Emerald Care Center Claremore
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremore, Oklahoma.
- Location
- 2800 North Hickory Street, Claremore, Oklahoma 74017
- CMS Provider Number
- 375499
- Inspections on file
- 33
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Emerald Care Center Claremore during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow dietician-approved, posted menus for three observed meal services, affecting over one hundred residents who received meals from the kitchen. Instead of the scheduled ham, meatloaf, and tuna melt meals with specified sides and desserts, staff served alternate entrees such as meatballs, kielbasa, and beef pot pie with different sides and desserts. A cook reported that the food service director and supervisor sometimes changed menus at the last minute, likely due to inadequate food supplies. The food service director confirmed choosing alternate meals because required items were not available, while residents reported that posted menus often did not match what was served. The administrator stated they were unaware menus were not being followed, and the dietician reported not being informed of the changes despite regulations requiring adherence to the approved menus.
Surveyors found that meals were not consistently palatable or attractive, as evidenced by a sampled dinner tray with mushy, bland squash and soggy, bland biscuit topping on a beef pot pie, contrary to the facility’s own food preparation policy. Resident council minutes over two months documented ongoing complaints that food was not cooked properly, was getting worse, and that dietary concerns were not being addressed. Multiple residents reported that food never tasted good, vegetables were always mushy, alternatives were rarely offered, and meals were not appetizing in appearance, with food either too salty or too bland. When asked to sample the tray, the administrator rated the meal only 5/10 for taste and appearance, while the food service director maintained that meals were appetizing despite resident complaints about inconsistent seasoning.
The facility did not complete required advance directive acknowledgment forms for two residents. Policy required staff at admission to determine whether a resident had an advance directive or wished to formulate one and to obtain and file all related documents in the chart. Record review showed each of the two residents had physician orders indicating full code status, but neither had an advance directive acknowledgment form in the medical record. The admission director reported that the acknowledgments were missing because staff were waiting for families to provide them.
A resident on chronic Warfarin therapy for atrial fibrillation and thrombophilia sustained a ground-level fall resulting in head bleeding, a T12 vertebral fracture, and bilateral subdural hematomas, and was sent to the ER via ambulance. Facility policy and state regulatory guidance required reporting incidents involving fractures, hospital treatment, and significant head injuries within 24 hours, but the DON and ADON did not report the event to the state health department, with the DON stating it was not considered a major injury and therefore not reportable.
The facility did not complete required annual competency reviews for two CNAs. Record review showed that one CNA hired in the prior year and another hired in the current year had no documented annual competency evaluations for the current year. In an interview, the HR director acknowledged that these reviews had not been done and that the facility did not have a policy for annual competencies.
A resident with thrombocytopenia had a physician’s order for nightly eltrombopag olamine 50 mg, but the medication was not administered on two consecutive days. The MAR documented missed doses, while nurse notes alternately indicated the pharmacy would not dispense the drug and that staff were waiting on delivery, even though an incident report later showed the medication had been received and locked in the narcotic box. One CMA reported being unable to find the medication, marked it as not in the building when a family member requested it, and did not escalate to the ADON as expected, while another CMA could not recall if the medication was given. The ADON stated that the process when a medication cannot be found is for the medication aide to notify the nurse and for the nurse to notify the physician.
A resident with hypertension was prescribed nifedipine ER and later amlodipine for blood pressure control, but the physician orders for these antihypertensive medications did not include hold parameters. Pharmacy drug regimen reviews generated written recommendations to add hold parameters for both medications, which were reported to the DON per facility policy. The DON, who was responsible for processing pharmacy reviews and obtaining necessary physician orders, acknowledged during interview that these recommendations were missed and that the medications continued without the recommended administration parameters.
Two residents were forced to take medication against their will by an LPN and a CMA, violating their rights to refuse treatment. One resident with Alzheimer's was given medication mixed with pudding despite verbal refusal, while another with vascular dementia was physically restrained to administer lorazepam.
A resident with vascular dementia was physically restrained by an LPN during medication administration, violating the facility's policy on restraints. The LPN held the resident's arms and shoulders to prevent them from standing and pushing away medication, which was confirmed by the ADON as a violation of the resident's rights.
A resident with Alzheimer's disease was improperly administered lorazepam as a chemical restraint by an LPN and CMA, violating facility policy. The resident, who repeatedly stood from their wheelchair, was physically restrained and forced to take the medication against their will. The incident led to the termination of the LPN and suspension of the CMA.
A facility failed to ensure timely reporting of an abuse allegation involving a resident with vascular dementia. A CMA witnessed an LPN forcibly administering medication to the resident but did not report the incident until more than 24 hours later, contrary to the facility's policy requiring immediate reporting of abuse allegations. The delay was confirmed by the ADON, highlighting a deficiency in the facility's adherence to reporting protocols.
A facility failed to include necessary interventions for a resident's pressure ulcer in their care plan, despite a physician's order for wound care. The resident had an unstageable pressure ulcer, and staff confirmed that such conditions should be addressed in the care plan.
A resident with obstructive and reflux uropathy was observed with their catheter bag on the floor on two occasions. The facility's RN and ADON confirmed that catheter bags should not be on the ground, highlighting a failure in infection prevention and control practices.
A facility failed to notify a resident's representative about changes in antipsychotic medication for a resident with delusional disorder. The resident was prescribed risperidone and later Nuplazid, but there was no documentation of notification to the representative. The ADON confirmed this oversight, acknowledging it was against facility policy.
The facility failed to thoroughly investigate the disappearance of 60 Oxycodone/APAP tablets. The ADON discovered the discrepancy when attempting to reorder the medication and found it was too soon. Despite attempts to contact the LPN who signed for the delivery, no documentation of a comprehensive investigation was available, and the LPN was unaware of the issue.
A resident with hemiplegia and hemiparesis experienced an unobserved fall and was inadequately assessed by an LPN, who reported no issues despite the resident's complaints of hip pain and an externally rotated leg. The following day, the ADON and a nurse practitioner identified the issues, and the resident was sent to the ER, where a hip fracture was diagnosed. The LPN's failure to follow the facility's Falls Management policy delayed treatment.
