Citations in Oklahoma
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Oklahoma.
Statistics for Oklahoma (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Oklahoma
A resident with moderate cognitive impairment was transferred to the hospital for increased confusion, hallucinations, and respiratory changes after receiving one-half of a Xanax tablet from a family member, despite having no Xanax order in the EMR or MAR. An LPN learned from the family member that they had given the resident their own Xanax and relayed this to another LPN, who confirmed the incident with the family member and notified ambulance staff. The administrator was informed and discussed the event with the DON and a corporate nurse but decided it was not reportable because the state incident form did not specifically address this type of event, resulting in the failure to report an alleged criminal act involving a controlled substance to state authorities and law enforcement within the required 2-hour timeframe.
The facility failed to maintain comfortable water temperatures in all shower rooms, resulting in water that quickly became uncomfortably cold during use. Temperature checks by surveyors showed significant drops from initially warm or hot water to much cooler levels within minutes in multiple shower rooms. A resident reported that shower water became "ice cold" after a brief period and that they avoided showers, while others described the water as "freezing" and "frigid." CNAs reported that water turned very cold within a few minutes, forcing them to rush bathing and leading some residents to refuse showers. Staff stated they had reported the issue to maintenance several times, but the maintenance supervisor admitted there were no routine water temperature checks or logs, and the administrator acknowledged the water was too cold for them to take a shower.
Surveyors found that dietary staff lacked proper training and competency to operate the low-temperature dish machine. Two dietary aides relied on the presence of suds and visual checks of a temperature gauge instead of using required test strips or documented temperature checks, and one aide stopped the dish machine mid-cycle and walked away. One aide reported receiving informal training from another staff member and had not been taught how to check temperatures or use test strips, despite frequent use of the machine. The DM could not produce quarterly training records, 90-day nutrition services training, or annual competency documentation for dietary staff and acknowledged that, although procedures were reviewed in orientation, staff did not understand or follow the required dish machine testing process.
The facility failed to ensure proper sanitation and monitoring of dishware and cooking utensils for residents receiving meals from the kitchen. Surveyors observed a low-temp dishwasher stopped mid-cycle with suds in the reservoir and a temperature around 140°F, while the warewashing log lacked required daily documentation for multiple days. Staff reported hot water problems, use of three plastic tubs with heated water from the stove, and reliance on paper products, but the dietary manager and other dietary staff did not check or document water or sanitizer temperatures as required. One dietary aide relied only on the dishwasher gauge and visible suds and did not use test strips, while another had not been trained to test the machine. The administrator and dietary manager acknowledged uncertainty and lack of documentation regarding required daily dishmachine testing.
A resident with diabetes, intact cognition, and partial to moderate ADL dependence had thick, overgrown toenails that had not been trimmed despite the resident repeatedly telling staff they needed cutting. Nursing notes over several months contained no indication that toenail care was needed or that a podiatry referral was made, and the facility lacked a nail care policy. The DON reported that LPNs were expected to assess toenails weekly as part of skin assessments and that nursing and social services enrolled residents for podiatry, but the podiatrist had not provided services in the facility for several months. The ADON stated staff tried to cut the resident’s toenails, yet no documentation of this attempt existed.
A resident who was cognitively intact and dependent on staff for mobility, with a care plan requiring use of a mechanical lift for transfers, fell from the lift during a transfer performed by two CNAs. Facility policy required proper sling use, two trained staff, and adherence to manufacturer instructions. During the transfer, a sling loop came off the lift, and the resident was later found on the floor under the lift, reporting pain and subsequently diagnosed with a nondisplaced distal femur fracture. CNAs reported they were expected to inspect the lift, ensure correct sling placement, and secure hooks or straps before use, and the administrator noted multiple residents in the facility depended on mechanical lifts, with no documentation that quality assurance was involved.
A resident with severely impaired cognition, dementia, anxiety, and documented wandering was repeatedly assessed as high risk for elopement, yet the facility failed to revise and implement a comprehensive care plan to address ongoing exit-seeking and multiple elopements. The care plan initially included general diversion and structured activity interventions, but it was not updated with enhanced measures after repeated incidents in which the resident exited or attempted to exit the building, including being found in the parking lot near a busy road. Facility records show the resident was repeatedly placed on 1:1 supervision for extended periods following these events, but this intervention was never added to the care plan. A later revised care plan referenced door-pulling and following visitors out but still omitted prior elopements and the 1:1 supervision intervention. CNAs and nursing staff reported relying on the care plan and word of mouth to identify elopement risk, with some uncertainty about what to do after multiple attempts, and leadership acknowledged a system failure in documenting exit-seeking and 1:1 supervision in the care plan, leading to an Immediate Jeopardy finding.
