Accel At Crystal Park: IV Infection Control Failures - OK
OKLAHOMA CITY, OK. The IV tubing was hanging two to three inches above the floor, open at the end, connected to a bag of a powerful antibiotic, with no date written on it and no protective cap sealing the tip. That is how inspectors found Resident #5's setup at Accel At Crystal Park on the morning of October 7, 2025.
Twenty-two minutes later, a nurse picked up that tubing and connected it directly into the resident's bloodstream.
The resident had a PICC line, a peripherally inserted central catheter that runs from the arm to a large vein near the heart. They were receiving meropenem, an antibiotic used to treat serious bacterial infections, ordered every eight hours in connection with an ulceration on their right leg. The resident had also been flagged for Enhanced Barrier Precautions, a protocol the facility uses specifically to reduce the spread of multidrug-resistant bacteria.
LPN #1, who was five days into her job at the facility, put on gloves and wiped the end of the tubing with an alcohol prep wipe. She wiped the PICC hub with another prep wipe. Then she connected the tubing and started the infusion. She was not wearing a gown.
Two empty meropenem bags sat in the trashcan in the room. So did a white syringe cap and a small amount of clear liquid.
When inspectors spoke with LPN #1 that morning, she said she had set up the antibiotic earlier while the resident was out of the room. Asked about the tubing change schedule, she said she was not sure of the frequency at this facility but thought it was every 24 hours. She confirmed she had not changed the tubing and acknowledged it had no date on it.
Then she said she was not sure whether the resident was supposed to be on Enhanced Barrier Precautions.
Then she said she did not know what Enhanced Barrier Precautions meant.
She did know, when asked directly, that the tubing was supposed to have an end cap for infection control. She explained that the tubing had come with a white syringe cap on it, so she had thrown it away, treating a contamination barrier as disposable packaging.
The facility's own policy on administration set changes, revised in October 2024, required staff to attach a new single-use sterile cap to the end of the tubing after each intermittent use, label the tubing with the date and time it was hung, the date it needed to be replaced, and staff initials, and change the tubing every 24 hours. None of that had been done. The facility's Enhanced Barrier Precautions policy, revised as recently as March 2025, specifically listed central line care as a situation requiring a gown and gloves.
The travelling director of nursing, reached later that day, confirmed that IV tubing used for multiple administrations in a single day needed an end cap and had to be discarded after 24 hours. She confirmed the tubing needed a date, a time, and initials. She confirmed that EBP required both a gown and gloves.
There are 21 residents on Enhanced Barrier Precautions at the facility, the travelling DON told inspectors.
The inspection report rated the violation at the lowest level of harm, minimal harm or potential for actual harm, affecting few residents. But the resident at the center of it was receiving a central line infusion of a broad-spectrum antibiotic for an open wound on their leg, under a precaution protocol designed specifically because multidrug-resistant organisms were a documented concern. The tubing connecting that antibiotic to their heart had been lying near the floor, open, for an unknown period of time before a nurse who did not know the facility's protocols connected it and started the drip.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accel At Crystal Park from 2025-10-16 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Accel At Crystal Park in Oklahoma City, OK was cited for violations during a health inspection on October 16, 2025.
That is how inspectors found Resident #5's setup at Accel At Crystal Park on the morning of October 7, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.