A facility failed to accurately document medication administration for a resident, as the MAR incorrectly showed that Nuplazid was administered multiple times despite the medication never arriving due to an insurance issue. This error was identified by a CMA and confirmed by the ADON with pharmacy records.
The facility exhibited multiple deficiencies in food safety and sanitation, including improper storage of scoops in flour and corn starch bins, undated and uncovered food in the refrigerator, and a dish machine failing to reach required temperatures. Additionally, the ice machine was inadequately cleaned, and staff did not follow proper infection control practices during meal service. The kitchen environment showed a lack of regular cleaning, with buildup on equipment and sticky floors.
The facility did not create comprehensive care plans for three residents with dementia who were severely cognitively impaired and exhibited wandering behaviors. These residents were observed wandering in wheelchairs on the memory care unit, with one entering another resident's bathroom. The MDS coordinator and ADON admitted that care plans for wandering were not developed, despite the need.
The facility failed to secure chemicals and medications on the memory care unit, leaving them accessible to wandering residents, including those in wheelchairs. Staff acknowledged the need to secure these items, but they were found unsecured. Additionally, the facility did not implement effective fall interventions for a resident with a history of falls and significant medical conditions, resulting in a fall and hip fracture. Another resident with dementia was observed attempting to enter other residents' rooms, indicating a need for supervision.
The facility failed to prevent significant weight loss in three residents, each with different medical conditions, by not implementing necessary nutritional interventions. A resident with morbid obesity experienced a 5.9% weight loss, another with coronary artery disease had a seven-pound loss unreported to the physician, and a third with Alzheimer's faced severe malnutrition. Despite recommendations for nutritional supplements and appetite stimulants, the facility did not adequately address these needs.
The facility failed to notify the physician of significant weight loss in two residents, leading to a deficiency in care. One resident with morbid obesity and breast cancer experienced a 5.9% weight loss, and the facility did not inform the physician or the resident's representative. Another resident with hypertension and coronary artery disease lost seven pounds, which was not reported to the physician, despite the facility's policy to report weight changes of five pounds or more.
The facility failed to provide adequate staffing to meet the bathing preferences of two residents requiring substantial assistance with ADLs. One resident with diabetes and depression received only four showers out of 13 opportunities, while another with hemiplegia and stroke received five out of 12. Staff reported that baths were often left incomplete due to insufficient staffing, and the DON acknowledged the issue, noting efforts to hire additional aides.
The facility failed to monitor side effects for two residents on antipsychotic medications. One resident with dementia was not monitored for side effects of Olanzapine, and AIMS assessments were not conducted. Another resident with anxiety disorder did not receive a physician-approved dose reduction of hydroxyzine, as the DON failed to update the medication order.
The facility failed to address the dental needs of two residents, one with a cracked tooth causing pain and another needing dental care due to missing top teeth. Despite requests and documented needs, appointments were not scheduled, indicating a lapse in the facility's process for managing dental care.
The facility failed to provide meals in a palatable and safe manner, with residents reporting cold and unappetizing food. Observations showed meals served on styrofoam plates without heated bottoms, and milk delivered uncovered and not on ice. Staff did not sanitize hands between passing trays, and a cleaning cart passed by uncovered drinks, contributing to the deficiency.
The facility failed to maintain an effective pest control program, with multiple reports of roaches and ants in resident rooms, the dining room, and the kitchen. Despite contacting pest control services, the issue persisted, with residents and staff reporting sightings of pests. Observations confirmed the presence of ants and roaches, and interviews revealed ongoing concerns about cleanliness and pest control measures.
The facility failed to maintain resident dignity during meal assistance. Two residents, one with Alzheimer's and another with aphasia, were assisted by CNAs who stood instead of sitting, contrary to facility protocol. The DON confirmed that staff should sit to maintain dignity.
The facility failed to ensure safe self-administration of medications for two residents. A resident with dementia had medicated powder unsecured at their bedside, and another with COPD had multiple medications without a physician's order for self-administration. The DON and an LPN confirmed the absence of necessary assessments and orders, highlighting a lapse in medication management policy adherence.
The facility failed to accurately document code status and offer advance directives to residents. One resident's DNR status was not updated in the electronic medical record, while another resident with severely impaired cognition did not have advance directives discussed upon admission. These deficiencies indicate lapses in the facility's processes for managing residents' code statuses and advance directives.
Two residents requiring assistance with bathing did not receive showers as scheduled due to staffing issues. One resident, with diabetes and depression, received only four showers out of 13 opportunities, while another resident, with hemiplegia and stroke, received five showers out of 12 opportunities. Staff acknowledged the shortfall, and the DON confirmed awareness of the issue, citing staffing constraints.
A resident with diabetes, nicotine dependence, and hypertension requested an eye appointment, which was not scheduled despite the request being made through the clinic. The social services director and DON acknowledged their roles in ensuring appointments were arranged, but the resident reported not seeing an eye doctor since admission.
The facility failed to prepare pureed food to meet the needs of residents requiring a pureed diet. During a meal observation, the taco meat and flour tortillas were not pureed to a smooth consistency, with grainy and lumpy textures noted. Despite the dietary manager's assurance, the food was not suitable for residents on a pureed diet.
The facility failed to ensure proper garbage disposal in the kitchen, affecting meal service for 111 residents. Observations revealed the absence of garbage cans at the handwashing sink and lidless large barrel-type garbage cans in critical areas. Despite previous identification of this issue, it persisted, with the dietary manager acknowledging the need for lids and a small garbage can.
The facility failed to follow proper infection control practices during wound care for four residents. An RN was observed using the same gauze to clean wounds multiple times and not changing gloves between removing old dressings and treating wounds, compromising infection control measures.
The facility failed to update the care plan for a resident with significant changes in condition, including re-admission to Hospice and a change to a pureed diet. The MDS Coordinator acknowledged the care plan had not been updated per facility policy.
