Ambassador Manor Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 1340 East 61st Street, Tulsa, Oklahoma 74136
- CMS Provider Number
- 375168
- Inspections on file
- 33
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Ambassador Manor Nursing Center during CMS and state inspections, most recent first.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
A resident with diabetes and other complex medical conditions had an order for daily insulin glargine that was correctly reflected on the MAR but not on the TAR. Over several days, a CMA documented the insulin order on the MAR and in progress notes and reported it to the nurse, but did not notify anyone else and believed the resident did not receive the medication. An LPN stated they only used the TAR when administering medications and did not review the MAR, resulting in the ordered insulin not being given because it was placed on the MAR instead of the TAR, leading to multiple missed doses.
A resident with a history of alcohol abuse, cannabis use, stimulant dependence, and other psychoactive substance abuse, and who was cognitively intact, was found in possession of suspected illicit drug paraphernalia after housekeeping observed a small glass pipe with residue and notified the administrator. The administrator met with the resident, revoked self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and disposed of the pipe, while nursing documentation noted continued illicit substance use and reports of providing substances to other residents. Despite a facility policy requiring prompt physician notification and documentation when changes may require physician intervention, the physician/medical director was not notified and there was no documentation of any physician notification related to the incident.
A resident with a history of substance abuse and intact cognition was found in possession of suspected drug paraphernalia after staff observed them handling a small glass pipe with residue. The administrator obtained the item from the resident and disposed of it in the trash, and nursing documentation noted ongoing illicit substance use and reports that the resident provided substances to others despite prior education and revocation of self sign-out privileges. Although facility policy and state law require reporting suspected crimes and drug paraphernalia to law enforcement and the state health department, the DON and administrator acknowledged that no reports were made to either authority.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
The facility did not maintain complete and accurate clinical records for two residents receiving wound care and one resident receiving insulin, as required by physician orders. Documentation was missing for several wound care treatments and insulin administrations, with staff and the DON confirming that these treatments were either not documented or the records could not be found.
A resident with severe cognitive impairment, unhealed pressure ulcers, and on hospice care was observed in a room with multiple flies, with both the resident and an LPN noting the persistent fly problem. Facility policy identified mechanical controls for fly abatement, but an exterminator's report found gaps around exterior doors, and the maintenance supervisor noted that doors were often left open, allowing flies to enter.
A resident with moderate cognitive impairment and a history of anxiety and depression had a medication card containing several doses of alprazolam, along with the corresponding narcotic sheet, go missing from the medication cart. The missing medication was reported by a CMA to the DON, who was unable to determine the cause of the loss, resulting in a failure to safeguard the resident's property.
A resident with moderate cognitive impairment and a history of anxiety and depression was prescribed alprazolam as needed. When a CMA discovered that several doses of this medication and the corresponding narcotic sheet were missing, the incident was reported internally to the DON but not to law enforcement or the state health department, contrary to facility policy and state regulations.
A resident with anxiety and moderate cognitive impairment had several doses of alprazolam and the related narcotic sheet go missing from the medication cart. The CMA reported the incident to the DON, who did not obtain written staff statements or document interviews, and was unable to determine the fate of the missing medication, resulting in a failure to thoroughly investigate the allegation.
A medication cart was found unlocked and unattended outside the DON's office. A CMA later locked the cart and confirmed that facility policy requires carts to be locked when not attended.
A facility failed to properly label an enteral feeding bag for a resident with a gastrostomy. The feeding bag was observed to be dated two days prior without necessary information like the resident's name, formula type, and time of change. An RN admitted that bags were sometimes refilled instead of changed, and the DON confirmed the requirement for a 24-hour change and proper labeling.
The facility did not ensure dishes were air-dried before use. A CNA was observed preparing room trays with wet plate covers, and the dishwasher staff admitted to stacking dishes immediately after washing. The dietary manager confirmed that dishes should be air-dried before stacking.
A resident with dementia and a history of traumatic brain injury was involved in an incident where they hit an RN, who then slapped the resident. This action violated the facility's policy on resident abuse, which ensures residents' rights to be free from physical abuse.
A facility failed to provide daily nephrostomy care as ordered for a resident with urinary tract issues and anxiety. An LPN confirmed that dressings had not been changed for two days, contrary to physician orders. The DON acknowledged that care should be provided daily.
