Citations in Oklahoma
Statistics, citations 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
Surveyors found that staff failed to follow Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. Facility policy required targeted gown and glove use for high-contact care under EBP, and the resident had physician orders for catheter care every shift and placement on EBP. During an observation, two CNAs provided catheter care without wearing gowns. Both CNAs later acknowledged that gowns should have been used, and the DON confirmed that gowns are required for catheter care for residents on EBP. The resident, who was cognitively intact, reported that staff usually did not wear gowns during catheter care.
The facility did not update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed licensed nursing staff. The written assessment specified one RN for one day shift per week and projected a need for 10 LPNs across 24 hours, with detailed LPN coverage by shift, and stated it should be reviewed and updated as needed to guide staffing decisions. At the time of survey, the DON reported 36 residents in the facility, acknowledged that resident acuity was higher than when the assessment was completed, and stated that the actual pattern was two LPNs on the floor for the day shift and two LPNs for the night shift, with the DON, ADON, and MDS coordinator available only during weekday business hours. The DON identified a total of seven licensed staff available and stated that more staff were needed to work directly with residents, confirming that the facility assessment no longer reflected current resident needs or staffing resources.
A resident with a pressure ulcer received wound care during which an LPN and CNAs failed to follow basic infection control practices. The overbed table was not sanitized before wound supplies were placed, gloves were not changed after contact with feces, and the resident was repositioned onto a clean bed pad while still soiled. The LPN used the same contaminated gloves to handle personal items, suction equipment, wound care supplies, and to cleanse the resident’s skin and pressure ulcer, including applying collagen paste and calcium alginate with gloved fingers. Hand hygiene was not performed between glove changes, and the resident’s open wound came into contact with a cloth bed pad or pillow after cleansing and medication application but before the final dressing was applied.
A deficiency was cited for failure to prevent elopement and recurrent falls due to inadequate supervision, unsecured exits, and incomplete care planning. A newly admitted resident assessed as at risk for elopement and wandering had no related interventions on the baseline care plan, despite moderately impaired cognition and psychiatric and seizure diagnoses. This resident later left the building, was found several blocks away after falling and sustaining abrasions, and was subsequently observed at times without the one-on-one supervision that had been ordered, while a dining room exit door and perimeter gate remained unlocked and accessible. Another resident with vascular dementia, muscle weakness, and a history of multiple falls experienced several unwitnessed falls over months, culminating in two right hip fractures requiring surgical repair, yet fall-prevention interventions were not added to the care plan, and staff relied on verbal instructions and vague "close observation" rather than documented, individualized fall-prevention measures.
A resident with atrial fibrillation on Eliquis, with documented orders and a care plan to monitor and report signs of bleeding, experienced multiple episodes of active rectal bleeding while on the toilet, accompanied by anxiety, complaints of not being able to breathe, pain, pallor, and shivering. An ACMA and an LPN observed and documented that the toilet was full of blood and that the resident repeatedly refused transfer to the ER, but the LPN did not contact the physician or the family and instructed staff to continue monitoring. ACMA staff later attempted to follow instructions to contact family but reported no family contact information in the medical record, did not notify the physician, and ultimately called EMS only when the resident became pale and shivering; EMS found the resident unconscious amid evidence of a significant hemorrhagic event. Progress notes contained no documentation of physician or family notification during the change in condition, and the family, listed as POA and emergency contact in admission paperwork, reported they were not informed of the change in condition and learned of the resident’s death hours later.
A resident with recent abdominal aortic aneurysm repair and a history of circulatory surgery was on multiple anticoagulant and antiplatelet agents (Eliquis, aspirin, Plavix) and had care plans directing staff to monitor for and report abnormal labs and signs of bleeding, including black or bloody stools. A critical hemoglobin of 6.3 g/dL was reported by the lab, which documented unsuccessful attempts to reach nursing staff; the result was later signed by facility staff, but the DON confirmed the physician was never notified and no intervention was documented. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding with screaming, shortness of breath, and anxiety while on the toilet; an ACMA notified an LPN, who did not promptly assess the resident and instead instructed continued monitoring and attempts to convince the resident to go to the hospital. Nursing notes and EMS documentation showed a significant hemorrhagic event with extensive blood in the room and on the resident, yet there was no evidence of ongoing assessment, monitoring, or timely physician notification for the change in condition or the critical lab, leading surveyors to cite a deficiency under F684 for failure to provide appropriate treatment and care according to orders and the resident’s condition.
