Hennessey Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Hennessey, Oklahoma.
- Location
- 705 East 3rd Street, Hennessey, Oklahoma 73742
- CMS Provider Number
- 375485
- Inspections on file
- 22
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Hennessey Nursing & Rehab during CMS and state inspections, most recent first.
Survey results were not posted in a readily accessible location for residents, family members, or legal representatives. Staff observed no sign in the halls or lobby directing people to the survey results binder, and the binder was found in a wooden cabinet behind closed doors near the front door. During resident council, 10 members said they did not know where to find the state survey results, and the Administrator acknowledged there was no accessible posting for residents or visitors.
RN coverage was not maintained for the required 8 consecutive hours, 7 days per week. The facility policy required an RN on duty daily, but staffing and timecard records showed multiple days with no RN hours. The MDS coordinator confirmed the facility had only three RNs and no RN coverage on those days, and the Administrator stated they were unaware of the gaps.
Dietary Supervisor Not Certified Within Required Timeframe: The facility failed to ensure the food service supervisor completed certified dietary manager certification within the State-required timeframe. Record review showed the dietary supervisor was hired for the role but had no documentation of completing a certified program, and the supervisor stated they had not completed a certification course. The administrator acknowledged awareness that the dietary supervisor was not certified.
The facility failed to notify the physician when a resident repeatedly refused ordered ipratropium-albuterol breathing treatments and reported shaking, shakiness, and weakness with use. The resident had COPD and cough, and staff documented multiple refusals over the month, but there was no documentation that the physician was informed. An LPN knew the resident was getting shaky but did not notify the physician, and both the physician and DON stated they could not locate documentation of notification.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
Failure to document self-administration of breathing medication: A resident with COPD and intact cognition had ipratropium-albuterol neb vials left at bedside and was observed self-administering them, but there was no assessment or physician order for self-medication. The resident said the nurse gave the vials that morning, an LPN confirmed the resident administered the treatment and had no order to keep it at bedside, and the DON stated the resident lacked the required assessment and order.
Inaccurate documentation of a breathing treatment was found for a resident with COPD and cough. An LPN initialed the 8:00 a.m. dose as given on the MAR even though the resident said the nurse gave them the vials and the LPN did not observe the treatment being self-administered. The LPN later acknowledged the entry was not accurate, and the DON stated the treatment should be documented as refused unless witnessed as given.
The facility did not complete bed rail safety assessments, review risks and benefits with residents or their representatives, or obtain informed consent before installing bed rails for three residents. The DON acknowledged the lack of necessary documentation according to facility policy.
The facility did not ensure that influenza and pneumococcal vaccinations were offered to four residents. The DON confirmed that these immunizations should be offered during admission and annually, but there was no documentation in the clinical records showing that the residents or their representatives had been offered or received the vaccines.
A resident with psychiatric disorders was transferred to a VA hospital ER due to behaviors, but the facility failed to document follow-up or discharge. The DON stated the resident was a danger and the facility couldn't meet their needs, yet there was no documentation supporting this decision or a physician's discharge order.
A resident with multiple psychiatric diagnoses was transferred to the VA hospital ER due to behaviors and subsequently discharged from the facility without notification to the resident or their family. The DON acknowledged the lack of notification.
A facility failed to complete a discharge MDS assessment within the required timeframe for a resident discharged at the end of their skilled days. The EHR review showed the assessment was not completed, which was confirmed by a nurse consultant.
A facility failed to complete a baseline care plan within the required 48-hour timeframe for a resident. The resident was admitted, but the care plan was only documented as completed several days later. This issue was identified during a review and interview with a nurse consultant.
A facility failed to implement a comprehensive care plan for a resident with an indwelling urinary catheter, despite having a physician order for catheter changes and documentation of the catheter in the admission assessment. The baseline care plan did not include the catheter, and a nurse consultant confirmed the absence of a comprehensive care plan, stating it was still being completed.
A facility failed to complete a discharge summary and discharge instructions for a resident upon their discharge. The resident's clinical record contained an incomplete 'Discharge Summary' form and an undated, incomplete Discharge Instructions form. The DON acknowledged the oversight.
