Accel At Crystal Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 315 Sw 80th Street, Oklahoma City, Oklahoma 73139
- CMS Provider Number
- 375570
- Inspections on file
- 36
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Accel At Crystal Park during CMS and state inspections, most recent first.
A resident with a new colostomy and complex medical history did not receive prescribed bowel medications or daily assessments of their stoma, leading to a necrotic and odorous stoma that was not promptly addressed. Nursing staff failed to document vital signs, pain, and bowel sounds during the resident's decline, and communication with the physician was delayed. Another resident also lacked required daily skilled assessments, indicating a broader issue with compliance to care protocols.
Two residents, one recently re-admitted after major orthopedic surgery and another admitted with multiple chronic conditions, did not have baseline care plans completed within 48 hours of admission or re-admission. The DON confirmed the absence of these care plans and indicated that nurses were responsible for their completion.
The facility did not fully transcribe and administer hospital discharge medication orders for a resident with multiple diagnoses, omitting key medications at admission. Additionally, another resident did not receive prescribed pain medication as ordered, with several doses held without proper documentation or communication, despite reports of significant pain.
A resident with a PICC line did not have this device included in their care plan, despite documentation of central IV access and a relevant surgical diagnosis. Staff confirmed the PICC line had been present since admission and acknowledged that such devices should be addressed in the care plan, but this was not completed.
A resident receiving IV meropenem for a vascular condition was administered the medication without a specified infusion rate in the physician's order or MAR. An LPN started the infusion at a standard rate without consulting the physician, despite facility policy requiring verification of the infusion rate. The medication bag listed a different rate, which was not initially followed, and the DON confirmed the order was incomplete.
A resident receiving IV antibiotics via a PICC line was observed with uncapped IV tubing hanging near the floor, no date labeling, and improper use of personal protective equipment by an LPN who did not wear a gown as required under Enhanced Barrier Precautions. The LPN was unfamiliar with EBP protocols and did not replace the end cap after discarding it, contrary to facility policy. The DON confirmed these actions did not meet infection control standards.
A resident with end-stage renal disease and legal blindness reported feeling intimidated and verbally abused by a CNA, but the incident was not reported to the Abuse Coordinator within the required two-hour timeframe. The resident's family member also expressed concerns about the staff's behavior. The administrator only learned of the incident the next day through clinical notes, highlighting a failure to follow the facility's abuse policy.
A resident with acute respiratory failure received a nebulizer treatment without staff supervision, contrary to facility policy. The oxygen concentrator was set at 3.5 liters per minute instead of the ordered 2 liters. The LPN admitted to managing multiple treatments simultaneously and not staying with the resident, and could not provide documentation for the oxygen discrepancy. The DON confirmed the resident was not assessed to self-administer the treatment.
A facility failed to document post-dialysis care for a resident with end-stage renal disease. The facility's policy required nurses to complete post-dialysis sections of communication forms, including vital signs and assessments. However, forms for two dates lacked this documentation. The resident confirmed that staff did not take their vital signs or assess them before or after dialysis. An LPN and the DON acknowledged the missing documentation.
A medication error occurred when a resident with hypothyroidism received their prescribed levothyroxine dose at 9:10 a.m. instead of the ordered 5:00 a.m. The error was identified when a CMA, after being informed by an outgoing nurse that all medications had been given, noticed the levothyroxine was missed and administered it late. An LPN confirmed the error, and the DON notified the resident's physician.
A resident with a scheduled toileting program was not assisted in a timely manner despite activating the call light. The resident expressed the need to urinate, but staff, including the DON, failed to promptly address the call light and inquire about the resident's needs, resulting in a delay in care.
A facility failed to obtain admission and weekly weights for a dialysis resident, as required by their weight monitoring policy and physician orders. The resident, who has end-stage renal disease, had only one weight recorded despite orders for weekly monitoring. Interviews with staff confirmed the deficiency, with an LPN acknowledging the lack of documentation in the EHR.
A facility failed to implement a fluid restriction for a resident with chronic kidney disease and pulmonary edema, as specified in the hospital's discharge orders. The resident's fluid restriction status was unclear to staff, and no fluid restriction orders were present in the resident's records. A water pitcher with 700 ml of fluids was observed at the bedside, and staff confirmed the oversight in entering the hospital orders upon admission.
A facility failed to administer a prescribed topical pain medication to a resident with a diagnosis of pain. The physician's order required Voltaren arthritis pain 1% topical gel to be applied every 12 hours to the resident's right knee. However, the MAR indicated the medication was not given on multiple occasions, marked with an 'x' and noted as 'due to special parameters,' without explanation. Interviews with the resident, a family member, and staff confirmed the medication was not administered, and the DON acknowledged the issue.
The facility failed to implement infection control measures, including enhanced barrier precautions and proper hand hygiene, during wound and incontinent care. Staff did not change gloves or sanitize hands between tasks, leading to potential cross-contamination. The facility's policies were not consistently followed, as observed in the care of multiple residents with pressure ulcers and other conditions.
A resident with acute respiratory failure and other conditions experienced significant drops in oxygen saturation levels, but the facility failed to notify the physician as required. Despite interventions to stabilize the resident, documentation showed no evidence of physician notification, which was confirmed by the DON and family member.
The facility failed to protect two residents from the misappropriation of their controlled medications. One resident with a fracture and low back pain and another with hip and back pain were affected when their prescribed pain medications were found missing. The DON discovered the issue when the medications were not available despite being received from the pharmacy. An LPN was suspended pending investigation, and the facility determined that 60 tablets of each medication were missing.
