Fairfax Behavioral Health & Memory Care Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfax, Oklahoma.
- Location
- 282 County Road 6300, Fairfax, Oklahoma 74637
- CMS Provider Number
- 375467
- Inspections on file
- 22
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Fairfax Behavioral Health & Memory Care Community during CMS and state inspections, most recent first.
A resident who was cognitively intact but required substantial/maximal assistance and two-person help for toileting and transfers sustained two separate left arm fractures when staff did not follow the care plan or facility transfer policy. On one occasion, a CMA used a one-person transfer to the bathroom despite the resident stating they needed two-person assistance, and the resident fell and fractured the left arm. On another occasion, two CNAs transferred the resident to a shower chair by lifting under the arms instead of using a gait belt or approved technique, and a pop was heard in the resident’s shoulder, followed by confirmation of a left humerus fracture. The DON later stated staff were to use gait belts and not lift residents under their arms.
A resident with dementia and impaired mobility, identified as at risk for falls, experienced multiple witnessed and unwitnessed falls over time, including events causing skin tears, facial laceration, bruising, and swelling. Although some fall-related interventions such as non-slip socks, proper fitting shoes, staff presence, frequent toileting, distraction with snacks, and use of a specialized chair were documented in incident notes or described by staff, these interventions were not incorporated into the resident’s care plan after an earlier post-fall entry. Staff reported relying on the EHR, room postings, charts, or verbal instructions to know interventions, while the DON acknowledged that care plans were supposed to be updated after each fall but that the subsequent interventions were not added and were only reflected in progress notes that CNAs could not access.
A resident with severe cognitive impairment, dementia, anxiety, a history of wandering, and an identified elopement risk was able to leave the facility and was later found at a nearby park despite existing care plan interventions and staff presence. The resident required hands-on assistance for ambulation and was frequently observed walking the halls with a CNA, who attempted but was unable to consistently redirect the resident to sit. Staff and the DON reported that the resident was supposed to have 1:1 supervision during waking hours, that only staff knew the exit door code, and that staff were instructed to check exit doors and keep residents engaged, yet the resident still eloped from the building, indicating a failure to provide adequate supervision to prevent elopement.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
A resident with diabetes and a below-the-knee amputation did not receive prescribed wound care for a toe, as the order was entered incorrectly and the treatment was not completed. The resident confirmed no treatment was being done, and both the ADON and DON acknowledged the lapse.
The facility did not ensure that food served was hot and palatable, as observed during a test tray review where meals were found to be inadequately heated and poorly prepared. Two residents with intact cognition reported dissatisfaction with the temperature and taste of the food, and similar concerns were raised during a resident council meeting. The dietary manager acknowledged attempts to serve hot, appealing meals.
A dietary aide was seen washing dishes without a beard guard, and a bulk sugar container with a broken lid was found in the kitchen. The dietary manager confirmed that staff should use hair restraints and that the container lid should have been replaced. Meals from this kitchen were served to 48 residents.
The facility did not follow the posted menu for two meal services, serving meals that did not include the required bread and providing a pureed meal that did not match the planned menu. Staff confirmed that bread was omitted and that frozen pureed items were used instead of pureeing the prepared meal.
A resident prescribed haloperidol for delusional and anxiety disorders did not have required side effect monitoring documented on the treatment administration record, despite facility policy and care plan directives. The DON confirmed that monitoring should occur every shift and be recorded, but no such documentation was found.
The facility did not transmit MDS assessment data to the State within the required 14-day period for four residents. The ADON/MDS coordinator, who had recently taken over responsibility for MDS assessments, reported being behind in completing and submitting the assessments on time, resulting in late transmissions.
A resident with an indwelling urinary catheter for urinary retention did not have the catheter use addressed in their care plan, despite facility policy and staff acknowledgment that it should have been included. The omission was confirmed through record review and staff interviews.
