Windsor Hills Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 2416 North Ann Arbor, Oklahoma City, Oklahoma 73127
- CMS Provider Number
- 375400
- Inspections on file
- 25
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Windsor Hills Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dependent on staff for care was found in bed while another cognitively impaired resident was observed making inappropriate sexual contact. The incident was discovered and stopped by staff, but the facility failed to prevent the occurrence of this non-consensual contact, despite policies prohibiting abuse.
A resident with COPD and continuous oxygen use was not properly identified or care planned for vaping or smoking behaviors. Staff were aware the resident vaped in their room and charged the devices, but the care plan did not address vaping. The resident lit a cigarette while on oxygen, resulting in facial burns. Facility records and staff interviews showed a lack of supervision and monitoring for safe smoking and vaping.
A resident who used vaping devices and chewing tobacco did not have their care plan updated to address vaping, despite staff and the DON being aware of the behavior and facility policy requiring documentation of safe smoking measures. The care plan only referenced tobacco use, omitting interventions for vaping, even though the resident was dependent on staff for daily living and used oxygen for COPD.
A resident with an indwelling urinary catheter did not receive timely catheter changes as ordered by a physician, leading to a deficiency in care. The resident, who had acute kidney failure and urine retention, experienced symptoms of a UTI and was placed on antibiotics. Despite this, the catheter was not changed due to supply issues and the resident's refusal, which was not communicated to the physician or DON. The resident was later diagnosed with a bladder stone after hospital transfer.
A resident with communication needs was unable to express pain levels due to the unavailability of picture exchange tools as outlined in their care plan. The ADON noted the resident pointed instead of using an iPad, and the Administrator recognized the need for a consistent communication method for staff.
The facility failed to complete advance directive acknowledgment forms for two residents. One resident admitted in April and another in May did not have the necessary forms in their electronic health records or admission packets. Social services confirmed the absence of these documents, indicating a failure to document the residents' or their representatives' decisions regarding advance directives.
A resident with Congestive Heart Failure was prescribed Buspirone HCL, an anti-anxiety medication, without a documented diagnosis or reason for its use. The medication order and subsequent care plan reviews lacked an anxiety diagnosis, which was confirmed by the ADON and Regional Director of Clinical Systems.
The facility failed to create and implement accurate care plans for three residents, resulting in unmet needs. One resident with vascular dementia lacked a care plan for their condition, another with an ileostomy had no care plan, and a third resident's care plan inaccurately documented their need for assistance. Staff interviews indicated that care plans were not reviewed or updated appropriately.
The facility failed to post and follow accurate menus for three meal services, as required by policy. Meals served did not match the menu guide, and alternatives and weekly menus were not posted. Supply issues and lack of resident preference consideration contributed to the discrepancies. The dietary manager and staff acknowledged these issues, with the administrator confirming the requirement for residents to access menus a week in advance.
The facility failed to maintain appropriate food temperatures and sanitary conditions during meal preparation and service. Observations revealed that food was not kept at the required temperature, with pureed sausage at 113.2°F and a test tray showing eggs at 110°F, sausage patty at 98°F, and hash brown at 94°F. Additionally, a cook used the same gloves to handle different items without changing them, and the prep table was not cleaned as required.
The facility failed to secure the medication room when not in use, as observed when the door was propped open with no staff present. The room was across from the dining room with mobile residents nearby, including one in a wheelchair. An LPN confirmed the policy to keep the door closed and locked, attributing the oversight to staff who forgot to close it. The facility's policy requires all drugs to be stored in locked compartments.
The facility did not ensure proper disinfection of glucometers before and after use on residents. An LPN was observed using a glucometer without cleaning it, despite acknowledging the policy to do so. The administrator and a corporate nurse confirmed the requirement for proper cleansing.
A resident with a history of anxiety and psychotic disorder exhibited frequent behaviors such as yelling for help, which were not accurately documented in their Resident Assessment. Despite multiple progress notes indicating observed behaviors, the quarterly assessment inaccurately reported no behaviors. Staff interviews confirmed the inaccuracy, highlighting a failure to adhere to the facility's policy of accurate MDS coding.
A resident with severe intellectual disabilities and dysphagia experienced significant weight loss due to the facility's failure to implement physician-ordered dietary interventions in a timely manner. Despite recommendations and orders for health shakes and weekly weights, these were not provided or documented as required, leading to continued weight decline.
A facility failed to arrange a physician-ordered psychiatric evaluation for a resident with depression. Despite procedures requiring social services to coordinate such services, the order was not fulfilled. Interviews revealed that the nurse would notify the physician and DON, who would then involve social services to arrange the appointment. However, the facility did not ensure the evaluation and treatment were provided.