The facility failed to follow enhanced barrier precautions during wound care for two residents. An RN did not don a gown before providing wound care to residents with MASD and a stage 2 pressure ulcer. The RN acknowledged not following the facility policy for enhanced barrier precautions.
Failure to Follow Dietician-Approved Menus for Multiple Meal Services
Penalty
Summary
The facility failed to follow the dietician-approved menus for three observed meal services, despite having policies requiring adherence to written menus and standardized recipes. Surveyors observed that the posted Week 3 menus, approved for 2025–2026, specified sliced ham, crispy cubed sweet potatoes, seasoned greens, cornbread, and chocolate cream pie for a Monday lunch; glazed meatloaf, red roasted potatoes, southern green beans, a honey kissed roll, and gelatin parfait for a Tuesday lunch; and a tuna melt sandwich, steak fries, mixed green salad, and apple crisp for a Tuesday dinner. Instead, the kitchen served meatballs, mashed potatoes with gravy, boiled mixed vegetables, and yellow cake with cream cheese frosting for the Monday lunch; kielbasa sausage, mashed potatoes, creamed corn, and Jello for the Tuesday lunch; and beef pot pie, boiled squash, cornbread, and peach cake for the Tuesday dinner. The administrator identified 112 residents receiving meals from the kitchen, with one additional resident receiving nutrition and hydration solely via feeding tube. Staff interviews confirmed that menu changes were made without following the established process or involving the dietician. Cook #1 reported that the food service director instructed preparation of meatballs instead of the scheduled menu item and stated that the food service supervisor sometimes changed the menu at the last minute, possibly due to insufficient quantities of the planned food items. The food service director acknowledged deciding on alternative meals because not all items for the written menus were available and also acknowledged that the written menus had not been followed. During a resident council meeting, residents reported that posted menus were often not the meals actually served. The administrator stated they were unaware that written menus were not being followed and believed kitchen staff should have all required food items to follow the dietician-approved menus daily. The dietician stated the written menus should have been followed per regulations and reported not being informed by the food service director about the menu changes that week.
Failure to Provide Palatable and Attractive Meals
Penalty
Summary
Surveyors identified a failure to ensure food was palatable, attractive, and served appropriately from the kitchen, affecting all residents who received meals from the kitchen. A sampled dinner tray consisting of beef pot pie, boiled squash, cornbread, and peach cake was observed with the pot pie presented as one large scoop of mixed vegetables and ground beef topped with slightly browned biscuits, surrounded by water and pieces of squash. The squash pieces were mushy and bland, and water from the boiled squash had soaked into the biscuit topping, making it soggy and bland. The facility’s Food Preparation Guidelines policy stated that food should be palatable, attractive, and at the proper temperature to ensure resident satisfaction and meet individual needs. Resident council minutes from two consecutive months documented that residents were concerned the food was not being cooked properly, seemed to be getting worse, and that their dietary concerns were not being addressed. Individual residents reported that the food never tasted good, vegetables were always mushy, the food was bad with rarely offered alternatives, and meals were not appetizing in appearance, with vegetables always mushy and food either too salty or too bland. During a resident council meeting, residents again voiced concerns regarding the palatability of meals. When presented with the sampled dinner tray, the administrator rated the meal 5/10 for taste and appearance. The food service director, when informed of the observations, stated they felt the meals served were appetizing and palatable and noted that residents complained meals were either seasoned too much or not enough, making it difficult to prepare consistently tasty meals.
Failure to Complete Advance Directive Acknowledgment Forms for Two Residents
Penalty
Summary
The facility failed to ensure completion of advance directive acknowledgment forms for two sampled residents, as required by its January 2024 Advance Directive Policy and Procedure, which states that upon admission staff must identify whether a resident has an advance directive and, if not, determine if the resident wishes to formulate one, and that all advance directive documents will be obtained and placed in the resident’s chart. Record review showed that one resident, admitted on an unspecified date, had a physician’s order dated 12/09/24 indicating full code status, but there was no advance directive acknowledgment form in the medical record. A second resident, also admitted on an unspecified date, had a physician’s order dated 09/08/25 indicating full code status, with no advance directive acknowledgment form located in the medical record. During interview on 12/16/2025 at 1:42 p.m., the admission director stated the acknowledgments were not in the records because they were waiting for the families to provide them. These findings occurred in the context of a census of 112 residents, with 23 sampled residents reviewed for advance directives, and demonstrated that for at least two residents the facility did not complete the required acknowledgment documentation at or after admission despite having established policy and existing code status orders.
Failure to Report Fall With Major Injury to State Health Department
Penalty
Summary
The deficiency involves the facility’s failure to report a fall with major injury to the state health department as required by its own policy and state regulatory guidance. The facility’s document titled “Long Term Care Reportable Incidents - Regulatory Requirements,” dated 06/28/22, stated that all reports to the Department must be made within 24 hours and that incidents resulting in fractures, injuries requiring hospital treatment, a physician’s diagnosis of closed head injury or concussion, or head injuries requiring more than first aid must be reported. Resident #97’s November 2025 MAR showed the resident was on chronic anticoagulation therapy with Warfarin Sodium for atrial fibrillation and thrombophilia. A nurse’s note dated 12/01/25 documented that a head-to-toe assessment after a fall revealed bleeding from the frontal forehead and the left side of the skull, and the resident was sent to the emergency room via ambulance. A neurosurgery consult progress note dated 12/02/25 documented that the resident, with atrial fibrillation on Warfarin, had a ground-level fall at the facility and was diagnosed with a T12 vertebral fracture and bilateral subdural hematomas. An MDS dated 12/05/25 confirmed the resident’s diagnoses, including atrial fibrillation, heart failure, and thrombophilia. During interviews, the ADON stated that they or the DON were responsible for reporting incidents other than abuse to the state health department. The DON stated that the fall on 12/01/25 was not reported because they did not consider it a reportable incident, asserting there were no stitches or major injury and that the T12 fracture and bilateral subdural hematomas were not considered major injuries since the resident was discharged with no treatment recommendations. The DON later acknowledged, after reviewing the LTC reportable incidents document, that the incident should have been reported.