A resident with dementia, severe cognitive impairment, and independently ambulatory status was repeatedly assessed as high risk for elopement yet experienced multiple episodes of exit seeking and elopement by following visitors, delivery drivers, and other residents through the front door. Staff often became aware of these events only after others alerted them, including one incident where the resident was found outside near a busy street and was agitated and difficult to redirect. Although one-on-one supervision was intermittently ordered, documentation of that supervision was incomplete and the intervention was not incorporated into the care plan, which contained only general wandering and cueing strategies and was not updated to reflect increased supervision needs after repeated incidents. Direct care staff reported inconsistent awareness of the resident’s elopement risk, reliance on word of mouth or the care plan, and uncertainty about how to respond to multiple elopement attempts, and leadership acknowledged system failures in documentation and care plan updates related to supervision after these events.
The facility did not complete criminal history background checks for two LPNs, even though its policy required screening employees for histories of abuse, neglect, or mistreatment through prior employer information and checks of licensing boards and registries. Employee file reviews showed no background check results for an LPN hired in late 2024 and another hired in mid-2025, while the administrator reported believing that nurses with valid licenses overseen by the state nursing board did not require separate background checks. At the time of the survey, 80 residents were identified as residing in the facility.
Staff failed to follow proper infection control practices during a noon meal service involving about 80 residents. A dietary aide placed a sanitizing bucket on a food prep table next to a food processor used for puréed items, wiped a prep table with a rag from the sanitizing bucket, and then handled food trays without handwashing. In a separate instance, a cook used a sanitizing rag as a potholder to remove a pan of burritos from the oven and then prepared meal trays without performing hand hygiene.
Failure to Report Unauthorized Administration of Controlled Substance to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of a crime toward a resident to the state survey agency and local law enforcement within the required 2-hour timeframe. Facility policy dated 10/11/22 required all allegations of abuse, neglect, misappropriation of resident property, exploitation, injuries of unknown source, and suspected criminal acts to be reported to appropriate authorities within required time frames. Resident #4 had a quarterly assessment dated 04/18/25 showing a BIMS score of 12, indicating moderate cognitive impairment. On 06/24/25, a Transfer to Hospital Summary documented that the resident was transferred due to increased confusion, hallucinations, shortness of breath, and abdominal breathing of 30 breaths per minute, and that the nurse had informed the hospital that the resident had received one-half of a Xanax tablet from a family member. Review of the resident’s EMR and medication records showed there was no order for Xanax for this resident. During interviews, one LPN stated that during a lunch break a family member told them they had given the resident one of their own Xanax tablets because the resident was yelling out for their deceased husband. The LPN reported that they informed another LPN, who was arranging the resident’s transfer to the hospital, about the Xanax, and that ambulance staff were notified. The second LPN recalled being informed that a specific family member had given the medication, and stated they called that family member, who confirmed giving the tablet and explained why. The administrator stated they were informed of the incident by the DON at the time, and that they and the corporate nurse discussed whether to report it but decided it was not reportable because there was no place for such an incident on the state incident reporting form. The administrator later acknowledged that if someone administered their personal controlled substance to a resident, it should have been reported as a criminal activity and that they had not fully followed the facility’s abuse policy.
