Willow Park Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawton, Oklahoma.
- Location
- 7019 Northwest Cache Road, Lawton, Oklahoma 73505
- CMS Provider Number
- 375431
- Inspections on file
- 29
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at Willow Park Health Care Center during CMS and state inspections, most recent first.
A resident with severely impaired cognition, dementia, anxiety, and documented wandering was repeatedly assessed as high risk for elopement, yet the facility failed to revise and implement a comprehensive care plan to address ongoing exit-seeking and multiple elopements. The care plan initially included general diversion and structured activity interventions, but it was not updated with enhanced measures after repeated incidents in which the resident exited or attempted to exit the building, including being found in the parking lot near a busy road. Facility records show the resident was repeatedly placed on 1:1 supervision for extended periods following these events, but this intervention was never added to the care plan. A later revised care plan referenced door-pulling and following visitors out but still omitted prior elopements and the 1:1 supervision intervention. CNAs and nursing staff reported relying on the care plan and word of mouth to identify elopement risk, with some uncertainty about what to do after multiple attempts, and leadership acknowledged a system failure in documenting exit-seeking and 1:1 supervision in the care plan, leading to an Immediate Jeopardy finding.
A resident with dementia, severe cognitive impairment, and independently ambulatory status was repeatedly assessed as high risk for elopement yet experienced multiple episodes of exit seeking and elopement by following visitors, delivery drivers, and other residents through the front door. Staff often became aware of these events only after others alerted them, including one incident where the resident was found outside near a busy street and was agitated and difficult to redirect. Although one-on-one supervision was intermittently ordered, documentation of that supervision was incomplete and the intervention was not incorporated into the care plan, which contained only general wandering and cueing strategies and was not updated to reflect increased supervision needs after repeated incidents. Direct care staff reported inconsistent awareness of the resident’s elopement risk, reliance on word of mouth or the care plan, and uncertainty about how to respond to multiple elopement attempts, and leadership acknowledged system failures in documentation and care plan updates related to supervision after these events.
A resident with significant physical and cognitive impairments was transferred using a portable lift by a single CNA, contrary to facility policy requiring two staff members for such transfers. The CNA proceeded alone because the resident was in a hurry, resulting in the lift tilting and the resident being lowered to the floor without injury. Staff interviews confirmed the policy violation and that sufficient staff were available at the time.
A resident assessed to require supervision and a smoking apron was observed smoking unsupervised, leading to an incident where their beard caught fire. Despite documented needs, staff were unaware of the resident's requirements, resulting in inadequate supervision and safety measures. This deficiency led to an Immediate Jeopardy situation.
The facility failed to complete advance directive acknowledgement forms for two residents, despite having physician orders indicating full code status. The facility's policy requires inquiry about advance directives upon admission, but the forms were not completed as part of the admission process.
The facility failed to refer residents with newly diagnosed mental illnesses for a Level II PASARR evaluation. A resident was diagnosed with bipolar disorder, major depressive disorder, and schizophrenia, another with major depressive disorder and mood disorder, and a third with schizoaffective disorder and mood disorder. The MDS coordinator was unaware of the requirement to report these diagnoses, leading to the deficiency.
The facility failed to implement enhanced barrier precautions for two residents during wound care and one during Foley catheter care, and contact precautions for a resident with a MRSA infection. Observations revealed a lack of PPE use and signage, despite care plans indicating the need for such measures. The ADON was unaware of the MRSA infection and the necessary precautions, highlighting a systemic issue in staff awareness and adherence to infection prevention protocols.
A facility failed to report an allegation of neglect involving a resident with hemiplegia and impaired cognition to the State Agency. An incident report was created, but there was no proof of fax transmission to the OSDH. The OSDH confirmed no incident reports had been received since June, and an email confirmation provided by the administrator did not confirm receipt of the fax.
The facility did not complete discharge summaries for two residents as required by their policy. One resident, who was cognitively intact, was discharged home with medications and instructions, while another, who was cognitively impaired and monitored for wandering, was transferred to another LTC facility. The DON confirmed the absence of these summaries.
A resident with cognitive impairment and wandering behaviors eloped from the facility, reaching near the street before being escorted back by staff. Despite being identified as an elopement risk, there was no incident report or documentation of the event. The facility's supervision and elopement prevention measures were inadequate, as staff were unaware of the incident, and the DON did not report it, believing the resident was never out of sight.