Failure to Complete Annual CNA Competency Reviews
Penalty
Summary
The facility failed to perform required annual nurse aide competency reviews for two certified nurse aides, despite having 112 residents in the facility. Record review showed that one CNA hired on 10/13/23 had no documentation of an annual competency review for 2025, and another CNA hired on 04/17/24 also had no documentation of an annual competency review for 2025. During an interview, the HR director acknowledged that annual competencies for these two CNAs were not completed, stating that the facility tried to get them done but sometimes did not, and confirmed that there were no reviews for these two CNAs. When asked for a policy regarding annual competencies, the HR director stated that the facility did not have one. No additional information was provided in the report regarding specific residents’ medical histories or conditions at the time of the deficiency.
Failure to Administer Ordered Platelet-Stimulating Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a prescribed medication as ordered by the physician. Resident #124 was admitted with thrombocytopenia and had a physician’s order dated 11/14/25 for eltrombopag olamine 50 mg by mouth at bedtime. The November 2025 MAR showed the medication was not administered on 11/14/25, and a nurse note for that date documented that the pharmacy would not dispense the medication. An incident report later indicated the medication had actually been received on 11/14/25 and was locked in the narcotic box on the medication cart, yet the resident did not receive the medication on 11/14 and 11/15. A nurse note dated 11/15/25 stated they were waiting on delivery, and the November MAR also showed the medication was not administered on 11/15/25. Staff statements further described the actions and inactions that led to the missed doses. CMA #1 stated there was a medication for Resident #124 that they could not find and that they must have overlooked it; they reported looking everywhere for it, being unable to find it, and then marking it as not in the building when the resident’s family member wanted the medications immediately. CMA #1 acknowledged they should have called the ADON. An email from CMA #2 to the ADON stated they did not recall if the medication was given. A facility document showed CMA #2 was terminated in part for not administering the medication on 11/14/25. The ADON stated that when a medication cannot be found, medication aides are to notify the nurse and the nurse is to notify the physician, and also stated they had counted the resident’s medication with CMA #2 and did not know why it was not given on 11/15/25.
Pharmacy Drug Regimen Review Recommendations for Antihypertensives Not Implemented
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were implemented for a resident receiving antihypertensive medications. Facility policy titled "Drug Regimen Review-With Consultant Agreement only" (dated 2021) required that the drug regimen review include analysis of prescribed medications and nursing documentation, with findings and recommendations reported to leadership and nursing providing a written response within two weeks. For one resident with a diagnosis including hypertension, a physician’s order dated 09/05/25 for nifedipine ER 30 mg at bedtime for blood pressure did not include administration parameters. A subsequent Director of Nursing (DON) Report from pharmacy dated 09/17/25 documented a recommendation that the nifedipine order needed hold parameters, but the order was not updated to include them. The same resident later had a physician’s order dated 09/19/25 for amlodipine besylate 5 mg once daily, and another order dated 11/25/25 for amlodipine besylate 10 mg once daily for hypertension, neither of which included administration parameters. A DON Report from pharmacy dated 10/08/25 again documented that the amlodipine order needed hold parameters, but this recommendation was also not implemented. During an interview on 12/17/25, the DON stated they were responsible for handling pharmacy reviews, providing those needing physician attention to the physician, and entering orders into the electronic record as needed. When reviewing the pharmacy recommendations for both nifedipine and amlodipine against the resident’s medication list, the DON acknowledged that both medications lacked parameters and stated they "must have missed it," confirming that the pharmacy’s recommendations for hold parameters were not followed.
Violation of Residents' Rights to Refuse Medication
Penalty
Summary
The facility failed to uphold the residents' rights to refuse medication, as evidenced by two separate incidents involving two residents. The first incident involved a resident diagnosed with Alzheimer's disease, who was allegedly forced by an LPN to take medication against their will. A visitor observed the LPN mixing the medication with pudding and attempting to administer it to the resident, who verbally refused and tried to spit it out. The LPN then attempted to force the resident to drink water to swallow the medication, despite the resident's continued objections. The second incident involved a resident with vascular dementia, who was reportedly forced to take lorazepam, an antianxiety medication. A CMA witnessed the LPN holding the resident's arms while the medication was administered, despite the resident's physical resistance. The ADON confirmed that both residents had the right to refuse medication, and the actions of the LPN and CMA violated these rights.
Resident Restrained by LPN During Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by their policy on abuse, neglect, and exploitation. The incident involved a resident diagnosed with vascular dementia, who was allegedly forced to take medication against their will by an LPN. The incident report documented that the LPN physically restrained the resident's arms while attempting to administer medications, which was determined by the facility staff to have occurred. On a separate occasion, a CMA observed the same resident repeatedly standing up from their wheelchair and attempting to walk to the nurses' station. The LPN intervened by holding the resident by their shoulders, moving them back into their wheelchair, and then pushing the wheelchair to a table in the common area. The LPN stood behind the chair to prevent the resident from standing and held the resident's arms to prevent them from pushing away the medication being administered. The ADON confirmed that the LPN violated the resident's rights by using physical restraints, which was against facility policy.