Failure to Maintain Comfortable Shower Water Temperatures
Penalty
Summary
The facility failed to maintain comfortable water temperatures in all five shower rooms, affecting residents' right to a safe, clean, comfortable, and homelike environment. Surveyors measured water temperatures in multiple shower rooms over two days and found that while initial temperatures were within or near a comfortable range, they dropped significantly within minutes. In the large South shower, water started at 100.4°F and fell to 77.4°F within 11 minutes. In the small East shower, water began at 107.4°F and dropped to 85.2°F within eight minutes. The large East shower showed a relatively stable temperature (97.6°F to 98.4°F within one minute), but the North shower dropped from 81.3°F to 70.5°F within two minutes, and the small South shower decreased from 104.6°F to 85.8°F within five minutes. Facility policy on ADL bathing required ensuring the bathing area was at a comfortable temperature, and a maintenance document dated 11/17/25 noted that hot water was not working on the north hall. Residents and staff reported ongoing problems with shower water becoming uncomfortably cold. One resident stated the shower water was warm for about two minutes and then became "ice cold," leading them to avoid taking many showers. Another resident reported that within five minutes the water became "freezing" and described it as "frigid," while another said the water on the north hall became freezing within a minute. CNAs reported that when they started showers, the water turned very cold within about three minutes, forcing them to hurry to rinse soap off residents and resulting in residents feeling their showers were cut short or refusing showers because they knew the water would get cold quickly. Staff also stated they had reported the cold water issue in the shower rooms to the maintenance supervisor several times. The maintenance supervisor acknowledged they did not perform routine water temperature checks and had no temperature logs, and the administrator stated that after feeling the water from the north hall shower, they personally would not take a shower in that water because it was too cold.
Inadequate Training and Competency of Dietary Staff in Dish Machine Operation
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure dietary staff were properly qualified and competent to operate the dishwashing equipment and carry out food and nutrition services. The DON reported that 81 residents received nutrition from the kitchen, and the DM reported there were 11 dietary staff members. During observation, two dietary aides were seen operating a low-temperature dish machine when one aide stopped the machine mid-wash cycle and walked away. One aide stated they determined the water was not hot enough by observing suds in the side tank and would wait and then try running the dishwasher again, rather than using the temperature gauge or test strips. The same aide reported working at the facility for about a month and stated they had been trained by another staff member but had not been instructed on checking the dish machine temperature or using test strips, despite using the machine several times a day. The other aide stated they checked the temperature gauge to ensure it was between two green lines and knew there were strips to check the machine but did not know where they were kept and did not usually worry about testing or documentation, instead relying on the presence of suds to judge water temperature. The DM later stated they were unable to locate quarterly training documents, 90-day nutrition services training, or annual competencies for dietary staff, and although they reported reviewing dish machine temperature and sanitation strip procedures during orientation, they acknowledged staff were not following or understanding the required testing process or frequency.
Failure to Ensure Proper Dishwashing Sanitation and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper sanitation of dishware and cooking utensils in accordance with professional standards and its own warewashing policy. Surveyors observed a low-temperature dishwasher being stopped mid-cycle by a dietary aide, with visible suds in the reservoir and a gauge reading around 140°F. The facility’s warewashing policy required dishware to be washed in a three-sink unit with sanitizer or disposable dishware to be used if the dish machine was not working or not meeting regulatory requirements, and required daily checks and documentation of sanitizer test strip results. The warewashing log for the dishmachine showed entries marked through one date with a note that hot water was being installed, and no documentation of testing or results for several subsequent days, despite the Director of Nursing identifying that 81 residents received nutrition from the kitchen. Staff interviews revealed that hot water had been an issue and a new hot water tank was being installed, during which time staff reported washing dishes in tubs, heating water on the stove for pots, pans, and utensils, and using paper plates and containers for resident meals. The dietary manager and cook stated they were using three plastic tubs and sanitizer but did not know they needed to check or document water or sanitizer temperatures in the tubs. One dietary aide stated they only checked that the dishwasher gauge was between two green lines, knew test strips existed but did not know their location, and did not usually worry about testing or documentation, instead relying on the presence of suds to judge water temperature. Another dietary aide reported not being shown how to check water temperature or use test strips and had been trained only by another staff member. The administrator acknowledged being unsure whether staff were completing dish machine testing due to lack of documentation, and the dietary manager later confirmed that temperature and sanitizer checks and documentation had not been completed for several days, attributing this to miscommunication among staff.
Failure to Provide and Document Necessary Toenail Care
Penalty
Summary
The facility failed to provide appropriate toenail care for one resident when surveyors observed the resident’s toenails to be thick, overgrown, and approximately half an inch long. The resident, who had intact cognition with a BIMS score of 13, had been admitted with diagnoses including diabetes mellitus and required partial to moderate assistance with most ADLs. A significant change assessment documented these needs, yet nurse’s notes from late August through January contained no indication that the resident’s toenails required cutting or that a podiatry referral was needed. The resident reported that their toenails had needed cutting since admission and that they had informed staff on multiple occasions. The facility had no policy related to nail care, and although the DON stated that LPNs were expected to assess toenails weekly as part of skin assessments and that nursing and social services were responsible for signing residents up for podiatry services, there was no documentation that this occurred for this resident. The podiatrist reported that services were last provided in the facility several months earlier, and the ADON stated staff had attempted to cut the resident’s toenails but this was not documented. These combined observations and record reviews showed that the facility did not ensure toenail care was provided or documented for this resident in accordance with their needs and stated practices.
