investigation results.
Failure to Protect Resident from Resident-to-Resident Sexual Abuse
Penalty
Summary
A deficiency was identified when the facility failed to protect a resident from abuse, specifically resident-to-resident sexual abuse. The incident involved a cognitively intact resident with a history of anoxic brain damage, major depressive disorder, and anxiety disorder, who reported being pushed down on a bed, held down, and subjected to unwanted kissing by another resident. The resident stated they told the perpetrator to stop and eventually left the room after a few minutes. The incident was not immediately reported to the appropriate authorities, and the resident indicated that after the event, the perpetrator continued to approach them in common areas, causing the resident to feel afraid and to isolate themselves in their room for approximately two weeks. The facility's policy required thorough investigation and documentation of all alleged or actual incidents of abuse, including obtaining detailed accounts from the resident and assessing for mood or behavioral changes. However, the report shows that the initial allegation was not promptly or thoroughly investigated. The resident stated they had reported the incident to staff, but staff interviewed by police denied knowledge of the abuse. Documentation indicates that the administrator was eventually informed, and a care plan was developed identifying the resident as at risk for unwanted physical contact, but this occurred after a significant delay from the time of the incident. Records also show that the facility did not immediately notify the appropriate authorities or conduct a timely assessment of the resident's well-being following the allegation. The resident's statements and subsequent interviews revealed that the incident had a negative impact on their sense of safety and emotional state. The facility's failure to promptly investigate, document, and protect the resident from further unwanted contact constituted a deficiency in ensuring residents are free from abuse.
Delay in CPR Initiation Due to Unclear Code Status Documentation
Penalty
Summary
The facility failed to prevent a delay in care when a resident was found unresponsive. According to the facility's policy, if a resident's Do Not Resuscitate (DNR) status is unclear, CPR should be initiated until a DNR or physician's order is confirmed. In this incident, the resident had a care plan indicating full code status and a wish to have CPR performed. However, when the resident was found unresponsive, staff were initially unsure of the resident's code status because it was not listed in the electronic health record under the resident's name. Staff had to consult the resident's Kardex to determine the code status, which led to a delay in initiating CPR. Nursing notes indicated that the resident was found unresponsive with no respirations, pulse, or heart sounds. Although CPR was eventually started and continued until emergency services arrived, the EMS report showed that the facility did not start resuscitation efforts prior to their arrival. The EMS was called at 5:06 a.m. and arrived at 5:12 a.m., but the timeline provided by staff interviews suggested that CPR may have only been started around the time EMS arrived, rather than immediately upon finding the resident unresponsive. Interviews with staff revealed confusion and lack of clarity regarding the process for determining a resident's code status, as well as the timing of when CPR should be initiated. The Assistant Director of Nursing (ADON) and Certified Nursing Assistants (CNAs) confirmed that the code status was not readily available in the electronic health record at the time of the incident, contributing to the delay in care. The deficiency was identified as an Immediate Jeopardy situation due to the failure to provide timely basic life support to a resident who was a full code.
Removal Plan
- Review all residents' code status, update electronic records, and update care plans.
- Maintain a list of all residents' current code status at each nurse's station.
- In-service all staff on calling 911 when a resident is found unresponsive regardless of code status and maintain a resident code status list at each nurse's station.
- In-service all licensed nurses on initiating CPR on any resident that is a full code and continuing until emergency services arrive.
- Make any employee who cannot be reached for in-service inactive and remove from the schedule until education is provided.
Failure to Provide Necessary Care and Treatment for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with multiple mental health disorders, including schizoaffective disorder, psychosis, and depression, who exhibited behaviors such as threatening self-harm and harm to others. Documentation showed that the resident had episodes of screaming, cussing, and threatening to kill themself and others, as well as hearing voices and being aggressive toward staff. Despite these behaviors, there was no evidence that the resident was placed on behavior monitoring or received a psychiatric evaluation or medication reconciliation following these incidents. Nursing notes indicated that after a significant incident where the resident threatened self-harm and aggression, one-on-one monitoring was initiated and emergency services were contacted, but the resident was not transferred to the emergency room. Subsequent documentation revealed further aggressive behavior, including physically assaulting a nurse and another resident. Staff interviews confirmed that the resident was not on any special monitoring after re-admission and that no interventions for self-harm or aggression were in place. The care plan did not reflect the necessary interventions for the resident's mental health needs. Staff, including LPNs and the ADON, acknowledged that the resident should have received a higher level of care and that the facility environment was not equipped to manage such behaviors. There was no documentation of timely notification to psychiatric providers or adjustments to the resident's medication regimen after the incidents. The lack of appropriate assessment, monitoring, and intervention for the resident's mental health and behavioral issues led to the deficiency.