A facility failed to obtain physician-ordered vital signs for a resident with acute respiratory failure and other conditions. The order required vital signs every two shifts, but records showed missing entries for several nights, indicating they were not taken. The DON confirmed the oversight, noting the presence of new nurses and the resident's short stay.
A resident with a sacral pressure ulcer did not receive wound care as ordered by the physician. The LPN applied a xeroform and foam bordered dressings instead of following the prescribed regimen of cleansing with normal saline, packing with mesalt, and using a nonbordered dressing. The LPN admitted to not following the orders, citing their own knowledge from nursing school. The DON stated that staff should perform an initial skin assessment and follow wound care orders upon a resident's admission.
A resident with acute respiratory failure experienced inadequate oxygen therapy management when staff increased oxygen flow to 10 LPM without a physician's order, contrary to the prescribed 3 LPM. Family members expressed concerns about the facility's response to the resident's breathing difficulties, and the DON acknowledged the need for staff to contact the physician when oxygen saturation dropped.
A facility failed to provide showers in a timely manner for a resident with a fracture and muscle atrophy, as per the care plan and physician orders. The resident was supposed to receive baths twice a week, but documentation showed only two instances of bathing during a two-week stay. Interviews with staff revealed missing documentation and a lapse in following established procedures for shower assignments.
A dirty bedside commode was found in the hallway, contrary to infection control protocols, as confirmed by two CNAs. The administrator acknowledged the oversight, noting it should have been stored in the dirty utility closet. Other unattended items were also observed in the hallway.
The facility failed to investigate abuse allegations for two residents. One resident with severe quadriplegia reported feeling unsafe and had their call light moved away by staff, while another resident with bacterial pneumonia reported feeling unsafe depending on the staff. The Administrator admitted to not addressing these issues in a timely manner.
The facility failed to provide adequate staff to ensure timely administration of medications for two residents. One resident with chronic pain received oxycodone-acetaminophen late multiple times, while another resident received gabapentin and a Lidocaine patch late on several occasions. Staff interviews indicated that the heavy workload and insufficient staffing contributed to the delays.
The facility failed to ensure timely administration of medications for two residents. One resident with chronic pain received oxycodone-acetaminophen late multiple times, while another resident with pain received gabapentin and a Lidocaine patch late on several occasions. Staff interviews confirmed frequent delays in medication administration, and the DON acknowledged the issue.
A resident with depression requested their entire medical record but did not receive it in a timely manner. Despite completing the necessary paperwork, the request took significantly longer than the typical three to four days, and the records were not released because the resident was no longer in the facility and there was uncertainty about payment.
The facility failed to resolve a resident's grievance regarding not receiving pain medication during the night as per their grievance policy. The resident reported the issue, but there was no documentation of resolution, and the Administrator confirmed the absence of an official timeframe for resolving grievances.
The facility failed to ensure care plan fall interventions were in place for a resident with a femur fracture. The resident's call light was observed out of reach on multiple occasions, and staff confirmed it was not accessible, contrary to the care plan's requirements.
Failure to Follow Physician Orders and Perform Timely Colostomy Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that physician orders were followed for medication administration and colostomy care, resulting in a resident not receiving timely intervention for a new stoma that became necrotic. The resident, who had a history of volvulus, heart failure, and chronic kidney disease, was admitted with a pink, patent, and protruding ostomy. Physician orders included medications such as Colace and polyethylene glycol for bowel management, as well as daily colostomy care and assessments. However, documentation revealed that the resident did not receive the ordered Colace, and there was no evidence that daily assessments of the colostomy site, stoma, and bowel sounds were performed as required. The resident experienced ongoing pain, nausea, and changes in condition, including a black, necrotic, and odorous stoma, which was not promptly addressed. Nursing notes indicated that the resident's condition deteriorated, with symptoms such as slurred speech, bleeding from the stoma, and abdominal distention. Despite these changes, there was a lack of comprehensive assessment and documentation, including vital signs, pain assessment, and bowel sound evaluation at critical times. Communication with the physician was delayed, and the facility did not demonstrate a sense of urgency in responding to the resident's declining condition. Further review showed that other residents also experienced lapses in daily skilled assessments, as required by facility policy. For example, another resident with multiple diagnoses did not have daily skilled notes or assessments completed for several days. Interviews with staff confirmed that assessments were expected but not consistently performed or documented. These failures contributed to the deficient practice of not providing appropriate treatment and care according to physician orders and resident needs.
Removal Plan
- Audit of current residents inhouse was performed to ensure stoma is patent and healthy appearing
- Stoma site will be evaluated daily with care on the treatment record
- DON/designee will provide education to all clinical staff on completion of colostomy care, evaluation, and documentation on the treatment record
- The Administrator/designee will be responsible for the implementation of the New Process
- The New Process/system will be started and no licensed staff will be able to return to work until they complete the above stated education
Failure to Complete Baseline Care Plans Upon Admission or Re-admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed for two of nine sampled residents upon admission or re-admission. For one resident who was re-admitted following major orthopedic surgery, there was no documentation of a baseline care plan being completed at the time of re-admission, as confirmed by the Director of Nursing (DON) who was unable to locate the required documentation. Another resident, admitted with diagnoses including diabetes, hypertension, and gait and mobility abnormalities, also did not have a baseline care plan completed upon admission. The DON confirmed that this resident did not have a baseline care plan and stated that nurses were responsible for completing these plans at the time of admission.
