Checotah Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Checotah, Oklahoma.
- Location
- 321 Southeast 2nd Street, Checotah, Oklahoma 74426
- CMS Provider Number
- 375140
- Inspections on file
- 28
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Checotah Nursing Center during CMS and state inspections, most recent first.
Two residents sustained first- and second-degree burns after spilling excessively hot coffee or tea that had been served without lids and without adherence to the facility’s hot liquid safety policy. One resident with dementia, psychosis, and impaired vision, who could not complete a BIMS interview, was left drinking hot coffee alone without a lid despite a care plan intervention to ensure awareness of hot liquids and provide lids as needed. Another cognitively intact resident with convulsions, reduced mobility, muscle weakness, and tremors treated with propranolol also drank from an unlidded cup and later reported spilling hot tea, resulting in a second-degree burn. Surveyors measured coffee and hot water temperatures well above the policy threshold, and kitchen staff reported they did not temp hot beverages and were unaware of the hot liquid policy.
The facility did not provide quarterly written statements of financial transactions to residents with personal funds managed in a trust, as required by facility policy. Instead, residents were only shown their trust fund ledger when they inquired about their balance.
Surveyors found that the facility did not keep the kitchen clean and served unpasteurized shell eggs that were not fully cooked to residents. The dietary manager confirmed the use of unpasteurized eggs and acknowledged that kitchen floors had not been cleaned for about a week, with the cleaning schedule left incomplete. Meals prepared in these conditions were served to 39 residents.
The facility did not provide RN coverage for eight consecutive hours on multiple days, as shown by the October schedule and confirmed by the administrator. At the time, 43 residents were in the facility.
A resident's room was found to have a large crack in the window and significant dirt and grime buildup. Housekeeping staff indicated windows should be cleaned weekly and cracks reported to maintenance, but maintenance was unaware of the issue. This resulted in a failure to provide a clean, comfortable, and homelike environment.
A resident with severe cognitive impairment, fully dependent on staff for transfers, slipped out of a sit-to-stand mechanical lift when only one staff member assisted, contrary to facility policy requiring two staff for such transfers. Staff interviews confirmed knowledge of the policy, but the required assistance was not provided at the time of the incident.
A facility failed to update a care plan with interventions for a resident with a history of inappropriate sexual behaviors, despite the resident's severe cognitive impairment and previous incidents. The DON acknowledged the lack of a formal plan to prevent such behaviors, although staff knew how to respond.
The facility failed to implement its abuse policy after a CNA was reported for verbal abuse, using offensive language in front of a resident. Despite the substantiated allegation, the CNA was not terminated as per policy and continued working without documented training. This led to a deficiency due to improper handling and documentation of the incident.
The facility failed to document an investigation into abuse allegations, affecting all residents. A resident reported a CNA using offensive language, which was substantiated, resulting in termination. Another allegation of aggression by the same CNA was not substantiated, allowing the CNA to continue working. No witness statements or investigation documentation were available, and employees confirmed the lack of documentation despite claiming an investigation was conducted.
The facility failed to adhere to professional standards for respiratory care by not dating oxygen tubing for residents requiring oxygen therapy. Observations revealed that several residents with chronic respiratory conditions had undated oxygen tubing, despite physician orders for weekly changes. The DON confirmed that staff were expected to change and date the tubing as ordered.
The facility failed to employ sufficient staff in the food and nutrition service, leading to inadequate meal service. Observations showed a lack of staff during meal times, with residents eating from disposable trays due to staff shortages. The Dietary Manager noted that meal menus had to be adjusted due to insufficient staffing, affecting the preparation and service of meals for 28 residents and one resident on tube feeding.
The facility did not have a system in place for surveillance and monitoring to prevent Legionnaires' disease. Although a policy for Legionella surveillance existed, the DON was unaware of any documentation for monitoring efforts. This deficiency was identified despite the presence of 29 residents in the facility.
The facility failed to ensure correct and legal documentation of advance directives for two residents. One resident's care plan lacked documentation of an advance directive, and the DON could not locate the necessary documents. Another resident's POA form was not notarized, making it invalid, and their advance directive was not documented in the care plan.
The facility failed to store food safely as the refrigerator had been dripping for several days, with bowls placed to catch the liquid. The ice machine was also broken, requiring ice to be sourced externally. The refrigerator door gasket was sticking out, indicating a need for repair. The DM acknowledged these issues.