A facility failed to document a DNR consent form for a resident, despite having a physician's order and care plan indicating DNR status. The DON acknowledged the absence of the form, stating that residents should have both a physician's order and a DNR form upon admission or remain a full code until the form is obtained. An LPN confirmed that code statuses were found in health records and the resident roster.
A facility failed to administer oxygen as ordered by a physician and did not change oxygen tubing as per policy for a resident with COPD and respiratory failure. The resident was receiving oxygen at 3.5 LPM instead of the ordered 3 LPM, and the tubing had not been changed weekly as required.
The facility did not complete annual competency reviews for two CNAs, as required by policy. CNA #2, hired in 2022, and CNA #1, hired in 2023, both lacked these reviews in their files. The BOM confirmed the absence of these reviews.
The facility failed to implement a physician order for a GDR for a resident's trazodone medication, resulting in continued administration of a higher dose. Additionally, there was no physician response to GDR recommendations for another resident's psychotropic medications, including buspirone, Abilify, and duloxetine. The DON confirmed the lack of documentation for these GDRs.
A resident receiving IV antibiotic therapy via a PICC line experienced a breach in infection control practices. An LPN used unlabeled IV tubing, placed it on a pillow, and continued using it after it fell to the floor. The DON confirmed that facility policy was not followed, as IV tubing should be changed every 24 hours and labeled.
A resident experienced a significant change in condition, including weakness, irregular heart rate, and mental status decline. Despite being diagnosed with pneumonia and prescribed Augmentin, the facility failed to notify the physician, order the medication, and administer it. The resident's condition worsened, leading to hospital admission.
A facility failed to accurately assess a resident's risk for pressure ulcers and did not initiate necessary dietary measures, leading to the development of pressure ulcers. The RD's assessment contained discrepancies, and the care plan was not updated to reflect changes in the resident's condition, such as weight loss, decreased mobility, and incontinence. The DON acknowledged the inaccuracies and the need for dietary measures and care plan interventions.
The facility failed to ensure proper care of a PICC line for a resident, including timely dressing changes and obtaining physician orders for continued flushes and removal of the PICC line after antibiotic therapy completion. Interviews confirmed that facility policy and professional standards were not followed.
A resident with multiple diagnoses, including insomnia, was prescribed temazepam 15 mg to be taken nightly as needed for sleep. However, the medication was administered at 12 a.m. on multiple dates due to an incorrect transcription of the order by an LPN. The ADON confirmed the medication was not given as per the physician's order.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post the most recent state survey results in a place readily accessible to residents, family members, and legal representatives. During observation of the halls and lobby, there was no posting showing where to find the survey results binder. The facility policy stated that a copy of the most recent standard survey, any subsequent extended surveys, follow-up revisits, and the state-approved plan of correction would be maintained in a 3-ring binder in an area frequented by most residents, such as the main lobby or resident activity room. During resident council, 10 members stated they did not know where to find the state survey results. The Administrator stated there was a little card on the table where the results were located, but the survey results binder was found in a wooden cabinet behind closed doors in the lobby near the front door. The Administrator later stated there was no posting telling visitors or residents where to find the survey results and that the sign showing where to find them was not accessible to residents and visitors.
RN Coverage Not Maintained for Required Hours
Penalty
Summary
The facility failed to ensure RN coverage for 8 consecutive hours 7 days per week. The facility’s staffing policy, updated 10/2023, stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report for 10/01/25 through 12/31/25 showed no RN hours on 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25. An Employee Timecard Report for the same period also did not show RN hours for 8 consecutive hours on those dates. During interview, the MDS coordinator stated those were the only three RNs for the facility and confirmed there was no RN coverage on those dates. The Administrator stated they were not aware there was no RN coverage on those dates and said that if they had known, they would have called the Infection Control Preventionist in to cover the shifts.
Dietary Supervisor Not Certified Within Required Timeframe
Penalty
Summary
The facility failed to ensure the food service supervisor completed certification as a certified dietary manager within the State-required timeframe. Record review showed the facility’s Food and Nutrition Services Staff policy required the nutrition service manager, if not already certified, to be enrolled in an accredited or approved program within the regulatory timeframe. An Employee Information Report showed the dietary supervisor was hired on 02/04/20, but there was no documentation that the supervisor had completed a certified program. During interview on 03/23/26, the dietary supervisor stated they had not completed a certification course. On 03/26/26, the administrator stated they were aware the dietary supervisor was not certified and confirmed the dietary supervisor had been hired for the role on 02/04/20.
