Meadowbrook Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chouteau, Oklahoma.
- Location
- 113 East Jones, Chouteau, Oklahoma 74337
- CMS Provider Number
- 375276
- Inspections on file
- 18
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Meadowbrook Nursing Center during CMS and state inspections, most recent first.
A resident with CHF and HTN, assessed as cognitively intact and ambulatory with a walker, was not identified as an elopement risk and was able to leave the building unattended. While a nurse was charting at the nurse’s station, staff discovered the resident had exited through a coded door, walked toward a highway, and approached a stopped semi-truck to ask the driver for a ride home. The resident later stated they waited for the nurse to leave the desk, used the door code, and walked down the road to the highway after becoming upset with a family member. A corporate nurse consultant acknowledged the resident should not have been able to leave the building unsupervised.
A resident with COPD, lung cancer, respiratory failure, and other psychiatric diagnoses, who was cognitively intact and used oxygen, repeatedly obtained and used cigarettes in their room despite a facility policy prohibiting smoking materials in resident rooms. Staff and leadership were aware of prior evidence of in-room smoking, including ashes found on the toilet and an incident where the resident hid a cigarette in their pocket, yet smoking assessments continued to rate the resident as safe to smoke with minimal supervision. Ultimately, the resident smoked in their room while on oxygen, causing facial burns, and a lighter was later found under the bed, demonstrating that the facility failed to adequately enforce its smoking policy and supervise the resident to prevent accident hazards.
The facility did not consistently post required daily nurse staffing information for residents and visitors. Surveyors first observed that no staffing information was posted, and later saw a dry erase board near the nurse’s station listing the date, staff names with titles, census, and number of residents in the hospital. Facility policy required daily staffing reports to be posted for residents and visitors. An LPN and the DON reported that staffing information was documented on the dry erase board, and the DON noted that a separate assignment book was kept at the nurse’s station but not accessible to residents or visitors. The administrator acknowledged that staffing information had been posted in the past but admitted that this practice had lapsed.
Facility administration failed to report and investigate abuse allegations involving a resident, relying instead on a police determination and a lack of visible bruising, and did not document key conversations. Comprehensive care plans were not initially developed for two residents who smoked, and several residents’ care plans were not reviewed or revised quarterly to reflect current conditions such as hospice services, nutrition/weight loss, and removal of outdated fluid restrictions. One resident with a known history of smoking in their room continued to do so multiple times, with a lighter later found under the bed, while leadership acknowledged they could not ensure residents were free of smoking materials. Regional leadership reported systemic failures and that offers of support to facility administration were often refused.
The facility failed to maintain an effective QAPI/QAA program, as it did not systematically identify, report, investigate, analyze, or prevent adverse events, nor document development and evaluation of performance improvement activities. Despite a policy requiring quarterly departmental monitoring reports and QAA review, surveyors found ongoing systemic problems, including unrecognized and unreported abuse allegations, incomplete or unrevised comprehensive care plans, and inadequate supervision to prevent smoking-related accident hazards for the 34 residents in the facility. The administrator reported that QAPI meetings occurred at least quarterly and that an annual PIP had been completed on urinary catheters, but acknowledged that these significant system failures were not identified by the QAPI committee, attributing this to things being hectic.
The facility failed to review and revise care plans at least quarterly and when residents’ conditions or services changed, as required by its care planning policy. Several residents had care plans that had not been updated for over a year despite new hospice admissions, significant weight loss with dietician interventions, and documented unsafe smoking behaviors while on oxygen. Care plans lacked current problems and interventions, such as hospice services, nutrition and weight loss management, and smoking safety, even though recent MDS assessments and progress notes reflected these issues. The DON acknowledged responsibility for overseeing MDS and care planning and confirmed that care plans had not been reviewed or revised as required.
The facility did not consistently inform residents or their representatives about new or changed medications and the associated risks and benefits. A cognitively intact resident receiving antipsychotics had new orders for clozapine and haloperidol without documented notification or discussion of risks/benefits, and the resident was unsure if they had been informed. Another cognitively intact resident with depression and schizoaffective disorder received multiple psychotropic and opioid medications, including Rexulti, tramadol, trazodone, and buspirone, with no documentation that risks and benefits were explained. A third resident with moderate cognitive impairment and multiple chronic conditions received new orders for insulin and levofloxacin without documented discussion of benefits or side effects. Staff, including an LPN and the DON, reported that charge nurses were responsible for notifying residents and documenting this, but acknowledged that discussing and documenting risks and benefits was not common practice.