Improper Use of Chemical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a chemical restraint was not used on a resident, leading to a deficiency in care. Resident #2, who had a diagnosis of Alzheimer's disease, was involved in an incident where a narcotic, lorazepam, was administered against their will. On the evening of 11/08/24, the resident repeatedly stood from their wheelchair and was reminded to sit back down. Despite complying with these reminders, the resident later attempted to walk using the window frame for support. LPN #1, upon confirming that the resident had an order for lorazepam, instructed CMA #1 to administer the medication. When the resident resisted, LPN #1 physically restrained the resident by holding their arms and covering their mouth to ensure the medication was ingested. The facility's policy on abuse, neglect, and exploitation clearly states that residents must be free from physical or chemical restraints used for discipline or convenience. The actions of LPN #1 and CMA #1 violated this policy by using lorazepam as a chemical restraint to control the resident's movements instead of employing less restrictive measures. The incident was confirmed by an incident report, and LPN #1's employment was terminated as a result. The ADON acknowledged the violation of the resident's rights and indicated that CMA #1 was also involved in the administration of the medication, leading to their suspension pending further investigation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an employee reported an allegation of abuse within the mandated time frame for a resident diagnosed with vascular dementia. The facility's policy requires that all alleged violations involving abuse be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. If the events do not involve abuse or result in serious bodily injury, they must be reported within 24 hours. However, a Certified Medication Aide (CMA) witnessed a Licensed Practical Nurse (LPN) forcibly administering antianxiety medication to a resident against their will. This incident occurred between 5:30 p.m. and 7:00 p.m. on a specific date, but the CMA did not report the incident until more than 24 hours later. The delay in reporting was confirmed during an interview with the CMA, who stated that they observed the abusive behavior after 5:00 p.m. but did not inform the Assistant Director of Nursing (ADON) until two days later at 9:40 a.m. The ADON confirmed that the CMA did not follow the facility's abuse policy by failing to report the allegation of abuse in a timely manner. This failure to report promptly constitutes a deficiency in the facility's adherence to its own policies and state regulations regarding the reporting of abuse allegations.
Failure to Include Pressure Ulcer Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a pressure ulcer, as required by their policy. The resident, who had a diagnosis of a pressure ulcer in the sacral region and hypertension, was observed to have an unstageable pressure ulcer. Despite a physician's order for wound care to be administered three times a week, the resident's care plan did not include any interventions related to pressure ulcers. This omission was confirmed through interviews with facility staff, including a registered nurse, a licensed practical nurse, and the assistant director of nursing, all of whom acknowledged that pressure ulcers should be addressed in the care plan.
Catheter Bag Placement Deficiency
Penalty
Summary
The facility failed to ensure that catheter bags were not placed on the floor for one of the four sampled residents reviewed for catheters. Resident #12, who had diagnoses including obstructive and reflux uropathy, was observed on two separate occasions with their catheter bag on the floor next to their recliner. A quarterly assessment had documented that Resident #12 had an indwelling urinary catheter. On November 25th and 26th, 2024, the resident was observed with the catheter bag on the floor. Both RN #1 and the Assistant Director of Nursing (ADON) confirmed that catheter bags should not be on the ground, indicating a lapse in infection prevention and control practices.
Failure to Notify Resident's Representative of Medication Change
Penalty
Summary
The facility failed to notify a resident's representative when a new antipsychotic medication was ordered for a resident diagnosed with delusional disorder. The resident was prescribed risperidone, an antipsychotic medication, on two separate occasions, with the orders being discontinued shortly after. Subsequently, the resident was prescribed Nuplazid, another antipsychotic medication, for delusions and psychosis. A review of the progress notes revealed no documentation indicating that the resident's representative had been informed of these medication changes. The Assistant Director of Nursing (ADON) confirmed the lack of notification and acknowledged that the facility's policy required such notifications to be made.
Failure to Investigate Missing Narcotic Medications
Penalty
Summary
The facility failed to conduct a thorough investigation into the disappearance of a container of narcotic pain medications, specifically 60 unaccounted tablets of Oxycodone/APAP 10-325 mg. The pharmacy manifest indicated that 168 tablets were delivered to the facility, signed by an LPN. However, the discrepancy was discovered when the facility attempted to reorder the medication and was informed by the pharmacy that it was too soon to do so. The Assistant Director of Nursing (ADON) acknowledged the missing pills but lacked documentation of a comprehensive investigation, including interviews with staff or attempts to contact the involved LPN. The ADON stated that they had tried to contact the LPN who signed for the medication, but the LPN had not returned calls or worked at the facility since the incident. The LPN, when interviewed, claimed to be unaware of the missing medications and stated that no one from the facility had contacted them regarding the issue. The ADON admitted that the investigation was completed with the limited information available and that the fate of the missing medication remained unknown.
Failure to Assess and Treat Resident After Fall
Penalty
Summary
The facility failed to assess and promptly treat a resident following an unobserved fall. The resident, who had diagnoses including hemiplegia and hemiparesis, complained of pain in their right hip and exhibited an externally rotated right leg, which they were unable to straighten. Despite these symptoms, the initial assessment by an LPN after the fall reported no issues or pain. It was only the following day that the ADON and a nurse practitioner assessed the resident and identified the pain and leg rotation, leading to the resident being sent to the emergency room where a right hip fracture was diagnosed. The incident report revealed that the LPN's assessment was inadequate, and the failure to properly assess the resident after the fall delayed necessary treatment. The former administrator substantiated a complaint from the resident's family regarding this incident, and the LPN's employment was subsequently terminated. The deficiency was identified as a failure to follow the facility's Falls Management policy, which requires a complete head-to-toe assessment after a fall before moving the resident unless there are life-threatening safety concerns.
Medication Administration Record Error
Penalty
Summary
The facility failed to accurately document medication administration for a resident due to an error in the medication administration record (MAR). Specifically, the MAR for June and July 2024 indicated that Resident #3 had been administered Nuplazid, an antipsychotic medication, multiple times. However, it was later discovered that the medication had never been available at the facility due to an insurance issue. This discrepancy was identified when a certified medication aide (CMA) reviewed the MARs and confirmed that the entries were incorrect. The assistant director of nursing (ADON) corroborated this finding with documentation from the contracted pharmacy, which showed that the medication had never arrived at the facility.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in several areas of its kitchen operations. Observations revealed that scoops were improperly stored inside bins of flour and corn starch, contrary to the facility's policy that required scoops to be stored in sealed bags. Additionally, the walk-in refrigerator contained several undated and uncovered food items, including cornbread, desserts, gelatin, and fish, indicating a lack of adherence to food labeling and dating protocols. The dish machine used for sanitizing kitchenware did not consistently reach the required minimum temperatures for washing and rinsing, as documented in the temperature logs. Despite recent servicing, the machine's wash temperature often fell below the necessary 120 degrees Fahrenheit, compromising the sanitation process. Furthermore, the ice machine was found to have a red, orange, and brown substance on its deflector panel, suggesting inadequate cleaning and maintenance. Infection control practices were also deficient during meal service, with dietary staff failing to use proper hair restraints and handling food with the same gloves used to touch various surfaces. The kitchen environment was observed to have a buildup of dark substances on equipment and sticky floors, indicating a lack of regular and thorough cleaning. The dietary manager acknowledged the absence of a consistent cleaning schedule, contributing to the unsanitary conditions observed.