Failure to Notify Physician of Resident’s Refusal and Shaking With Breathing Treatments
Penalty
Summary
The facility failed to notify the physician of Resident #24’s change in condition related to repeated refusals of ordered ipratropium-albuterol breathing treatments and complaints of shaking. Resident #24 had diagnoses including chronic obstructive pulmonary disease and cough, and the quarterly assessment showed intact cognition with a BIMS of 15. A physician’s order dated 02/03/26 directed the resident to inhale one vial of ipratropium-albuterol three times a day for wheezing. The March 2026 administration notes showed the resident refused the breathing treatment multiple times, including refusals because it made them shake, caused shaking after use, or made them feel shaky and weak. There was no documentation that the physician was notified of the refusals or the shaking. The resident stated they got shakes from receiving the treatment three times a day and would self-administer it two times a day. An LPN stated they were aware of the shaking but did not personally notify the physician and could not locate documentation of notification. The physician stated they were not aware of any notification from the facility regarding the resident being shaky or refusing treatment, and the DON also stated they could not locate documentation that the provider was notified.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Document Self-Administration of Breathing Medication
Penalty
Summary
The facility failed to ensure a resident had both a physician order and an assessment to self-administer medications. Resident #24 had diagnoses including chronic obstructive pulmonary disease and cough, and the quarterly assessment dated 01/27/26 showed intact cognition with a BIMS score of 15. On 03/24/26 at 8:42 a.m., two vials of ipratropium bromide/albuterol sulfate 0.5-3 mg in 3 ml were observed sitting on the resident’s bedside table. The resident had a physician order dated 02/03/26 for ipratropium-albuterol inhalation solution, one vial three times a day for wheezing. There was no documentation that Resident #24 had an assessment or physician order for self-medication administration. The resident stated the nurse gave them the breathing treatment vials that morning and that they last self-administered the treatment the prior afternoon. An LPN stated the resident administered their own breathing treatment, that there was no order to leave the medication at bedside, and that the resident did not have an assessment for self-administration of medications. The LPN also stated the breathing medications should not be left at bedside. The DON confirmed the resident did not have an assessment and physician order for self-medication administration and stated the facility does not allow residents to self-administer medications.
Inaccurate Documentation of Breathing Treatment
Penalty
Summary
The facility failed to ensure a resident's breathing treatment was accurately documented for one sampled resident. Resident #24 had diagnoses including chronic obstructive pulmonary disease and cough, and the quarterly assessment noted the resident's cognition was intact with a BIMS of 15. A physician's order directed ipratropium-albuterol inhalation solution three times daily for wheezing, and the March 2026 treatment administration record showed the 8:00 a.m. dose was initialed as given on 03/24/26. During observation that morning, two vials of ipratropium bromide/albuterol sulfate were found on the resident's bedside table. The resident stated the nurse gave them the breathing treatment vials that morning and that the last time they self-administered the treatment was the prior afternoon. The LPN stated the resident self-administered the breathing treatments, but also stated they documented the 8:00 a.m. dose as given because they assumed the resident had self-administered it. The LPN acknowledged the documentation was not accurate and stated they did not observe the resident administering the treatment. The DON stated the breathing treatment should be documented as refused unless witnessed as given.
Failure to Complete Bed Rail Safety Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to adhere to its policy regarding the use of bed rails, resulting in a deficiency. Specifically, the facility did not complete necessary bed rail safety assessments, nor did it review the risks and benefits of bed rails with the residents or their representatives. Additionally, informed consent was not obtained prior to the installation of bed rails for three residents. Observations revealed that these residents were using bed rails without the required documentation in their clinical records. The Director of Nursing acknowledged that the necessary paperwork had not been completed according to the facility's policy.