Removal Plan
- A review of all resident records was conducted to identify those with mental health disorders that may exhibit behaviors related to those disorders. All residents identified will have care plans updated to reflect mental health disorder/behavior. PCP and mental health will be aware of the identified residents to ensure all are evaluated and referred for services.
- All staff in-serviced that a current list of residents with mental health disorders is maintained at each nurse's desk.
- All staff in-serviced that when a resident displays that he/she is a harm to themselves or others and to report behavior immediately to nurse supervisor/administrator.
- Nursing staff will be in-serviced to notify the physician and mental health provider of the harmful behaviors immediately.
- The nursing staff will be in-serviced to request medication reconciliation with the physician and mental health provider following harmful/ mental health behaviors.
- Department supervisors are responsible for ensuring all in-services are completed.
- Employees who are unable to be reached will be required to in-service upon return to the facility.
Failure to Notify Physician After Resident Threatened Self-Harm and Harm to Others
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician after a resident, with diagnoses including schizoaffective disorder bipolar type, hallucinations, psychosis, and depression, verbalized threats to harm themself and others. The resident, who had intact cognition and a history of hallucinations and delusions, was observed at the nurses' station exhibiting aggressive behavior, threatening self-harm and harm to others, and reporting auditory hallucinations. Although the resident was placed on one-on-one monitoring and 911 was called, there was no documentation that the physician or psychiatric provider was notified of the incident, as confirmed by staff interviews and record review.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A resident with severe cognitive impairment, including a diagnosis of focal traumatic brain injury and frontotemporal neurocognitive disorder, was not protected from sexual abuse by another resident. The cognitively impaired resident, who had a BIMS score of 7 indicating severe impairment, was observed sitting in a common area when another resident, who was cognitively intact, sat beside them and engaged in inappropriate sexual touching. Staff immediately intervened and separated the two residents, but the incident had already occurred. The cognitively impaired resident was unable to recall or participate in an interview about the event due to their condition, and a family member confirmed that the resident was not capable of consenting to sexual advances. The facility's abuse policy and sexual consent policy both require protection of residents from abuse and specify that consent must be based on intact decision-making ability. Despite these policies, the incident occurred in a common area, and the resident at risk was not adequately protected from inappropriate contact. The event was documented in nursing notes and reported to the state health department. Prior to the incident, there was no indication of a relationship or interaction between the two residents beyond casual greetings.
Failure to Protect Resident from Abuse Due to Inadequate Supervision and Policy Implementation
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse, specifically resident-to-resident physical aggression. On one occasion, a resident with a history of aggressive behaviors physically assaulted another resident, resulting in the victim sustaining a facial injury that required emergency medical evaluation. The aggressor had a documented history of multiple prior incidents of physical aggression toward both peers and staff, as noted in their care plan and facility records. Despite the aggressor's known behavioral risks, the facility did not implement immediate one-on-one safety observations as required by its own policy following the incident. Documentation failed to show that the aggressor was placed on one-on-one supervision immediately after the event, and there were no documented witness statements from residents or staff regarding the incident. Additionally, the care plan for the aggressor was not updated with new interventions after each aggressive episode, contrary to facility policy. The victim was severely cognitively impaired and had no prior documented history of aggressive behaviors. The aggressor was also severely cognitively impaired and had a pattern of physical aggression. The facility's failure to follow its abuse prevention and monitoring policies, including timely implementation of supervision and care plan updates, directly contributed to the occurrence and inadequate response to the abuse incident.