Failure to Transcribe and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that hospital discharge medication orders were fully transcribed and administered as ordered for one resident, and failed to administer medications as ordered for another resident. In the first case, a resident admitted with diagnoses including volvulus, heart failure, and chronic kidney disease had a hospital discharge summary listing several medications, including Lasix and Colace. Upon review, it was found that while most medications were ordered by the facility, Lasix and Colace were not ordered at admission as required. The Director of Nursing (DON) confirmed that these medications should have been ordered and that the facility's process involves initialing orders and having them checked by the DON or assistant DON. In the second case, a resident with diabetes, hypertension, and mobility issues had a physician's order for Lortab to be given every six hours for pain. The medication administration record (MAR) showed that several doses were held, some without documented reasons, even when the resident reported significant pain. Staff interviews revealed that medications were sometimes held due to unavailability or other undocumented reasons, and there was no evidence of communication with the pharmacy or physician regarding the missed doses. The DON stated that staff should notify the physician if medications are held for reasons not specified in the orders.
Failure to Develop Care Plan for PICC Line Use
Penalty
Summary
The facility failed to ensure that a resident with a peripherally inserted central catheter (PICC) line had an appropriate care plan in place to address the use and management of the PICC line. Observation on 10/07/25 confirmed the presence of a PICC line in the resident's right arm. The resident's 5-day PPS scheduled assessment documented central IV access and a diagnosis of major orthopedic surgery, but the care plan revised on 09/08/25 did not include any documentation regarding the PICC line. Interviews with the RN and MDS coordinator confirmed that the resident had a PICC line since admission and that all PICC lines should be included in the care plan, but this was not done for this resident.
Failure to Administer IV Medication as Ordered Due to Missing Infusion Rate
Penalty
Summary
A deficiency occurred when a resident with a history of atherosclerosis of the right leg with ulceration was ordered to receive intravenous meropenem every eight hours. The physician's order and the medication administration record did not specify the rate of infusion for the antibiotic. During observation, an LPN initiated the infusion at a rate of 125ml/hr, based on routine practice rather than a specific order. The medication bag itself indicated a rate of 100ml/hr, but the LPN did not initially follow this rate and did not contact the physician to clarify the appropriate infusion rate prior to administration. The facility's policy required nurses to verify that the medication label matched the prescriber's order, including the infusion rate, and to contact the physician if the rate was not specified. Both the LPN and the DON acknowledged that the rate should have been confirmed with the physician before administration. The DON also confirmed that the order lacked the required infusion rate and emphasized the importance of this information for safe medication administration.
Failure to Follow Infection Control Protocols During IV Therapy
Penalty
Summary
The facility failed to properly handle intravenous (IV) tubing and follow evidence-based protocols during IV medication administration for a resident with a peripherally inserted central catheter (PICC) line. Observations revealed that the IV tubing was left without an end cap and was hanging 2 to 3 inches above the floor, connected to a new bag of meropenem, with no date labeled on the tubing. Two empty medication bags and a syringe cap were found in the trash, and the tubing was not dated as required by facility policy. During the administration of the IV medication, the LPN did not wear a gown as required under Enhanced Barrier Precautions (EBP) and was unsure about the frequency of IV tubing changes or the meaning of EBP. The LPN also admitted to discarding the original end cap and not replacing it, leaving the tubing uncapped. The resident involved had a diagnosis of major orthopedic surgery and a physician's order for meropenem IV infusions related to atherosclerosis with ulceration. The facility's policies required that intermittent administration sets used more than once in 24 hours be capped with a sterile end cap, labeled with date and time, and changed every 24 hours. The Director of Nursing confirmed that the observed practices did not align with facility policy, as the tubing should have been capped, dated, and the staff should have worn both gown and gloves for EBP. The LPN's lack of knowledge regarding EBP and proper IV tubing handling contributed to the deficiency.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement its abuse policy and report an incident of alleged abuse in a timely manner, as required by their policy. The incident involved a resident with end-stage renal disease and legal blindness, who reported feeling intimidated and verbally abused by a CNA. The resident's family member also expressed concerns about the staff's behavior, which they perceived as abusive. The facility's policy mandates that any suspected abuse be reported to the Abuse Coordinator within two hours, but this was not done. The incident began when the resident requested pain medication, and there was a delay in receiving it. The resident reported that the CNA became rude and made derogatory comments about their eyes and family. The situation escalated when the resident's family member called the facility, upset about the alleged intimidation and verbal abuse. The family member reported the incident to the charge nurse, who did not immediately report it to the Abuse Coordinator as required by the facility's policy. The administrator was only made aware of the incident the following morning after reading the clinical notes, rather than being informed directly by the staff. The charge nurse involved did not perceive the incident as abuse but rather a misunderstanding, and allowed the CNA to continue working with other residents. This failure to report the incident promptly and follow the facility's abuse policy resulted in a deficiency being cited by the surveyors.
Failure in Supervision and Administration of Respiratory Care
Penalty
Summary
The facility failed to ensure proper administration and supervision of respiratory care for a resident, specifically in the administration of oxygen and nebulizer treatments. The resident, who had a diagnosis of acute respiratory failure, was observed receiving a nebulizer treatment without staff supervision, contrary to the facility's policy which requires staff to remain with the resident unless they are assessed and authorized to self-administer. The resident was unsure of the time the treatment was administered and had to turn off the nebulizer themselves, indicating a lack of supervision. Additionally, the oxygen concentrator was set at 3.5 liters per minute, which was not in accordance with the physician's order of 2 liters per minute. The LPN responsible for the resident's care admitted to administering multiple nebulizer treatments simultaneously and not being able to stay with the resident during the treatment. The LPN also acknowledged that the resident's oxygen was set higher than the ordered amount and could not provide documentation to support any communication with the provider regarding this discrepancy. The DON confirmed that staff were expected to follow physician orders and remain with residents during nebulizer treatments, and that the resident had not been assessed to self-administer the treatment.