Failure to Offer Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were offered to four of the five residents reviewed for immunizations. The Director of Nursing (DON) confirmed that immunizations should be offered during the admission process and annually. However, there was no documentation in the clinical records of Residents #15, #18, #22, and #82 indicating that they or their representatives had been offered or received these vaccines. This deficiency was identified during a record review and interview with the DON, who acknowledged the lack of documentation for these residents.
Inadequate Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that a resident was not involuntarily discharged without adequate reason and proper documentation. A resident with multiple psychiatric diagnoses, including anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD, was transferred to a VA hospital ER due to behaviors. However, there was no documentation in the clinical record indicating follow-up on the resident's status after the transfer or stating that the resident had been discharged. The Director of Nursing (DON) later stated that the resident did not return because they were a danger to themselves and others, and the facility could not meet their needs. Additionally, there was no documentation in the clinical record indicating that the facility would not be able to meet the resident's needs upon their return, nor was there a physician's order to discharge the resident.
Failure to Notify Resident and Family of Discharge
Penalty
Summary
The facility failed to provide timely notification of a facility-initiated discharge for a resident diagnosed with anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. The resident was admitted on an unspecified date and was transferred to the VA hospital emergency room due to behaviors on June 25, 2024, as documented in a nurse's note. A discharge summary dated June 26, 2024, indicated that the resident had been discharged from the facility on June 25, 2024. However, there was no documentation in the clinical record that the facility notified or attempted to notify the resident or their family about the discharge. On August 6, 2024, the Director of Nursing acknowledged that neither the resident nor their family had been informed of the discharge.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge MDS assessment within the required timeframe for a resident who was discharged at the end of their skilled days. The resident was admitted to the facility and discharged on April 12, 2024. A review of the electronic health record (EHR) revealed that the discharge MDS assessment had not been completed. This was confirmed during an interview with Nurse Consultant #1 on August 6, 2024, who acknowledged the oversight.
Failure to Timely Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan in a timely manner for a resident. The resident was admitted on an unspecified date, and the baseline care plan was documented as completed on 07/27/24. However, it was noted during an interview with a nurse consultant on 08/06/24 that the baseline care plan was not completed within the required 48-hour timeframe following the resident's admission. This deficiency was identified during a review of records and interviews conducted by the surveyors.
Failure to Implement Comprehensive Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was admitted with diagnoses including neuromuscular dysfunction of the bladder and hydronephrosis. The resident had a physician order to change the Foley catheter every 30 days, specifically on the 1st of the month during the night shift. Despite the resident's admission assessment documenting the presence of an indwelling catheter, the baseline care plan did not include this information. Furthermore, there was no record of a comprehensive care plan being completed for the resident. During an interview, a nurse consultant confirmed that the resident did not have a comprehensive care plan and stated that they were in the process of completing one.
Incomplete Discharge Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a discharge summary and discharge instructions were completed for a resident upon their discharge. The resident was admitted to the facility and discharged at the end of their skilled days. A 'Discharge Summary' form was found in the resident's clinical record, dated prior to the discharge, but it was not completed. Additionally, a Discharge Instructions form was also found in the clinical record, undated and not completed. The Director of Nursing (DON) acknowledged that these documents had not been completed for the resident.
Failure to Document DNR Consent Form for a Resident
Penalty
Summary
The facility failed to have a process in place to identify a resident's code status, specifically for one resident reviewed for advanced directives. The resident was admitted with a physician's order indicating Do Not Resuscitate (DNR) status, dated 07/23/24, and a care plan dated 07/27/24, also documented the resident's preference for DNR. However, there was no documentation of a completed Oklahoma DNR consent form in the resident's record. On 08/05/24, the Director of Nursing (DON) acknowledged the absence of the DNR consent form in the health record, stating that residents should have both a physician's order and a DNR form upon admission or remain a full code until the form is obtained. Additionally, an LPN confirmed that residents' code statuses were found in their health records and the resident roster at the nurse's station.
Failure to Administer Oxygen as Ordered and Change Tubing
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician and that oxygen tubing was changed as per facility policy for a resident receiving respiratory care. The resident, who had diagnoses including COPD and acute and chronic respiratory failure with hypoxia, had a physician's order for oxygen at 3 liters per nasal cannula to maintain oxygen saturation at 90% or above. However, during an observation, the resident was found to be receiving oxygen at 3.5 liters per minute, contrary to the physician's order. Additionally, the oxygen tubing was dated from 07/22, indicating it had not been changed weekly on Sundays as required by the facility's policy. RN #1 confirmed that the physician's order was not followed and that the tubing should have been changed according to the policy.