The facility failed to administer medications as ordered for two residents, leading to multiple missed doses. One resident with multiple diagnoses had several medications not documented as administered in February 2024, while another resident with atrial fibrillation, hypertension, and depression had missed doses in January 2024. The ADON confirmed the medications were not given as required.
The facility failed to complete a baseline care plan within 48 hours for a resident admitted with multiple diagnoses, including UTI, cerebral infarct, A-fib, dysarthria, heart failure, hemiplegia, and aphasia. The MDS Coordinator confirmed the care plan had not been created yet.
Failure to Control Hot Liquid Temperatures Resulting in Resident Burns
Penalty
Summary
The facility failed to ensure hot liquids were served at a safe temperature and that residents at risk for burns were adequately protected, resulting in burns to two residents. One resident with vascular dementia, behavioral disturbance, unspecified psychosis, and mildly impaired vision, and who was unable to complete a BIMS interview (score 99), was observed sitting alone at a table drinking from a brown coffee cup without a lid. This resident later sustained scalding burns to both thighs and a blister on the left thigh after spilling a hot fluid, with the physician describing the injury as 99% first-degree and 1% second-degree burns. The resident’s care plan included an intervention to ensure awareness of hot liquids and to provide lids as needed, but no lid was observed in use. A state incident report documented the hot fluid spill and resulting burns. A subsequent surveyor temperature check of coffee measured 160.9°F, and food temperature records showed coffee holding temperatures of 180°F on two dates, despite a facility policy stating that hot liquids above 140°F should be held in dietary until they reached an appropriate temperature. A second resident, who was cognitively intact (BIMS 13) but had diagnoses including unspecified convulsions, reduced mobility, impaired cognitive functions and awareness, and muscle weakness, and who was receiving propranolol for tremors, was also observed drinking from a brown coffee cup without a lid. This resident had previously reported spilling hot tea on their lap before breakfast, resulting in a wound measuring 6.0 x 2.5 inches with a blistered area of 4.0 x 1.5 inches; a physician later classified this as a second-degree burn, with updated wound measurements of 6 cm x 2 cm x 0.1 cm. A surveyor-measured hot water temperature was 166.9°F. The assistant director of nursing identified four residents at risk for burns from hot liquids. The cook stated they did not take temperatures of coffee or tea before serving and simply provided drinks to CNAs, and the dietary manager reported not knowing the policy for serving hot liquids, indicating that the facility’s written hot liquid safety policy was not being followed in practice.
Failure to Provide Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly written itemized statements of financial transactions to all 16 residents whose personal funds were managed in a trust by the facility. According to facility documents and policies, residents or their representatives were to receive these statements at least quarterly. However, interviews with the Business Office Manager (BOM) and the administrator revealed that they were unaware of the policy requirements and had not been issuing the required quarterly statements. Instead, residents were only shown their trust fund ledger upon request, rather than receiving regular written statements as stipulated by facility policy.
Failure to Maintain Kitchen Cleanliness and Use Pasteurized Eggs
Penalty
Summary
Surveyors observed that the facility failed to maintain kitchen cleanliness and did not ensure the use of pasteurized eggs for residents' meals. Unpasteurized shell eggs were found stored in the kitchen refrigerator and were used to prepare soft or over-medium eggs for residents, as confirmed by the dietary manager (DM), who was unaware if the eggs were pasteurized. A receipt confirmed the purchase of unpasteurized eggs, and there was no evidence that pasteurized eggs had been ordered. Additionally, the kitchen floor was found to be unclean, with a brown substance present against the walls, around table legs, and under the dish machine. The DM acknowledged that the kitchen floors had not been swept or mopped for about a week, and the cleaning schedule for the month had not been completed. A total of 39 residents were identified as having received meals prepared by the kitchen during this period. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours each day, seven days per week, as required. Review of the facility's schedule for October 2025 revealed that no RN was scheduled to work on six specific days during the month. The administrator confirmed that there was no RN present in the facility on those days. At the time, the facility had 43 residents residing there. This deficiency was identified through record review and administrator interview, with direct evidence that the required RN coverage was not maintained on the specified dates.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
A deficiency was identified when a resident's room was observed to have a 10 to 12 inch crack in the window glass along with a build-up of dirt and grime. The housekeeping supervisor stated that resident windows were supposed to be cleaned weekly and that any cracks should be reported to maintenance for repair. However, the maintenance supervisor reported being unaware of the crack in the window and acknowledged that it should be repaired. These findings indicate that the facility failed to maintain a clean and comfortable environment for the resident as required.
Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate assistance to prevent a resident from sliding out of a mechanical lift. According to the facility's policy, two staff members are required for any transfer involving a sit-to-stand mechanical lift. A resident with severe cognitive impairment, who was totally dependent on staff for transfers, slipped out of the sit-to-stand mechanical lift and was assisted to the ground. The incident report indicated that staff were to be educated on the requirement for two-person assistance during such transfers. Interviews revealed that at the time of the incident, only one staff member was present during the transfer, despite knowing the policy required two. The staff member reported being unable to find another person to assist. Other staff, including a CNA, an LPN, and the assistant director of nursing, confirmed that the facility policy mandates two staff members for transfers using the mechanical lift. This failure to follow established policy resulted in the resident sliding out of the lift.
Failure to Implement Interventions for Resident Safety
Penalty
Summary
The facility failed to implement necessary interventions to protect residents from abuse, specifically in the case of a resident with a history of inappropriate sexual behaviors. This resident, who was severely cognitively impaired and had diagnoses including sexual disorders, depressive disorders, and anxiety, was documented to have inappropriately touched another resident. Despite being admitted to a geri-psych facility for treatment, upon return, the resident's care plan was not updated with interventions to prevent further inappropriate behaviors. The Director of Nursing acknowledged that while staff were aware of how to respond to such behaviors, there was no formal plan in place to prevent them.
Failure to Implement Abuse Policy and Document Disciplinary Actions
Penalty
Summary
The facility failed to implement its abuse policy regarding an allegation of verbal abuse by a certified nursing assistant (CNA) which had the potential to affect all residents. The incident involved a resident who reported that the CNA used offensive language, including profanity, which was particularly upsetting during a gospel singing event. The director of nursing (DON) substantiated the allegation of verbal abuse, and the facility's policy stated that the employee should be terminated if the allegations were true. However, there was no documentation of the termination in the CNA's personnel file, and the employee roster did not reflect the termination. Despite the substantiated abuse, the CNA was allowed to return to work in the dietary department without undergoing any training on proper language use, contrary to what was documented. The CNA was later observed working in the nursing department and was reported by several anonymous employees to have not been terminated as initially decided by the administrator. This failure to adhere to the facility's abuse policy and the lack of proper documentation and follow-through on disciplinary actions led to the deficiency.
Failure to Document Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation regarding an allegation of abuse, which has the potential to affect all residents. The Reporting Resident Abuse policy requires the completion of an incident report form and, when possible, statements from any witnesses. An incident report dated June 2, 2024, documented that a resident reported a CNA using offensive language, which was substantiated, leading to the CNA's termination. Another incident report dated June 27, 2024, accused the same CNA of being aggressive with residents, but the investigation was not substantiated, and the CNA continued to work. There were no documented witness statements, interviews, or investigation records available for review. Interviews with several anonymous employees confirmed that no documentation of their interviews or the investigation was made, despite their claim of conducting an investigation.
Failure to Adhere to Oxygen Tubing Change Protocols
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for four residents who required oxygen therapy. Resident #9, diagnosed with congestive heart failure, chronic respiratory failure, and cerebral infarction, had physician orders to receive oxygen via nasal cannula and to have the oxygen tubing and humidifier changed weekly. However, observations on two separate occasions revealed that the oxygen tubing was not dated, indicating non-compliance with the physician's orders. Similarly, Resident #19, with chronic obstructive pulmonary disease and heart failure, was observed with undated oxygen tubing on two occasions, despite orders to change the tubing weekly. Resident #23, who had pneumonia, chronic obstructive pulmonary disease, and congestive heart failure, also had undated oxygen tubing during two observations, contrary to the physician's orders for weekly changes. Resident #24, diagnosed with chronic obstructive pulmonary disease, was found with oxygen tubing and a humidifier dated several weeks prior, indicating that the equipment had not been changed as required. The Director of Nursing acknowledged that the staff was expected to change and date the oxygen tubing as per the orders, and the lack of dating could lead to uncertainty about whether the tubing was changed as scheduled.
Staff Shortage in Food and Nutrition Service
Penalty
Summary
The facility failed to employ enough staff to effectively carry out the functions of the food and nutrition service. Observations, record reviews, and interviews revealed that the dietary schedule for August 2024 included only one cook and one dietary aide for the morning shift, one cook and one aide for a split shift, and one cook with no dietary aide for the evening shift. On a specific morning, a cart with eight disposable trays was observed unattended in the resident hall, and three residents were seen eating from disposable trays in the dining room. The Dietary Manager (DM) explained that breakfast was served on disposable trays due to staff shortages, with only one staff member available to serve breakfast that morning. Additionally, the DM provided menus for the week and stated that the lunch and supper menus had been switched because more time and staff were required to prepare the lunch menu. The DM acknowledged the need for more staff in the kitchen to adequately meet the dietary needs of the residents, which included 28 residents receiving meals prepared by the kitchen and one resident receiving nutrition via tube feeding.