A resident with diabetes and a foot ulcer received wound care from an ADON who did not wear a gown, contrary to the facility's Enhanced Barrier Precautions (EBP) policy. No signage indicated EBP was in place, and both the ADON and acting DON were unaware or did not follow EBP requirements for wound care, as confirmed by observation and interviews.
The facility failed to provide a safe and comfortable environment due to the lack of hot running water in rooms on the 100 hall. A resident with arthritis reported pain from washing hands in cold water, and two other residents confirmed the absence of hot water for over a month. The maintenance supervisor stated the issue is due to a broken hot water tank, which will not be replaced until a government grant is received.
A resident with dementia was observed by staff inappropriately touching another resident, also with dementia, in their room. The residents were immediately separated, and an assessment showed no signs of trauma. The incident was reported to the physician, family, and police.
A resident with a history of aggressive behavior verbally and physically threatened another resident in the dining room, resulting in an abusive interaction. Despite staff training on abuse identification and reporting, the incident was not initially recognized as abuse until later acknowledged by the ADON.
A resident with vascular dementia and leg amputations was left unclothed in their room and had an uncovered catheter bag in public areas, despite the facility having dignity covers. The resident was unable to reposition themselves or call for help, and staff failed to ensure their dignity was maintained. An LPN acknowledged the availability of dignity covers, and the DON confirmed the importance of respecting resident rights.
The facility did not provide three residents the opportunity to develop or refuse an advance directive as part of their admission process. An LPN confirmed that one resident's advance directive was signed late, and two others were not documented as having been offered the opportunity. The DON stated that advance directives should be completed during admission.
The facility failed to ensure interdisciplinary team participation in care planning for several residents. The MDS Coordinator did not invite other care team members to meetings, and there was no documentation of these meetings. The DON acknowledged the meetings should have been documented and that the physician was only informed of issues as required.
The facility failed to educate residents on the risks and benefits of bed rails, obtain informed consent, inspect bed frames and rails, and attempt alternatives before use. Two residents with dementia and amputations were affected, with no documentation of necessary assessments or attempts at alternative measures. The DON confirmed the lack of documentation and alternative interventions.
The facility failed to maintain registered nurse coverage for eight hours daily, as required. PBJ reports and staffing schedules revealed missing RN hours on several dates across two quarters. Interviews indicated a lack of awareness and communication among staff, with the DON unaware of the issue and an LPN responsible for staffing unable to fill gaps effectively.
The facility experienced delays in administering medications to residents due to sudden staffing shortages. On two consecutive days, a significant number of residents received their morning medications hours later than scheduled. The issue arose when two CMAs quit unexpectedly, leaving the facility short-staffed, and administrative nurses were unavailable due to emergencies. The DON acknowledged the situation and confirmed that medications should have been administered on time.
A facility failed to provide a written notice of discharge to a resident and did not notify the ombudsman when the resident was discharged to a hospital. The DON admitted to not giving a notice of transfer and not reporting the discharges to the ombudsman. A resident was discharged four times to a hospital for medical reasons, but the required notifications were not made.
A resident with vascular dementia and leg amputations developed a pressure wound on the coccyx, which was not accurately documented in the MDS quarterly assessment. The MDS Coordinator admitted to the error, and the DON acknowledged the lack of peer review among MDS nurses, leading to the inaccurate assessment.
A resident with vascular dementia and recent leg amputation developed a new pressure ulcer, but the facility failed to perform a significant change assessment within the required timeframe. The MDS Coordinator admitted the oversight, noting the part-time nurse responsible for assessments was unsupervised. The DON acknowledged the need for timely and accurate assessments.
The facility did not have policies and procedures for obtaining feedback from staff, residents, and resident representatives. A review of QAPI and QAA records showed no documentation of a feedback program. The Administrator confirmed the absence of such a program, despite having a grievance process for residents.