The facility failed to ensure a prescribed medication was available for administration for a resident with sepsis and hypertension. The resident was prescribed bisacodyl 10 MG suppository daily, but the medication was not documented as given or held on one day and was held on another day before being administered. The DON stated that the pharmacy delivers medication twice a day and it should not take over 24 hours to receive medication.
The facility failed to ensure accurate resident records for a resident with nephrostomy care orders. The Treatment Administration Record (TAR) indicated care was provided on two specific dates, but an LPN found that the dressings had not been changed since an earlier date, contradicting the TAR entries.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
Missed Insulin Doses Due to Transcription and MAR/TAR Workflow Errors
Penalty
Summary
The deficiency involves a failure to accurately transcribe and administer an ordered insulin medication for one resident. The resident had multiple medical diagnoses, including diabetes mellitus due to an underlying condition with diabetic amyotrophy, acute kidney failure, COPD, and hyperkalemia. Clinical discharge instructions directed administration of insulin glargine 30 units subcutaneously every 24 hours, and the facility’s physician order and MAR reflected an active order for insulin glargine 30 units subcutaneously once daily starting the day after admission. The MAR entries for several consecutive days showed a chart code indicating documentation in nurses’ notes rather than actual administration of the insulin. Progress notes documented that a CMA repeatedly noted the insulin glargine order and reported it to the nurse each morning, stating they did not administer insulin and only informed the nurse when such medications appeared on the MAR. The CMA also stated they did not inform anyone else and did not think the resident received the medication. An LPN reported that they administered medications listed on the TAR and that CMAs administered medications on the MAR, and acknowledged they did not review the MAR when giving medications, which led to the insulin being missed because it was listed on the MAR instead of the TAR. The ADON confirmed that the insulin order had been placed on the MAR rather than the TAR and that the resident had missed doses of insulin as a result of this transcription and administration process failure.
Failure to Notify Physician of Resident’s Suspected Illicit Drug Paraphernalia
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of suspected illegal drug paraphernalia found in a resident’s possession, contrary to its own Notification of Change policy. The policy, dated 06/2025, required prompt notification of the resident, physician, and representative when there is an accident involving the resident that results in injury or has the potential for requiring physician intervention, with all notifications documented in the medical record. Resident #7 was admitted with diagnoses including alcohol abuse with withdrawal, cannabis use, other stimulant dependence, and other psychoactive substance abuse, and had a BIMS score of 15 indicating cognitive intactness. On 02/17/26, the care plan team and administrator met with the resident and in-serviced them regarding revocation of self sign-out privileges due to non-compliance with facility rules related to smoking devices and paraphernalia, which the resident acknowledged and signed as understanding. A subsequent nurse’s note dated 02/24/26 documented that on 02/17/26 the resident had received education about revocation of self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and that the resident continued to use illicit substances and was reported to provide substances to other residents despite prior education. There was no documentation that the physician was notified of the illicit paraphernalia found on 02/17/26. The resident later stated that a methamphetamine pipe had been found in their room in February, confiscated, and thrown in the trash. The HK supervisor reported that housekeeping observed the resident place a small glass pipe with residue in a box, notified the administrator, and then accompanied the administrator to the resident’s room, where the resident handed over the suspected drug paraphernalia, which was disposed of in the trash. The medical director confirmed they were not notified of the suspected drug paraphernalia, and the DON and administrator both stated that physician notification was not documented or completed.
Failure to Report Suspected Drug-Related Criminal Activity to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to notify law enforcement and the Oklahoma State Department of Health of suspected criminal activity involving drug paraphernalia. Facility policy on Resident Abuse, Neglect and Misappropriation of Property, revised 11/01/22, states that if there is a suspicion of a crime against a resident, the facility shall report the incident to the Department and law enforcement, and references Oklahoma statutes defining crime and prohibiting drug paraphernalia. Resident #7 was admitted with diagnoses including alcohol abuse with withdrawal, cannabis use, other stimulant dependence, and other psychoactive substance abuse, and had a BIMS score of 15, indicating cognitive intactness. A nurse’s note dated 02/17/26 documented that the care plan team and administrator met with the resident and in-serviced them regarding revocation of self sign-out privileges due to non-compliance with facility rules related to smoking devices and paraphernalia. A subsequent nurse’s note dated 02/24/26 documented that the resident had received education on 02/17/26 about revocation of self sign-out privileges due to ongoing illicit substance use and possession of smoking devices/paraphernalia, and that the resident continued to use illicit substances and was reported to provide substances to other residents. There was no documentation that the suspected illegal activity or the paraphernalia found on 02/17/26 was reported to police or the state health department. In interviews, the resident stated that a methamphetamine pipe was found in their room and that staff confiscated and discarded it. The housekeeping supervisor reported seeing the resident place a small glass pipe with residue in a box, notifying the administrator, and accompanying the administrator when the resident surrendered the suspected paraphernalia, which was then thrown in the trash. The DON stated they followed the abuse policy but were not aware the suspected drug paraphernalia was a crime, acknowledged the incident should have been reported to the state health department, and confirmed it was not. The administrator also confirmed that neither police nor the state health department were notified of the incident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or the circumstances at the time of the deficiency are provided in the report.