Failure to Implement Abuse Policy and Investigative Procedures
Penalty
Summary
The facility failed to implement its abuse policy in response to an incident where a resident with a history of physical aggression, related to dementia and other psychiatric diagnoses, physically assaulted another resident. The incident resulted in the victim sustaining a red discharge from the nose and swelling to the head, requiring emergency room evaluation. Documentation showed that the aggressor had a documented history of multiple physical aggression incidents toward both peers and staff, yet the care plan did not reflect new interventions after each event, and the intervention of one-on-one observation had been repeatedly used without documented updates or changes. The facility did not provide evidence of a complete and thorough investigation, as there were no documented witness statements from residents or staff regarding the incident. Additionally, the facility failed to immediately implement one-on-one safety measures as required by policy, and there was no documentation of coordination with QAPI or the implementation of new interventions to prevent recurrence. The administrator confirmed that required documentation and QAPI review were not completed following the incident.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with severe cognitive impairment and multiple neuropsychiatric diagnoses. According to facility policy, investigations of resident-to-resident abuse require interviews with cognitive residents and witnesses, as well as head-to-toe assessments for non-cognitive residents if necessary. An incident report documented that the resident was punched in the face by another resident, resulting in a red discharge from the nose, swelling to the head, and a subsequent emergency room visit. Despite these events, there were no documented witness statements from staff or other residents regarding the incident, and the administrator confirmed that a thorough investigation was not completed.
Failure to Prevent Elopement and Document Falls
Penalty
Summary
The facility failed to prevent elopement and document falls for multiple residents, resulting in deficiencies related to supervision and accident prevention. One resident with moderate cognitive impairment and a history of falls was able to leave the facility unsupervised and was found walking down the road by a visitor, who notified staff. The resident was picked up by a CNA and returned to the facility, but there was no documentation of the elopement in the resident's health record, and staff were unclear about which residents were at risk for elopement. Another resident, identified as high risk for elopement and with a history of schizo-affective disorder, was able to leave the facility without staff knowledge and was found three miles away on a state highway in a construction zone by an off-duty staff member. This resident had previously attempted to elope multiple times and was returned to the facility covered in mud and fecal matter, but again, there was no documentation of the elopement in the health record. Staff interviews revealed confusion and inconsistency regarding the identification and supervision of residents at risk for elopement. Some staff relied on verbal communication from charge nurses to determine which residents could leave unsupervised, while others were unaware of any formal assessment or list. The DON and administrator were not notified of the elopements, and there was no documentation or incident reporting for these events. The care plans for residents at risk for elopement did not include appropriate interventions to prevent elopement, and staff were not consistently aware of or following facility policy regarding elopement prevention and response. Additionally, the facility failed to document an unwitnessed fall for another resident with a history of traumatic brain injury and dementia. An anonymous email with a photo showed the resident on the floor, but there was no documentation of the fall in the health record. The charge nurse admitted to finding the resident on the floor and assessing them but did not document the incident, mistakenly believing the resident was care planned to be on the floor. These failures in supervision, documentation, and communication contributed to the deficiencies cited by surveyors.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest management program as evidenced by multiple observations of pests and pest evidence in a resident's room. On several occasions, surveyors observed a roach on a resident, mouse droppings along the walls and in the resident's dresser, and a mouse trap at the head of the bed. Additional observations included live and dead roaches behind the refrigerator and further mouse droppings in the room. The facility's pest control policy stated that an ongoing program would be maintained to keep the building free of insects and rodents. However, the pest sighting log documented sightings of mice and roaches in the same room and other areas, with no evidence that these sightings were addressed after being recorded. The last preventative pest treatment was documented nearly two months prior to the most recent sightings. The resident involved had diagnoses including dysphagia and major depressive disorder, was dependent for all activities of daily living, and had intact cognition. The resident reported frequent issues with roaches crawling on them and stated that repeated complaints to staff were not addressed. Facility staff, including housekeeping and the administrator, confirmed the presence of roaches, mouse droppings, and traps in the resident's room. The maintenance supervisor acknowledged that roaches were still present in the facility, though their numbers had decreased.
Failure to Notify Resident of Trust Account Balance Near Medicaid Limit
Penalty
Summary
The facility failed to notify a resident when their trust account balance was within $200 of the Medicaid resource limit of $2000, as required. Record review showed that the resident, who had Medicaid as a payer source, an intact BIMS score of 15, and was dependent for all activities of daily living, had a trust account balance of $2353.44. There was no documentation in the resident's health record indicating that notification was provided when the balance approached the Medicaid limit. The resident confirmed they were not notified, and the Business Office Manager stated they were unaware of the requirement to provide such notification.