A facility failed to maintain a functioning call light system for a resident with multiple diagnoses, including vascular dementia. The resident's call light was out of reach and not ringing at the front desk. Despite the facility's policy to provide alternative alert methods, no immediate intervention was implemented. The issue was identified on June 3, 2024, but a hand bell was only provided after the malfunction was discovered.
Unsafe Transfer Techniques Resulting in Repeated Arm Fractures
Penalty
Summary
The facility failed to ensure safe transfer techniques were used for a cognitively intact resident who required substantial/maximal assistance and two-person help for toileting and incontinence care, resulting in two separate left arm fractures. The resident’s care plan, dated 10/02/25, specified moderate to maximum assistance of two staff for toileting and incontinent care. On 11/30/25, a CMA used a one-person transfer to assist the resident to the bathroom; the resident began to fall and used their left hand to break the fall, after having told the CMA they needed two-person assistance. The resident was subsequently found to have an acute distal left arm fracture on x-ray and was sent to the hospital for stabilization. The CMA later stated they did not know the resident was a two-person transfer. On 01/09/26, two CNAs transferred the same resident to a shower chair by placing their arms under the resident’s arms, rather than using a gait belt or other approved technique. Both CNAs and an LPN reported that during this transfer they heard a pop in the resident’s left shoulder. A mobile x-ray on 01/10/26 showed an acute distal fracture of the left humerus, and the resident was again sent to the hospital for stabilization. The resident later stated they broke their left arm when two aides transferred them under their armpits to get into a shower chair. The DON stated staff were expected to use gait belts and not lift residents under their arms, indicating that the transfer methods used with this resident were inconsistent with facility policy and the resident’s care plan.
Failure to Update Fall Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to update and revise a resident’s fall care plan after multiple falls, despite a policy requiring that interventions be reflected in the care plan and updated with revised or additional interventions. The resident, admitted with non-Alzheimer’s dementia and identified as at risk for falls due to weakness, impaired mobility, abnormal gait, and balance, initially had a care plan dated 08/20/25 with a post-fall intervention added on 11/02/25 for frequent checks while in their room. After that date, the care plan contained no additional interventions, even though the resident experienced numerous subsequent falls. Incident notes documented a witnessed fall without injury on 12/26/25 with interventions of non-slip socks and proper fitting shoes, an unwitnessed fall with a right elbow skin tear on 01/01/26 with no interventions documented, and another unwitnessed fall on 01/18/26 with no injuries or interventions documented. Further documentation showed the resident was seen in the emergency department on 01/20/26 for a fall resulting in a facial laceration repaired with tissue glue, facial bruising, and a knee injury, followed by monitoring for bruising and swelling to the right eye on 01/21/26. Additional unwitnessed falls occurred on 01/22/26, 01/24/26, and three times on 01/28/26, with no injuries or interventions documented for several of these events. On 01/29/26, the resident had two unwitnessed falls; one had non-slip socks as an intervention and the other resulted in a right elbow skin tear and bruising with an intervention to start Buspar for agitation. Observations showed the resident was unsteady, required hands-on assistance to walk, and was frequently ambulating in the halls with a CNA. Staff interviews revealed that CNAs and an LPN described various fall interventions (such as constant staff presence, snacks for distraction, frequent toileting, non-slip socks, and use of a specialized chair) and stated they relied on the electronic health record, room postings, charts, or verbal communication to know interventions. The DON stated care plans were to be updated after every fall but acknowledged that interventions after 11/02/25 were not on the care plan and that CNAs could not see progress notes where interventions were documented.