Failure to Maintain Complete and Accurate Clinical Records for Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents regarding wound care and medication administration. For one resident with severe cognitive impairment and multiple ulcers, treatment sheets did not show documentation of daily dressing changes on several specified dates, despite physician orders requiring these treatments. The Director of Nursing (DON) confirmed that there was no documentation for the dressing changes on the missing dates and acknowledged that undocumented treatments are considered not done. The resident was unsure about the frequency or progression of their wound care, and the DON was unable to locate any records for the specified dates. Another resident, who was cognitively intact and had an ostomy and pressure ulcers, had physician orders for wound care to multiple sites. The treatment administration record lacked documentation for wound care on a specific date, and staff later admitted that the wound care was performed but not documented. Additionally, a third resident with diabetes and a high cognitive score had missing documentation for insulin administration on three occasions, even though the resident stated they received their insulin as ordered. The DON confirmed the absence of documentation for these medication administrations.
Failure to Control Flies in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program for the abatement of flies in one of four halls observed. During an observation of wound care, multiple flies were seen in a resident's room. The resident, who was severely impaired in daily decision making, had unhealed pressure ulcers, and was receiving hospice services, reported struggling with flies throughout the day. An LPN also commented on the severity of the fly problem in the room, and both the resident and staff were observed waving flies away during care. A review of the facility's pest control policy indicated that mechanical control measures such as window screens, screen doors, electric fans, and black light style traps were important for fly abatement. The exterminator's service report noted visible light around exterior doors, providing entry points for pests, and recommended replacing seals or door sweeps. The maintenance supervisor acknowledged the presence of flies in the facility and noted that exterior doors were often held open for extended periods, allowing insects to enter, but stated that no specific concentration of flies in any resident's room had been reported to them.
Failure to Protect Resident's Property: Missing Controlled Medication
Penalty
Summary
The facility failed to protect a resident's property from misappropriation when a medication card containing approximately six doses of alprazolam, prescribed for anxiety, and the corresponding narcotic sheet were discovered missing from the medication cart. The resident involved had diagnoses of anxiety disorder and major depressive disorder, with a BIMS score indicating moderate cognitive impairment. The missing medication was first noticed by a CMA, who was unable to locate the narcotic sheet at the nurse's desk and subsequently reported the incident to the DON. The DON confirmed being notified of the missing medications but was unable to determine what had happened to them. This incident demonstrates a failure to ensure the security of a resident's controlled medication and related documentation, as required by facility policy prohibiting misappropriation of property.
Failure to Report Suspected Misappropriation of Resident Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of property involving a resident's medication to local law enforcement and the Oklahoma State Department of Health (OSDH). According to facility policy, upon receiving an allegation of resident abuse, neglect, or misappropriation of property, the facility is required to begin an investigation and file reports with appropriate agencies if there is reasonable suspicion that a crime has occurred. Despite this, when a certified medication aide (CMA) discovered that a medication card containing approximately six doses of alprazolam and the corresponding narcotic sheet were missing from the medication cart, the incident was only reported internally to the Director of Nursing (DON) and not to external authorities. The resident involved had diagnoses including anxiety disorder and major depressive disorder, with a BIMS score indicating moderate cognitive impairment. The missing medication was an antianxiety drug prescribed as needed. The DON confirmed being notified of the missing medications but did not report the incident to OSDH or law enforcement, as required by facility policy and state regulations. This omission constituted a failure to follow mandated reporting procedures for suspected misappropriation of resident property.