A facility failed to administer and ensure the availability of medications for a resident with chronic pain syndrome. The resident's lidocaine patch and gabapentin were not administered on several days, despite physician orders. Staff interviews revealed lapses in medication ordering and administration processes, with the DON confirming the medications were not given as required.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. An incident occurred in which one resident, who had severe cognitive impairment and required extensive assistance with daily activities, was found in bed while another resident, also with severe cognitive impairment and a diagnosis of dementia, was observed with their hand underneath the first resident's gown, making a fondling motion. The resident being touched was unable to respond appropriately to the situation or to questions, and the staff member who discovered the incident reported that the resident being touched was unaware of their circumstances or surroundings. Prior to the incident, there were no documented behavioral issues or similar incidents involving the resident who committed the inappropriate touching. Staff interviews indicated that this resident had previously entered another resident's room to use the bathroom but had not exhibited sexually inappropriate behavior before. The staff member who discovered the incident was alerted by a housekeeper and intervened immediately. The resident who was touched had a history of metabolic encephalopathy, severe memory and thinking problems, and was dependent on staff for all personal care needs. The facility's policy prohibits and aims to prevent all forms of abuse, including sexual abuse, and requires the protection of residents' health, welfare, and rights. Despite these policies, the incident occurred, and the resident was subjected to unwanted sexual contact. The event was witnessed and stopped by staff, but the deficiency lies in the facility's failure to prevent the occurrence of this inappropriate and non-consensual contact between residents.
Failure to Supervise and Monitor Safe Smoking and Vaping Practices
Penalty
Summary
A deficiency occurred when the facility failed to implement a system to ensure residents were properly supervised and monitored for safe smoking and the use of electronic vaping devices. One resident, who was a known user of vaping devices and required continuous oxygen therapy due to COPD and other medical conditions, was not identified on the facility's smoking or vaping user list. The resident's care plan did not address the use of vaping devices, nor did it provide interventions or supervision related to vaping or smoking in the resident's room. Staff were aware that the resident vaped in their room and charged the devices for them, but there was no documentation or care plan intervention addressing this behavior. The resident was observed with multiple vaping devices and chewing tobacco in their room, along with an oxygen concentrator. Despite the facility's policy prohibiting smoking and vaping in non-designated areas and specifically warning against the use of such devices around flammable gases like oxygen, the resident continued to vape in their room. Staff interviews confirmed that the resident was known to vape in their room while on oxygen, and that staff routinely charged the vaping devices for the resident. The resident was not listed as a smoker or vape user on the facility's records, and their care plan only addressed tobacco chewing, not vaping or smoking. The deficiency resulted in a serious incident where the resident, while using oxygen in their room, lit a cigarette, causing a flash burn to their face and nose. The incident report and hospital records confirmed partial thickness burns to the resident's face, requiring emergency evaluation and treatment. Staff and administrative interviews revealed a lack of awareness and oversight regarding the resident's vaping and smoking behaviors, as well as a failure to update care plans and assessments to reflect the resident's actual practices.
Failure to Update Care Plan for Resident's Vaping and Tobacco Use
Penalty
Summary
The facility failed to ensure that care plans were developed and revised to address the use of electronic vaping devices for a resident who used both vaping devices and chewing tobacco. Despite the facility's policy requiring a safe smoking assessment and documentation of all safe smoking measures, the resident's care plan did not include interventions or assessments related to vaping. Observations revealed multiple vaping devices in the resident's room, along with an oxygen concentrator, and staff interviews confirmed that the resident regularly vaped in their room and staff assisted with charging the devices. The care plan only addressed tobacco use and did not mention vaping, even though the resident's smoking assessment indicated vape use. The resident was dependent on staff for all activities of daily living, required oxygen for COPD, and was cognitively intact. Staff and the resident reported that the resident removed their oxygen when vaping, but this practice and the use of vaping devices were not reflected in the care plan. The Director of Nursing confirmed that the care plan did not address the resident's vape use, despite facility policy and staff awareness of the resident's behaviors.
Failure to Follow Catheter Change Orders and Prevent UTI
Penalty
Summary
The facility failed to follow a physician's order for monthly catheter changes for a resident with an indwelling urinary catheter, leading to a deficiency in care. The resident, who was cognitively intact and had diagnoses including acute kidney failure and urine retention, had a physician's order to change the catheter monthly. However, the catheter was not changed as scheduled due to the unavailability of the correct catheter size, and there was no documentation that the physician or Director of Nursing (DON) was notified of this issue. The order was removed from the medication administration record after three days without being fulfilled. The resident experienced symptoms of a urinary tract infection (UTI), including cloudy urine with a foul odor and sediment, and was placed on antibiotics. Despite these symptoms, the catheter was not changed, and the resident refused to allow nurses to change it, insisting on a urologist for the procedure. The refusal was not communicated to the physician or DON, and the catheter remained unchanged for an extended period. Eventually, the resident was diagnosed with a bladder stone after being transferred to the hospital. Throughout the period, the resident continued to refuse catheter changes by facility staff, preferring to wait for a urologist. The facility's protocol for notifying the DON or administrator about supply shortages was not followed, and the resident was not adequately educated on the consequences of not changing the catheter. The facility's failure to ensure timely catheter changes and proper communication with medical staff contributed to the deficiency in care.