Failure to Revise and Implement Comprehensive Elopement Care Plan for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan with measurable objectives and time frames to address a resident’s high elopement risk and repeated exit-seeking behaviors. The resident had severely impaired cognition with a BIMS score of 2 and diagnoses including dementia and anxiety. An admission assessment documented wandering behaviors and independent ambulation and transfers. Multiple Elopement Risk Assessments consistently identified the resident as high risk for elopement with scores of 10. Despite this, the care plan initiated for elopement did not show that interventions were revised or expanded after multiple elopement events and exit-seeking incidents. The resident’s care plan, initiated in early May, included interventions such as distraction with food and activities, identifying patterns of wandering, and providing structured activities like signs, memory boxes, and walking inside and outside. These interventions were later cancelled in early August, and the care plan did not reflect additional or modified interventions after an elopement on mid-July. Incident reports documented that the resident eloped or attempted to elope on multiple occasions, including exiting with visitors, attempting to exit when a visitor or delivery driver held the door, and being found walking in the parking lot near a busy street and a storage facility. Each incident report stated that the resident was redirected inside, assessed, and that the care plan was updated to reflect current status, but the care plan did not show the addition of one-on-one supervision or other enhanced interventions corresponding to these events. Facility documents titled "Resident One on One" showed that after each elopement or exit-seeking incident on multiple dates in July, August, and September, the resident was placed on one-on-one supervision for extended periods, ranging from several hours to most of a shift. However, one-on-one supervision was never added as an intervention in the resident’s care plan. A revised care plan in mid-October again focused on elopement and referenced the resident pulling on locked doors and walking out of the facility following visitors, but it only listed interventions such as distraction with pleasant diversions, observing for fatigue and weight loss, observing location in the community, and providing directional cues. It did not include prior elopements or the repeated use of one-on-one supervision as an intervention, nor did it show that interventions were revised after the multiple documented elopements and exit-seeking behaviors. Staff interviews further illustrated the deficiency in implementing and communicating a comprehensive care plan. A CNA stated that interventions for elopement risk should be found in the care plan and reported being unsure what to do when a resident had multiple elopement attempts, indicating reliance on the RN for direction. Another CNA reported identifying residents at risk for elopement by word of mouth or the care plan and mentioned an elopement book but was unsure who checked it, also noting the difficulty of monitoring exits without constant presence at the door. The ADON stated that residents with an elopement risk score of 10 or higher were considered high risk and acknowledged that the resident’s care plan was revised after an early elopement attempt, but subsequent incidents still occurred. The DON stated that the resident eloped and was found in the parking lot near a very busy street and identified a system failure related to one-on-one forms and the lack of documentation in the care plan for the resident’s exit-seeking and elopements. A resident representative reported they were never informed that the resident was placed on one-on-one supervision and that the resident was later moved to another facility with memory care because the resident was not safe due to exit-seeking behaviors. An Immediate Jeopardy situation was determined to exist related to the facility’s failure to ensure a comprehensive care plan was developed and implemented for this resident to prevent elopement. The facility’s own policy on comprehensive care plans required measurable objectives and time frames to meet resident needs identified in the assessment, with alternative interventions documented as needed. Despite repeated high-risk assessments, multiple elopements and exit-seeking incidents, and the repeated use of one-on-one supervision in practice, the resident’s care plan did not reflect these interventions or show appropriate revision after each incident. This failure to integrate actual interventions and incident history into the written care plan, and to ensure staff understood and followed it, formed the basis of the cited deficiency.
Removal Plan
- Elopement Risk Assessments were completed on 100% of residents.
- Facility completed 100% audit of residents who were identified at risk for elopement.
- Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.
- IDT received education on reviewing, revising, developing and implementing care plans from the VP of Reimbursement or designee(s).
- IDT team implemented an appropriate monitoring sheet for residents at risk for elopement.