Failure to Maintain Clean, Sanitary, and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary and unsafe conditions in resident rooms. In one instance, a resident's room was found to have black and green mold spots under the sink cabinet, with the affected area measuring approximately 20 inches along the back wall and spots ranging from 0.5 to 3 inches in size and 7 to 11 inches in height. The flooring under the sink was cracked and stained. The maintenance supervisor confirmed the presence of mold due to water damage and stated there were no work orders for this issue, indicating a lack of timely response to maintenance needs. Another resident's room was observed to have soiled bed linens, a baby roach on the resident, damaged and stained walls, cracked and dirty floor tiles with brown residue, and a window sill with visible dirt and debris. The resident, who was cognitively intact but dependent for all activities of daily living, reported frequent issues with roaches and dissatisfaction with the room's cleanliness, stating that staff had not addressed their concerns. Housekeeping and administrative staff acknowledged the presence of pests, dirt, and the need for cleaning and repairs. Facility policies require a clean, sanitary, and homelike environment, but these standards were not met in the observed cases.
Failure to Prevent Abuse and Protect Resident Privacy
Penalty
Summary
A facility failed to prevent abuse for a resident with a history of traumatic brain injury and dementia, who was moderately impaired for decision making and required supervision for mobility. The resident was identified as being at risk for falls. An anonymous email was sent to the state health department containing a picture of the resident lying on the floor with their hospital gown exposing their bottom, after an unwitnessed fall. The picture showed the resident looking at the camera and unable to prevent the photo from being taken. The LPN on duty admitted to taking the picture of the resident after finding them on the floor, before assessing the resident. The LPN stated they did not document the fall in the health record, believing the resident was care planned to be on the floor. The facility's abuse policy specifically prohibits taking demeaning or privacy-violating pictures of residents, considering such actions as abuse. The LPN attempted to obscure the resident's buttocks in the image but still took and retained the photo, in violation of facility policy.
Unattended and Unlocked Treatment Cart with Insulin Found
Penalty
Summary
A treatment cart located on the East side of the nurses station in the Southwest hall was observed to be unlocked and unattended. Inside the first drawer of the cart, a Lantus SoloStar Subcutaneous Pen-injector (insulin glargine) prescribed for a resident was found. Facility policy, revised in January 2018, requires that medications and biologicals be stored safely, securely, and properly, and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During an interview, an LPN confirmed that the treatment cart was supposed to be locked and attended at all times, in accordance with facility policy.
Non-Functioning Call Light in Shower Room
Penalty
Summary
A deficiency was identified when a call light was found not working in one of the three shower rooms used by residents, specifically the shower room on the East side of the middle hall. This was observed during a facility visit, and confirmed by an advanced certified medication aide who stated the call light in that shower room was not operational. The administrator acknowledged that call lights were supposed to be functional in all shower rooms. Review of the facility's maintenance policy indicated that the Maintenance Department is responsible for ensuring all equipment is safe and operable at all times. However, the maintenance supervisor reported that there were no work orders submitted regarding the non-functioning call light.
Failure to Document Antibiotic Order and Administration
Penalty
Summary
The facility failed to ensure that a resident's chart was updated with a new antibiotic order. A resident, who was admitted with diagnoses including overactive bladder, hypertension, and anxiety, began receiving Cipro, an antibiotic, at a dosage of 500 mg twice a day. However, the physician's orders did not document this antibiotic order, and the medication administration record (MAR) also lacked documentation of the order. Despite this, a count sheet indicated that the first dose of Cipro was administered. When questioned, a Certified Medication Aide (CMA) admitted to not documenting the administration of the antibiotic on the MAR. The Assistant Director of Nursing (ADON) confirmed that if the medication was not on the MAR, it should not have been administered.
Failure to Maintain Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to maintain a consistent temperature log for the medication refrigerator in the medication room, as required by professional principles. During a tour of the medication room, it was observed that there was no temperature log for December 2024, and the logs for November and October 2024 had significant gaps, with 21 and 8 days of missing temperatures, respectively. CMA #1 indicated that the nurses were responsible for maintaining these logs. LPN #1 further clarified that the night shift nurses were specifically tasked with this responsibility. The Director of Nursing (DON) confirmed that the temperature logs were supposed to be completed daily, highlighting a lapse in the facility's protocol for monitoring medication storage conditions.