Failure to Use Gowns During Catheter Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during catheter care. The facility’s Infection Control policy dated 04/01/24 required targeted gown and glove use during high-contact resident care activities under EBP. Physician orders showed that Resident #7 had an indwelling catheter with catheter care ordered every shift as of 01/07/26 and was placed on EBP as of 01/16/26. A quarterly assessment dated 03/27/26 documented that Resident #7 had intact cognition, with a Brief Interview for Mental Status score of 15, and an indwelling catheter. On 04/29/26 at 11:03 a.m., CNA #1 and CNA #2 were observed providing catheter care to Resident #7 without wearing gowns, despite the resident being on EBP and the facility’s policy requiring gown use for such care. CNA #1 acknowledged that gowns should have been worn under EBP, and CNA #2 stated they had forgotten to put on a gown. Resident #7 reported that staff usually did not wear gowns during catheter care, and on 04/30/26 the DON confirmed that gowns should be worn when providing catheter care to residents on EBP.
Failure to Update Facility Assessment to Reflect Increased Resident Acuity and Staffing Needs
Penalty
Summary
The facility failed to update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed nursing resources. The written facility assessment dated 10/15/25 stated that one RN was needed for one day shift per week, including weekends, and projected a total of 10 LPNs needed to provide care in a 24-hour period. The assessment further specified that seven LPNs were needed for the day shift, five for the evening shift, and four for the night shift. The assessment document itself stated that it was to be reviewed annually and updated as needed, and that it was to be used to evaluate the resident population and determine the resources necessary to care for residents competently during day-to-day operations and emergencies, and to drive staffing decisions. At the time of the survey, the DON identified that 36 residents resided in the facility and reported that the acuity level of the residents was higher than it had been in October 2025 when the facility assessment was completed. The DON stated that the projected need for ten LPNs in a 24-hour period was not correct and described the actual staffing pattern as two LPNs working on the floor from 7 a.m. to 7 p.m. and two LPNs working on the floor from 7 p.m. to 7 a.m., with the DON (RN), assistant DON (RN), and MDS coordinator (LPN) available to assist with resident needs during business hours, five days a week. The DON counted a total of seven licensed staff members available and acknowledged that more staff were needed to work directly with residents given the current higher acuity, demonstrating that the facility assessment had not been updated to reflect the current resident population and resource needs.
Improper Infection Control During Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care in a manner that prevented contamination and potential infection for one resident with a pressure ulcer. During an observed dressing change, an LPN entered the resident’s room, pushed personal items aside, and placed plastic trash bags and wound care supplies on the overbed table without sanitizing the surface. The LPN and CNAs provided incontinent care during which feces remained on the resident’s legs and buttocks, and at least one CNA did not change gloves after wiping feces and before placing a clean cloth bed pad under the resident. The resident was repositioned onto the new pad while still soiled with feces. Wearing the same gloves used during incontinent care, the LPN handled the resident’s personal items, oral suction yankauer, and suction machine, and prepared wound care supplies, including soaking gauze in a cleansing solution. The LPN then used the same contaminated gloves to obtain wet gauze from the cleansing solution and clean feces from the resident’s legs and buttocks before proceeding to remove the old dressing and packing from the pressure ulcer. Some packing fell onto the cloth bed pad, and the resident’s back and buttocks, including the open pressure ulcer area after cleansing and medication application but before placement of the absorbent dressing, came into contact with the cloth bed pad or pillow. The LPN applied a collagen paste to the wound bed by inserting gloved fingers into a cup of white paste and then applied calcium alginate with the same gloved fingers, without using an applicator. The LPN discarded the gloves but did not perform hand hygiene before donning a new pair of gloves stored on the overbed table. During a post-observation interview, the LPN acknowledged feeling nervous, recognized that their gloves and multiple items and surfaces may have been contaminated by contact with feces, and stated that the resident’s bed pad and wound bed were likely contaminated during the dressing change.
