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 who had a physician's order for BIPAP with oxygen at 3 LPM during sleep and naps was repeatedly observed resting in bed without the BIPAP machine in use, and the mask was left on the bedside table. An RN confirmed the resident should have been using the BIPAP during naps, but the order was not followed.
An allegation of abuse involving a resident with dementia and behavioral disturbances was not reported to the state agency within the required timeframe. The administrator conducted an internal investigation but decided not to submit an incident report, resulting in a failure to comply with mandatory reporting policies.
A resident with cognitive impairment and behavioral challenges was physically restrained and verbally antagonized by an agency CNA during care, despite objections from other staff. The CNA pinned the resident's arms behind their back, dragged them to a chair, squeezed their wrist, and encouraged the resident to strike staff. The resident expressed pain and distress during the incident, which was witnessed and reported by other CNAs. The DON confirmed the abusive actions and noted missing orientation documentation for the agency CNA.
A resident with severe cognitive impairment, sharing a room with another resident in isolation for COVID-19, was observed without PPE or isolation signage and was allowed to move freely throughout the facility without a mask. Staff did not intervene or enforce infection control protocols, and no PPE supplies or isolation barriers were present in the room.
A cognitively intact resident with multiple medical conditions was subjected to sexual abuse by a CNA who was unaccounted for during their shift and provided care in an unassigned area. The facility failed to prevent unauthorized staff access and did not adequately supervise staff, resulting in a substantiated incident of sexual abuse.
A resident who was dependent on staff for transfers and required a mechanical lift sustained a femur fracture when the lift sling broke during a transfer. Two staff members were present and reported checking the sling, but there was no documented process for monitoring slings for wear or damage, leading to the use of a defective sling and resulting injury.
Eighteen dietary contract staff members did not receive required abuse prevention and reporting training prior to working, due to an oversight by the dietary contractor and unclear contract terms. The DON and facility leadership confirmed the omission, which affected all dietary contract staff while 141 residents were present.
The facility did not ensure that all dietary contractor staff received required training on abuse prevention and reporting, as mandated by facility policy. Eighteen dietary staff members began working without this training due to an oversight in the contractor's orientation process, leaving 141 residents without the protection of fully trained staff.
A resident with cognitive impairment and multiple diagnoses reported verbal abuse by a CNA. Other staff members indicated they had previously reported the same CNA for similar behavior, but were unsure if those reports were investigated. The facility did not ensure the resident was protected from abuse as required by policy.
A resident with severe cognitive impairment and mental health diagnoses was involved in an incident where a CNA shouted at and antagonized them, as witnessed and reported by multiple staff. Although staff submitted written statements and notified the administrator, no investigation was conducted because the administrator did not consider the incident to be verbal abuse.
Failure to Follow Physician's Order for BIPAP Use During Sleep and Naps
Penalty
Summary
The facility failed to follow a physician's order for respiratory care for one resident who required the use of a BIPAP machine with oxygen at 3 LPM during sleep and naps. On three separate occasions, the resident was observed resting in bed during nap times without the BIPAP machine turned on, and the mask was found on the bedside table rather than in use. The physician's order, dated 07/14/25, specifically required the BIPAP to be used at bedtime and while napping. An RN confirmed that the resident should have had the BIPAP on during naps, indicating the order was not followed as required.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with dementia, behavioral disturbances, hyperlipidemia, anxiety disorder, and migraines to the state agency within the required 2-hour timeframe. According to facility policy, all alleged violations and substantial incidents must be reported to the state agency. On the date in question, a staff member was observed being rough and speaking loudly to the resident while assisting them to a chair. The incident was reported to the facility administrator, who immediately initiated an internal investigation, including a camera review by the corporate office. However, the administrator determined the incident was not reportable and did not submit an incident report to the state agency, resulting in noncompliance with reporting requirements.