Failure to Develop Comprehensive Care Plans for Wandering Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with dementia, who were severely impaired in cognition for daily decision-making and exhibited wandering behaviors. Resident #40 was observed wandering in a wheelchair on the memory care unit and had to be redirected by staff. Resident #55, also severely cognitively impaired, was observed wandering in a wheelchair on the same unit. Resident #64, with similar cognitive impairments, was seen wandering and entering another resident's bathroom. Despite these observations, the MDS coordinator and the ADON acknowledged that care plans addressing wandering had not been developed for these residents, although they should have been.
Failure to Secure Hazardous Items and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that chemicals and medications were secured on the memory care unit, which housed residents known to wander. Observations revealed unsecured items such as nail polish remover, vapor rub, peri wash, and Lantiseptic barrier cream in various rooms. These items were accessible to residents who wandered, including those in wheelchairs, posing potential hazards. Staff members, including a CNA and LPN, acknowledged the presence of wandering residents and the need to secure potentially harmful items, but the items were still found unsecured. The DON admitted that monitoring for unsecured items was not frequent enough, and the facility lacked a specific policy for the storage of chemicals. Additionally, the facility failed to implement effective fall interventions for a resident with a history of falls and significant medical conditions, including hemiplegia, hemiparesis, and a history of stroke. The resident had fallen and broken their hip while attempting to transfer themselves alone in their room. The baseline care plan noted the resident's fall risk but did not specify the level of assistance required. The ADON acknowledged that the intervention of observation was ineffective for this resident and did not provide a clear method for ensuring frequent observations were completed. The report also highlighted the case of another resident with dementia and anxiety, who was observed self-propelling in a manual wheelchair and attempting to enter other residents' rooms. This resident's quarterly assessment documented severely impaired cognition, indicating a need for supervision. The facility's failure to secure potentially hazardous items and implement effective fall interventions for residents at risk demonstrates a lack of adequate supervision and safety measures on the memory care unit.
Failure to Prevent Significant Weight Loss in Residents
Penalty
Summary
The facility failed to implement necessary interventions to prevent significant weight loss in three residents, leading to a deficiency in maintaining adequate nutrition and hydration. Resident #12, diagnosed with morbid obesity and malignant neoplasm of the breast, experienced a significant weight loss of 5.9% over less than 30 days. Despite having a care plan to maintain stable weight and nutritional status, the resident's weight fluctuated, and interventions such as healthshakes and Pro-Heal were not effectively managed. The resident's diet was downgraded to mechanical soft due to jaw pain, but no additional nutrition recommendations were made despite continued weight loss. Resident #21, with diagnoses including hypertension and coronary artery disease, also experienced significant weight loss. The resident's weight dropped from 134.6 pounds to 127.4 pounds within a week, a loss that should have been reported to the physician but was not. The resident's admission assessment noted a low BMI, and a healthshake was recommended, but the facility failed to adequately monitor and address the weight loss. Resident #65, diagnosed with Alzheimer's disease and major depressive disorder, was identified with severe protein-calorie malnutrition and significant weight loss over 90 days. Despite recommendations for increased nutritional supplements and an appetite stimulant, the facility did not address these recommendations in a timely manner. The DON acknowledged the responsibility to follow up on the dietitian's recommendations but failed to do so, contributing to the resident's continued weight loss.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss in two residents, leading to a deficiency in care. Resident #12, diagnosed with morbid obesity and malignant neoplasm of the breast, experienced a significant weight loss of 5.9% over less than 30 days. Despite the care plan's goal to maintain stable weight and adequate nutrition, the resident's weight fluctuated, and the facility did not inform the physician of the weight loss. The resident's diet was adjusted to mechanical soft due to jaw pain and swelling, but the facility did not communicate the weight loss to the resident's representative or the physician. Resident #21, with diagnoses including hypertension and coronary artery disease, also experienced a significant weight loss of seven pounds, which was not reported to the physician. The resident's admission assessment noted a low BMI, and a healthshake was recommended. Despite the resident's ability to consume meals without difficulty, the facility failed to notify the physician of the weight loss, as required for changes of five pounds or more. The DON and RN acknowledged the oversight in monitoring and reporting the weight changes.
Inadequate Staffing Leads to Unmet Bathing Preferences
Penalty
Summary
The facility failed to ensure adequate staffing to meet the bathing preferences of two residents, both requiring substantial assistance with activities of daily living (ADLs). Resident #73, diagnosed with diabetes type two and depression, was documented as needing substantial/maximal assistance for most ADLs, including bathing. However, records showed that Resident #73 received only four showers out of 13 opportunities over a month, despite expressing a desire for more frequent showers. Similarly, Resident #93, who had hemiplegia and a history of stroke, required substantial assistance for bathing but only received five showers out of 12 opportunities in the same period. Resident #93 also expressed a preference for more frequent showers. The deficiency was attributed to inadequate staffing levels, as indicated by staff interviews. LPN #4 reported that aides often did not complete baths, leaving them for the next shift, and highlighted the need for more CNAs in areas with residents requiring lifts. The Director of Nursing (DON) acknowledged the issue, noting that a shower aide had been hired but was also required to work the floor due to staffing shortages. The Assistant Director of Nursing (ADON) stated that staffing levels were determined based on state minimum requirements and adjusted daily according to acuity, but no concerns about staffing had been reported to them.