Failure to Adequately Supervise High-Risk Resident to Prevent Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for one resident identified as an elopement risk. The resident had non-Alzheimer's dementia, delirium due to a psychological condition, anxiety disorder, a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive dysfunction, and a documented history of wandering. The care plan, initiated prior to the incident, identified the resident as an elopement risk with interventions including structured activities and diversions. Despite these identified risks and care plan interventions, the resident was able to leave the facility and was later found at a nearby park approximately 50 yards from the facility's back door, on the other side of a small hill. At the time of the elopement, eight direct care staff were on duty. Following the elopement, documentation and staff interviews showed that the resident was to have one-on-one supervision with staff during waking hours, and staff described interventions such as remaining with the resident, providing snacks, treats, and fidget items, and using distraction with activities and toileting. Observations on multiple days showed the resident walking up and down the halls with a CNA, unsteady on their feet and requiring hands-on assistance, and staff attempting to redirect the resident to sit in a chair without success. The facility’s elopement prevention policy stated it was the policy to protect residents from elopement, and staff reported that only employees had the door code and that they were educated to check exit doors when near them and keep residents engaged. Despite these measures and the resident’s known elopement risk and cognitive impairment, the resident had previously been able to exit the building and reach the nearby park, demonstrating a failure to provide adequate supervision to prevent elopement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes mellitus type 2 and a below-the-knee amputation, who was assessed as having moderate cognitive impairment. The physician's order directed that the resident's left great toe be cleansed with normal saline, patted dry, Betadine applied every shift, and left open to air twice daily for wound care. Review of the Treatment Administration Record (TAR) for July 2025 showed no documentation of wound care for the left great toe as of mid-month. The resident confirmed that no treatment was being performed on the toe, and facility staff, including the ADON and DON, acknowledged that the wound care order had been entered incorrectly and the treatment was not being completed as ordered.
Failure to Provide Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food served from the kitchen was palatable and at an appetizing temperature for its residents. During a test tray observation, the food was found to be not hot, with the meatloaf described as dry and bland, mixed vegetables as soggy, potatoes as not well seasoned, and the brownie as undercooked; bread was also missing from the meal. Two residents with intact cognition reported that the food was not hot when served in their rooms and sometimes did not taste appealing, with one stating the food was not good. Additionally, concerns about food temperature and palatability were raised by multiple residents during a resident council meeting. The dietary manager acknowledged efforts to serve hot, palatable food.
Failure to Ensure Proper Food Storage and Staff Hygiene in Kitchen
Penalty
Summary
During a kitchen inspection, a dietary aide was observed washing dishes without wearing a beard guard, which is required as a hair restraint in food preparation areas. Additionally, a bulk sugar container with a broken lid was found in the kitchen. The dietary manager confirmed that staff are expected to wear hair restraints and that the broken lid should have been replaced. The administrator reported that 48 residents received meals prepared in this kitchen. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Follow Posted Menu for Regular and Pureed Meals
Penalty
Summary
The facility failed to follow the posted menu for two observed meal services, affecting all 48 residents who received meals from the kitchen. During observation, the regular meal served included meatloaf, mixed vegetables, au gratin potatoes, and a brownie, but no bread was provided, despite the menu specifying 'bread of choice.' For the pureed diet, the meal included pureed meatloaf, pureed corn, pureed bowtie pasta, and banana pudding, which did not match the menu that called for a vegetable blend and bread. Staff interviews confirmed that bread was forgotten during lunch service and that the pureed meal did not follow the planned menu, as frozen pureed items were used instead of pureeing the prepared meal.
Failure to Document Psychotropic Medication Side Effect Monitoring
Penalty
Summary
The facility failed to ensure that side effect monitoring was completed and documented for a resident who was receiving psychotropic medication. According to facility policy, nursing staff are required to document the resident's response to antipsychotic medications and any side effects, including extrapyramidal symptoms or sedation, every shift. Record review showed that a resident with diagnoses of delusional disorder and unspecified anxiety disorder, and with intact cognition, was prescribed haloperidol daily. The resident's care plan specified monitoring for medication side effects every shift. However, review of the treatment administration records for two months did not show any documentation of side effect monitoring. The Director of Nursing confirmed that such monitoring should be documented in the treatment administration record and acknowledged that if it was not documented, it was not done.