Resident Fall and Femur Fracture During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a resident did not fall from a mechanical lift during a transfer, resulting in a fall and injury. The facility had a Safe Lifting & Mechanical Lift Policy dated 01/01/25 that required use of proper sling and equipment, two trained staff for transfers, and adherence to manufacturer instructions. The resident’s care plan for activities of daily living, dated 10/30/25, specified the need for a mechanical lift for transfers, and a quarterly assessment dated 12/31/25 documented that the resident was cognitively intact with a BIMS score of 15 and was dependent on staff for mobility. On 11/13/25, a late entry nursing progress note recorded that an LPN found the resident on the floor under the mechanical lift, with the resident complaining of pain all over, and the resident was sent to the emergency room for evaluation. A hospital imaging report from the same day showed a nondisplaced fracture deformity of the distal femur in the resident’s right leg. A facility incident report dated 11/14/25 documented that the resident fell from a mechanical lift while being transferred by two CNAs. The resident’s fall care plan, dated 11/17/25, stated that the resident had been up in a mechanical lift when a sling loop came off the lift, causing the resident to fall to the floor toward the right lower corner of the sling, and that the resident was sent to the hospital for evaluation and treatment. CNAs interviewed later stated they were responsible for inspecting the lift before use, ensuring the resident was correctly positioned in the sling, and confirming that hooks or straps were properly secured. The administrator identified that 19 residents in the facility were dependent on mechanical lifts for transfers and there was no documentation that quality assurance was involved in the process.
Failure to Revise and Implement Comprehensive Elopement Care Plan for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan with measurable objectives and time frames to address a resident’s high elopement risk and repeated exit-seeking behaviors. The resident had severely impaired cognition with a BIMS score of 2 and diagnoses including dementia and anxiety. An admission assessment documented wandering behaviors and independent ambulation and transfers. Multiple Elopement Risk Assessments consistently identified the resident as high risk for elopement with scores of 10. Despite this, the care plan initiated for elopement did not show that interventions were revised or expanded after multiple elopement events and exit-seeking incidents. The resident’s care plan, initiated in early May, included interventions such as distraction with food and activities, identifying patterns of wandering, and providing structured activities like signs, memory boxes, and walking inside and outside. These interventions were later cancelled in early August, and the care plan did not reflect additional or modified interventions after an elopement on mid-July. Incident reports documented that the resident eloped or attempted to elope on multiple occasions, including exiting with visitors, attempting to exit when a visitor or delivery driver held the door, and being found walking in the parking lot near a busy street and a storage facility. Each incident report stated that the resident was redirected inside, assessed, and that the care plan was updated to reflect current status, but the care plan did not show the addition of one-on-one supervision or other enhanced interventions corresponding to these events. Facility documents titled "Resident One on One" showed that after each elopement or exit-seeking incident on multiple dates in July, August, and September, the resident was placed on one-on-one supervision for extended periods, ranging from several hours to most of a shift. However, one-on-one supervision was never added as an intervention in the resident’s care plan. A revised care plan in mid-October again focused on elopement and referenced the resident pulling on locked doors and walking out of the facility following visitors, but it only listed interventions such as distraction with pleasant diversions, observing for fatigue and weight loss, observing location in the community, and providing directional cues. It did not include prior elopements or the repeated use of one-on-one supervision as an intervention, nor did it show that interventions were revised after the multiple documented elopements and exit-seeking behaviors. Staff interviews further illustrated the deficiency in implementing and communicating a comprehensive care plan. A CNA stated that interventions for elopement risk should be found in the care plan and reported being unsure what to do when a resident had multiple elopement attempts, indicating reliance on the RN for direction. Another CNA reported identifying residents at risk for elopement by word of mouth or the care plan and mentioned an elopement book but was unsure who checked it, also noting the difficulty of monitoring exits without constant presence at the door. The ADON stated that residents with an elopement risk score of 10 or higher were considered high risk and acknowledged that the resident’s care plan was revised after an early elopement attempt, but subsequent incidents still occurred. The DON stated that the resident eloped and was found in the parking lot near a very busy street and identified a system failure related to one-on-one forms and the lack of documentation in the care plan for the resident’s exit-seeking and elopements. A resident representative reported they were never informed that the resident was placed on one-on-one supervision and that the resident was later moved to another facility with memory care because the resident was not safe due to exit-seeking behaviors. An Immediate Jeopardy situation was determined to exist related to the facility’s failure to ensure a comprehensive care plan was developed and implemented for this resident to prevent elopement. The facility’s own policy on comprehensive care plans required measurable objectives and time frames to meet resident needs identified in the assessment, with alternative interventions documented as needed. Despite repeated high-risk assessments, multiple elopements and exit-seeking incidents, and the repeated use of one-on-one supervision in practice, the resident’s care plan did not reflect these interventions or show appropriate revision after each incident. This failure to integrate actual interventions and incident history into the written care plan, and to ensure staff understood and followed it, formed the basis of the cited deficiency.
