Wilson Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilson, Oklahoma.
- Location
- 867 Us Highway 70a, Wilson, Oklahoma 73463
- CMS Provider Number
- 375571
- Inspections on file
- 11
- Latest survey
- August 9, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Wilson Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment in an LTC facility exhibited aggressive and sexually inappropriate behaviors towards other residents, leading to multiple incidents of abuse. Despite these occurrences, the facility failed to notify state agencies, families, and physicians, and did not assess affected residents for injuries. The facility's policies on abuse reporting and prevention were not followed, contributing to ongoing risks.
Two residents in the facility experienced worsening of pressure ulcers due to the failure to obtain timely wound care orders. One resident, with a history of traumatic brain injury and diabetes, developed an unstageable pressure ulcer on the right hip, while another resident with heart disease and dementia had a blood blister on the right heel. Despite being at high risk for pressure sores, the facility did not implement appropriate wound care, and staff failed to secure necessary orders, leading to the deterioration of the residents' conditions.
The facility did not submit direct care staffing payroll data for PBJ reporting for Quarter 2. The administrator stated that the Director of Operations tried to submit the data but missed the deadline, resulting in the system being locked. The Director of Operations confirmed that the data was collected but not submitted as the system was closed.
The facility failed to report multiple incidents of abuse and neglect involving residents to state agencies, as required by policy. A resident with dementia and explosive disorder was involved in several unreported incidents of physical and sexual aggression towards other residents. Additionally, a fall resulting in a major injury was not reported. The facility did not notify families of the incidents, and no new interventions were implemented to address ongoing aggressive behaviors.
A facility failed to investigate and report multiple incidents of resident-to-resident abuse and sexual abuse involving a resident with dementia and explosive disorder. Despite documented aggressive and inappropriate behaviors, no incident reports were filed, and state agencies were not notified. The facility's policy on reporting abuse was not followed, as confirmed by interviews with the DON and Administrator.
The facility failed to properly label and store food items according to policy. During a survey, it was observed that food items in the refrigerator were undated and unlabeled, contrary to the facility's Safe Food Handling policy. A Dietary Aide confirmed that items like bacon, hashbrowns, and steak fingers were stored without labels or dates, despite the requirement for proper labeling to prevent cross-contamination.
A facility failed to implement enhanced barrier precautions for a resident with a suprapubic catheter, resulting in a deficiency in infection prevention and control. The resident, diagnosed with dementia and acute kidney disease, was observed without proper signage or PPE for EBP. The IPC nurse admitted to not using gowns and only recently learning about EBP precautions, which were not implemented during care.
The facility failed to document accurate code status and advance directives for two residents. One resident's electronic health record lacked a code status, and their hard chart did not have a signed DNR, despite a sticker indicating DNR. Another resident, with dementia, had no documented advance directives, and their representative did not provide a living will or DNR order upon admission. This resulted in a lack of directives for medical emergencies.
A facility failed to document the assessment and death record for a resident with Congestive Heart Failure. The DON reported the absence of these records, which was confirmed during a review and interview process. This issue affected one of the 28 residents in the facility.
A facility failed to update a resident's care plan to reflect hospice services, despite the resident having been admitted to hospice care. The resident had diagnoses including heart disease, type two diabetes mellitus, and acute kidney failure. An LPN confirmed the absence of hospice documentation in the care plan during a review.
An LPN failed to verify physician orders before administering medications to two residents. One resident with chronic conditions received a Ventolin inhaler, and another with diabetes and dementia received Tresiba insulin without order verification. The LPN admitted to not checking the orders, citing routine practice and lack of updates during shift change.
The facility failed to obtain laboratory tests as ordered for two residents. One resident with diabetes and dementia had a missing C-Peptide result despite an order, while another resident with multiple conditions had no follow-up on a lab order that was not collected. Staff confirmed the absence of results in both cases.
A facility failed to document and educate a resident with high blood pressure and depression about influenza and pneumococcal vaccinations. The resident's records lacked documentation of consent or refusal for immunizations, and the IPC nurse confirmed the absence of such documentation. Additionally, the resident's representative was not educated about the immunizations, a task usually performed by Social Services upon admission.