Failure to Timely Transmit MDS Assessment Data
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessment data to the State within 14 days after completion for four residents. According to the facility's policy, all MDS assessments must be completed accurately and submitted electronically to the Quality Improvement and Evaluation System (QIES) within mandated timelines. Record review showed that for four sampled residents, the assessments were completed but not transmitted within the required 14-day period. Batch transmittal forms confirmed that the submission dates for these assessments exceeded the 14-day window. The Assistant Director of Nursing (ADON)/MDS coordinator reported that they had recently assumed responsibility for MDS assessments and, despite assistance, were still behind in completing and submitting the assessments on time.
Failure to Address Indwelling Urinary Catheter in Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing the use of an indwelling urinary catheter for one resident, despite having a policy requiring individualized care plans for each resident. Record review showed that the resident had diagnoses including unspecified retention of urine and dementia, and a physician's order documented the presence of a size 16 French indwelling urinary catheter. However, the resident's care plan did not include any information regarding the catheter. Interviews with the ADON and acting DON confirmed that catheter use should have been addressed in the care plan, and they were unable to explain why it was omitted.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During a wound care observation, the Assistant Director of Nursing (ADON) was seen providing wound care to a resident with a history of diabetes mellitus and a foot ulcer without wearing a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy. There was no signage indicating that the resident was on EBP, despite the policy mandating the use of personal protective equipment (PPE) for residents colonized or infected with multidrug-resistant organisms (MDROs) in accordance with CDC guidance. The resident confirmed that staff did not wear gowns during wound care, and the ADON acknowledged not using EBP during the procedure. Additionally, the acting Director of Nursing (DON) stated they were unaware of the requirement to use EBP during wound care.
Facility Fails to Provide Hot Water in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the lack of hot running water in the rooms on the 100 hall. Observations and interviews revealed that residents have been without hot water for over a month due to a broken hot water tank. Resident #4, who suffers from arthritis, reported experiencing pain when washing hands in cold water. The maintenance supervisor confirmed the issue and stated that the hot water tank would not be replaced until a government grant is received in March. Resident #5 and Resident #6 also confirmed the absence of hot water in their rooms since their arrival and for over a month, respectively, expressing the inconvenience it causes for daily activities like washing hands and face.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents with dementia. One resident, with a BIMS score of 11, was observed by staff with their hand on the pubic area of another resident, who had a BIMS score of 5. This incident occurred in the resident's room, and the two residents were immediately separated following the observation. A head-to-toe assessment was conducted on the affected resident, revealing no signs of trauma or injury. The incident was reported to the physician, family, and local police department.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents. Resident #3, who has diagnoses including diabetes mellitus and hypertension, was observed in the dining room shouting obscenities and threatening Resident #8, who has diagnoses including schizophrenia and convulsions, with bodily harm. Resident #3 propelled their wheelchair into Resident #8's leg, causing a physical altercation. A nurse's note documented the incident, and RN #2 acknowledged that such behavior is common for Resident #3 and agreed that the interaction was abusive. The Assistant Director of Nursing (ADON) confirmed that staff receive training on identifying and reporting abuse, and acknowledged that the incident met the definition of abuse.
Failure to Maintain Resident Dignity in Dressing and Catheter Management
Penalty
Summary
The facility failed to uphold the dignity of a resident who required assistance with dressing and catheter management. The resident, who had vascular dementia and amputations of both legs, was observed lying nude from the waist down in their room after returning from the hospital. They were unable to reposition themselves or reach the call light for assistance, indicating a lack of staff attention to their needs. The resident expressed dissatisfaction with being left unclothed, although they could not recall the duration of this state. Additionally, the resident's catheter bag was repeatedly observed uncovered in public spaces, such as the dining room and hallway, despite the facility having dignity covers available. The catheter bag was noted to be partially or fully filled with urine during these observations. An LPN acknowledged the availability of dignity covers and stated they would instruct aides to use them. The DON later confirmed that all resident rights should be respected, and the resident should not have been left unclothed or with an uncovered catheter bag.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to provide residents the opportunity to develop or refuse the creation of an advance directive for three out of five residents reviewed. The facility's policy on residents' rights regarding advance directives was not dated but stated that every competent person has the right to determine their health care decisions, including life-sustaining treatment and organ donation. Resident #15's advance directive form was signed only after the survey began, despite being admitted earlier. For Residents #21 and #36, there was no documentation indicating they were offered the opportunity to develop an advance directive, although the facility had a document for this purpose during the admission process. The Director of Nursing stated that advance directives should be completed thoroughly during or before admission.