Failure to Prevent Elopement and Recurrent Falls Due to Inadequate Supervision and Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to elopement risk and fall prevention. One resident identified as a new admission was evaluated on 02/28/26 as being at risk for elopement and wandering, with documentation that the resident wandered around the facility and into rooms. Despite this evaluation, the baseline care plan dated the same day did not include any interventions for wandering or elopement risk. An admission assessment dated 03/06/26 documented moderately impaired cognition with a BIMS score of 09 and diagnoses including schizophrenia and seizure disorder. On 03/07/26, the resident was reported missing from their room around 11:20 a.m., and an incident report and progress note showed the resident was found a couple of blocks from the facility, having tripped and fallen outside and sustaining abrasions to the hand and knee that required first aid. Following the elopement, documentation showed the resident was placed on one-on-one staff supervision and the care plan was updated; however, subsequent observations revealed lapses in supervision. On 03/11/26, the resident was observed in bed with a staff member seated outside the door, and the resident stated they were not allowed to leave the facility alone. On 03/12/26, the resident was observed in bed with no staff supervision, then walking out of the room toward the dining room without staff present, until an unidentified staff member later noticed the resident in the hall and alerted the charge nurse. Interviews indicated that prior to the elopement the resident had not been on frequent checks because staff did not consider them an elopement risk, despite the earlier evaluation. The ADON later stated the baseline care plan lacked elopement/wandering interventions because they had failed to communicate with the weekend RN who completed the elopement evaluation and were unaware the resident was at risk. Environmental observations on 03/13/26 showed the dining room exit door and the outside perimeter gate in the smoking area were unlocked and accessible to residents, and the DON and administrator acknowledged the dining room exit door was not secured and that the resident likely exited through the unlocked door and perimeter gate. The deficiency also includes the facility’s failure to provide adequate supervision, reassess fall risk, investigate root causes, and implement fall-prevention interventions for a resident with a history of multiple falls. Facility records identified this resident as having several falls without injury on 06/04/25, 06/05/25, 06/18/25, 06/30/25, and 07/31/25, with no fall-prevention interventions documented for any of these events. A fall on 09/25/25 resulted in severe right leg pain and an emergency room visit, with a subsequent nurse’s note documenting a right hip fracture requiring surgical repair. Review of the care plan dated 07/31/25 showed no fall-prevention interventions in place for the 09/25/25 fall, and a later care plan dated 10/06/25 documented the resident’s diagnoses, including vascular dementia and muscle weakness, and the prior falls, but still showed no interventions for those falls. A nurse’s note dated 10/20/25 documented another fall on 10/19/25 that resulted in a second right hip fracture, again with no documentation of interventions in place to prevent that fall. Observations and interviews further demonstrated the lack of systematic fall-prevention planning for this resident. On 03/12/26, the resident was observed sitting in a geriatric chair near the nurse’s station with a fall mat at bedside and was later assisted to stand and ambulate with a walker. The resident reported falling frequently and not knowing why, and stated that staff followed them everywhere to prevent falls but were unsure what specific interventions were in place. An LPN stated the resident had frequent falls and that interventions included a fall mat at bedside and keeping the resident under close observation, but could not clarify what “close observation” entailed and acknowledged that interventions were communicated verbally rather than being reflected in the care plan. Another LPN stated they relied on the care plan to know fall-prevention interventions and, if not listed, had to depend on other staff for guidance. The MDS coordinator stated all falls, regardless of injury, should result in care plan interventions to prevent recurrence and did not know why this resident’s falls lacked interventions, and the DON confirmed there were no interventions on the care plan for the resident’s falls despite the expectation that such interventions should have been in place. Facility policies reviewed by surveyors underscored the deficiencies. An undated wandering policy stated that the facility would ensure the safety of residents who wander and that the MDS nurse would complete a wandering assessment on admission and work with the care plan team to develop, maintain, and update a care plan for each resident who wanders. A Falls – Clinical Protocol dated 03/2018 stated that staff and the physician would identify pertinent interventions to prevent subsequent falls and address the risks of clinically significant consequences of falling. A Care Plan Completion policy stated the facility would develop a comprehensive person-centered care plan for each resident that includes measurable objectives, timeframes, and services to meet medical, nursing, mental, and psychosocial needs. Despite these policies, the facility did not ensure that the elopement risk assessment for the first resident was communicated and incorporated into the baseline care plan, did not secure exit doors and perimeter fencing to prevent elopement, and did not consistently implement or document individualized fall-prevention interventions for the second resident after multiple falls and two hip fractures.