A resident with dementia but a BIMS score indicating intact cognition was admitted with documentation noting a POA and that advance directive documents had not been received. Although the business office manager typically reviewed admission packets with new admissions, the DON reported that this resident was not offered, did not decline, and did not accept assistance to formulate an advance directive, resulting in a failure to assist the resident with advance directive development.
Two residents who were identified smokers did not have comprehensive smoking care plans reflecting their needs and behaviors. One resident’s admission assessment documented smoking and the resident reported needing someone to stay with them while smoking due to use of a transport wheelchair, yet the initial care plan omitted any smoking concern and a smoking care plan with interventions was only added later. Another resident, observed smoking outside and documented as able to smoke with minimal supervision and having signed the facility’s smoking policy, also lacked a smoking-related care plan. The DON acknowledged responsibility for overseeing the MDS coordinator and confirmed both residents had been smokers since admission without appropriate smoking care plans in place.
The facility did not complete or document required competency assessments for multiple newly hired CNAs, despite a policy stating that new employees must undergo competencies and floor training under the DON’s direction. Review of several CNA personnel files showed no completed competency forms, and the DON confirmed that new CNAs were trained by other CNAs but that the competency check-off forms were not filled out due to staff turnover and oversight.
The facility failed to complete required annual performance reviews for a CMA employed for more than 12 months. A CMA was observed administering 50 mg of zinc to a resident despite a physician order for 30 mg daily. Review of the CMA’s personnel file showed no performance evaluation since hire, and the DON acknowledged there was no system to ensure CNAs/CMAs received performance reviews at least every 12 months and that no review documentation could be found for this CMA.
Surveyors found that a nurse treatment cart containing medications was left unlocked and unattended on more than one occasion, with facility leadership and visitors passing by before an LPN returned to use it, despite staff acknowledging carts were required to be locked when unattended. Review of the same cart showed opened but undated glucometer check strips and multiple undated insulin pens for several residents, as well as medications with future expiration dates, while nursing staff could not state how long the undated insulin had been in use or how often the cart was checked for expired drugs. The DON reported that nurses were supposed to date insulin when opened and that one LPN was responsible for monitoring the cart, but did not verify that audits occurred. Discontinued narcotics were kept in a drawer of a locked cart inside the DON's locked office, but the cart’s internal separately locked compartment could not be used due to lack of a key, and the cart was not permanently affixed.
Surveyors found that the facility did not follow professional food safety standards when unpasteurized eggs were routinely used for scrambled, over easy, and fried eggs served to multiple residents, and leftover foods in the kitchen refrigerator were not consistently labeled, dated, or properly sealed. Observations included residents eating eggs over easy made from unpasteurized eggs, sliced cheese stored in an unsealed bag with an old date, and an unlabeled container with an unknown liquid in the refrigerator, while no policy on food storage or pasteurized egg use was provided and leadership was unaware that the eggs supplied were not pasteurized.
A cognitively intact resident with schizophrenia twice alleged being beaten by staff, first telling other residents they had bruises on their arms and back, and later calling 911 claiming staff were beating them with whips and chains. An LPN documented each allegation and reported them to leadership, and a police officer and LPN conducted a full body assessment with no bruising noted. Despite a written policy requiring immediate reporting of all suspected abuse to OSDH, the DON and administrator did not report either allegation to state authorities, instead relying on the absence of injuries and the police officer’s findings.
A cognitively intact resident with schizophrenia repeatedly alleged being beaten by staff, first telling other residents they had bruises on their arms and back and later calling 911 claiming staff were beating them with whips and chains. LPNs documented these allegations and reported them to the DON and administrator, and a full body assessment with a police officer found no bruising. Despite a policy requiring immediate investigation of suspected abuse, the DON confirmed there was no evidence of any investigation, and the administrator acknowledged not initiating or documenting an abuse investigation, relying instead on the police response, a shower aide’s observation, and the resident’s later denial.