Failure to Update Fall Care Plan with New Interventions
Penalty
Summary
The facility failed to update a fall care plan with necessary interventions for a resident diagnosed with rheumatoid arthritis. The resident's fall care plan, dated August 6, 2023, included interventions such as using a wheelchair for mobility, referring to a restorative program if functional changes were noted, and monitoring for changes in condition that might require increased supervision or assistance. An incident report from November 2, 2024, indicated that the facility planned to implement a low bed with a fall mat at the bedside for the resident. However, the care plan initiated on November 6, 2024, did not document the low bed with mat as a fall intervention. On December 9, 2024, the resident was observed in bed with the bed in the lowest position and a fall mat at the bedside, yet the resident denied any recent falls. The MDS coordinator later stated there was no established process to communicate new interventions to their department, and they were unaware of the low bed with mat placement.
Failure to Conduct Scheduled Activities for Residents
Penalty
Summary
The facility failed to ensure scheduled activities were conducted for its residents, as observed and reported by both residents and staff. The activity calendar for November 2024 listed activities such as Dominoes and Bingo on specific dates, but these activities were not observed to be in progress at the scheduled times. Residents expressed dissatisfaction, noting the lack of activities and the absence of an activity director. One resident mentioned that activities like Bingo were offered infrequently, and another resident confirmed that the posted activities did not occur. The Social Services director and the administrator acknowledged the lack of daily activities, with discussions about splitting activity responsibilities between staff members but no implementation at the time of the survey.
Deficiencies in Smoking Area Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety of residents in the smoking area, leading to deficiencies in accident prevention. Specifically, a smoking assessment was not completed for a resident with schizophrenia, who was observed smoking without a smoking apron despite having shaky hands. This oversight was acknowledged by the MDS coordinator, who confirmed that a smoking assessment had not been conducted for this resident. The lack of assessment and supervision contributed to the resident's exposure to potential hazards while smoking. Another resident, diagnosed with depression, experienced a burn hole in their jacket due to overcrowding in the smoking area. The resident reported that the area was too crowded, which led to another resident accidentally burning their jacket. Staff members, including the laundry supervisor and a CMA, confirmed the crowded conditions and the incident. The administrator acknowledged the overcrowding issue and the resulting burn incident, indicating a failure to provide adequate space and supervision in the smoking area to prevent such accidents.
Failure to Develop Comprehensive Care Plan for Smoking
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident with schizophrenia, specifically regarding their smoking habits. The facility's policy requires a comprehensive care plan to be developed within seven working days of completing a resident's comprehensive assessment. However, for this resident, whose assessment documented tobacco use, no care plan was completed by the required date. On a specific day, the resident was observed smoking outside with the assistance of a staff member, yet there was no care plan addressing this behavior in the resident's clinical record. The MDS coordinator admitted to being behind on care plans, resulting in the omission for this resident.
Failure to Document Adverse Behaviors in Resident Records
Penalty
Summary
The facility failed to accurately document adverse behaviors for a resident diagnosed with hallucinations and other psychotic disorders. The resident exhibited several adverse behaviors, including urinating in inappropriate places, aggression towards staff and other residents, and entering other residents' rooms without permission. These behaviors were recorded in the nursing progress notes but were not reflected in the Treatment Administration Records (TAR) for September and October 2024. The discrepancy was confirmed when an LPN acknowledged that the behaviors documented in the progress notes should have been recorded in the TAR. The failure to document these behaviors accurately on the TAR represents a deficiency in maintaining medical records in accordance with accepted professional standards, as required by the facility's policies and procedures.
Failure to Notify Mental Health Physicians of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to notify the mental health physicians following incidents of resident-to-resident abuse involving two residents who were receiving routine mental health services. The facility's abuse policy, updated in July 2021, mandates that a physician be notified to implement actions to prevent a recurrence when a person is suspected of abusing another. However, this protocol was not followed for two residents with mental health diagnoses, including hallucinations and psychotic disorders, who were involved in multiple incidents of aggression towards other residents. Resident #5 was involved in three separate incidents of aggression, including hitting another resident with a cane, taking away a walker, and slapping another resident. Despite these incidents, there was no documentation that the mental health physician was notified, and a progress note later indicated no combative behaviors. Similarly, Resident #6 was involved in an incident of choking another resident, but again, there was no documentation of physician notification. Interviews with the mental health physicians confirmed they were not informed of these incidents, and the MDS Coordinator acknowledged the oversight.