Failure to Document Post-Dialysis Care
Penalty
Summary
The facility failed to ensure that dialysis communication forms were consistently filled out for a resident with end-stage renal disease who required dialysis services. The facility's Dialysis-Hemodialysis policy required community nurses to complete specific sections of the communication form post-dialysis, including vital signs and an assessment of the resident. However, for two separate dates, the forms for a resident were missing documentation in the post-dialysis section. The resident confirmed that staff did not take their vital signs or assess them before or after returning from dialysis. An LPN acknowledged the absence of documentation, and the DON verified the missing forms and confirmed the resident's statement.
Medication Administration Error Leads to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 7.14% error rate during a medication administration observation. The deficiency involved Resident #142, who had a diagnosis of hypothyroidism and was prescribed levothyroxine 200 mcg and 25 mcg tablets to be taken together at 5:00 a.m. On the date of observation, the medication was administered at 9:10 a.m., which was not in accordance with the physician's orders. The facility's Medication Administration policy requires medications to be administered as prescribed and within 60 minutes of the scheduled time, except for specific meal-related orders. The error occurred when CMA #1 prepared and administered the medication at 9:01 a.m., after being informed by an outgoing agency nurse that all medications due had been given. However, upon observation, the CMA noticed the levothyroxine had not been administered and proceeded to give it to the resident. LPN #2 confirmed that the medication was not administered according to the physician's orders and acknowledged the error. The Director of Nursing (DON) was informed of the incident and notified the resident's physician and nurse practitioner, but no new orders were received.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance to Resident #142, who had a care plan in place to reduce incontinent episodes through a scheduled toileting program. On the morning of January 14, 2025, Resident #142 expressed the need to urinate to CMA #1, who activated the call light and left the room. Despite the call light being on and beeping, it was not addressed promptly by the staff. Observations noted that both CMA #1 and LPN #2 were present in the hallway, and the wellness director passed by the room without responding to the call light. The Director of Nursing (DON) eventually entered the room, turned off the call light, but did not inquire about the resident's needs. The resident later confirmed they were still waiting to use the urinal. The DON acknowledged the oversight and arranged for CNA #4 to assist the resident. The delay in responding to the call light and addressing the resident's toileting needs resulted in the resident's needs not being met in a timely manner, as confirmed by the DON.
Failure to Obtain Weekly Weights for Dialysis Resident
Penalty
Summary
The facility failed to ensure that admission and weekly weights were obtained for a resident on dialysis, identified as Resident #21. The facility's weight monitoring policy, reviewed in May 2023, requires newly admitted residents to be weighed upon admission and weekly for four weeks, then monthly unless otherwise indicated by a physician's order. Resident #21, who was admitted with end-stage renal disease and dependence on dialysis, had a physician order dated December 28, 2024, specifying weekly weights every Wednesday on day shift for 28 days on admission, then weekly for four weeks, and monthly if stable. However, the resident's weight record showed only one weight recorded on January 1, 2025. Interviews with the resident, a CNA, and an LPN revealed that the weekly weights were not conducted as ordered, with the LPN acknowledging that only one weight was documented in the electronic health record (EHR).
Failure to Implement Fluid Restriction for Resident
Penalty
Summary
The facility failed to follow a discharge hospital order for a fluid restriction for one resident with chronic kidney disease and pulmonary edema. The hospital's After Visit Summary specified a fluid restriction of no more than 2000 milliliters in a 24-hour period, but the resident had no fluid restriction orders upon admission to the facility. The resident reported that staff were unsure about their fluid restriction status, and a water pitcher with 700 ml of clear fluids was observed at the bedside. A CNA stated that they would be informed by nurses if a resident was on a fluid restriction, but there was confusion about the resident's status. An LPN confirmed that there was no order for a fluid restriction in the resident's records. The ADON acknowledged that the resident should have been on a fluid restriction and identified an oversight in entering the hospital orders upon admission.