Failure to Supervise High-Risk Resident Resulting in Multiple Elopements
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident with severe cognitive impairment and a documented high risk for elopement. The resident had dementia, anxiety, a severely impaired BIMS score of 2, and was independently ambulatory, with assessments repeatedly identifying them as high risk for elopement. Despite this, the resident experienced multiple episodes of exit seeking and elopement over several months, beginning with an incident in which the resident walked out the front door with visitors and had to be redirected back inside by staff after other residents alerted them. Subsequent nursing notes documented wandering, exit-seeking behaviors, and attempts to follow others out of the building. The facility’s documentation showed repeated incidents where the resident exited or attempted to exit the building by following visitors, delivery drivers, or other residents through the front door. On one occasion, the resident was observed outside walking toward a storage facility next door near a busy street and was described as agitated, difficult to redirect, and continuing to exit seek. Another incident documented the resident being found outside by the curb and returned to the facility by a staff member’s car after a visitor notified staff. In several of these events, staff were not initially aware the resident had left the building and only became aware after being notified by others or upon observing the resident outside. Although the facility intermittently placed the resident on one-on-one supervision following some of these incidents, the one-on-one forms were not completed with time intervals to show that the supervision was actually provided, and this increased supervision was not incorporated into the resident’s care plan. The care plan, revised later, did include a focus related to elopement and listed interventions such as distraction with activities, observing for fatigue and weight loss, observing location in the community, and providing directional cues. However, it did not show that supervision interventions were updated or increased after the resident’s repeated exit-seeking behaviors and documented elopements. Staff interviews further revealed that direct care staff were not consistently aware of the resident’s elopement risk, relied on word of mouth or the care plan to identify such residents, and expressed uncertainty about what to do when a resident had multiple elopement attempts. The DON acknowledged that the resident had eloped to the parking lot near a very busy street and identified a system failure related to incomplete one-on-one documentation and the lack of care plan updates to ensure adequate supervision after multiple elopement-related events. An Immediate Jeopardy situation was determined to exist due to this failure to ensure adequate supervision to prevent elopement for the resident. The survey findings noted that the facility’s own elopement and wandering policy required adequate supervision and care in accordance with a person-centered care plan for residents at risk of elopement. Despite multiple high-risk assessments and repeated incidents of exit seeking and elopement, the facility did not consistently implement, document, or care-plan increased supervision measures for the resident. Direct care staff reported gaps in communication and training regarding elopement risk and interventions, and the resident’s representative stated they were not informed when the resident was placed on one-on-one supervision and ultimately moved the resident to another facility with a memory care unit because the resident was not safe due to exit seeking attempts and elopements.
Removal Plan
- Elopement Risk Assessments were completed on all residents.
- Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.
- An At-Risk Elopement Book with care plan was created and posted at the nurse's station, accessible only to staff, in accordance with HIPAA requirements.
- All nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s).
- Elopement and wandering residents' policy was reviewed.
- Facility implemented a monitoring sheet for residents at risk for elopement.
- An Elopement Response Drill schedule was implemented, with drills occurring on all shifts.
- The DON or designee will perform a daily audit of clinical data to ensure adequate supervision is in place for residents with active wandering and elopement risk.
Failure to Provide Required Two-Person Assist During Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was moderately cognitively impaired and dependent on staff for activities of daily living due to multiple sclerosis, paralytic syndrome, lack of coordination, and tremors, was transferred using a portable lift by a single certified nursing assistant (CNA) instead of the required two-person assist. Facility policy, as well as standard practice reported by multiple staff members, mandated that two staff members be present when using the lift for resident transfers. Despite this, the CNA proceeded alone because the resident was in a hurry to get up for a smoke break, resulting in the lift tilting and the resident being lowered to the floor. The incident was observed on camera, and the resident did not sustain injuries. Interviews with staff confirmed that the use of the lift by one person was a violation of both policy and standard procedure, and that adequate staffing was available at the time of the incident. The CNA involved acknowledged awareness of the policy but chose not to wait for assistance. The event was documented in a progress note, and the resident later confirmed the occurrence, stating they were not injured or afraid of the lift.
Failure to Supervise Smoking Resident Leads to Immediate Jeopardy
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified at the facility due to the failure to provide adequate supervision and safety measures for a resident who required assistance while smoking. The resident, who had been assessed to need supervision and a smoking apron, was observed smoking without these precautions. This lapse in supervision led to an incident where the resident's beard caught fire, resulting in burns to the face and under the ear. The resident had multiple assessments indicating the need for supervision and the use of a smoking apron. Despite these documented requirements, staff members were unaware of the resident's need for a smoking apron and failed to provide the necessary supervision. Observations showed the resident smoking unsupervised, with cigarette ashes on their clothing, and dozing off while smoking, which posed a significant safety risk. Interviews with staff revealed a lack of awareness and understanding of the smoking safety requirements for the resident. Staff members were unsure about which residents required supervision and the use of smoking aprons, indicating a breakdown in communication and adherence to the facility's smoking policy. This deficiency in supervision and safety measures directly contributed to the incident and the subsequent identification of an IJ situation.