Failure to Monitor and Prevent Legionnaires' Disease
Penalty
Summary
The facility failed to implement a system of surveillance and monitoring to identify and prevent Legionnaires' disease. The Director of Nursing (DON) identified that 29 residents resided in the facility. A policy titled 'Legionella Surveillance' was documented, indicating that Legionella surveillance is a component of the facility's water management plans for reducing the risk of Legionella. The policy stated that in the absence of Legionella infections for at least one year, the facility should implement primary prevention strategies, including diagnostic testing. However, during an interview on August 7, 2024, the DON provided a Legionella Policy but was unaware of any documentation for monitoring the prevention of Legionnaires' disease.
Deficiency in Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that information regarding advance directives was correct and legal for two residents. Resident #9, who had diagnoses including congestive heart failure, chronic respiratory failure, type 2 diabetes mellitus, and cerebral infarction, was documented as having a full code status in their care plan dated 12/19/23. However, the care plan did not document an advance directive. An acknowledgment form dated 06/18/24 indicated that the resident had executed an advance directive and a Power of Attorney (POA), but the Director of Nursing (DON) could not locate these documents in the resident's clinical record. Resident #20, with diagnoses including congestive heart failure, type 2 diabetes mellitus, and hypertension, had a care plan dated 08/15/23 that documented a full code status but did not include an advance directive. A POA form dated 03/02/21 was found in the records but was not notarized, rendering it not a legal document. An acknowledgment form dated 08/07/23 indicated that the resident had executed an advance directive and a POA, but the DON confirmed that an advance directive was not available in the resident's records.
Food Storage Deficiency Due to Equipment Issues
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During a kitchen tour, it was observed that the refrigerator had two plastic bowls on the top rack collecting liquid dripping from the ceiling. The Dietary Manager (DM) acknowledged that the refrigerator had been dripping for about four to five days. Additionally, the ice machine was broken, and ice was being sourced externally. During a meal service observation, the refrigerator still had the bowls in place to catch drips, and staff were seen moving the bowls to access other items. The refrigerator door also had a piece of the gasket sticking out, indicating a need for repair. The DM confirmed that both the refrigerator and the ice machine required maintenance.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for two residents, leading to multiple instances of missed doses. Resident #4, who had diagnoses including anxiety, major depression, hyperlipidemia, disc degeneration lumbar region, dementia, and DMII, had several medications not documented as administered on specific dates in February 2024. These medications included baclofen, tramadol hydrochloride, acetaminophen, divalproex sodium extended release, mirtazapine, atorvastatin calcium, trazodone hydrochloride, and levemir. The Assistant Director of Nursing (ADON) confirmed that the lack of documentation indicated the medications were not given, and no records were found in the paper medication administration book either. Similarly, Resident #1, who had diagnoses including atrial fibrillation, hypertension, and depression, also experienced missed medication administrations. The January 2024 Medication Administration Record (MAR) showed no documentation of time given for several medications, including budesonide, ipratropium bromide, refresh celluvisc, senna-plus, eliquis, folic acid, diltiazem hydrochloride, hydralazine hydrochloride, famotidine, levothyroxine sodium, and levalbuterol hydrochloride. The ADON reviewed the MAR and confirmed that the medications were not administered on the specified dates and times. The facility's failure to administer medications as ordered and to properly document medication administration led to significant gaps in the residents' treatment regimens. This deficiency was identified through record reviews and interviews, highlighting a critical lapse in the facility's pharmaceutical services and adherence to physician orders.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure a baseline care plan was completed within 48 hours for one of seven sampled residents reviewed for baseline care plans. The facility's policy mandates that a baseline plan of care to meet the resident's immediate needs should be developed by the Interdisciplinary Team (IDT) within 48 hours of admission. Resident #7, who was admitted with diagnoses including UTI, cerebral infarct, A-fib, dysarthria, heart failure, hemiplegia on the right dominant side, and aphasia, did not have a care plan located in their clinical record. The MDS Coordinator confirmed that the care plan had not been put together yet.
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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