Failure to Administer Topical Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a topical pain medication was administered as ordered for a resident diagnosed with pain. The physician's order specified the application of Voltaren arthritis pain 1% topical gel every 12 hours to the resident's right knee. However, the Medication Administration Record (MAR) for January 2025 documented that the medication was not administered on several occasions, marked with an 'x' and noted as 'due to special parameters,' without any explanation provided for these parameters. During interviews, the resident stated they had not received any topical medication for their knee, and a family member confirmed they had never seen staff apply any pain cream. An LPN and the Director of Nursing (DON) reviewed the MAR and confirmed the medication was not administered, with the DON indicating that the 'x' meant the medication was not given and that the 'due to parameters' could be related to vital signs. The LPN also admitted to not administering the topical pain gel during the resident's current stay.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to implement its infection prevention and control program effectively, as evidenced by multiple deficiencies observed during wound care and incontinent care. Specifically, the facility did not adhere to its enhanced barrier precautions policy for a resident with a pressure ulcer. The staff did not use gowns and gloves as required for direct patient care, and there was no use of normal saline to clean the resident's wound, contrary to the physician's orders. Additionally, the facility did not ensure proper hand hygiene and glove use during incontinent care for several residents. Staff members were observed not changing gloves or washing/sanitizing their hands when transitioning from dirty to clean tasks. This was noted during the care of multiple residents, where staff continued to perform tasks and handle items without changing gloves or sanitizing hands, leading to potential cross-contamination. The facility's policies on hand hygiene and perineal care were not followed, as staff failed to wash or sanitize their hands after providing care to one resident and before assisting another. This was observed in several instances, including when staff moved between residents and handled personal items and equipment without proper hand hygiene. The Director of Nursing and other staff members acknowledged the expected procedures, but these were not consistently practiced, resulting in the identified deficiencies.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician when a resident experienced a change in condition, specifically regarding oxygen saturation levels. The resident, who had diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase, was admitted for a skilled stay related to orthopedic aftercare for cervical stenosis. On one occasion, the resident removed their oxygen, leading to a significant drop in oxygen saturation to 76%, prompting a family member to request hospital transfer. The staff responded by increasing the oxygen flow, stabilizing the resident's condition, but did not notify the physician of the incident. Further documentation revealed another instance where the resident's oxygen saturation was recorded at 86%, yet again, there was no evidence of physician notification. Interviews with the family member and the Director of Nursing (DON) confirmed these events, with the DON acknowledging that staff should have contacted the physician when the resident's oxygen levels dropped. The facility's policy required documentation of physician notification in such cases, which was not adhered to, leading to the deficiency.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, affecting two residents who were reviewed for this issue. Resident #8, with diagnoses including an unspecified fracture of the shaft of the left fibula and low back pain, had a physician's order for hydrocodone 10 mg - acetaminophen 325 mg to be administered every four hours as needed for pain. Resident #9, with diagnoses including low back pain and pain in both hips, had a physician's order for acetaminophen 300 mg - codeine 30 mg to be administered every six hours as needed for low back pain. Both residents were affected by the misappropriation of their prescribed pain medications. The incident was identified when the Director of Nursing (DON) discovered that the pain medications for these residents were not available, despite having been received from the pharmacy. An investigation revealed that the medications were missing, and LPN #1, who was the receiving staff member, was suspended pending further investigation. The facility determined that 60 tablets of hydrocodone 10 mg - acetaminophen 325 mg and 60 tablets of acetaminophen 300 mg - codeine 30 mg were missing. The medications had to be reordered, and the facility conducted a search and staff interviews to address the issue.
Failure to Obtain Physician-Ordered Vital Signs
Penalty
Summary
The facility failed to ensure that physician-ordered vital signs were obtained for a resident who was being monitored for a change in condition. The resident had diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase. A physician order dated June 24, 2024, required vital signs to be checked every two shifts, including systolic and diastolic blood pressure, pulse, respirations, temperature, and O2 saturation. However, the medication administration record for June 2024 showed blanks for the night shift vital signs on the 26th, 28th, and 30th, indicating that these vital signs were not obtained. The Director of Nursing (DON) confirmed that the absence of recorded vital signs meant they were not taken and noted that the facility had several new nurses and the resident was not at the facility for long.
Failure to Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered for a resident with a sacral pressure ulcer. The resident was admitted with a physician's order to cleanse the wound with normal saline, pat dry, pack with mesalt, cover with a nonbordered dressing, and secure with tape, to be changed daily and as needed. However, during an observation, it was noted that the wound was not cleaned with normal saline, was not packed with mesalt, and a nonbordered dressing was not used. Instead, an LPN applied a xeroform and two foam bordered dressings over the resident's coccyx, which did not align with the physician's orders. The LPN involved admitted to not following the physician's orders, stating they used their own knowledge from nursing school to decide on the wound care. The LPN also mentioned that the resident's dressing had come off earlier in the shift and that they attempted to get an order for wound care. The Director of Nursing (DON) stated that when a resident is admitted with a wound, staff are expected to perform an initial skin assessment and follow any existing wound care orders. If no orders are present, staff should contact the provider to obtain them. The failure to adhere to the prescribed wound care regimen resulted in a deficiency in the care provided to the resident.
Inadequate Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure oxygen therapy was consistent with professional standards of practice for a resident who had diagnoses including acute respiratory failure with hypoxia, cervical disc disorder with myelopathy, and dysphagia oropharyngeal phase. A physician order indicated the resident was to receive three liters per minute (LPM) of oxygen via nasal cannula. However, a nurse note documented an incident where the resident removed their oxygen, leading to a significant drop in oxygen saturation to 76%. In response, staff increased the oxygen flow to 10 LPM without obtaining a physician's order, which was not in accordance with the prescribed treatment plan. Family members reported concerns about the resident's breathing difficulties and the facility's response. They noted instances where the resident's oxygen saturation dropped significantly, and they had to intervene by increasing the oxygen flow themselves. The Director of Nursing (DON) acknowledged the situation and stated that staff should have contacted the physician when the resident's oxygen saturation dropped. The DON also reviewed the nurse note and could not explain the charting of 'hyperventilate,' indicating a lack of clarity and adherence to proper procedures in managing the resident's oxygen therapy.
Failure to Provide Timely Showers According to Care Plan
Penalty
Summary
The facility failed to provide showers in a timely manner and according to the plan of care for a resident with diagnoses including a fracture of the lower end of the left femur and muscle atrophy. The facility's Bathing policy, revised in January 2023, required staff to provide bathing services within standard practice guidelines and document the procedure. A Self-Care Deficit care plan initiated in January 2024 indicated the resident would assist with bathing and hygiene daily over the next 90 days. A physician order from January 2024 specified the resident was to receive baths on Tuesdays and Fridays. However, during a two-week stay, documentation showed that a bath or shower was only offered on two occasions. Interviews with facility staff revealed that showers should be given twice a week, but documentation to support this was missing. The Assistant Director of Nursing (ADON) confirmed the lack of documentation, and the Director of Nursing (DON) stated that shower assignments are listed on daily assignment sheets, which were not located for the relevant time frame. The regional nurse mentioned that orders for baths should be entered at admission and checked the next business day, indicating a lapse in following the established procedures.