A resident was discharged home with hospice services, medications, and personal belongings, but the clinical record did not contain the reason for discharge, the resident’s status at discharge, a physician discharge order, or documentation of resources required or provided. Staff, including an LPN, the DON, the administrator, and a family member, all described the discharge as a planned return to the resident’s apartment with hospice and medications, yet these details were not recorded in the medical record.
A resident was discharged home with hospice services without a completed discharge summary or notification to the State Ombudsman office. Record review showed that, although a discharge return-not anticipated assessment documented the admission and discharge, the clinical record contained no discharge summary and no evidence of Ombudsman notification. An LPN reported the resident left with medications and personal belongings. The DON stated discharge summaries should be completed by the MDS coordinator and filed in the record but confirmed none was present for this resident. The administrator, who is responsible for notifying the Ombudsman, acknowledged that the Ombudsman was not notified and stated they only provide such notification for involuntary discharges.
A resident with end stage renal disease and moderately impaired cognition, receiving thrice-weekly dialysis per physician orders and care plan, did not have required pre- and post-dialysis assessments documented on two dialysis treatment days. Dialysis communication forms and progress notes lacked any record of these assessments, despite an LPN stating they should be recorded there. The DON confirmed the absence of documentation for those dates and was unable to explain why the assessments were not completed or what monitoring process existed to ensure such assessments were performed.
A resident was observed using an enabler-style bedrail to assist with getting out of bed, with a physician order and care plan referencing its use for positioning and transfers. However, review of records over several months showed no documented safety assessment for the bedrail, despite facility expectations that such assessments occur at the time of the order and quarterly. The DON reported being unaware that the resident had a bedrail and confirmed there was no documentation of a safety assessment, indicating the facility did not follow its own process for assessing bedrail safety, reviewing risks and benefits, and obtaining informed consent.
The facility failed to ensure required TB testing and annual flu and pneumonia vaccinations were completed and documented for two residents. One cognitively intact resident with dementia had no record of a TB test on admission or of annual flu and pneumonia immunizations. Another cognitively intact resident with right lower lobe lung cancer, who had been re-admitted, had no documentation of a TB test upon admission. When surveyors requested records, the DON indicated the information should be in the EHR or in the administration office and stated TB tests were to be completed on admission, but the requested TB and immunization documentation for these residents was not provided by the end of the survey.
The facility failed to maintain an effective pest control program in the kitchen, with roaches observed around the dish machine and various environmental deficiencies such as missing baseboards, standing water, and unsecured doors. Despite pest control efforts, roaches were reported in the dining room, and the maintenance supervisor acknowledged the need for further action.
Failure to Prevent Resident Elopement and Unsupervised Exit
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an elopement for one resident. The resident had diagnoses including congestive heart failure and hypertension, was assessed on 02/12/26 as not at risk for elopement, and a significant change assessment on 02/13/26 documented a BIMS score of 13, indicating cognitive intactness for daily decision making, and that the resident was ambulatory with a walker. On multiple observations in mid-April, the resident was seen in their room, either resting in bed or sitting on the side of the bed, appearing clean and appropriately dressed. The facility’s undated Missing Resident policy stated the intent to be aware of residents’ usual habits and locations as reasonably practicable to identify a possible missing resident. On 04/04/26, while a nurse was at the nurse’s station charting, staff informed the nurse that the resident was out of the building and walking toward the highway. The resident walked onto the highway, stood in front of a stopped semi-truck, and asked the driver to take them home before staff were able to return the resident safely to the facility without injury. In a typed statement dated 04/06/26, the resident reported being angry after a family member hung up on them, then walking slowly down the hallway while waiting for the nurse to leave the desk, observing that the nurse was no longer at the desk, hurrying to the door, entering the code, exiting the building, and continuing down the road toward the highway until a passing truck stopped. The resident confirmed they did not walk in front of the truck until it had stopped. The corporate nurse consultant later stated the resident should never have been able to leave the building unattended.