A facility failed to screen, offer, and educate a resident on the COVID-19 vaccination, as required by their policy. There was no documentation of the resident receiving the vaccine or any record of consent or refusal. The IPC nurse confirmed the lack of documentation and stated that education on immunizations was not provided to the resident's representative, which was usually done by Social Services upon admission.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving a resident with severe cognitive impairment who exhibited aggressive and sexually inappropriate behaviors towards other residents. This resident, diagnosed with dementia, Alzheimer's disease, and intermittent explosive disorder, was involved in multiple incidents of physical and sexual abuse against other residents, all of whom had moderate to severe cognitive impairments. The incidents included hitting and inappropriate sexual touching, which were documented in progress notes and assessments. Despite the repeated occurrences of abuse, there was a lack of documentation indicating that all necessary parties, including state agencies, families, and physicians, were notified of these incidents. Additionally, there was no evidence that the affected residents were assessed for injuries following the altercations. The facility's failure to report these incidents and assess the residents for injuries highlights a significant deficiency in their abuse prevention and reporting protocols. The facility's policies on abuse, which mandate thorough investigation and documentation of suspected abuse, were not adhered to. The DON and Administrator acknowledged that the incidents were not reported as required, and the behaviors of the aggressive resident were not discussed in the facility's QA meetings. This oversight contributed to the ongoing risk of harm to residents, as the aggressive behaviors were not adequately addressed or mitigated.
Removal Plan
- Immediate action to protect residents at risk from abuse from Resident #3.
- Agreement between the facility and a hospital to take Resident #3 for evaluation and treatment to remove any threat of harm.
- Resident #3 taken to the hospital by a family member.
- Staff responsible for reporting and documenting suspected abuse will receive additional training.
- Care Plan for Resident #3 will be updated to reflect behavioral issues and necessary interventions.
- Facility policy regarding abuse reviewed by members of the IDT.
- Additional training regarding abuse, prevention, reporting, and chain of command will be completed with all staff.
- Nurses will receive training specific to their duties and responsibilities.
- If Resident #3 returns to the facility, a staff member will be assigned by the Charge Nurse to conduct one-on-one monitoring of the resident to ensure they are prevented from harming or abusing other residents until final discharge.
- Policy review and staff training regarding abuse and facility policies and procedures will be completed.
Failure to Provide Timely Wound Care Orders
Penalty
Summary
The facility failed to ensure timely wound care orders for two residents, leading to the worsening of their conditions. Resident #10, who had a history of traumatic brain injury, type two diabetes mellitus, dementia, and muscle weakness, developed an unstageable pressure ulcer on the right hip. Despite being at risk for pressure sores, as indicated by a Braden Scale assessment, the facility did not obtain or implement appropriate wound care orders in a timely manner. The resident's condition was documented to have worsened over time, with multiple notes indicating the presence of pressure sores and the lack of effective treatment. Resident #17, diagnosed with heart disease, dementia, and chronic kidney disease, was also affected by the facility's failure to provide adequate wound care. The resident was identified as high risk for pressure sores, yet there was no documentation of a skin assessment or wound care from mid-July until the end of the month. The resident's right heel developed a blood blister, and despite the presence of dressings provided by hospice, there were no physician orders or documentation of treatment being administered. The facility's staff, including LPNs and the DON, were aware of the residents' conditions but failed to take appropriate action to secure necessary wound care orders. Communication issues with hospice and a lack of proactive measures to obtain orders from the facility's medical director contributed to the deficiency. The facility's inaction resulted in the worsening of the residents' wounds, as evidenced by the observations and interviews conducted during the survey.
Removal Plan
- Immediate action was taken to protect residents at risk of serious injury, harm, impairment or death.
- Orders were obtained for the appropriate wound care.
- All nursing staff, including hospice personnel, were notified of the deficient practice and educated on the importance of timely, and effective communication.
- Nursing Center staff was educated on obtaining orders from facility Medical Director in the event of not being able to obtain orders from a hospice medical director.
- Baseline skin assessment completed and documented on all residents residing in the facility.
- Facility policy regarding wound care was reviewed by members of the IDT.
- Nursing Center will perform weekly skin assessments on all residents and document in skin assessments as well as in narrative format.
- Any resident with a known wound will have photo documentation under the miscellaneous tab in the EHR.
- Additional training regarding skin integrity, wound prevention, reporting, and chain of command will be completed with ALL staff by the in-service training.
- The Director of Nurses will perform chart audits and QA all orders and notes on every patient.
- The Director of Nurses will delegate chart audits to a registered nurse to assist in accurate and timely documentation.
- Residents having an area of concern or wound will be assessed and documented.
- Resident care plans will be updated to reflect the area of concern with skin integrity.
- Results of the audits will be reviewed by the QA Committee.
- Orders were received upon notification of the deficient practice.
- Nursing Center will educate and in-service all ancillary staff, to include hospice providers on orders being received and in place.
- Policy review and staff training regarding wound care and facility policies and procedures will be completed.
Failure to Submit PBJ Staffing Data for Quarter 2
Penalty
Summary
The facility failed to submit direct care staffing payroll data for the PBJ report for the period from January 1, 2024, to March 31, 2024, which corresponds to Quarter 2. This deficiency was identified through record review and interviews. The PBJ Staffing Data Report indicated that the data for this quarter was not submitted. During an interview on August 2, 2024, the administrator explained that the Director of Operations attempted to report the data but was unable to do so because the system was locked, and they had missed the submission deadline. On August 5, 2024, the Director of Operations confirmed that although the data was collected, the submission was not completed as the system was closed.