Resident Subjected to Physical and Verbal Abuse by Agency CNA
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, non-Alzheimer's dementia, depression, and hoarding disorder was subjected to physical and verbal abuse by a certified nursing assistant (CNA) employed through an agency. The resident, who was known to display verbal and physical behaviors and to reject care, was being assisted by three CNAs to prepare for bed. During the interaction, the resident became combative and grabbed one CNA by the neck. In response, another CNA restrained the resident by pinning their arms behind their back and dragging them to a chair, despite objections from the other staff present. The same CNA also grabbed and squeezed the resident's wrist and verbally antagonized the resident by encouraging them to strike out at staff. Witness statements from the other CNAs present confirmed that the agency CNA repeatedly used physical force to restrain the resident, even after being told to stop by colleagues. The resident was heard yelling for help and expressing pain, and staff noted that the resident's behavior escalated while the agency CNA was present but calmed after the CNA left the room. The incident included both physical restraint and verbal provocation, with the resident being encouraged to hit staff members. The resident initially complained of arm pain but later denied discomfort and refused further assessment. Interviews with the involved CNAs and the Director of Nursing (DON) confirmed that the actions of the agency CNA were considered abusive. The DON stated that the agency CNA had worked at the facility for about a month and that the facility provided orientation materials and abuse prevention training to all staff, including agency personnel. However, the facility was unable to locate the completed orientation packet for the agency CNA involved in the incident.
Failure to Implement Infection Control Measures for COVID-19 Exposure
Penalty
Summary
The facility failed to minimize the risk of spreading infection by not implementing appropriate infection prevention and control measures for a resident exposed to COVID-19. Observation revealed that a resident who shared a room with another resident in isolation for COVID-19 was not provided with or observed using personal protective equipment (PPE) such as masks, gowns, or gloves. There were no isolation signs or PPE supplies at the entrance to the room, and no barriers were present between the two residents. The resident, who was severely cognitively impaired and required supervision for decision-making, was seen leaving the room and walking through common areas without a mask. Staff did not intervene or encourage the resident to wear a mask or return to their room, and staff themselves were not observed wearing isolation masks in the hallway. Record review indicated that the resident had a history of removing isolation signage and PPE supplies from their room, and staff were aware of this behavior. The resident had tested negative for COVID-19 but chose to remain in the room with the COVID-19 positive roommate. Despite being informed of the need to wear a mask when leaving the room, the resident was allowed to move freely throughout the facility without adherence to infection control protocols, and staff did not enforce or support these measures.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from sexual abuse by staff. The incident involved a cognitively intact resident with diagnoses including heart failure, DVT, hypertension, depression, and bipolar disorder. The facility's records indicated that a certified nursing assistant (CNA) was found to be missing from their assigned area for 45 minutes during a shift and was discovered to have been providing care to the resident on a hall where they were not assigned. An investigation substantiated that an oral sex interaction occurred between the CNA and the resident. The failure to ensure the resident's safety and prevent unauthorized staff access led to the substantiated incident of sexual abuse. The facility's lack of adequate supervision and monitoring of staff assignments contributed to the occurrence of the abuse, as the CNA was able to interact with the resident without detection for a significant period of time.
Failure to Monitor and Maintain Lift Equipment Results in Resident Injury
Penalty
Summary
A resident with morbid obesity, who was dependent on staff for all transfers and required a mechanical lift with two staff members for assistance, sustained a femur fracture during a transfer. The incident occurred when staff were transferring the resident post-shower using a Hoyer lift, and the lift sling broke while the resident was suspended, causing the resident to fall to the floor. The resident reported severe pain in the right leg, which was observed to be rotated inward and warm to the touch. Surgery was subsequently performed for the femur fracture. Review of facility records and staff interviews revealed that there was no documentation of routine monitoring or inspection of lift slings for signs of wear, such as frays or holes. Although staff reported that they always used two people for transfers and checked the slings, there was no formal process or documentation in place to ensure the slings were in good repair. The lack of documented monitoring contributed to the use of a defective sling, resulting in the resident's injury.
Failure to Provide Abuse Training to Dietary Contract Staff
Penalty
Summary
The facility failed to ensure that all 18 dietary contract employees received required training on abuse prevention, identification, and reporting prior to working. According to the facility's Abuse Prevention Program policy, mandated staff training on abuse is required for all staff, including contract employees. However, record review and interviews revealed that the dietary contractor was responsible for providing this training but did not include the necessary abuse training in their orientation or supplemental materials for dietary staff. The DON confirmed that the dietary staff had not been trained on identifying and reporting abuse before starting their duties. Interviews with human resources, the regional director of operations, and the administrator indicated that there was confusion regarding the responsibility for abuse training. The facility expected the dietary contractor to provide the training, but the contractor omitted the abuse training supplement. The contract between the facility and the dietary contractor did not clearly specify the requirement for abuse training, leading to the oversight. At the time of the survey, 141 residents resided in the facility, and none of the 18 dietary contract staff had received the mandated abuse training.