Inaccurate Assessment of Resident's Adverse Behaviors
Penalty
Summary
The facility failed to accurately assess adverse behaviors in a resident with diagnoses of hallucinations and other psychotic disorders. The nursing progress notes documented multiple instances of aggressive and inappropriate behavior by the resident, including urinating in inappropriate places, physical aggression towards staff and other residents, and taking items from other residents. Despite these documented behaviors, the Significant Change MDS assessment for the resident did not reflect any physical, verbal, or other behavioral symptoms, and several sections related to the impact of behaviors on others and wandering were either not completed or inaccurately documented. The MDS Coordinator acknowledged that the assessment was not completed accurately after reviewing the resident's clinical records and progress notes. The coordinator stated that the assessment process should involve talking to various staff, reviewing clinical records, and interviewing the resident if possible. However, the failure to accurately document the resident's behaviors in the MDS assessment indicates a lapse in this process, leading to an incomplete and inaccurate assessment of the resident's condition.
Failure to Update Care Plans for Abuse Prevention
Penalty
Summary
The facility failed to update care plans with necessary interventions to protect vulnerable residents from abuse and prevent further potential abuse. Specifically, two residents with diagnoses including dementia, legal blindness, ESRD, and hypertensive heart disease were involved in incidents where they were assaulted by other residents. Despite these incidents, there was no documentation on their care plans of interventions designed to prevent occurrences of abuse perpetrated by other residents. Additionally, a resident with diagnoses of hallucinations and other psychotic disorders exhibited abusive behavior towards other residents on multiple occasions. This resident's care plan, however, did not include preventative interventions for their abusive behavior. The MDS Coordinator acknowledged that the interventions on the care plans for these residents should have been updated, indicating a lapse in the facility's adherence to its abuse policy, which mandates reassessment for preventative interventions at least quarterly.
Failure to Maintain Full-Time DON and RN Coverage
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) and did not ensure registered nurse (RN) coverage for eight consecutive hours, seven days per week. The administrator acknowledged that the facility had been without a full-time DON for several months, with a corporate RN occasionally filling in as the interim DON. A review of timecard reports for August and September 2024 revealed that there was no RN coverage for eight consecutive hours on 20 days each month. The interim DON confirmed that the facility had been without a full-time DON since May 15, 2024, and regular RN attendance had not been maintained since they assumed the interim role on August 1, 2024.
Inconsistent COVID-19 Isolation Procedures
Penalty
Summary
The facility failed to adhere to its COVID-19 isolation procedures, as outlined in their policy, for four residents who tested positive for COVID-19. The policy required residents who tested positive to be isolated for at least 10 days from the onset of symptoms or the first positive test. However, observations and interviews revealed inconsistencies in the implementation of these procedures. For instance, one resident was observed ambulating in the lobby and reported that isolation procedures were inconsistently applied, with isolation lasting only a few days. Additionally, staff members, including a CMA and LPNs, were uncertain about which residents were in isolation and for how long, indicating a lack of communication and adherence to the established protocol. The report highlights that the facility was in outbreak status for several weeks, yet there was no signage indicating the presence of positive COVID-19 cases upon entry. Staff interviews revealed confusion regarding the duration of isolation, with some residents being removed from isolation after only five days if asymptomatic, contrary to the 10-day policy. The corporate interim DON confirmed that residents who tested positive were not kept in isolation for the required duration, and the ADON acknowledged that isolation procedures were not consistently followed during the outbreak period. This lack of consistent implementation of isolation protocols contributed to the deficiency identified by the surveyors.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. The administrator identified the Assistant Director of Nursing (ADON) as the infection preventionist, but there was no documentation of the required certification for the ADON. The interim Director of Nursing (DON) stated they had the certification but had been on vacation, and the ADON had been handling the infection preventionist duties for several months. However, the ADON confirmed they had the certification but had not been asked to perform the infection preventionist duties, which were previously managed by the former full-time DON. The ADON attempted to manage COVID outbreak procedures but did not complete all required duties of the infection preventionist role.