Failure to Conduct Annual CNA Competency Reviews
Penalty
Summary
The facility failed to conduct a nurse aide performance review every 12 months for two certified nurse aides (CNAs) out of five employee files reviewed. The facility's policy, revised in October 2017, requires all nursing staff to meet specific competency requirements as defined by state law. CNA #2, hired on April 28, 2022, did not have an annual competency review in their file. Similarly, CNA #1, hired on May 12, 2023, also lacked an annual competency review in their file. On August 6, 2024, the Business Office Manager (BOM) confirmed the absence of these reviews for both CNAs.
Failure to Implement and Document GDRs for Psychotropic Medications
Penalty
Summary
The facility failed to implement a physician order for a gradual dose reduction (GDR) for a resident diagnosed with insomnia and anxiety. A medication regimen review (MRR) recommended reducing trazodone from 150 mg to 100 mg at bedtime. Although the physician agreed to the reduction, and a nurse acknowledged the recommendation, there was no corresponding physician's order until a week later. Consequently, the resident continued receiving the higher dose until the order was implemented, and the reduced dose was first administered the following day. Additionally, the facility did not have a physician's response to GDR recommendations for another resident diagnosed with schizophrenia, anxiety, insomnia, and depression. The MRRs recommended dose reductions for buspirone, Abilify, and duloxetine, but there was no documentation of a physician's response to these recommendations. The Director of Nursing (DON) confirmed the absence of a physician's response to the GDRs upon review of the MRRs.
Infection Control Breach During IV Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during the administration of medication for a resident receiving intravenous antibiotic therapy via a PICC line. During an observation, an LPN was seen using IV tubing that was not labeled with the date, time, and initials as required by the facility's policy. The LPN used the unlabeled tubing to spike a new IV bag and laid the end of the tubing on the resident's pillow. During the process of flushing the PICC line lumens, the end of the tubing fell to the floor. Despite this, the LPN picked up the tubing from the floor, removed the cap, connected it to the PICC line lumen, and started the IV. The Director of Nursing (DON) confirmed that the facility's policy required IV tubing to be changed every 24 hours and labeled accordingly. The DON acknowledged that the proper infection control practices were not followed, and the facility policy was not adhered to. The LPN's actions, including using unlabeled tubing and failing to replace the tubing after it fell to the floor, contributed to the deficiency in infection control practices.
Failure to Monitor and Administer Prescribed Antibiotic Therapy
Penalty
Summary
The facility failed to assess, monitor, and intervene for a resident experiencing a significant change in condition and did not ensure the resident received prescribed antibiotic therapy to treat pneumonia. On 03/08/24, the resident exhibited acute changes such as weakness, inability to stand or sit, irregular heart rate, low oxygen saturation, incontinence, and mental status decline. Despite notifying the MD, the resident was not sent to the ER, and no further MD notifications were documented as the resident's condition continued to deteriorate over the following days. On 03/19/24, the resident requested to be sent to the ER and was diagnosed with pneumonia, receiving an order for Augmentin. However, the facility failed to notify the resident's physician of the new order, did not submit the medication order to the pharmacy, and did not place the medication on the MAR. Consequently, there was no documentation that the prescribed antibiotic was ever ordered, received, or administered to the resident between 03/19/24 and 04/08/24. The resident's condition continued to decline, and on 04/08/24, they were sent to the ER with low blood pressure, labored breathing, erratic pulse, and altered mental status, leading to their hospital admission. The DON acknowledged that the resident had not been properly assessed, monitored, or received necessary interventions according to facility policy after experiencing a significant change in condition. Additionally, the resident did not receive the prescribed antibiotic therapy for pneumonia, as documented in the clinical records and MARs.
Removal Plan
- All Licensed RN/LPN staff educated on how to recognize acute changes in resident baseline condition, orientation, and/or change in vital signs with documentation of notification to the physician and family.