Improper Storage of Dirty Bedside Commode
Penalty
Summary
The facility failed to ensure proper storage of a dirty bedside commode, leading to a potential risk of cross-contamination among residents. On May 21, 2024, a dirty bedside commode with a yellow-orange substance was observed in the hallway outside a resident's room. This was contrary to the statements of two CNAs who confirmed that bedside commodes should be sterilized between uses and never stored in the hallway. Additionally, other items such as an IV pole with a blue baseball cap, a red cane, and wheelchair footrest attachments were also left unattended in the hallway. The administrator acknowledged that the commode should have been taken to the dirty utility closet for proper handling, indicating a lapse in staff adherence to infection control protocols.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were investigated for two residents. Resident #5, who had severe quadriplegia, reported feeling unsafe and disrespected by night staff. A grievance was filed by the resident's family, stating that staff had moved the call light away from the resident, who had limited use of their extremities. Despite these reports, there was no documentation that the allegations had been investigated. The Social Services Director (SSD) confirmed that the grievance was reported to the Administrator, who acknowledged the issue but had not addressed it in a timely manner. Resident #6, diagnosed with bacterial pneumonia, also reported feeling unsafe depending on the staff. This concern was documented in a Safe Survey, but again, there was no documentation that the allegation had been investigated. The SSD confirmed that the Safe Surveys were given to the Administrator, who admitted to not catching the issues sooner and failing to investigate the allegations promptly. The Administrator acknowledged that the failure to investigate these allegations was a problem and confirmed that the allegations had not been reported and investigated in a timely manner.
Failure to Provide Adequate Staffing for Timely Medication Administration
Penalty
Summary
The facility failed to provide adequate staff to ensure timely administration of medications for two residents. Resident #2, who had chronic pain, was prescribed oxycodone-acetaminophen to be taken every four hours. However, the medication was administered late multiple times between 12/08/23 and 12/22/23. Similarly, Resident #5, who also had pain, was prescribed gabapentin three times a day and a Lidocaine patch to be applied in the morning and removed in the evening. The resident received both medications late on several occasions between 12/01/23 and 12/27/23. Interviews with staff revealed that medications and treatments were often administered late due to a heavy workload and insufficient staffing.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure medications were administered timely for two residents reviewed for medications. Resident #2, who had a diagnosis of chronic pain, was prescribed oxycodone-acetaminophen 5 mg every four hours from 12/08/23 to 12/22/23 and 7.5 mg every four hours from 12/14/23 to 12/22/23. The medication administration record (MAR) showed that Resident #2 received the medication late multiple times. Similarly, Resident #5, who had a diagnosis of pain, was prescribed gabapentin three times a day and a Lidocaine patch to be placed in the morning and removed in the evening. The MAR indicated that Resident #5 received gabapentin and the Lidocaine patch late on several occasions. Interviews with staff confirmed that medications and treatments were often administered late, and the Director of Nursing (DON) acknowledged the delays after reviewing the administration times.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to ensure that residents had the right to view or receive copies of their clinical records. This deficiency was identified for one resident out of three reviewed. The resident, who had a diagnosis of depression, requested their entire medical record using the Oklahoma Standard Authorization To Use Or Share Protected Health Information form. Despite completing the necessary paperwork on 12/11/23, the resident did not receive their records in a timely manner. The Social Note dated 12/13/23 documented that the resident was informed they had to fill out the paperwork, which would then be submitted to corporate for processing before the records could be released. On 12/28/23, the medical records personnel confirmed that the resident's request was submitted on 12/11/23, but approval to release the records was not received until 12/26/23. The records had not been released because the resident was no longer in the facility, and there was uncertainty about the payment for the records. The medical records personnel stated that the timeframe for releasing records varied based on the size of the file and corporate processing times, typically taking three to four days. However, the resident's request took significantly longer, indicating a failure to comply with the policy and ensure timely access to medical records.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure the resolution of grievances for one of three sampled residents reviewed for grievances. The facility's grievance policy, dated 01/12/20, stated that residents would be informed of the findings of the investigation and the actions taken to correct any identified problems within three working days of filing the grievance. However, a grievance dated 12/21/23 documented that a resident reported not receiving pain medication during the night when requested and that the night shift ignored them. There was no documentation that the grievance had been resolved. The resident confirmed on 12/27/23 that they did not receive pain medication timely and had informed staff about their complaints. The Administrator stated that any staff could input a grievance in the EHR and that there was no official timeframe for resolving grievances, indicating a lack of adherence to the facility's grievance policy.
Failure to Ensure Call Light Accessibility for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure care plan fall interventions were in place for one of three sampled residents reviewed for falls. Resident #3, who had a diagnosis including a fracture of an unspecified part of the right femur, was observed with the call light out of reach on multiple occasions. On one occasion, the resident was observed looking for the call light and stated they did not know where it was. When asked, RN #3 also could not initially locate the call light and confirmed it was not within the resident's reach. The DON and other staff members acknowledged that ensuring call lights are within reach is a key measure to prevent falls, but this was not adhered to in the case of Resident #3.
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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.