Failure to Notify Physician and Family of Significant Bleeding Episode in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and family of a significant change in condition. The resident had a history of atrial fibrillation and was on Eliquis, with physician orders and a care plan directing staff to monitor and report signs of bleeding such as blood in urine or stool, black tarry stools, and other symptoms. The resident’s cognition was moderately impaired, with a BIMS score of 11, and they required supervision with ambulation and transfers and partial to moderate assistance with toileting hygiene. The admission contract identified a family member as the emergency contact and POA, with contact information provided. On the night of the incident, staff observed multiple episodes of active bleeding while the resident was on the toilet. Around 1:15 a.m., the resident was on the toilet and bleeding, with the toilet full of blood, and was reported to be screaming that they could not breathe. ACMA staff notified the LPN, left the blood in the toilet for the LPN to observe, and reported that the resident refused to go to the ER. The LPN assessed the resident at approximately 1:32 a.m., documented increased anxiety, complaints of not being able to breathe, and that most of the toilet contents were blood, and noted that the resident refused transfer to the emergency department. The LPN instructed ACMA staff to continue monitoring the resident and did not contact the physician or the family at that time. The resident continued to have episodes of bleeding while on the toilet around 2:00 a.m. and again around 2:50 a.m., with reports of pain, pallor, and shivering, and continued refusals to go to the hospital and to take pain medication. ACMA staff reported they were instructed by text to contact the family to encourage the resident to go to the ER but stated no family contact was listed in the medical record and did not call the physician. EMS was eventually called by ACMA staff when the resident became pale and shivering; EMS arrived to find the resident unconscious on the toilet with evidence of a significant hemorrhagic event in the room, including saturated towels and blood on the floor and on the resident. Progress notes did not show any contact with the physician or family during the change in condition, and the family member later stated they were not notified of the change in condition and did not learn of the resident’s death until several hours later. The facility’s failure to notify the physician and family of the resident’s serious change in condition was cited as an Immediate Jeopardy deficiency.