- All newly hired Licensed RN/LPN staff will be educated on how to recognize change in resident baseline condition, orientation, and/or change in vital signs with documentation of notification to the physician and family.
- All direct care nursing staff educated on how to recognize acute changes in resident baseline condition, orientation, and/or change in vital signs and report to charge nurse immediately.
- DON/Designee will review all new hire packets to ensure all training is completed.
- DON/Designee will report any negative findings to the QAPI team.
- All licensed RN/LPN In-serviced on Facility Policy and Procedure properly assessing, monitoring, and intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed.
- All licensed new hires will be educated on Facility Policy and Procedure on properly assessing, monitoring, intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed.
- DON/designee will review all new hire packets to ensure all training is completed.
- DON/designee will report any negative findings to QAPI.
- DON/Designee will compare physician orders on all new admissions to MAR and verify all medications are on hand.
- Any staff that are on leave will be educated prior to being placed on the schedule.
- DON/ADON in-serviced on reviewing all physicians' orders to include hospital discharges/doctor's appointment during clinical meeting to ensure orders are not missed.
- DON/ADON will review all physicians' orders to include hospital discharges/doctor's appointment during clinical meeting to ensure orders are not missed. Any negative findings will be corrected immediately.
- All Licensed nurses educated on comparing new orders/hospital discharge orders with the MAR and updating MAR to reflect any new orders.
Failure to Prevent Pressure Ulcers Due to Inaccurate Assessment
Penalty
Summary
The facility failed to accurately assess a resident's risk for pressure ulcers and did not initiate necessary dietary measures to prevent avoidable pressure ulcers. The resident had a history of left toe amputation and a PICC line in the upper right arm. Despite significant weight loss and a decline in nutritional intake, the Registered Dietitian (RD) assessed the resident as being at no/low risk for pressure ulcers. The RD's assessment contained several discrepancies, including incorrect documentation of weight loss, oral intake, mobility, and lab values. Additionally, the resident's care plan was not updated to reflect the changes in their condition, such as decreased mobility and incontinence, which increased the risk of skin breakdown. Physician's orders indicated the presence of open areas on the resident's coccyx, but there were no documented assessments or care plan updates addressing the risk of skin breakdown following the resident's change in condition. The Director of Nursing (DON) acknowledged that the RD's assessment was inaccurate and that dietary measures and care plan interventions should have been implemented to prevent the development of pressure ulcers. The lack of accurate assessment and timely intervention led to the resident developing pressure ulcers, which were not properly documented or addressed in the care plan.
Failure to Ensure Proper Care of PICC Line
Penalty
Summary
The facility failed to ensure the proper care of a peripheral intravenous central catheter (PICC) for a resident who had a PICC line in the upper right arm and was receiving intravenous antibiotics. The facility's policy required dressing changes every 3-7 days or as needed if the dressing became damp, loosened, or visibly soiled. However, there was no documentation that the PICC line dressing was changed between 03/11/24 and 04/08/24, despite a note on 03/11/24 indicating that the dressing was coming loose and was only reinforced with gauze. Additionally, the resident continued to receive PICC line flushes twice a day from 03/12/24 through 04/06/24 without a physician's order, and there was no documentation that the physician was contacted to obtain orders for these flushes or for the removal of the PICC line after the completion of the IV antibiotic therapy on 03/11/24. Interviews with the LPN and the Director of Nursing (DON) confirmed that the physician was not notified for an order to continue PICC line flushes or to remove the PICC line when the antibiotic therapy was completed. The DON also acknowledged that the facility policy and professional standards of practice were not followed, as there were no documented dressing changes or physician orders for the continued care of the PICC line during the specified period.
Medication Administration Error
Penalty
Summary
The facility failed to ensure medication was administered as ordered for one resident reviewed for medications. The resident had diagnoses including multiple sclerosis, insomnia, and abnormal weight loss. According to the hospital discharge summary, the resident was prescribed temazepam 15 mg to be taken nightly as needed for sleep. However, the April 2024 Medication Administration Record (MAR) showed that the medication was given at 12 a.m. on multiple dates. Upon review, an LPN acknowledged that the order had been transcribed incorrectly, and the Assistant Director of Nursing (ADON) confirmed that the medication had not been administered according to the physician's order.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