Failure to Facilitate Resident's Court Hearing Attendance
Penalty
Summary
The facility failed to ensure a resident attended a scheduled court hearing regarding guardianship, which was a violation of the resident's right to self-determination and choice. The resident, who had diagnoses including chronic pain and generalized anxiety disorder, was admitted to the facility with intact cognition. Upon admission, the resident informed the facility's social services and administrator about the upcoming court hearing. However, the facility did not take the necessary steps to ensure the resident's attendance at the hearing. The Business Office Manager (BOM) was only made aware of the hearing the day before it was scheduled and attempted to arrange a virtual appearance, but it was too late. The admitting nurse failed to communicate the court hearing information to social services, which was confirmed by the social services director and the interim Director of Nursing (DON). This lack of communication among the facility staff resulted in the resident missing the court hearing and having to wait for the next scheduled date.
Failure to Provide Scheduled Baths
Penalty
Summary
The facility failed to ensure that a resident received scheduled baths, resulting in a deficiency. The resident, who had diagnoses including edema and morbid obesity, was cognitively intact and dependent on staff for bathing. According to the facility's shower schedule, the resident was supposed to receive a bath or shower three times a week on Tuesdays, Thursdays, and Saturdays. However, there was no documentation in the medical record of any completed baths. During an observation, the resident was found shirtless in bed with breadcrumbs on and around their upper body, and they reported having received only three baths since admission. A CNA confirmed that completed baths should be documented in the electronic health record (EHR), and any refusals should be noted and reported to the charge nurse. The Assistant Director of Nursing (ADON) acknowledged the lack of documentation for the resident's baths.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents. One resident, with a cognitive communication deficit, was reported to have forced another resident, who had aphasia and dementia with behavioral disturbances, into their room and started to undress them. A witness, another resident, reported the incident to a CNA, who was on transport at the time. The CNA stated that the previous social services director also heard the allegation and reported it to the DON. However, the administrator did not complete an incident report, as they believed the residents were only holding hands and fully clothed. The incident occurred when several staff members were at a convention. Further interviews revealed discrepancies in the accounts of the incident. A witness stated they saw the resident's genitals and that the resident locked themselves in the bathroom afterward. LPN #1, who was in charge at the time, stated they were informed that the resident had pulled their pants down but there was no physical contact. LPN #1 moved the resident to a private room and was instructed to gather statements from staff. The police were also involved. Despite these actions, there was no documentation of the incident in the residents' medical records, no assessments were performed, and the incident was not reported to the Oklahoma State Department of Health.
Failure to Prevent Physical Abuse of a Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent physical abuse for a resident who was severely cognitively impaired and dependent on staff for most activities of daily living (ADLs). An email correspondence to the Assistant Director of Nursing (ADON) documented that a Certified Nursing Assistant (CNA) witnessed another CNA grab the resident's groin with force and yell at the resident during care, being rough during incontinent care. The facility's investigation substantiated the allegation of abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Oklahoma State Department of Health (OSDH) for one of the four sampled residents reviewed for allegations of abuse. The facility's undated Abuse Policy and Procedure mandates that any allegation involving abuse or resulting in serious bodily injury must be reported within two hours of notification. An email from a CNA to the Assistant Director of Nursing (ADON) documented that the CNA witnessed potential abuse by another CNA towards a resident. The incident occurred at approximately 8:00 p.m., but the report was not filed with OSDH until the following morning at 9:48 a.m., exceeding the two-hour reporting requirement.
Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a manner that promotes food safety and sanitation, affecting 74 residents who received services from the kitchen. During a tour of the kitchen, several deficiencies were observed, including an accumulation of grease, black residue, and food debris on and around the griddle, as well as black grease on the back panel and floor behind the griddle. Four 5-pound rolls of hamburger meat were found sitting in dirty dishwater in the sink, and the meat packages were warm to the touch. Additionally, there was an accumulation of food debris, grease, and dead cockroaches on the floor in the cook and preparation areas. Open garbage cans without lids were observed, filled with refuse and food waste, with live cockroaches crawling around them. Numerous cockroaches, both dead and alive, were found in the dry storage area and around the refrigerators and freezers. Further observations included an open uncovered cardboard box of hamburger patties in the freezer, undated open packages of sliced cheeses, shredded cheese, and coleslaw mix in the refrigerator, and a smashed unsealed plastic jug of peanut butter and salsa leaking in the refrigerator. There was also an accumulation of food debris and liquid in the bottom of the refrigerator. The facility's Freezer and Refrigerator Temperature Chart lacked documentation of daily temperatures for a week. Staff interviews revealed that the kitchen was not cleaned due to staff shortages, and there was an ongoing cockroach problem. The Dietary Manager (DM) was unaware of the kitchen's condition due to being on sick leave and expressed embarrassment over the situation, acknowledging that the facility had not promoted food safety and proper sanitation in the kitchen.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous cockroaches in the kitchen and dry storage areas. During a tour of the kitchen, both dead and live cockroaches were observed underneath wire racks, food bins, and around refrigerators and freezers. Live cockroaches were also seen crawling around open trash cans in the meal preparation area. A staff member acknowledged the ongoing cockroach problem, noting that while it had improved somewhat, it remained an issue. Additionally, a resident reported finding a cockroach in their breakfast eggs a few months prior, and another resident observed cockroaches in the dining area on multiple occasions. The Dietary Manager was informed of the cockroach presence and confirmed it as a major concern, despite a decrease in numbers over the past few months.