Removal Plan
- Elopement Risk Assessments were completed on 100% of residents.
- Facility completed 100% audit of residents who were identified at risk for elopement.
- Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.
- IDT received education on reviewing, revising, developing and implementing care plans from the VP of Reimbursement or designee(s).
- IDT team implemented an appropriate monitoring sheet for residents at risk for elopement.
Failure to Supervise High-Risk Resident Resulting in Multiple Elopements
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident with severe cognitive impairment and a documented high risk for elopement. The resident had dementia, anxiety, a severely impaired BIMS score of 2, and was independently ambulatory, with assessments repeatedly identifying them as high risk for elopement. Despite this, the resident experienced multiple episodes of exit seeking and elopement over several months, beginning with an incident in which the resident walked out the front door with visitors and had to be redirected back inside by staff after other residents alerted them. Subsequent nursing notes documented wandering, exit-seeking behaviors, and attempts to follow others out of the building. The facility’s documentation showed repeated incidents where the resident exited or attempted to exit the building by following visitors, delivery drivers, or other residents through the front door. On one occasion, the resident was observed outside walking toward a storage facility next door near a busy street and was described as agitated, difficult to redirect, and continuing to exit seek. Another incident documented the resident being found outside by the curb and returned to the facility by a staff member’s car after a visitor notified staff. In several of these events, staff were not initially aware the resident had left the building and only became aware after being notified by others or upon observing the resident outside. Although the facility intermittently placed the resident on one-on-one supervision following some of these incidents, the one-on-one forms were not completed with time intervals to show that the supervision was actually provided, and this increased supervision was not incorporated into the resident’s care plan. The care plan, revised later, did include a focus related to elopement and listed interventions such as distraction with activities, observing for fatigue and weight loss, observing location in the community, and providing directional cues. However, it did not show that supervision interventions were updated or increased after the resident’s repeated exit-seeking behaviors and documented elopements. Staff interviews further revealed that direct care staff were not consistently aware of the resident’s elopement risk, relied on word of mouth or the care plan to identify such residents, and expressed uncertainty about what to do when a resident had multiple elopement attempts. The DON acknowledged that the resident had eloped to the parking lot near a very busy street and identified a system failure related to incomplete one-on-one documentation and the lack of care plan updates to ensure adequate supervision after multiple elopement-related events. An Immediate Jeopardy situation was determined to exist due to this failure to ensure adequate supervision to prevent elopement for the resident. The survey findings noted that the facility’s own elopement and wandering policy required adequate supervision and care in accordance with a person-centered care plan for residents at risk of elopement. Despite multiple high-risk assessments and repeated incidents of exit seeking and elopement, the facility did not consistently implement, document, or care-plan increased supervision measures for the resident. Direct care staff reported gaps in communication and training regarding elopement risk and interventions, and the resident’s representative stated they were not informed when the resident was placed on one-on-one supervision and ultimately moved the resident to another facility with a memory care unit because the resident was not safe due to exit seeking attempts and elopements.
Removal Plan
- Elopement Risk Assessments were completed on all residents.
- Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.
- An At-Risk Elopement Book with care plan was created and posted at the nurse's station, accessible only to staff, in accordance with HIPAA requirements.
- All nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s).