Failure to Respond to Critical Lab and Acute Bleeding in Anticoagulated Post-Surgical Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess, identify, and intervene when a resident with a recent abdominal aortic aneurysm repair experienced an acute change in condition, including profuse bleeding from an unknown source and a critically low hemoglobin level. The resident had diagnoses including encounter for surgical aftercare following circulatory system surgery and presence of an aortocoronary bypass graft, and was receiving multiple anticoagulant and antiplatelet medications (Eliquis twice daily, aspirin daily, and Plavix daily), along with psyllium and Imodium for diarrhea. Facility policies required nurses to assess acute condition changes, obtain and report pertinent information to the physician, and promptly notify the physician in emergencies, as well as to review and act on lab and diagnostic test results based on the seriousness of abnormalities. The resident’s care plan directed staff to monitor for and report abnormal lab results and signs of bleeding, including black or bloody stools and significant changes in vital signs, and to avoid aspirin use with anticoagulant therapy. A laboratory report for the resident showed a critically low hemoglobin of 6.3 g/dL, with a normal reference range of 13.7–17.5 g/dL. The lab documented attempts to call the facility at 3:35 p.m. and again, with no answer and inability to reach a nurse, and the report was released later that afternoon. The report bore a staff signature dated several days later and a stamped physician signature without a date. The DON confirmed that the physician was not notified of this critical result and stated that the physician should have been notified immediately per facility procedure. Despite the resident’s anticoagulant therapy and care plan instructions to report abnormal labs, there was no evidence that the critical hemoglobin value was communicated to the physician or that any clinical intervention occurred in response to this lab finding. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding while on the toilet, accompanied by screaming, shortness of breath, increased anxiety, and refusal to go to the hospital. An ACMA reported to an LPN around 1:15–1:32 a.m. that the resident was having bloody stool and distress, but the LPN did not immediately assess the resident and instead instructed the ACMA to monitor and convince the resident to go to the hospital. The nursing progress note later documented that the resident’s toilet contents were mostly blood and that the resident was educated about the need to go to the ED but refused. EMS records indicated that when they arrived, the resident’s room showed signs of a significant hemorrhagic event, with towels saturated with blood and blood on the floor, legs, socks, and in the toilet. The nursing documentation showed no ongoing assessment, monitoring, or intervention for the resident’s shortness of breath, screaming, blood in the toilet, or refusal of transfer during the period before EMS was called. The facility’s failure to identify, monitor, and provide continuing assessments for the resident’s change in condition, to notify the medical provider of the critical hemoglobin result, and to promptly notify the provider and intervene for the acute onset of profuse bleeding constituted the cited deficiency. The report also notes that staff interviews revealed gaps in practice and understanding related to change in condition and bleeding. The LPN acknowledged being concerned the resident was “bleeding out” and stated they were traumatized by the amount of blood, yet did not perform an immediate assessment when first notified of bloody stool and pain, relying instead on the ACMA to monitor and attempt to persuade the resident to accept transfer. The LPN further stated they typically remained on one side of the building and did not routinely go to the other side unless needed, and that they did not visually see the resident in distress until later. A CNA reported having seen dark, clumped stool earlier in the week and indicated they had only minimal education on signs and symptoms of bleeding. These documented actions and inactions, in the context of the resident’s high-risk status and existing policies and care plans, led surveyors to determine that the facility failed to provide appropriate treatment and care according to orders, the resident’s condition, and established protocols for change in condition and critical lab results. The resident’s family reported that the resident had ongoing diarrhea with horrendous odor and black color since before admission, and that staff were aware of the stool characteristics. Another CNA described the resident’s stool as dark black and mixed solid/liquid, resembling stool from someone taking iron, though they only observed it once and did not report red blood. The care plan specifically directed staff to monitor for black tarry stools and other signs of bleeding in the context of anticoagulant therapy, and to report such findings to the physician. Despite these documented risk factors, symptoms, and care plan directives, the record lacked evidence that staff recognized and escalated these signs as potential bleeding or that they communicated them to the physician prior to the acute hemorrhagic event. This pattern of missed recognition, lack of timely assessment, and failure to notify the physician of both critical lab results and acute bleeding formed the basis of the deficiency under F684 (Quality of Care).