Failure to Train Dietary Contractor Staff on Abuse Prevention and Reporting
Penalty
Summary
The facility failed to implement its abuse prevention policy by not ensuring that all dietary contractor staff received training on identifying and reporting abuse. According to the facility's Abuse Prevention Program policy, all staff are required to undergo mandated training on abuse prevention, identification, and reporting. However, record review and interviews revealed that none of the 18 dietary contractor staff members had received this training prior to working in the facility. The dietary contractor was responsible for providing this training, as outlined in the Management Service Agreement, but the abuse training was omitted from the orientation process for these staff members. Interviews with facility leadership, including the DON, human resources, regional director of operations, and the administrator, confirmed that the dietary contractor was expected to provide abuse training to their employees, but this requirement was either overlooked or not included in the contract. As a result, 141 residents resided in the facility without assurance that all staff interacting with them were trained to identify and report abuse, neglect, or mistreatment, as required by facility policy.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a certified nursing assistant (CNA). According to the incident report, a resident with moderately impaired cognition, diabetes mellitus, and anxiety disorder alleged that a CNA was verbally abusive. The resident did not initially report the abuse, but the allegation was later brought to the administrator's attention. Interviews with other staff members revealed that they had previously reported the same CNA for verbal abuse, but were unsure if those reports had been investigated. The facility's abuse policy requires protection from all forms of abuse, but the repeated allegations and lack of clarity regarding prior investigations indicate a failure to ensure residents were free from abuse.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with severe cognitive impairment, anxiety, and depression. Multiple staff members, including a CNA and a CMA, witnessed and documented an incident in which a CNA shouted at the resident, with one staff member reporting that the CNA antagonized the resident who had expressed suicidal thoughts. Staff members wrote statements about the incident and slid them under the administrator's door, and the administrator was also notified via text message. Despite these reports and the facility's policy requiring immediate investigation of all alleged abuse, the administrator did not investigate the incident, stating they did not believe it constituted verbal abuse.
Some of the Latest Corrective Actions taken by Facilities in Oklahoma
- Secured keys for chemical-storage rooms on a separate key chain locked in the Medication Cart to prevent unauthorized access (J - F0689 - OK)
- Initiated facility-wide in-person and telephone in-services for all employees on chemical-storage procedures to reinforce safe handling and storage practices (J - F0689 - OK)
Unsecured Hazardous Chemicals Accessible to Wandering Residents in Memory Care Unit
Penalty
Summary
The facility failed to ensure that hazardous chemicals were secured and inaccessible to residents who wander, particularly in the memory care unit. Surveyors observed three rooms— a clean linen closet, a soiled linen closet, and a whirlpool/shower room— all found unlocked and containing unsecured hazardous chemicals such as disinfectant cleaner, all-purpose cleaner, degreaser, bleach, hand sanitizer, and personal care items labeled to be kept out of reach of children. Keys to these storage areas were found hanging nearby or missing, and staff interviews confirmed that the doors were supposed to be locked but were not, with one LPN noting that a resident had previously taken the key and that keys could not be located. Staff also reported that the cabinet in the shower room had not been locked for approximately one month. A resident with severe cognitive impairment and a diagnosis of dementia was observed wandering and opening the unlocked clean linen closet containing hazardous chemicals. The administrator acknowledged that there was no formal policy regarding chemical storage and assumed it was understood that doors should be locked. The deficiency was identified for 10 of 26 wandering residents in the memory care unit, with 12 rooms in the facility identified as storing hazardous chemicals.
Removal Plan
- Locks on the clean linen room and dirty room have been locked.
- Padlock on the shower cabinet has been replaced.
- Facility has been checked for chemicals.
- Keys to these rooms will be on a separate key chain locked in the Medication Cart.
- In person and telephone in-services were begun on all employees about chemical storage.
- Monitoring will be conducted.
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