Failure to Provide Effective Communication Tools for Resident
Penalty
Summary
The facility failed to provide effective communication tools for a resident who required picture exchange communication to express their needs and perform activities of daily living. The resident, diagnosed with atrial fibrillation, high blood pressure, and chronic pain, had a care plan indicating the use of pictures to communicate. However, during an observation, it was noted that the resident could not effectively communicate their pain location or level because the necessary communication pictures were unavailable. The Assistant Director of Nursing (ADON) reported that the resident did not use an iPad for communication and instead pointed, highlighting a gap in the communication strategy outlined in the care plan. The Administrator acknowledged the need for a consistent communication method for all staff to interact with the resident effectively.
Failure to Complete Advance Directive Acknowledgment Forms
Penalty
Summary
The facility failed to ensure that advance directive acknowledgment forms were completed for two of the three sampled residents reviewed for advance directives. Resident #7, who was admitted on April 11, 2023, did not have an advance directive form in their electronic health record or admission packet, indicating the decision by the resident or their representative. Similarly, Resident #23, admitted on May 6, 2023, also lacked an advance directive form in their electronic health record or admission packet. On September 24, 2024, social services confirmed that there were no advance directives found in the admission packets or electronic health records for these residents, reflecting a failure to document the residents' or their representatives' decisions regarding advance directives.
Lack of Diagnosis for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident receiving an antipsychotic medication had an appropriate diagnosis for its use. Specifically, a resident with a diagnosis of Congestive Heart Failure was prescribed Buspirone HCL, an anti-anxiety medication, without a documented diagnosis or reason for its administration. The medication order, dated from June, lacked an associated diagnosis, and subsequent reviews of the resident's care plan, gradual dose reduction plan, and nursing level of care assessment also did not document an anxiety diagnosis. This oversight was confirmed by the Assistant Director of Nursing and the Regional Director of Clinical Systems, who acknowledged the absence of a necessary diagnosis for the medication's administration.
Deficient Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement accurate comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident, admitted with a diagnosis of vascular dementia with behavioral disturbances, did not have a care plan to address these needs. Another resident, who had an ileostomy, also lacked a care plan to manage their condition. A third resident, who was dependent on staff for incontinent care, had a care plan that inaccurately documented their needs, stating they required assistance with toileting and transferring on/off the toilet, despite being unable to perform these tasks. Interviews with staff revealed that the care plans were not reviewed or updated as necessary, contributing to the oversight in care planning.
Failure to Post and Follow Accurate Menus
Penalty
Summary
The facility failed to ensure that accurate menus were posted and followed for three observed meal services. The facility's policy required menus to be posted at least one week in advance and followed as posted, with any deviations notified as soon as practicable. However, during observations, the meals served did not match the menu guide report. For instance, on one occasion, breakfast served included oatmeal, scrambled eggs, sausage patties, bacon, and toast, while the menu guide indicated a ham egg cheese skillet. Similarly, for lunch, mashed potatoes were served instead of the wild rice listed on the menu guide. The dietary manager admitted to changing the menu due to recent repetition of rice and supply issues. The facility also failed to post alternative meal options and the weekly menu, as required. Cook #1 mentioned that they did not receive supplies to make blueberry pancakes, leading to a substitution without proper notification. The dietary manager acknowledged frequent supply issues and the need to update menus to reflect resident preferences and available supplies. Additionally, a CNA reported that residents were not asked for their breakfast preferences and received what the kitchen provided, with changes made only if residents expressed dissatisfaction. The administrator confirmed that residents should have access to the menu a week in advance.
Failure to Maintain Food Temperature and Sanitary Conditions
Penalty
Summary
The facility failed to maintain appropriate food temperatures and sanitary conditions during meal preparation and service. During observations, it was noted that the food intended for residents was not kept at the required temperature of 135 degrees Fahrenheit or greater. Specifically, pureed sausage was recorded at 113.2 degrees Fahrenheit, and a test tray showed eggs at 110 degrees, sausage patty at 98 degrees, and hash brown at 94 degrees. The facility lacked a steam table, which contributed to the inability to maintain proper food temperatures. Additionally, the facility did not adhere to its policy on maintaining a sanitary tray line. A cook was observed using the same gloves to handle different items, including touching menu cards and food, without changing gloves as required. The prep table was not cleaned as per the facility's policy, and the staff did not consistently monitor food temperatures throughout meal service. The administrator acknowledged that staff are supposed to check food temperatures and change gloves between tasks to prevent foodborne illness.