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Compliance trends in Oklahoma
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Oklahoma
- Restricted access to controlled substances to licensed nurses only (K - F0755 - OK)
- Discontinued CMAs from receiving or administering controlled substances (K - F0755 - OK)
- Implemented end-of-shift dual-signature controlled-substance counts by two licensed nurses (K - F0755 - OK)
- Required narcotic deliveries to be verified against pharmacy delivery receipts and signed into controlled-drug count sheets at receipt (K - F0755 - OK)
- Required delivery receipts to be attached to the unit narcotic packet and routed to the DON by end of shift (K - F0755 - OK)
- Verified controlled-substance storage as double-locked and functional (K - F0755 - OK)
- Re-educated licensed nurses and CMAs on reconciliation, documentation, chain of custody, discrepancy escalation, and reporting expectations (K - F0755 - OK)
Failure to Reconcile and Account for Controlled Narcotics for Two Residents
Penalty
Summary
The facility failed to maintain an effective system for the receipt, disposition, and reconciliation of controlled narcotic medications, resulting in unaccounted controlled drugs for two residents. Facility policy required a system for receipt, storage, administration, counting, reconciliation, investigation of discrepancies, and destruction of all controlled substances, including verification by two authorized staff upon delivery and documentation of the initial count. However, for one resident with chronic pain, hypertension, and major depressive disorder, a pharmacy packing slip showed that 120 oxycodone/APAP tablets were delivered, but count sheets and medication cards for 90 tablets could not be located. The controlled drug count sheet for this resident showed only 30 tablets received and documented 19 administered doses that were not recorded on the MAR. For this same resident, the Medication Log of Receiving did not reflect the oxycodone/APAP delivery, and the MAR for the relevant months showed only three administered doses, while the resident reported they had not taken the medication because they did not like how it made them feel and that the last dose was about two months prior. A CMA reported that their name had been forged on the narcotic count sheet on multiple days and stated the resident had only taken the first dose; this was reported to the administrator. Another CMA confirmed the issue was discovered during a cart count and that it was immediately reported to the administrator. Nursing staff, including an LPN, denied administering narcotics to this resident or signing the count sheet, and pharmacy staff confirmed the full quantity of 120 tablets had been delivered. For a second resident with chronic pain and major depressive disorder, a physician’s order prescribed hydrocodone/APAP three times daily, and a pharmacy packing slip showed 90 tablets were delivered. The Medication Log of Receiving did not show that this delivery was logged, and a count sheet and medication card for 30 tablets were missing. When the resident’s controlled drug count sheets and packing slips for several months were reconciled with the ADON, 30 hydrocodone/APAP tablets were found to be unaccounted for, and the ADON stated there should have been three count sheets for one month but only two were located. The administrator acknowledged the facility had been without a full-time DON for an extended period during the time these discrepancies occurred, and staff interviews indicated that reconciliation practices were limited to matching the count sheet and card, with RNs usually responsible for medication reconciliation.
Removal Plan
- The administrator and DON were in-serviced by the corporate administrator regarding the facility's controlled-substance reconciliation system, including mandatory reporting and record keeping requirements.
- All narcotic deliveries received would be verified against the pharmacy delivery receipt and signed into the controlled drug count sheets by a licensed nurse at the time of receipt.
- Delivery receipts would be attached to the unit's narcotic packet and routed to the DON by end of shift.
- The nurse consultant completed a full-scope audit of all units and verified medication availability for all residents with active orders.
- Access to controlled substances was restricted to licensed nurses only.
- CMAs would no longer receive or administer controlled substances.
- Medication storage for controlled substances was verified as double-locked and functional.
- End of shift dual signature counts by two licensed nurses were implemented.
- All licensed nurses and CMAs were re-educated by the ADON and LPN #4 on reconciliation, documentation, chain of custody, discrepancy escalation, and reporting expectations.
Failure to 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 Enforce Smoking Policy and Supervise Oxygen-Dependent Smoker
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accident hazards related to smoking, resulting in a resident smoking in their room while wearing oxygen and sustaining facial burns. The facility had a written smoking policy stating that residents would not be allowed to have cigarettes, matches, or lighters in their possession or in their rooms, and that no smoking was permitted in resident rooms or hallways. Despite this, the resident was able to obtain and use smoking materials in their room. Staff, including the administrator and DON, acknowledged that housekeeping had previously found ashes on the resident’s toilet seat and that the resident had been reported to have smoked in their room multiple times over a two‑month period. The resident involved had diagnoses including COPD, lung cancer of the right lower lobe, respiratory failure, anxiety, depression, and paranoid schizophrenia, and used oxygen. Assessments showed the resident was cognitively intact with a BIMS score of 15 and was identified as a smoker. A smoking assessment documented on 11/12/25 indicated the resident could safely smoke with minimal supervision, and a subsequent assessment on 02/12/26 noted the resident had been observed hiding a cigarette in their pocket to smoke later, yet still concluded they could safely smoke with minimal supervision. A nurse progress note on 02/12/26 recorded that staff had observed the resident placing a cigarette in their jacket pocket and had educated the resident on the dangers of smoking while wearing oxygen. Despite these documented concerns and prior observations of unsafe smoking behavior, the resident continued to access smoking materials and smoke in their room. A nurse progress note dated 03/03/26 recorded that the resident had smoked in their room the night before while wearing oxygen, resulting in burns to the resident’s face. On observation, the resident was noted to have singed mustache hair and a wound near the upper lip. The administrator reported that the maintenance director later found a lighter under the resident’s bed and that it had been reported the resident had smoked in their room six times between early January and early March. Staff interviews confirmed that residents were not supposed to have smoking materials in their possession and were to be supervised while smoking, but also revealed that there was no guarantee that all lighters and cigarettes had been removed from the resident’s room.