Failure to Ensure Medical Appointment Completion
Penalty
Summary
The facility failed to ensure a medical appointment was completed for a resident who was scheduled for a urology surgery. The resident, who was admitted with diagnoses including cerebral infarction, urinary catheter, hemiplegia, and stage II pressure ulcers, was cognitively intact and dependent on most ADLs and mobility. The resident had a supra-pubic catheter causing chronic pain and irritation and was scheduled for a surgical procedure to evaluate the possible permanent removal of the catheter. However, the appointment was canceled by the facility due to a lack of transportation and necessary paperwork, and it was not rescheduled promptly. The facility's social services policy required assistance with appointment scheduling and arranging transportation, but due to staff turnover, there was no consistent social services staff member to manage these responsibilities. The interim DON acknowledged the failure to transport the resident and the lack of planning to ensure both residents attended their appointments. The resident expressed frustration over the missed appointment and the continued need for a urinary catheter. The facility did not reschedule the appointment until nearly a month later, after a new SSD was employed.
Failure to Maintain Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food was palatable, attractive, and served at appetizing temperatures during two observed meal services. The Food and Nutrition Services policy, revised in October 2017, required staff to inspect food trays to ensure food was palatable and served at safe temperatures. However, the Food Temperature Chart lacked documentation of steam holding temperatures for several meals, indicating a failure to monitor and record food temperatures as required. During an observation on May 20, 2024, the lunch service revealed that food items were not at the correct holding temperatures, with the meat loaf, mixed vegetables, and potatoes all below the required 135 degrees F. Staff acknowledged that the lids had been left off the food too long, causing it to cool. Residents expressed dissatisfaction with the meals, stating that the food was often cold and unappetizing. One resident mentioned that the salad was frequently wilted and rotten, while another resorted to eating cereal for most meals due to the poor quality of the food. A test tray on May 22, 2024, further confirmed the issue, with food items such as pork rib, baked beans, fried okra, and a biscuit all served at temperatures significantly below the required 135 degrees F. The Dietary Manager acknowledged the oversight and confirmed that staff should have been documenting food temperatures for each meal, as per the facility's policy.
Improper Garbage Disposal in Kitchen
Penalty
Summary
The facility failed to ensure that garbage containers in the food preparation area were covered with lids, as required by their Food-Related Garbage and Refuse Disposal policy. During a kitchen tour, surveyors observed a large plastic garbage can without a lid next to the metal food preparation table, filled with refuse including food waste from the breakfast meal. Another large plastic garbage can without a lid was found next to the refrigerator and freezer area, also filled with food waste. Three live cockroaches were seen crawling around these open garbage cans. The Dietary Manager (DM) confirmed that the garbage cans should always be covered to reduce the risk of contamination and pest infestation.
Failure to Follow Menu and Serve Planned Meal
Penalty
Summary
The facility failed to ensure that the lunch menu was followed as planned for one meal service observed. The menu for 05/20/24 was supposed to include turkey pot pie with biscuit top, oven roasted potatoes, tossed side salad with dressing, frosted cinnamon roll, and a beverage of choice. However, due to the absence of the Dietary Manager (DM) who was on sick leave, the Food Services staff decided to serve meat loaf, au gratin potatoes, mixed vegetables, cherry cheesecake, and a bread roll instead. The Food Services Manager was not informed of this substitution, and the DM later confirmed that the ingredients for the turkey pot pie were available and that no menu change had been approved. Additionally, there was a delay in serving meals as the au gratin potatoes ran out before all residents were served, necessitating the preparation of mashed potatoes for the remaining residents.
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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