Medication Room Security Breach
Penalty
Summary
The facility failed to ensure the medication room was secured when not in use, as observed on 09/23/24 at 10:45 a.m. The medication room door was found propped wide open with a trash can, and there were no staff present or in sight. This room was located directly across from the dining room, where multiple mobile residents were present, including one resident in a wheelchair who was within four feet of the open door. LPN #1 acknowledged that the policy is to keep the door closed and locked, attributing the oversight to staff who had just loaded their cart and forgot to close the door. On 09/27/24, during an interview with the administrator and corporate nurse #2, it was confirmed that the policy was to keep medications locked and secured. The facility's Medication Storage policy, dated 01/08/24, mandates that all drugs and biologicals be stored in locked compartments under proper temperature controls.
Failure to Disinfect Glucometers
Penalty
Summary
The facility failed to ensure that glucometers were disinfected appropriately before and after use on residents. The Glucometer Disinfection policy, which was undated, stated that blood glucometers should be cleaned and disinfected after each use and according to the manufacturer's instructions for multi-resident use. On September 25, 2024, at 10:24 a.m., an LPN was observed using a glucometer on a resident without disinfecting it before or after use, despite sanitizing their hands and wearing gloves. The LPN acknowledged that the policy was to clean the glucometer before and after use but admitted to not doing so. On September 27, 2024, at 9:38 a.m., the administrator and a corporate nurse confirmed that the policy required proper cleansing of the glucometer before and after use. The facility housed 58 residents at the time of the observation.
Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to ensure accurate coding of Resident Assessments for a resident with a history of generalized anxiety, psychotic disorder with delusions, and sclerosis of the central nervous system. The resident's care plan, initiated in 2019, documented behavior problems related to dementia and psychological causes, including continuously screaming out. However, a quarterly Resident Assessment and Care Screening inaccurately documented that the resident had no behaviors in the previous seven days, despite multiple progress notes indicating observed behaviors during that period. Observations during the survey confirmed that the resident frequently yelled for help, even after staff had just left their room. Interviews with staff, including a corporate nurse, acknowledged the inaccuracy of the Minimum Data Set (MDS) regarding the resident's behaviors. The facility's policy requires that MDS assessments be accurately coded, but this was not adhered to in the case of this resident, leading to the identified deficiency.
Failure to Implement Physician-Ordered Dietary Interventions
Penalty
Summary
The facility failed to provide dietary interventions as ordered by the physician for a resident with severe intellectual disabilities, cerebral palsy, and dysphagia. The resident experienced a significant weight loss, dropping from 176.8 lbs to 164.0 lbs over one month. Despite the dietician's recommendation for health shakes twice a day to prevent further weight loss, the physician's order for weekly weights and health shakes was not implemented in a timely manner. The resident's weight continued to decline, reaching 156.2 lbs by August. The deficiency was further compounded by the lack of documentation indicating that weekly weights were conducted as ordered in June. The health shakes, initially ordered by the physician in early June, were not provided to the resident until August, two months later. Interviews with facility staff revealed that the responsibility for entering physician orders into the computer system was not executed promptly, leading to a delay in the resident receiving the necessary dietary supplements.
Failure to Arrange Psychiatric Evaluation for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered psychiatric evaluation was arranged for a resident diagnosed with depression. The physician had ordered a psychiatric evaluation and treatment as indicated on 06/11/24, but there was no documentation that this order had been acted upon. The facility's policy required the social services designee to pursue the provision of medically-related services, including making referrals and obtaining needed services from outside entities. However, the social services department was unavailable for an interview, and it was found that the order for the psychiatric evaluation had not been fulfilled. Interviews with facility staff revealed that when a resident's family requested an appointment for psychological services, the nurse would notify the physician and the DON. The physician would then sign the resident up for services, and the nurse would print out the order and give it to social services. The DON confirmed that the facility had a company that provided these services once a month, and social services would have been responsible for coordinating with the company to complete the order. Despite these procedures, the facility did not arrange for the resident to receive the necessary psychiatric evaluation and treatment.
Medication Administration and Availability Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered as ordered and available for a resident with chronic pain syndrome. The resident had a physician's order for a lidocaine patch to be applied daily and gabapentin to be taken orally once a day. However, the facility's records showed that the lidocaine patch was not administered on several days in May, and the gabapentin was not given on multiple days in June. The facility's Medication Administration policy requires medications to be administered as ordered by the physician, but this was not adhered to in the case of this resident. Interviews with staff revealed that there was a schedule for administering medications, and everyone was responsible for ensuring medications were ordered. However, there were lapses in the process, as indicated by the blanks in the administration records. The LPN and DON acknowledged that the medications were on order but not available in the facility, and there was no explanation for the missing administrations. The DON confirmed that the medications were not given on the specified dates, indicating a failure in the facility's medication management system.
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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