A resident with a history of circulatory surgery, an aortocoronary bypass graft, and on anticoagulant therapy experienced an acute onset of profuse rectal bleeding and shortness of breath during a night shift. An ACMA was functioning as charge on one hall while an LPN covered the other hall; the ACMA reported the resident’s bleeding and distress, and the LPN came once to the room but did not provide ongoing assessment or monitoring, later stating they were behind on work and relying on the ACMA to monitor. EMS later found the room with evidence of a significant hemorrhagic event and the resident unconscious on the toilet. Progress notes lacked documentation of significant change in condition, assessments, or interventions for the bleeding and respiratory distress, and the facility failed to notify the medical provider of a critical Hgb of 6.3 or of the acute bleeding. The facility also could not produce annual competency records for the LPN or ACMA, and the resident’s family was not notified of the change in condition or death until later.
A resident with a history of abdominal aortic aneurysm repair and on anticoagulant therapy had a critically low Hgb on lab testing, but the lab’s critical results were not successfully communicated to a nurse and the physician was not notified. Later, the resident developed anxiety, SOB, screaming, and profuse rectal bleeding while on the toilet. An LPN was notified of these symptoms and received a photo showing a large amount of blood but did not perform an assessment or ongoing monitoring, relying instead on an ACMA despite acknowledging this was not standard procedure. There was no documentation of a significant change in condition or interventions in the progress notes. EMS was eventually called and found evidence of a major hemorrhagic event in the room before transporting the resident, and the incident was identified by the regional nurse consultant as neglect.
Surveyors found multiple food safety deficiencies involving approximately 80 residents, including unlabeled and undated stored food items, and an ice machine with visible pink and brown residue on the chute above the ice. The dietary manager acknowledged that food should be labeled and noted visible dirt when wiping the ice machine. A cook was observed preparing pureed food with one gloved and one ungloved hand, using the same gloved hand to handle both ready-to-eat food and kitchen surfaces without changing gloves or performing hand hygiene until after taking equipment to the dishwasher. The DON reported there was no policy for food storage or ice machine maintenance, and only prior-year invoices were available to show servicing of the ice machine, with no recent documentation provided.
A resident with moderately impaired cognition who required partial to moderate assistance with ADLs expired in an ambulance, but staff documentation did not accurately reflect the resident’s status. A nursing progress note describing severe anxiety, complaints of inability to breathe, and blood in the toilet was entered without being identified as a late entry. Task logs showed ADL assistance documented as completed after the resident’s death, instead of being marked as not available or not applicable. Staff interviews confirmed that tasks should not be documented as completed when a resident is no longer in the facility or has died, indicating a failure to follow the facility’s nursing documentation policy.
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).
Failure to Assess, Monitor, and Notify Provider for Resident With Profuse Bleeding and Critical Lab Value
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and competent nursing staff to assess, monitor, and intervene for a resident with a known high-risk medical history who experienced an acute onset of profuse bleeding. The resident had a history of surgical aftercare following surgery on the circulatory system, including the presence of an aortocoronary bypass graft, and was receiving anticoagulant therapy (Eliquis) for atrial fibrillation. The resident’s care plan and physician orders directed staff to monitor for specific signs of bleeding and adverse reactions to anticoagulant therapy, such as blood in the stool or urine, changes in mental status, shortness of breath, and other symptoms. The facility also had an Acute Condition Changes – Clinical Protocol policy requiring baseline assessments, monitoring, and timely physician notification for acute changes in condition. On the night of the incident, assignment sheets showed that an ACMA was the charge nurse on one hall (South hall) for the 7:00 p.m. – 7:00 a.m. shift, while an LPN was the charge nurse on the other hall (North hall). EMS records documented that they were dispatched in the early morning hours after facility staff reported that the resident had blood in the stool starting about three hours earlier and was recovering from abdominal aortic aneurysm surgery. When EMS arrived, they observed the resident’s room with signs of a significant hemorrhagic event, including towels saturated with blood and blood on the floor, and found the resident unconscious on the toilet with blood on their socks, legs, and in the toilet. Progress notes for that date did not show documentation of a significant change in condition, nor did they show assessments, monitoring, or interventions for the resident’s shortness of breath, screaming, blood in the toilet, or refusal to be transported to the hospital. Interviews revealed that the LPN was the only licensed nurse in the building on the weekend and did not obtain a full report on the South hall because the ACMA was functioning as the charge for that hall. The LPN stated that the ACMA reported the resident was screaming, hurting, having a bowel movement, and there was blood, and that the resident had a history of abdominal aortic aneurysm surgery, raising concern about bleeding. The LPN instructed the ACMA to send the resident to the hospital, but the resident refused, and the LPN did not perform ongoing assessments or monitoring, citing being behind on work and relying on the ACMA to monitor and report. The ACMA reported that the resident was on the toilet and bleeding around 1:15 a.m., with vital signs within normal limits, and refused to go to the ER; the ACMA contacted the LPN, who came once at about 1:32 a.m. to check on the resident while the resident was back in bed, with blood left in the toilet for the LPN to see. The ACMA stated that later, as the resident continued to pass blood, became pale and shivering, and remained in pain while refusing pain medication and hospital transfer, they eventually called 911 when the resident’s condition worsened. The facility was unable to produce annual skills competencies for either the LPN or the ACMA, and a family member reported they were not notified of the resident’s change in condition or of the resident’s death until later, despite the resident’s room being on the South hall where the events occurred. The report also notes that the facility failed to notify the medical provider of a critical hemoglobin lab value of 6.3 (normal reference range 13.7–17.5) and failed to notify the medical provider of the acute onset of profuse bleeding. There is no documentation that the physician was contacted regarding the critical lab result or the resident’s active bleeding, despite facility policy requiring timely physician notification for acute changes in condition and the resident’s known risk factors and anticoagulant therapy. Additionally, the facility’s own policy required that direct care staff, including nursing assistants, be trained to recognize and report significant changes, and that phone calls to physicians be made by adequately prepared nurses with organized, pertinent information; however, the documented events and interviews show that the ACMA was functioning as charge on one hall and that the LPN did not consistently assess or directly manage the resident’s rapidly changing condition. These combined failures to assess, monitor, intervene, and notify the medical provider for a resident with profuse bleeding and a critical hemoglobin value constituted the cited deficiency.