Failure to Enforce Smoking Policy and Supervise Oxygen-Dependent Smoker
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accident hazards related to smoking, resulting in a resident smoking in their room while wearing oxygen and sustaining facial burns. The facility had a written smoking policy stating that residents would not be allowed to have cigarettes, matches, or lighters in their possession or in their rooms, and that no smoking was permitted in resident rooms or hallways. Despite this, the resident was able to obtain and use smoking materials in their room. Staff, including the administrator and DON, acknowledged that housekeeping had previously found ashes on the resident’s toilet seat and that the resident had been reported to have smoked in their room multiple times over a two‑month period. The resident involved had diagnoses including COPD, lung cancer of the right lower lobe, respiratory failure, anxiety, depression, and paranoid schizophrenia, and used oxygen. Assessments showed the resident was cognitively intact with a BIMS score of 15 and was identified as a smoker. A smoking assessment documented on 11/12/25 indicated the resident could safely smoke with minimal supervision, and a subsequent assessment on 02/12/26 noted the resident had been observed hiding a cigarette in their pocket to smoke later, yet still concluded they could safely smoke with minimal supervision. A nurse progress note on 02/12/26 recorded that staff had observed the resident placing a cigarette in their jacket pocket and had educated the resident on the dangers of smoking while wearing oxygen. Despite these documented concerns and prior observations of unsafe smoking behavior, the resident continued to access smoking materials and smoke in their room. A nurse progress note dated 03/03/26 recorded that the resident had smoked in their room the night before while wearing oxygen, resulting in burns to the resident’s face. On observation, the resident was noted to have singed mustache hair and a wound near the upper lip. The administrator reported that the maintenance director later found a lighter under the resident’s bed and that it had been reported the resident had smoked in their room six times between early January and early March. Staff interviews confirmed that residents were not supposed to have smoking materials in their possession and were to be supervised while smoking, but also revealed that there was no guarantee that all lighters and cigarettes had been removed from the resident’s room.
Removal Plan
- Notify Medical Director
- Notify resident #26 hospice provider of IJ and coordinate care
- Complete a new Smoking Assessment for all smokers
- Review and revise the smoking policy with the resident and resident council (with agreement/approval) to include checking for any smoking material at the end of each smoke break; update the policy to include observation of smoking residents to ensure smoking material (e.g., cigarette butts) is distinguished and disposed of and the lighter is returned at the end of smoking times; implement a checklist to ensure each resident has complied; staff supervising smoke breaks will keep the smoking materials container in their possession with only one lighter available and will give each resident only one cigarette at a time; all smoking materials brought in by friends/family will be checked in at the nurse's station
- Post the reviewed/revised smoking policy with resident council approval at the nurses' station and by the exit leading to the smoking area
- Have smoking residents sign the revised smoking policy acknowledging the policy
- Administrator to in-service staff on the revised smoking policy
- Regional supervisor to in-service Administrator/DON on ODHS Form 283 and completing it with adequate supervision of residents and follow-up for accidents/incidents related to smoking and charting interventions and follow-up care
- Update the care plan for resident #26
- Review all smoking residents' care plans and revise as needed for adequate supervision/intervention to prevent accidents/injury and ensure follow-up if an occurrence happens
- Move resident #26 to a room closer to the nurse's station
- Educate resident #26 on hazards of smoking in the room and potential harm due to combustion with oxygen; have resident sign education sheet and upload to the resident EHR under resident documents
- Send all ODHS Form 283 reports to a Regional Supervisor for review for completeness and adequate intervention to prevent reoccurrence and ensure follow-up
- Initiate QAPI for the IJ and monitor implementation of the above interventions for removal of IJ
Failure to Consistently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure required daily nurse staffing information was posted for residents and visitors. Surveyors observed on 03/12/26 at 1:30 p.m. that nurse staffing information was not posted anywhere in the facility, despite the administrator identifying that 34 residents resided there. On 03/13/26 at 9:28 a.m., a dry erase board by the nurse’s station was observed that listed the date, staff names with titles, census, and the number of residents in the hospital. The facility’s undated “Staffing Requirement Policy” stated that daily staffing reports would be posted for residents and visitors to view. During interviews, an LPN stated that nurse staffing information was posted on the dry erase board by the nurse’s station, and the DON stated that nurse staffing information was documented on that board for visitors and residents, while also noting that a separate book at the nurse’s station contained daily staff assignments but was not available to residents and visitors. The administrator acknowledged that nurse staffing information had been posted in the past but stated that “the ball has been dropped on that,” confirming the lapse in maintaining required staffing postings. No specific resident medical histories or conditions were described in relation to this deficiency, only that 34 residents were residing in the facility at the time of the survey.