- Elopement and wandering residents' policy was reviewed.
- Facility implemented a monitoring sheet for residents at risk for elopement.
- An Elopement Response Drill schedule was implemented, with drills occurring on all shifts.
- The DON or designee will perform a daily audit of clinical data to ensure adequate supervision is in place for residents with active wandering and elopement risk.
Failure to Complete Criminal Background Checks for Nursing Staff
Penalty
Summary
The facility failed to complete required criminal history background checks for two sampled LPN employees, despite having a policy stating that employees would be screened for a history of abuse, neglect, or mistreatment by obtaining information from previous or current employers and checking appropriate licensing boards and registries. Record review showed that one LPN hired on 10/08/24 and another LPN hired on 06/25/25 had no criminal history or background check results in their employee files. During an interview, the administrator stated they believed background checks were not required for nurses because the Oklahoma nursing board managed nursing licenses and that a valid license was sufficient for nurses to work in Oklahoma. At the time of the survey, the administrator identified that 80 residents resided in the facility. This deficiency was identified through review of the facility’s undated abuse/neglect/exploitation policy, undated employee lists, and the personnel files of the two LPNs, as well as the administrator’s statements explaining the facility’s practice regarding background checks for licensed nursing staff.
Improper Hand Hygiene and Sanitizer Use During Meal Preparation
Penalty
Summary
The facility failed to prepare and handle food in a manner that minimized the risk of infection and cross-contamination during the noon meal service, which served approximately 80 residents. During a kitchen tour, dietary aide (DA) #1 was observed preparing puréed dessert while also carrying a bucket of sanitizing water to a sink located beside the prep table used for puréed food. After dumping the sanitizing water into the sink, DA #1 placed the bucket on the prep table next to the food processor used for food preparation. Later, DA #1 was observed wiping down a prep table with a rag from the sanitizing bucket and then handling food trays without performing hand hygiene. In a separate observation, cook #1 removed a large sheet pan of burritos from the oven using a sanitizing rag as a potholder and then proceeded to prepare meal trays without washing their hands. The dietary manager (DM) later stated that staff should have washed their hands and should not have had the sanitizing bucket or rag in the area where food was being prepared.
Some of the Latest Corrective Actions taken by Facilities in Oklahoma
- Updated the resident care plan to include transfer-focused interventions (K - F0689 - OK)
- Implemented ongoing audits of residents requiring mechanical-lift transfers and forwarded monthly audit results to the QAPI Committee for review/action (K - F0689 - OK)
- Reeducated nursing staff on selecting proper mechanical-lift slings and weight requirements and restricted staff from working until educated (K - F0689 - OK)
- Stopped resident transport and implemented mandatory in-service and hands-on training for transport staff on wheelchair securement (orientation, brakes, four-point tie-downs, strap tightening, separate occupant lap/shoulder belt, final tug/visual check, and steps if securement could not be achieved) (J - F0689 - OK)
- Required hands-on demonstration on the facility transport vehicle and completed administrator/DON competency validation checklists for each designated transporter (J - F0689 - OK)
Unsafe Mechanical Lift Transfer and Inadequate Elopement Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a dependent resident using a mechanical lift and failure to provide adequate supervision to prevent elopement for another resident. One resident with intact cognition, end-stage renal disease, lower extremity impairments, and dependence on staff for all transfers was being transferred from bed to wheelchair with a mechanical lift when the sling strap broke, causing the resident to fall. The resident’s quarterly assessment documented dependence for all transfers, but the care plan dated shortly after the incident did not contain a focus or interventions for transfers at the time the accident occurred. The facility’s transfer policy required staff to provide safe, effective transfer techniques and to utilize manufacturer guidelines for mechanical lifts, and a facility document on sling care required inspection of slings for wear, tears, and loose stitching after laundering. During the transfer incident, a CNA reported going to the laundry room to obtain a sling because the resident’s usual blue sling was not available in the room. The CNA stated that slings in the laundry came in different sizes and that they selected a medium white sling based on their own judgment, guessing the size and not usually checking for sizes. The CNA further stated they had never been trained on how to determine sling size, did not know the white slings were disposable, and did not understand why such slings were hanging in the laundry room. While two aides were transferring the resident with the mechanical lift, the white sling broke on one side, and the resident fell from approximately three feet in the air, landing on the back of the head, both shoulders, both hips, and the left knee, and later being diagnosed with fractures of the right clavicle and left tibia. The resident reported experiencing significant pain, needing staff assistance with feeding due to the clavicle fracture, and feeling embarrassed and fearful of transfers. The deficiency also includes failure to provide adequate supervision to prevent elopement for another resident with significantly impaired cognition, dementia with behavioral disturbances, and chronic kidney disease. This resident had been assessed twice as a moderate elopement risk, with elopement assessment scores of 19 and 16, and had a prior care plan focus for exit-seeking behavior that included interventions such as frequent visual checks, maintaining a behavior log, and analyzing triggers. However, after the facility implemented a new EHR system, the DON acknowledged that the existing elopement focus and interventions from