Failure to Assess and Respond to Resident’s Significant Bleeding and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident experiencing a significant change in condition and profuse bleeding was assessed and monitored by a licensed nurse. The facility had an Acute Condition Changes - Clinical Protocol requiring nurses to assess and document vital signs, neurological status, pain, level of consciousness, cognitive and emotional status, onset and severity of symptoms, and other clinical information, and to promptly contact the physician for emergencies. The resident had a history of abdominal aortic aneurysm repair and was on anticoagulant therapy for atrial fibrillation, with care plans directing staff to monitor and report signs and symptoms of cardiovascular issues and adverse reactions to anticoagulants, including blood in stool and shortness of breath. A physician’s order required weekly CBC and CMP labs while on skilled services. A lab report for the resident showed a critically low hemoglobin level of 6.3 g/dl, but the lab’s attempts to call the facility at 3:35 p.m. and again later were unsuccessful, and the physician was not notified of the results. Subsequently, during the night, the resident experienced increased anxiety, was screaming that they could not breathe, was on the toilet with most of the contents being blood, and refused to go to the emergency department. LPN #1 was notified at 1:32 a.m. of the resident’s condition, including shortness of breath, screaming, and blood in the toilet, but did not perform an assessment or ongoing monitoring, and there was no documentation of a significant change in condition or interventions for these symptoms in the progress notes. LPN #1 reported typically being the only licensed nurse in the building on weekends and stated they did not go to the resident’s hall for a full report, relying instead on an ACMA to monitor residents and report concerns. LPN #1 acknowledged being told that the resident was screaming, hurting, having bloody stool, and had a recent abdominal aortic aneurysm, and expressed concern about the resident bleeding out. LPN #1 received a texted picture of the blood at 2:25 a.m. and described being traumatized by the amount of blood, but still did not assess or monitor the resident, citing being behind on work and relying on the ACMA, despite stating that it was not standard procedure for an ACMA to assess, monitor, and send a resident to the hospital. EMS was finally contacted at 3:12 a.m., arrived to find evidence of a significant hemorrhagic event with blood-saturated towels and blood on the floor, and transported the resident, who expired in the ambulance shortly thereafter. The regional nurse consultant stated the incident was considered neglect.
Improper Food Storage, Ice Machine Sanitation, and Glove Use in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food storage and ice handling practices during kitchen observations. In one kitchen tour, they observed a white paper bowl containing orange ice cream wrapped in plastic wrap that was unlabeled and undated, as well as an opened bag of hamburger buns that was also unlabeled and undated. The ice machine had a pink substance on the white plastic chute directly above the ice, which, when wiped with a clean paper towel, resulted in a pink and brown speckled residue. The dietary manager acknowledged that the food items should have been labeled and stated they saw dirt on the towel used to wipe the ice machine chute. The DON reported there was no policy for food storage or the ice machine, and stated that ice machine maintenance was based on the machine’s indicator and then calling an outside company, with invoices available only for servicing dates in the prior year and no documentation provided for recent cleaning or maintenance. Additional deficiencies were observed in food handling and glove use by kitchen staff. One cook was seen working with one hand gloved and one hand ungloved, using the gloved hand to place cornbread into a blender, then touching the blender, a utensil, and returning to touch the cornbread without changing gloves or performing hand hygiene between contact with food and other surfaces. The cook later took the blender to the dishwasher and only then removed the glove and washed their hands. When interviewed, the cook stated their process for changing gloves was when changing the type of food and after touching utensils, and acknowledged they did not change gloves after touching the cornbread. The dietary manager stated the process for changing gloves was to change when staff touched something or something was dirty. The administrator identified that 80 residents resided in the facility at the time of the survey.
Inaccurate Post-Death Documentation and Failure to Follow Nursing Charting Policy
Penalty
Summary
The facility failed to ensure accurate and timely documentation in the medical record for a resident who died. Facility policy on nursing documentation required staff to chart as soon as possible after care, to enter the actual date and time of charting, and to clearly label any late entries with the date and time being documented. The admission assessment for the resident showed moderately impaired cognition with a BIMS score of 12 and a need for partial to moderate staff assistance with most ADLs. An EMS report documented that the resident expired in the ambulance at 3:40 a.m. on a specified date. A progress note for that same date, timed at 1:32 a.m., described the nurse being notified that the resident was on the toilet, screaming that he could not breathe, with oxygen saturation at 98% and most of the toilet contents being blood; this note was not identified as a late entry despite the timing and circumstances. Task logs for the resident showed that staff documented completion of ADL assistance after the resident’s death. Specifically, the task log reflected that the resident received ADL assistance at 10:08 a.m. on the date of death, and additional ADL assistance entries at 6:54 a.m., 8:32 a.m., and 11:59 p.m. on another date, even though the resident had already expired. During interviews, a CNA stated that if a resident was not in the facility, the scheduled ADL task should be documented as the resident not being available. The RNC confirmed that if a resident had passed away, staff should not document task completion for that resident and that any remaining scheduled tasks should be documented as not applicable. These findings showed that staff documentation did not accurately reflect the resident’s status or comply with the facility’s documentation policy.
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