Failure to Complete Advance Directive Acknowledgement Forms
Penalty
Summary
The facility failed to ensure that advance directive acknowledgement forms were completed for two of the 18 sampled residents reviewed for advance directives. Resident #10 was admitted to the facility with a re-entry date and had a physician order indicating full code status, but there was no acknowledgement form for an advance directive in either the clinical or electronic record. Similarly, Resident #24, who was also admitted to the facility, had a physician order documenting full code status, yet lacked an acknowledgement form for an advance directive in both records. The facility's Advance Directives policy, dated December 2016, requires the Social Services Director or designee to inquire about the existence of any written advance directive prior to or upon admission of a resident. However, during the survey, the administrator acknowledged that the advance directive forms, which were part of the admission packet, were not being completed for these residents.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer residents with newly diagnosed mental illnesses to the OHCA for a Level II PASARR evaluation, affecting three residents. Resident #9 was admitted with no documented mental illness on the Level I PASARR screen. However, the resident was later diagnosed with bipolar disorder, major depressive disorder, and schizophrenia, but these diagnoses were not reported for a Level II evaluation. Similarly, Resident #38 was admitted without a mental illness diagnosis, but later diagnosed with major depressive disorder and mood disorder, which were not reported. Resident #60 was also admitted without a mental illness diagnosis, but was later diagnosed with schizoaffective disorder and mood disorder, which were not reported for further evaluation. The MDS coordinator was unaware of the requirement to report new mental illness diagnoses not documented on the Level I PASARR screening at admission. The coordinator reported that they had only been reporting new mental illnesses if a resident had an inpatient mental hospital stay. Upon reviewing the facility's PASARR policy, the MDS coordinator acknowledged that the new diagnoses for Residents #9, #38, and #60 should have been reported to the OHCA when they became evident. This lack of awareness and adherence to the PASARR policy led to the failure in referring these residents for necessary evaluations.
Failure to Implement Infection Control Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents during wound care and one resident during Foley catheter care. Resident #78, who had diagnoses including diabetes mellitus, lung cancer, and dementia, was observed during wound care without the use of gowns for enhanced barrier precautions. The resident's room lacked signage and PPE supplies, despite having a care plan indicating the need for enhanced barrier precautions due to skin integrity issues. Similarly, Resident #69, with diagnoses including malignant neoplasm and local infection, had no enhanced barrier precautions signage or PPE supply available during wound care. The ADON provided wound care wearing only gloves, and a CNA later donned a gown and gloves for Foley catheter care, indicating inconsistent application of precautions. The facility also failed to implement contact precautions for Resident #49, who had a diagnosis of diabetes mellitus and a MRSA infection in a toe wound. The resident was observed without a dressing on the wound, and the wound care nurse used only gloves during care, disposing of supplies improperly. The ADON was unaware of the MRSA infection and the need for contact precautions, which should have included signage, biohazard bags, and PPE outside the resident's door. The lack of awareness and implementation of necessary precautions by staff contributed to the deficiency. The facility's policies on enhanced barrier and contact precautions were not followed, as evidenced by the lack of appropriate PPE use and signage for residents requiring such measures. The ADON acknowledged the failure to implement contact precautions for Resident #49 and the need for enhanced barrier precautions for residents with Foley catheters and open wounds. The report highlights a systemic issue in ensuring staff awareness and adherence to infection prevention protocols.
Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident with hemiplegia and impaired cognition to the State Agency (OSDH). The resident was dependent on staff for activities of daily living. An incident report was created on 09/03/24, documenting notifications to the physician, family, local law enforcement, and nurse aide registry. However, there was no proof of fax transmission to the OSDH. On 10/03/24, the OSDH complaint department confirmed that no incident reports had been received from the facility since 06/18/24. The administrator later provided an email confirmation submitted to the OSDH on 09/09/24, but it did not confirm receipt of the fax transmission by OSDH.
Failure to Complete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to complete discharge summaries for two residents, which is a requirement according to their Discharging the Resident policy dated December 2016. This policy mandates that a discharge summary, including a recapitulation of the resident's stay, should be completed and communicated to the resident and receiving health care provider at the time of discharge. Resident #4, who was cognitively intact, was discharged home with medications and discharge instructions as per a physician's order, but no discharge summary was completed. Similarly, Resident #5, who was cognitively impaired with memory problems and monitored for wandering behaviors, was discharged to another long-term care facility without a completed discharge summary. The Director of Nursing confirmed that the discharge summaries for both residents could not be located but should have been completed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as an elopement risk. The resident, who had a history of hemiplegia/hemiparesis, hypertension, aphasia, dysphagia, muscle weakness, and transient ischemic attack, was documented as cognitively impaired with memory problems and was known to ambulate independently. Despite being identified as an elopement risk due to wandering behaviors, the facility did not have an incident report or documentation of an elopement incident for this resident. Staff members, including the DON and LPNs, reported being unaware of any elopement incidents, although there were reports of the resident being seen outside the facility near the street. On one occasion, an LPN received a phone call from an anonymous caller reporting that a resident was outside near the street. By the time the LPN reached the door, an unidentified staff member was already escorting the resident back inside, unharmed. The DON later stated that the resident was never out of sight and therefore did not complete an incident report. The facility had been seeking more appropriate placement for the resident due to wandering behaviors, and the resident was eventually discharged to another long-term care facility. However, the lack of documentation and reporting of the incident indicates a failure in the facility's supervision and elopement prevention measures.
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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