the earlier care plan were not carried over, and the care plan was not updated following the elopement risk assessments. As a result, from mid-year until after the elopement event, the resident did not have a current care plan focus or interventions addressing elopement risk and increased supervision, despite being known by staff to watch doors and exit seek for several months. The resident subsequently eloped from the facility after another resident let them out, was discovered missing by a CNA, and was later found off premises near a church parking lot with scratches on the arms before being returned. The facility is located on a busy two-lane main street adjacent to a golf course with ponds, and the elopement policy required documentation of incidents, nursing notes with accurate accounts of situations and outcomes, social services notes addressing emotional aspects, updated elopement risk assessments, and updated care plans. In the elopement case, a facility incident report documented that the resident was missing and later found during a search, and nursing notes recorded that the resident was discovered missing, that another resident admitted to letting them out, and that the resident was located and returned with scratches. However, the care plan revision following the elopement added a focus for elopement risk and some interventions such as staff awareness in common areas, redirection when fixated on exits, and signage on exits, but did not include interventions for increased supervision compared to the earlier care plan. The DON confirmed that the facility did not follow its policy to update the care plan after the elopement assessments showed the resident was a moderate elopement risk, resulting in a period where the resident’s known exit-seeking behavior and risk were not addressed in the active care plan.
Removal Plan
- Send Resident #7 to the hospital and return to the facility for continued treatment.
- Update Resident #7's care plan with interventions and focus to include transfers.
- Have the DON or designee perform audits of residents who require assistance with transfers using a mechanical lift and update care plans accordingly.
- Have the DON or designee reeducate nursing staff on choosing the proper slings and weight requirement.
- Do not allow staff who did not receive education to work until educated.
- Notify the medical director of the IJ.
- Hold a QAPI meeting with the medical director, the facility administrator, and director of nursing to review the plan of removal.
- Have the director of nursing track, trend, and analyze audit results and forward results of audits monthly to the QAPI Committee for review and/or action.
Failure to Supervise High-Risk Resident Resulting in Multiple Elopements
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident with severe cognitive impairment and a documented high risk for elopement. The resident had dementia, anxiety, a severely impaired BIMS score of 2, and was independently ambulatory, with assessments repeatedly identifying them as high risk for elopement. Despite this, the resident experienced multiple episodes of exit seeking and elopement over several months, beginning with an incident in which the resident walked out the front door with visitors and had to be redirected back inside by staff after other residents alerted them. Subsequent nursing notes documented wandering, exit-seeking behaviors, and attempts to follow others out of the building. The facility’s documentation showed repeated incidents where the resident exited or attempted to exit the building by following visitors, delivery drivers, or other residents through the front door. On one occasion, the resident was observed outside walking toward a storage facility next door near a busy street and was described as agitated, difficult to redirect, and continuing to exit seek. Another incident documented the resident being found outside by the curb and returned to the facility by a staff member’s car after a visitor notified staff. In several of these events, staff were not initially aware the resident had left the building and only became aware after being notified by others or upon observing the resident outside. Although the facility intermittently placed the resident on one-on-one supervision following some of these incidents, the one-on-one forms were not completed with time intervals to show that the supervision was actually provided, and this increased supervision was not incorporated into the resident’s care plan. The care plan, revised later, did include a focus related to elopement and listed interventions such as distraction with activities, observing for fatigue and weight loss, observing location in the community, and providing directional cues. However, it did not show that supervision interventions were updated or increased after the resident’s repeated exit-seeking behaviors and documented elopements. Staff interviews further revealed that direct care staff were not consistently aware of the resident’s elopement risk, relied on word of mouth or the care plan to identify such residents, and expressed uncertainty about what to do when a resident had multiple elopement attempts. The DON acknowledged that the resident had eloped to the parking lot near a very busy street and identified a system failure related to incomplete one-on-one documentation and the lack of care plan updates to ensure adequate supervision after multiple elopement-related events. An Immediate Jeopardy situation was determined to exist due to this failure to ensure adequate supervision to prevent elopement for the resident. The survey findings noted that the facility’s own elopement and wandering policy required adequate supervision and care in accordance with a person-centered care plan for residents at risk of elopement. Despite multiple high-risk assessments and repeated incidents of exit seeking and elopement, the facility did not consistently implement, document, or care-plan increased supervision measures for the resident. Direct care staff reported gaps in communication and training regarding elopement risk and interventions, and the resident’s representative stated they were not informed when the resident was placed on one-on-one supervision and ultimately moved the resident to another facility with a memory care unit because the resident was not safe due to exit seeking attempts and elopements.