Failure to Ensure Interdisciplinary Team Participation in Care Planning
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in the planning process of resident care plans for six residents. The facility's policy stated that the comprehensive care plan should be developed by an IDT, including the attending physician, registered nurse, nurse aide, dietary staff representative, the resident and/or resident representative, and any other healthcare professional as identified by the resident's needs. However, a review of resident records found no documentation related to interdisciplinary team care plan meetings for the six residents reviewed. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the care plan meetings were not conducted as per the facility's policy. The MDS Coordinator admitted to not inviting other care team members to the care plan meetings and had no recollection of contacting the medical director regarding the results of the meetings. The DON stated that they believed the social services director attended the meetings, but acknowledged that the meetings should have been documented and that the physician was only informed of issues as required. The lack of documentation and participation of the required IDT members led to the deficiency identified during the survey.
Failure to Educate and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were educated on the risks and benefits of using bed rails, obtain informed consent, inspect bed frames and bed rails prior to their application, and attempt alternatives to bed rails before their use. Specifically, two residents, one with vascular dementia and amputations of both legs, and another with dementia, were not provided with education or informed consent regarding the use of bed rails. Additionally, there was no documentation of bed frame and bed rail inspections or attempts to use alternative measures before resorting to bed rails. The Director of Nursing (DON) acknowledged the lack of documentation and stated that no alternative interventions to bed rails had been attempted for the residents in question. The facility's policy on the use of bed rails was undated and did not provide clear guidance on the necessary steps to ensure resident safety and informed consent. Observations confirmed that positioning bars and full bed rails were in use without the required assessments and documentation.
Failure to Maintain Registered Nurse Coverage
Penalty
Summary
The facility failed to maintain registered nurses on duty for eight hours each day, seven days a week, as required. This deficiency was identified through a review of the facility's Payroll Based Journal (PBJ) reports and staffing schedules for the first and second quarters of 2024. The PBJ reports documented missing registered nurse hours on several dates, including specific days in November and December 2023, as well as January and February 2024. The facility's staffing schedules corroborated these findings, showing no registered nurses were documented as having worked on the identified dates. Interviews with facility staff revealed a lack of awareness and communication regarding the staffing deficiencies. The Director of Nursing (DON) was unaware of any dates without registered nurse coverage, relying on an LPN responsible for staffing to fill any gaps. The LPN described a process for finding replacements, which included contacting on-call staff, those willing to work overtime, staffing agencies, and an on-call person. However, this process failed to ensure registered nurse coverage on the identified dates. The Human Resources representative confirmed the accuracy of the PBJ reports, indicating that the facility's staffing records were consistent with the reported deficiencies.
Medication Administration Delays Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure medications were administered within the ordered time frame, as evidenced by a review of medication administration records and staff interviews. On two consecutive days, a significant number of residents did not receive their morning medications at the scheduled time of 7:00 a.m. Instead, these medications were administered after 12:00 p.m. Specifically, on the first day, 23 out of 48 residents were affected, and on the second day, 13 out of 49 residents experienced delays. The facility's Time of Administration policy outlines specific time frames for medication administration, which were not adhered to during this period. The delay in medication administration was attributed to staffing issues, as two Certified Medication Aides (CMAs) quit suddenly, leaving the facility short-staffed. Normally, two CMAs would pass medications, but due to the sudden resignations, only one CMA was available. Additionally, administrative nurses who could have assisted were unavailable due to emergencies. The Director of Nursing (DON) acknowledged the staffing challenges and confirmed that the medications should have been administered on time, despite the unforeseen circumstances.