Failure to Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report several incidents of abuse, neglect, and theft to the appropriate state agencies, as required by their policy. Specifically, the facility did not file incident reports for allegations of physical abuse involving four residents, allegations of sexual abuse involving four residents, and a fall resulting in a major injury for one resident. The facility's policy, dated September 2005, mandates that suspected or substantiated cases of resident abuse be thoroughly investigated, documented, and reported to state agencies. However, this protocol was not followed in multiple instances. Resident #3, who has diagnoses including dementia, Alzheimer's disease, and intermittent explosive disorder, was involved in several incidents of physical and sexual aggression towards other residents. Despite documented aggressive behaviors and altercations with other residents, such as hitting and inappropriate touching, there was no evidence that these incidents were reported to state agencies. Additionally, Resident #3's care plan and behavior logs indicated ongoing aggressive and sexually inappropriate behaviors, yet no new interventions were implemented after July 8, 2024, to address these issues. The facility also failed to notify the families of the residents involved in these incidents. For example, the family of Resident #30 was not informed about the inappropriate interactions with Resident #3. Furthermore, the facility did not report a fall incident involving Resident #3 that resulted in a fractured pelvis. The Director of Nursing (DON) and the Administrator acknowledged that these incidents should have been reported, but there was no documentation to confirm that state reports were filed. The lack of reporting and documentation highlights a significant deficiency in the facility's adherence to its abuse reporting policy.
Failure to Investigate and Report Resident Abuse
Penalty
Summary
The facility failed to investigate allegations of resident-to-resident abuse and sexual abuse involving multiple residents. Resident #3, who had diagnoses including dementia, Alzheimer's disease, and intermittent explosive disorder, was involved in several incidents of physical aggression towards other residents, such as hitting and cursing. Despite these documented incidents, there was no evidence that incident reports were filed or that state agencies were notified. Additionally, the care plan for Resident #3 did not include new interventions to address these behaviors. Resident #3 was also involved in several incidents of sexually inappropriate behavior towards other residents, including touching and rubbing inappropriately. These behaviors were documented in behavior notes, but there was no indication that the facility took appropriate action to report these incidents to state agencies or notify the families of the affected residents. The facility's policy on reporting abuse, neglect, or mistreatment was not followed, as the incidents were not thoroughly investigated or documented. Interviews with the Director of Nursing (DON) and the Administrator revealed that the incidents were not reported as required by the facility's abuse policy. The DON acknowledged that the incidents should have been reported, and the Administrator confirmed that resident-to-resident abuse and sexual abuse should be reported, especially when the residents involved are unable to consent. The lack of documentation and reporting of these incidents indicates a failure to adhere to the facility's policies and procedures for handling allegations of abuse.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to ensure that food items were properly labeled and stored according to their policy, as observed and reported during a survey. The facility's Safe Food Handling policy from the WNC Dietary Department, although undated, specifies that all food items must be labeled correctly to prevent cross-contamination and ensure proper identification. Labels should include the product name, preparation or expiration date, storage instructions, and any allergen information. However, during an observation on July 28, 2024, at 9:06 a.m., it was noted that there were undated and unlabeled food items in the refrigerator. At 9:07 a.m., a Dietary Aide reported that bacon, hashbrowns, and steak fingers were stored in the refrigerator without labels or dates. The Dietary Aide confirmed that the food is supposed to be stored with proper labeling and dating.
Failure to Implement Enhanced Barrier Precautions for Catheter Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a suprapubic catheter, leading to a deficiency in infection prevention and control. The resident had diagnoses including dementia, bladder neck obstruction, and acute kidney disease, with physician orders for catheter care and irrigation. During an observation, the resident was found in bed with a catheter bag hanging on the edge, but no signage for EBP precautions or personal protective equipment (PPE) was present near the resident's door. The Infection Prevention and Control (IPC) nurse admitted to not using gowns and only recently learning about EBP precautions, indicating that these precautions were not implemented during wound and catheter care. The nurse provided a CMS memo regarding EBP precautions, which they had reviewed.
Deficiency in Documenting Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that the clinical health records accurately reflected the code status and advance directives for two residents. Resident #27, who had diagnoses including atrial fibrillation and pain, did not have a documented code status in their electronic health record, and their hard chart lacked a signed Do Not Resuscitate (DNR) order. Despite a white sticker on the spine of the chart indicating DNR, there was no formal documentation to support this status. When questioned, the Infection Prevention and Control (IPC) nurse was uncertain of the resident's code status, and the Social Services Director (SSD) confirmed the absence of a DNR in the hard chart. Resident #27 themselves stated they were a DNR, highlighting the discrepancy between the resident's understanding and the facility's documentation. Resident #30, diagnosed with dementia, also lacked proper documentation of advance directives. The facility's records indicated that the review of Resident #30's advance directives was postponed, with no follow-up action documented. The SSD reported that at the time of admission, Resident #30's representative did not provide a living will or DNR order. Consequently, the facility had no directives to follow in the event of a medical emergency for Resident #30, as confirmed by the SSD. This lack of documentation and follow-up on advance directives for both residents demonstrates a failure to adhere to the facility's policy and procedure regarding residents' rights to formulate advance directives.