Failure to Thoroughly Investigate Missing Medication Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of a resident's property involving a resident with anxiety disorder and major depressive disorder, who had moderate cognitive impairment as indicated by a BIMS score of 11. The incident involved the disappearance of approximately six alprazolam tablets and the corresponding narcotic sheet from the medication cart, as reported by a CMA. The CMA searched for the missing narcotic sheet at the nurse's desk but was unable to locate it and subsequently reported the missing medication to the DON. Upon notification, the DON stated that an investigation was conducted; however, no written statements were obtained from staff members, and there were no notes documenting staff interviews. Additionally, the DON was unable to determine what happened to the missing medications. The lack of thorough documentation and follow-up in the investigation process led to the deficiency cited in the report.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart on the South hall, located outside the Director of Nursing's office, was observed to be unlocked and unattended at 3:05 p.m. This cart was one of two medication carts in the area. At 3:20 p.m., a certified medication aide (CMA) approached and locked the cart. The CMA confirmed that the cart should have been locked and stated that facility policy requires medication carts to be locked when unattended. The facility had 139 residents at the time of the observation.
Improper Labeling of Enteral Feeding Bag
Penalty
Summary
The facility failed to ensure proper labeling of an enteral tube feeding bag for a resident with a gastrostomy. The resident had a physician order for continuous feeding at a rate of 45 mL/hr. During an observation, the feeding bag was found to be dated two days prior and lacked additional required information such as the resident's name, formula type, and time of change. RN #2 acknowledged that the bag should be labeled with the date, time, and type of formula, and noted that sometimes bags were refilled instead of changed. The Director of Nursing confirmed that the tube feeding bag should be changed every 24 hours and properly labeled with the necessary details.
Failure to Air Dry Dishes
Penalty
Summary
The facility failed to ensure that dishes were properly air-dried before being used for meal service. During an observation, a CNA was seen preparing room trays with plate covers that had liquid running down the edges, indicating they were not dry. The CNA confirmed that the plate covers were not dry. Further interviews revealed that the dishwasher staff immediately stacked dishes on the rack after they came out of the dishwasher, without allowing them to air dry. The dietary manager acknowledged that dishes and plate covers should not be stacked immediately after washing but should be allowed to air dry.
Failure to Prevent Abuse of Resident
Penalty
Summary
The facility failed to prevent abuse for a resident who had diagnoses including dementia with behaviors and a history of traumatic brain injury. An incident occurred where the resident hit a registered nurse (RN), and the RN responded by slapping the resident. This incident was documented in an Incident Report Form. The facility's policy on resident abuse, neglect, and misappropriation of property states that residents have the right to be free from various forms of abuse, including physical abuse. The incident involving the RN and the resident constitutes a violation of this policy, as the RN's action of slapping the resident is considered physical abuse.
Failure to Provide Daily Nephrostomy Care
Penalty
Summary
The facility failed to ensure nephrostomy care was provided as ordered for a resident with diagnoses including acquired absence of other parts of the urinary tract and anxiety. A physician order dated 01/03/24 required the area around the left and right nephrostomy sites to be cleaned with normal saline, patted dry, and covered with a dry drainage sponge every day and as needed. On 02/05/25, an LPN was observed providing nephrostomy care and removed dressings dated 02/02/24, indicating that care had not been provided on 02/03/24 and 02/04/24. The LPN confirmed that the dressings had not been changed since 02/02/24. The Director of Nursing stated that nephrostomy care should be provided daily according to the physician order.
Failure to Ensure Timely Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure a prescribed medication was available for administration for one of three residents reviewed for medication administration. The resident had diagnoses including sepsis and hypertension and was prescribed bisacodyl 10 MG suppository daily. The physician order was dated 01/12/24. The Treatment Administration Record (TAR) for January 2024 did not document if the bisacodyl was given or held on 01/13/24 and indicated that the medication was held on 01/14/24. The medication was administered on 01/15/24. The Director of Nursing (DON) stated that the pharmacy delivers medication twice a day and that it should not take over 24 hours to receive medication from the pharmacy.
Inaccurate Resident Records for Nephrostomy Care
Penalty
Summary
The facility failed to ensure resident records were accurate for one of thirteen residents whose records were reviewed. Resident #1, who had diagnoses including acquired absence of other parts of the urinary tract and anxiety, had a physician order dated 01/03/24 for daily nephrostomy care. The Treatment Administration Record (TAR) for February 2024 documented that nephrostomy care was performed on 02/03/24 and 02/04/24. However, on 02/05/24, an LPN was observed providing nephrostomy care and found that the dressings on both nephrostomy sites were dated 02/02/24, indicating that care had not been provided on 02/03/24 and 02/04/24 as documented. The LPN confirmed that the dressings had not been changed since 02/02/24, contradicting the TAR entries.