Removal Plan
- Notify Medical Director
- Notify resident #26 hospice provider of IJ and coordinate care
- Complete a new Smoking Assessment for all smokers
- Review and revise the smoking policy with the resident and resident council (with agreement/approval) to include checking for any smoking material at the end of each smoke break; update the policy to include observation of smoking residents to ensure smoking material (e.g., cigarette butts) is distinguished and disposed of and the lighter is returned at the end of smoking times; implement a checklist to ensure each resident has complied; staff supervising smoke breaks will keep the smoking materials container in their possession with only one lighter available and will give each resident only one cigarette at a time; all smoking materials brought in by friends/family will be checked in at the nurse's station
- Post the reviewed/revised smoking policy with resident council approval at the nurses' station and by the exit leading to the smoking area
- Have smoking residents sign the revised smoking policy acknowledging the policy
- Administrator to in-service staff on the revised smoking policy
- Regional supervisor to in-service Administrator/DON on ODHS Form 283 and completing it with adequate supervision of residents and follow-up for accidents/incidents related to smoking and charting interventions and follow-up care
- Update the care plan for resident #26
- Review all smoking residents' care plans and revise as needed for adequate supervision/intervention to prevent accidents/injury and ensure follow-up if an occurrence happens
- Move resident #26 to a room closer to the nurse's station
- Educate resident #26 on hazards of smoking in the room and potential harm due to combustion with oxygen; have resident sign education sheet and upload to the resident EHR under resident documents
- Send all ODHS Form 283 reports to a Regional Supervisor for review for completeness and adequate intervention to prevent reoccurrence and ensure follow-up
- Initiate QAPI for the IJ and monitor implementation of the above interventions for removal of IJ
Fatal Medication Error Due to Failure to Correctly Identify Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically failing to correctly identify a resident before administering medications. A cognitively impaired resident with a history of atherosclerotic heart disease, hyperlipidemia, hypertension, and traumatic brain injury was admitted with orders that included amlodipine 5 mg for hypertension, to be held if systolic blood pressure was less than 115 or heart rate was less than 50. A quarterly assessment documented significantly impaired cognition with a brief mental illness score of 03, use of multiple psychotropic and other medications, and no indication that the resident rejected care. Vital signs taken the morning of the incident showed a blood pressure of 147/76 and pulse of 83 beats per minute. On the morning in question, a CMA administered medications intended for the resident’s roommate to this resident after asking the resident if they were the roommate and accepting the resident’s incorrect verbal confirmation as sufficient identification. The CMA reported being unfamiliar with the residents and relied on the resident’s verbal response rather than using other identification methods such as the photo in the health record, despite the resident’s known cognitive and hearing impairments. As a result, the resident did not receive 11 medications that were prescribed for them and instead received multiple medications prescribed for the roommate, including amlodipine 10 mg, lisinopril 40 mg, and labetalol 300 mg, all ordered with parameters to hold for low systolic blood pressure and/or low heart rate. Shortly after the medication error, nursing notes documented that the resident became diaphoretic, lethargic, pale, cyanotic around the lips, with labored breathing and unresponsiveness. EMS records indicated the facility reported that the resident had been given amlodipine, aldactone, aspirin, baclofen, cyanocobalamin, fluoxetine, glimepiride, labetalol, lamotrigine, lisinopril, metformin, and potassium chloride in error, and EMS found the resident lethargic with sinus bradycardia, shallow respirations, and initiated cardiac arrest protocol. Hospital records showed the resident was treated for having been administered the wrong medications and was diagnosed with hypotension, bradycardia, and asystole, and was pronounced expired later that morning. The medical director stated that labetalol 300 mg administered in error could have caused the resident to expire and that labetalol, amlodipine, and lisinopril all lower blood pressure, and further noted that epinephrine administered by EMS in the presence of labetalol could have caused an acute cardiac event. The resident’s representative stated the resident expired as a result of the medication administration error.