Failure to Monitor Antipsychotic Side Effects and Implement Dose Reduction
Penalty
Summary
The facility failed to adequately monitor side effects for residents receiving antipsychotic medications, specifically for two residents. One resident, diagnosed with dementia, was prescribed Olanzapine, an antipsychotic medication. The facility did not document monitoring for side effects related to this medication in the electronic clinical record. The Director of Nursing (DON) acknowledged that side effect monitoring was previously documented on the Medication Administration Record/Treatment Administration Record (MAR/TAR) but had been removed, assuming it was standard practice. The DON admitted that AIMS assessments, which are crucial for monitoring tardive dyskinesia, were not scheduled or completed for this resident, despite regulatory guidelines requiring such monitoring. Another resident, with diagnoses including major depressive disorder, delusional disorder, and anxiety disorder, was prescribed hydroxyzine for anxiety. A pharmacist recommended a gradual dose reduction, which the resident's physician agreed to. However, the DON, responsible for following up on medication changes, failed to implement the physician-approved dose reduction. This oversight resulted in the resident continuing on the original dosage, contrary to the agreed medication regimen review.
Failure to Provide Dental Care for Residents
Penalty
Summary
The facility failed to provide necessary dental care for two residents, leading to deficiencies in addressing their dental needs. Resident #66, who had diagnoses including hemiplegia, seizures, and anxiety, was noted by a dentist on 03/07/23 to require an oral surgeon for a cracked tooth extraction. However, by 05/14/24, the resident reported experiencing pain while eating due to the cracked tooth, indicating that the necessary referral and appointment had not been made. The social services director, newly employed, was unaware of any referral, and the DON acknowledged that the process for making appointments was not followed, resulting in the resident being overlooked. Similarly, Resident #73, diagnosed with depression, requested a dental appointment on 02/28/23 due to having natural lower teeth but no top teeth, which caused eating difficulties. By 05/16/24, the resident confirmed the need for dental care, but a review of their medical record by an LPN revealed that the request had not been addressed. The receptionist, responsible for scheduling appointments and transportation, found no documentation of a scheduled dental appointment for this resident, highlighting a lapse in the facility's process for managing dental care needs.
Failure to Provide Palatable and Safe Meals
Penalty
Summary
The facility failed to ensure that food and drink were provided in a palatable and attractive manner, as evidenced by multiple observations and resident complaints. Several residents reported receiving cold food, with one resident specifically mentioning that the scrambled eggs were watery and there was no sugar for the tea. Observations on a specific date revealed that meals were served on styrofoam plates without heated bottoms, and milk was delivered uncovered and not on ice, resulting in a temperature of 51.2 degrees Fahrenheit after being out for an hour. Additionally, the scrambled eggs were scorched and cold, and other food items were at room temperature. Staff actions contributed to the deficiency, as they were observed not sanitizing hands between passing trays and leaving meal carts open during meal service. A CNA admitted to typically receiving milk uncovered and not knowing where the lids were kept. The presence of a cleaning cart passing by uncovered drinks further highlighted the lack of attention to maintaining food safety and quality. These actions and inactions led to the failure in providing meals that were safe, appetizing, and at appropriate temperatures.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented instances of pest sightings in resident rooms, the dining room, and the kitchen. The Maintenance Request Log recorded numerous complaints and observations of roaches and ants in various rooms and common areas over several months. Despite contacting pest control services, the issue persisted, with residents and staff reporting sightings of pests, including roaches in the kitchen and dining room. Observations confirmed the presence of ants on window sills and bedside tables, and a roach was seen crawling on the kitchen floor. Interviews with residents and staff further highlighted the ongoing pest problem. A resident reported seeing pests in the kitchen and dining room, while a dietary aide and the dietary manager acknowledged the presence of roaches in the kitchen. The maintenance supervisor attributed the roach problem to the food vendor's cardboard boxes and noted that the pest control company had a policy against treating resident rooms. The administrator admitted the need for improved cleanliness in the kitchen to help eliminate pests, indicating that the facility's pest control measures were insufficient to address the issue effectively.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure staff provided dignity during dining for residents who required assistance with meals. Two instances were observed where staff did not sit while assisting residents with their meals, which is against the facility's protocol for maintaining resident dignity. Resident #65, diagnosed with Alzheimer's disease and severely impaired in cognition, required supervision and touch assistance for eating. On the morning of 05/13/24, CNA #1 was observed standing while assisting this resident with their meal. Similarly, Resident #7, diagnosed with aphasia and also severely impaired in cognition, was dependent on staff for eating. On the noon of 05/13/24, CNA #2 was observed standing while assisting this resident with their meal. On 05/17/24, CNA #1 explained that they did not sit to assist Resident #65 because a chair was not available. The Director of Nursing (DON) confirmed that staff are expected to sit with residents during meal assistance to maintain their dignity and that standing while assisting is not permitted.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safety of residents self-administering medications, as evidenced by the presence of medications at the bedsides of two residents without proper authorization or assessment. Resident #22, who was admitted with dementia, was found with a bottle of medicated powder on their nightstand, which was supposed to be secured and not kept at the bedside. The Director of Nursing (DON) confirmed that the medicated powder should not have been at the resident's bedside, and Licensed Practical Nurse (LPN) #1 was unaware of the powder's origin, noting that medications were often found at residents' bedsides at the start of their shifts. Resident #31, diagnosed with COPD, had multiple medications, including a Ventolin inhaler, Diclofenac cream, Incruse inhaler, Albuterol ampules, and Fluticasone drops, on their nightstand. LPN #1 confirmed that a physician's order was required for self-administration and bedside storage of medications, but upon reviewing the clinical record, found no such order for Resident #31. The DON also confirmed the absence of an assessment or physician order for self-administration in the resident's medical record, indicating a lapse in the facility's adherence to its policy on medication management.