Latest citations in Oklahoma
Surveyors found that staff failed to follow Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. Facility policy required targeted gown and glove use for high-contact care under EBP, and the resident had physician orders for catheter care every shift and placement on EBP. During an observation, two CNAs provided catheter care without wearing gowns. Both CNAs later acknowledged that gowns should have been used, and the DON confirmed that gowns are required for catheter care for residents on EBP. The resident, who was cognitively intact, reported that staff usually did not wear gowns during catheter care.
The facility did not update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed licensed nursing staff. The written assessment specified one RN for one day shift per week and projected a need for 10 LPNs across 24 hours, with detailed LPN coverage by shift, and stated it should be reviewed and updated as needed to guide staffing decisions. At the time of survey, the DON reported 36 residents in the facility, acknowledged that resident acuity was higher than when the assessment was completed, and stated that the actual pattern was two LPNs on the floor for the day shift and two LPNs for the night shift, with the DON, ADON, and MDS coordinator available only during weekday business hours. The DON identified a total of seven licensed staff available and stated that more staff were needed to work directly with residents, confirming that the facility assessment no longer reflected current resident needs or staffing resources.
A resident with a pressure ulcer received wound care during which an LPN and CNAs failed to follow basic infection control practices. The overbed table was not sanitized before wound supplies were placed, gloves were not changed after contact with feces, and the resident was repositioned onto a clean bed pad while still soiled. The LPN used the same contaminated gloves to handle personal items, suction equipment, wound care supplies, and to cleanse the resident’s skin and pressure ulcer, including applying collagen paste and calcium alginate with gloved fingers. Hand hygiene was not performed between glove changes, and the resident’s open wound came into contact with a cloth bed pad or pillow after cleansing and medication application but before the final dressing was applied.
A deficiency was cited for failure to prevent elopement and recurrent falls due to inadequate supervision, unsecured exits, and incomplete care planning. A newly admitted resident assessed as at risk for elopement and wandering had no related interventions on the baseline care plan, despite moderately impaired cognition and psychiatric and seizure diagnoses. This resident later left the building, was found several blocks away after falling and sustaining abrasions, and was subsequently observed at times without the one-on-one supervision that had been ordered, while a dining room exit door and perimeter gate remained unlocked and accessible. Another resident with vascular dementia, muscle weakness, and a history of multiple falls experienced several unwitnessed falls over months, culminating in two right hip fractures requiring surgical repair, yet fall-prevention interventions were not added to the care plan, and staff relied on verbal instructions and vague "close observation" rather than documented, individualized fall-prevention measures.
A resident with atrial fibrillation on Eliquis, with documented orders and a care plan to monitor and report signs of bleeding, experienced multiple episodes of active rectal bleeding while on the toilet, accompanied by anxiety, complaints of not being able to breathe, pain, pallor, and shivering. An ACMA and an LPN observed and documented that the toilet was full of blood and that the resident repeatedly refused transfer to the ER, but the LPN did not contact the physician or the family and instructed staff to continue monitoring. ACMA staff later attempted to follow instructions to contact family but reported no family contact information in the medical record, did not notify the physician, and ultimately called EMS only when the resident became pale and shivering; EMS found the resident unconscious amid evidence of a significant hemorrhagic event. Progress notes contained no documentation of physician or family notification during the change in condition, and the family, listed as POA and emergency contact in admission paperwork, reported they were not informed of the change in condition and learned of the resident’s death hours later.
A resident with recent abdominal aortic aneurysm repair and a history of circulatory surgery was on multiple anticoagulant and antiplatelet agents (Eliquis, aspirin, Plavix) and had care plans directing staff to monitor for and report abnormal labs and signs of bleeding, including black or bloody stools. A critical hemoglobin of 6.3 g/dL was reported by the lab, which documented unsuccessful attempts to reach nursing staff; the result was later signed by facility staff, but the DON confirmed the physician was never notified and no intervention was documented. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding with screaming, shortness of breath, and anxiety while on the toilet; an ACMA notified an LPN, who did not promptly assess the resident and instead instructed continued monitoring and attempts to convince the resident to go to the hospital. Nursing notes and EMS documentation showed a significant hemorrhagic event with extensive blood in the room and on the resident, yet there was no evidence of ongoing assessment, monitoring, or timely physician notification for the change in condition or the critical lab, leading surveyors to cite a deficiency under F684 for failure to provide appropriate treatment and care according to orders and the resident’s condition.
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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