Removal Plan
- Elopement Risk Assessments were completed on all residents.
- Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.
- An At-Risk Elopement Book with care plan was created and posted at the nurse's station, accessible only to staff, in accordance with HIPAA requirements.
- All nursing staff on all shifts received education on wandering, elopement, and resident safety from the DON or designee(s).
- Elopement and wandering residents' policy was reviewed.
- Facility implemented a monitoring sheet for residents at risk for elopement.
- An Elopement Response Drill schedule was implemented, with drills occurring on all shifts.
- The DON or designee will perform a daily audit of clinical data to ensure adequate supervision is in place for residents with active wandering and elopement risk.
Failure to Properly Train and Secure Wheelchair-Bound Resident During Transport Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a wheelchair-bound resident was protected from accidents and injuries during transportation. A quarterly assessment dated 10/27/25 showed Resident #20 had intact cognition with a BIMS score of 13, was dependent for positioning, and was wheelchair bound. The facility’s Transportation and Vehicle Use policy, dated 12/26/25, required all drivers to complete defensive driving, wheelchair and mobility device securement, resident safety and transfer training, facility transportation orientation, and annual refresher training. The policy also required that wheelchair users have wheelchair brakes locked, a four-point tie-down system secured, and lap and shoulder belts applied, with drivers visually confirming securement before moving the vehicle. However, employee files for transporter #1 and transporter #2 did not contain documentation of skills checks or training for properly transporting residents, and the DON stated there was no annual competency or training program for drivers, with current drivers informally training new hires. On 12/30/25, transporter #1 improperly secured Resident #20 in the transport vehicle, resulting in the resident’s wheelchair tipping onto its side when the driver swerved to avoid another vehicle. A state reportable incident documented that the resident sustained a fractured rib and moderate spleen damage requiring admission to a hospital trauma center. A nursing note dated 12/31/25 confirmed a rib fracture and a grade 2 spleen injury. A significant change assessment dated 01/12/26 later showed the resident’s BIMS score had declined to 12, indicating moderate impairment for daily decision making, and continued dependence for positioning and wheelchair use. During interview, the resident reported that while traveling to a doctor’s appointment, the vehicle swerved on the highway and the next thing they knew they were on the floor, after which they were hospitalized for several days and returned to the facility, still experiencing pain and discomfort requiring medication. Transporter #1 stated they had placed the resident facing the front of the van, used the four-point strap system and a seatbelt, but believed the straps were not tight enough, and reported having received training only once, 15 years earlier, with no subsequent training. The DON confirmed transporter #1 did not secure the wheelchair tightly enough and that scheduled defensive driver training for transportation staff had not yet been completed.
Removal Plan
- Stopped resident transport
- Conducted a mandatory in-service and hands-on training for all staff assigned to resident transport
- Trained staff on correct wheelchair orientation in the vehicle
- Trained staff on engaging wheelchair brakes
- Trained staff on proper four-point tie-down attachment to the wheelchair frame
- Trained staff on proper strap tightening until no movement remains
- Trained staff on application of a separate occupant lap and shoulder belt
- Trained staff on performing a final tug test and visual verification before vehicle movement
- Trained staff on the procedure to follow if securement cannot be achieved
- Required each designated transporter to complete a hands-on demonstration on the facility transport vehicle
- Administrator and Director of Nursing completed and signed a competency validation checklist for each transporter
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