Failure to Document Code Status and Offer Advance Directives
Penalty
Summary
The facility failed to ensure accurate documentation of code status and the offering of advance directives to residents. For one resident with diagnoses including hypertension and depression, there was a discrepancy between the documented DNR status on an advance directives form and the full code status recorded in the electronic medical record and physician's order. The Director of Nursing acknowledged the delay in updating the resident's code status, and the Administrator was unable to confirm who was responsible for following up on advance directives signed at admission. Eventually, the electronic medical record was updated to reflect the correct DNR status. Another resident, with diagnoses including fractures and hemiplegia and severely impaired cognition, did not have advance directives discussed with them or their representative upon admission. This oversight was confirmed by admissions staff, indicating a failure to adhere to the facility's policy of informing and assisting residents in formulating advance directives. These deficiencies highlight lapses in the facility's processes for managing and documenting residents' code statuses and advance directives.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide activities of daily living (ADLs) according to the care plan for two residents, both of whom required assistance with bathing. Resident #73, diagnosed with diabetes type two and depression, was documented to need physical help from one person for bathing. However, between April 15, 2024, and May 15, 2024, Resident #73 received only four showers out of 13 opportunities. The resident expressed a desire for more frequent showers, while staff members, including a CNA and an LPN, acknowledged that showers were not consistently completed due to staffing issues. The Director of Nursing (DON) confirmed awareness of the issue and mentioned efforts to hire a shower aide, although the aide also had to work the floor. Resident #93, with diagnoses including hemiplegia and stroke, was dependent on staff assistance from two aides for bathing. Despite being scheduled for showers three times a week, the resident reported receiving only one shower per week. Documentation showed that only five showers were completed in the last 30 days out of 12 opportunities. The DON acknowledged the shortfall in completing scheduled showers and indicated that staffing constraints were a contributing factor, with attempts being made to build up staff, including hiring a shower aide.
Failure to Schedule Vision Appointment for Resident
Penalty
Summary
The facility failed to ensure that a vision appointment was scheduled for a resident who had requested it. The resident, who had diagnoses including type two diabetes, nicotine dependence, and hypertension, had requested an eye and dental appointment through the clinic on February 28, 2023. The social services note indicated that the request was provided to the receptionist to schedule the appointment and arrange transportation. However, by May 13, 2024, the resident reported not having seen an eye doctor since admission. The social services director confirmed their responsibility for arranging appointments, and the DON stated that the nurse on duty was supposed to enter the order in the electronic record and provide the request to the receptionist. Ultimately, the DON acknowledged it was their responsibility to ensure the process was followed through.
Inadequate Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that pureed food was prepared to meet the needs of residents requiring a pureed diet during the noon meal observation. Specifically, the taco meat and flour tortillas were not pureed to a smooth consistency, as they were observed to be grainy and lumpy with chewable pieces remaining. This inconsistency was noted during the preparation and serving process, as dietary aide #3 was responsible for pureeing the meal, and dietary aide #1 plated the meal for a resident. Despite the dietary manager's assurance that the pureed meal was ready for service, the observation revealed that the food did not meet the required smooth consistency for a pureed diet.
Improper Garbage Disposal in Kitchen
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in the kitchen, affecting the meal service for 111 residents. Observations on multiple occasions revealed the absence of garbage cans at the handwashing sink and the presence of large barrel-type garbage cans without lids in critical areas such as near the stove, at the service line, and in the food preparation area. The facility's policy, dated January 2024, required garbage to be disposed of in containers with plastic liners and lids. Despite previous nutrition services visits identifying the lack of lids on large trash cans as an area for corrective action, the issue persisted. The dietary manager acknowledged the use of lidless garbage cans and the need to order a small garbage can for the handwashing sink and lids for the large garbage cans.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to follow proper infection control practices during wound care for four residents. Resident #8 had a diagnosis of MASD to the sacrum and required daily treatment with clotrimazole cream, zinc, and a large foam dressing. During an observation, RN #1 cleaned the wound by wiping back and forth around the area of skin breakdown five times using the same gauze soaked in normal saline (NS). Resident #4, who had a stage 2 pressure ulcer to the sacrum, was observed having their wound cleaned in up, down, and circular motions nine times using the same gauze soaked in NS. Both residents had no dressing on their wounds when the care began, which further compromised infection control measures. Resident #7, with a surgical wound to the right hip, had their old dressing removed by RN #1, who did not change gloves before treating the wound. The wound was cleaned by wiping up and down the length of the surgical site five times using the same betadine-soaked gauze. Similarly, Resident #6, who also had a surgical wound to the right hip, had their old dressing removed without a change of gloves by RN #1. The resident had two separate surgical wounds, both of which were cleaned using the same betadine-soaked gauze and patted dry with the same dry gauze. RN #1 acknowledged not following proper infection control measures when questioned about the process for cleaning wounds and changing gloves during wound care.
Failure to Update Care Plan with Significant Changes
Penalty
Summary
The facility failed to update the care plan for a resident with significant changes in condition. The resident had diagnoses including senile degeneration of the brain and dementia. A physician's order indicated the resident was to receive a regular diet with pureed texture and thin consistency. A Significant Change MDS assessment documented the resident required a mechanically altered diet and Hospice care. Despite these changes, the resident's care plan was not updated to reflect their re-admission to Hospice or the change to a pureed diet. The MDS Coordinator acknowledged that the care plan had not been updated per facility policy after reviewing the resident's care plan.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow enhanced barrier precautions during wound care for two residents. Resident #8, who had a diagnosis of MASD to the sacrum, and Resident #4, who had a stage 2 pressure ulcer to the sacrum, were both observed receiving wound care from RN #1. During these observations, RN #1 did not don a gown before providing wound care to either resident. When asked about the use of enhanced barrier precautions, RN #1 stated that such precautions were used when providing direct care to residents with catheters, drains, PEG tubes, IVs, and during wound care. RN #1 acknowledged that they had not followed the facility policy for enhanced barrier precautions during the dressing changes for Resident #4 and Resident #8.
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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