Removal Plan
- Conducted a QAPI meeting where the IDT reviewed the facility’s medication administration policies and procedures to ensure they would keep residents safe
- Provided in-service education by the DON and ADON for all staff administering medications covering medication administration policies and procedures, including correct resident identification during medication pass
- Implemented bi-weekly visual audits of staff administering medications to ensure compliance with medication administration policies and procedures
- Observed staff administering medications to verify they were identifying the correct resident during medication pass
- Verified medication aide certifications
- Completed medication aide skills check-offs
- Reviewed nursing licenses
- Suspended a medication aide
- Observed and interviewed medication aides and nursing staff across multiple shifts to confirm they had the skills and knowledge to correctly identify residents during medication pass and administer medications as prescribed
Failure to Supervise Cognitively Impaired Resident Leading to Elopement and Fatal Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident with known cognitive impairment and wandering risk. A quarterly assessment documented that the resident had moderate cognitive impairment with a BIMS score of 12, and the face sheet listed diagnoses including dementia, diabetes, and psychosis. The resident’s care plan identified the resident as being at risk for wandering. The administrator later stated that this resident had left the facility property approximately three times prior to the incident under investigation. The administrator also stated the facility did not have an alert system and had no policy regarding wandering or elopement. On the day of the incident, nursing documentation showed that at approximately 8:00 p.m. the resident insisted on leaving the facility. A CNA attempted twice to redirect the resident due to it being dark outside, and the nurse educated the resident about the safety concerns of walking in the dark while wearing dark clothing. The resident became agitated, cursed at staff, and then signed themself out of the facility. The nurse attempted to contact the resident’s family by phone, leaving voicemails and receiving no answer. CNA #2 reported seeing the resident sign out, telling the resident it was not a good idea, and then following the resident down the street for an undetermined distance before returning to the facility to care for other residents and informing the nurse. Subsequently, a police department case report documented that the resident was struck by a car, rolled onto the hood, and struck the windshield. An EMS run report showed that CPR was initiated by EMS and a police officer, an automated chest compression device was applied, and the resident was later pronounced deceased at the hospital. Surveyors determined that the facility failed to ensure adequate supervision to prevent elopement for this resident, despite the resident’s known wandering risk and prior episodes of leaving the property. The administrator identified two residents as being at risk for elopement at the time of the survey, and the survey findings concluded that the facility failed to provide adequate supervision to prevent elopements for one of three sampled residents reviewed for accident hazards.
Removal Plan
- Perform updated wandering risk assessments for all residents.
- Relocate any new admission or resident who develops wandering behavior to a facility with wander guard and secured doors or to the resident’s chosen home setting.
- Provide one-to-one supervision for any resident exhibiting wandering behavior until the physician assesses and the family and facility determine a plan.
- If a resident elopes and does not comply with staff direction, call 911 and the family immediately and keep staff with the resident.
- Develop and update individualized care plans for all residents, including interventions for wandering risk.
- Secure facility doors so staff must assist anyone entering or exiting.
- Require family and resident to sign a sign-out form when leaving the facility.
- Educate all staff on the sign-out process and related changes.
- If a resident leaves without signing out, call 911 and the family immediately.
- Change door access codes.
- Post signage instructing visitors to call the facility if no staff are present at the front entrance.
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