Failure to Notify Resident and Ombudsman of Hospital Discharge
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident and did not notify the ombudsman office when the resident was discharged to a hospital. This deficiency was identified for one of the two residents reviewed for discharges and hospitalizations. The facility's policy and procedure for transfer and discharge required notification to the resident, their representative, and the ombudsman, with documentation of the reason for transfer or discharge in the resident's medical record. However, the Director of Nursing (DON) admitted that they had not given a notice of transfer to the resident when discharged to a hospital and had not reported the discharges to the ombudsman office. Resident #12 was discharged from the facility four times since admission, with progress notes documenting transfers to a hospital for medical reasons on specific dates.
Inaccurate MDS Assessment of Pressure Wound
Penalty
Summary
The facility failed to accurately assess and code a pressure wound in Section M of a Minimum Data Set (MDS) quarterly assessment for a resident. The resident, who had vascular dementia and amputations of both legs, developed a new wound on the coccyx, which was documented in progress notes as increasing in size and later as an open area upon return from the hospital. However, the quarterly MDS assessment inaccurately documented that the resident had no pressure ulcers, despite the presence of an open wound observed during wound care. The MDS Coordinator admitted to the error, stating they were focused on the resident's surgical wounds rather than the pressure wound when completing the assessment. The Director of Nursing (DON) acknowledged that they were responsible for checking the MDS nurses' work but noted that the two MDS nurses did not review each other's assessments. The expectation was for all assessments to be accurate and timely, which was not met in this instance.
Failure to Conduct Significant Change Assessment
Penalty
Summary
The facility failed to conduct a significant change assessment for a resident following the development of a new pressure ulcer and a partial leg amputation. The resident, who had vascular dementia and had undergone an above-the-knee amputation, developed a wound on the coccyx. Despite these significant changes in the resident's condition, the facility did not perform the required assessment within the 14-day period as stipulated by their policy. The MDS Coordinator acknowledged that a significant change assessment should have been conducted due to the amputation and the new pressure wound. However, it was revealed that the part-time nurse responsible for MDS assessments was not supervised, which contributed to the oversight. The Director of Nursing stated that they were responsible for checking the work of the MDS nurses and agreed that the assessments should have been completed accurately and timely.
Lack of Feedback Program and Policies
Penalty
Summary
The facility failed to establish policies and procedures for obtaining and using feedback from staff, residents, and resident representatives. A review of the facility's Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) records revealed no documentation of a program to gather feedback from these groups. During an interview, the Administrator acknowledged that while there was a grievance process for residents, there was no formal feedback program or associated policies and procedures in place.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to maintain a functioning call light system for one of the residents, identified as Resident #47, who was part of a sample of 12 residents reviewed for this issue. Resident #47 had multiple diagnoses, including vascular dementia, atherosclerotic heart disease, and bipolar disorder. The resident's care plan, revised in April 2024, specified that the call light should be kept within reach and marked with bright tape. However, during an observation on June 3, 2024, the call light was found to be out of reach, attached to a privacy curtain, while the resident was seated in a wheelchair. Additionally, the resident was unable to confirm if the call light was functioning properly. The Director of Nursing (DON) confirmed that the call light for Resident #47 was not ringing at the front desk and admitted that no alternative intervention had been implemented at that time. The facility's policy stated that in the event of a call light malfunction, alternative methods such as a bell or buzzer should be provided, and maintenance should be notified immediately. However, the Administrator acknowledged that although they were informed of the issue on June 3, 2024, and maintenance had looked into it, a part needed to be ordered. A hand bell was provided to the resident only after the malfunction was discovered, indicating a delay in implementing the alternative alert method as per the facility's policy.
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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