Failure to Document Resident Assessment and Death Record
Penalty
Summary
The facility failed to ensure the coordination of resident assessment and death record for a resident diagnosed with Congestive Heart Failure. On the morning of August 1st, there was no documentation available for the resident's death record or assessment. The Director of Nursing (DON) had previously reported the absence of these records on July 31st. This deficiency was identified during a review of records and interviews, affecting one of the 28 residents residing in the facility.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to update the care plan for a resident to reflect that hospice services were in place. This deficiency was identified during a record review and interview process. The resident in question had diagnoses including heart disease, type two diabetes mellitus, and acute kidney failure. A hospice progress report documented that the resident was admitted to hospice services on January 3, 2024. However, the resident's care plan did not document that they were receiving hospice services. On August 5, 2024, an LPN was asked if the care plan documented the resident's hospice services, and upon review, the LPN stated that they did not see such documentation.
Failure to Verify Physician Orders Before Medication Administration
Penalty
Summary
The facility failed to ensure that staff reviewed physician orders prior to administering medications for two residents. Resident #22, who had diagnoses including chronic obstructive pulmonary disease and chronic kidney disease, was observed receiving a Ventolin inhaler without the LPN checking the physician's order beforehand. The physician's order, dated June 4, 2023, specified the administration of the Ventolin inhaler two puffs by mouth twice daily. However, during the medication observation on August 1, 2024, the LPN did not verify the order before administering the medication. Similarly, Resident #14, diagnosed with type two diabetes mellitus and dementia, was administered Tresiba insulin without the LPN checking the physician's order. The physician's order, dated May 18, 2024, required the administration of ten units of Tresiba insulin subcutaneously once a day. On the same day of observation, the LPN administered the insulin without verifying the order. When questioned, the LPN admitted to not checking the orders for both residents, stating they were accustomed to their routine and had not received any updates during the shift change.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were conducted as ordered by the physician for two residents. Resident #3, who had diagnoses including type two diabetes mellitus and dementia, had a physician order to obtain a HGB A1c and a C-Peptide lab on July 1st. However, the order was not noted by a nurse, and although the HGB A1c was obtained and resulted at 9.3, there was no documentation of the C-Peptide results. Despite inquiries, the facility did not provide any further documentation for the C-Peptide lab results. Resident #20, diagnosed with generalized edema, high blood pressure, and type two diabetes mellitus, had a physician order to obtain a CBC, CMP, CNP, CRP, and sed rate. The treatment administration record indicated a 9 on the date the labs were ordered, but a progress note later documented that the lab was unable to be collected and would be redrawn at a later date. However, there was no follow-up, and the clinical health record did not contain documentation that the lab had been obtained. Staff members confirmed they had not seen any lab results for the physician order.
Failure to Document and Educate on Vaccinations
Penalty
Summary
The facility failed to ensure that residents were screened, offered, and educated about the risks and benefits of influenza and pneumococcal vaccinations. Specifically, one resident, who had diagnoses including high blood pressure and depression, was not documented as having received any immunizations. There was no documentation in the electronic health record or the hard chart indicating that the resident or their representative had consented to or refused the immunizations. The Infection Prevention and Control (IPC) nurse confirmed the absence of a consent or refusal form and stated that such documentation should be present in either the computer or the hard chart. Additionally, the IPC nurse acknowledged that the resident's representative had not been educated about the immunizations, which is typically done by Social Services (SS) upon the resident's admission.
Failure to Document and Educate on COVID-19 Vaccination
Penalty
Summary
The facility failed to screen, offer, and educate a resident on the risks and benefits of the COVID-19 vaccination. The facility's policy and procedure for immunizations, which was undated, required following CDC and local health department guidelines and providing educational materials about the benefits and potential side effects of the vaccines. However, for one resident, there was no documentation in the electronic health record or hard chart indicating that the resident had received any immunizations, nor was there any record of consent or refusal for the COVID-19 vaccine. The Infection Prevention and Control (IPC) nurse confirmed the absence of documentation for consent or refusal and stated that it should have been recorded either in the computer or the hard chart. Additionally, the IPC nurse admitted that the resident's representative had not been educated about the immunizations, which was typically done by Social Services (SS) upon the resident's admission. This oversight affected one of the five sampled residents reviewed for immunizations, out of a total of 28 residents in the facility.
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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