Systemic Administrative Failures in Abuse Reporting, Care Planning, and Smoking Supervision
Penalty
Summary
Facility administration failed to use its resources effectively and efficiently to ensure residents attained or maintained their highest practicable well-being. The administrator did not report allegations of abuse involving one resident to the state survey agency (OSDH). The administrator acknowledged that allegations made on two separate dates were not reported because a skin assessment did not show bruising, a police investigation did not substantiate the allegation, and the resident later denied being abused. The administrator questioned the need for further action and did not document the conversation with the resident. The facility also failed to investigate the same resident’s abuse allegations. The administrator stated that the DON, MDS coordinator, or the administrator would normally investigate abuse allegations, but no internal investigation was conducted for either allegation. For one allegation, the administrator relied on the police determination that the allegation was unsubstantiated, and for the other, they relied on a shower aide’s observation that no bruising was present and the resident’s denial of abuse. The administrator stated they had never conducted an abuse investigation and did not initiate or document an internal inquiry. In addition, the facility did not develop or maintain comprehensive and current care plans for multiple residents and did not provide adequate supervision related to smoking. Two residents who smoked did not have appropriate smoking care plans developed initially, and several residents’ care plans were not reviewed or revised quarterly or as needed to reflect current conditions, including hospice services, nutrition/weight loss, and removal of outdated fluid restrictions. One resident with a history of smoking in their room had been reported multiple times for doing so, had smoking materials confiscated, and was later found to have a lighter under the bed, while the administrator acknowledged there was no guarantee residents did not have lighters or cigarettes in their rooms. Regional nursing staff reported that systemic failures existed and that offers of support to facility administration were often refused.
Failure to Maintain Effective QAPI/QAA Program for Abuse, Care Planning, and Smoking Safety
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Quality Assessment and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) program. Surveyors found the facility did not demonstrate systematic identification, reporting, investigation, analysis, and prevention of adverse events, nor did it show documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility had a written Quality Assessment and Assurance Program policy dated 06/27/13 that required each department or service to submit quarterly monitoring reports to the QAA committee, and for those reports to be evaluated to determine problems, plan solutions, implement actions, and ensure follow-up and consistent monitoring over a specified time frame. However, the survey findings, as referenced in CMS Form 2567 (F609, F610, F656, F657, and F689), showed that these processes were not effectively carried out. Surveyors identified systematic problems in several areas affecting the 34 residents in the facility, including failure to identify abuse allegations, failure to report abuse allegations to the state survey agency (OSDH), failure to develop and revise comprehensive care plans, and inadequate supervision to prevent accident hazards related to smoking. During interviews, the administrator stated that the QAPI committee met at least quarterly and that they completed an annual process improvement project, most recently focused on urinary catheters. The administrator also stated that during QAPI meetings they reviewed facility concerns and the relevant department head monitored whether goals were met. Nonetheless, the administrator acknowledged that the system failures related to smoking hazards, abuse reporting and investigation, and care plan development/revision had not been identified by the QAPI committee, explaining that this was because “things had been hectic.”
Failure to Review and Revise Care Plans Quarterly and With Significant Changes
Penalty
Summary
The deficiency involves the facility’s failure to review and revise resident care plans at least quarterly and as needed, as required by its own Care Planning-Interdisciplinary Team policy and federal regulations. The policy, revised in 09/2013, states that assessments are ongoing and care plans must be updated with significant changes, unmet outcomes, readmissions, and at least quarterly with the MDS. Surveyors found multiple examples where this did not occur. One resident with schizophrenia, cognitively intact per a recent quarterly assessment, had a care plan last revised more than a year earlier. Another resident, severely cognitively impaired and admitted to hospice for senile degeneration of the brain, had a care plan last revised over a year prior and with no hospice-related concern documented. The DON, who oversees the MDS coordinator, repeatedly stated they did not know why these care plans had not been updated. Additional residents also had outdated or incomplete care plans despite significant changes in condition or services. One resident with documented poor intake, significant weight loss over several months, dietician interventions including supplements, high-calorie snacks, and an appetite stimulant, and a quarterly assessment noting weight loss, had a care plan last revised months earlier that did not address nutrition or weight loss and still reflected an outdated fluid restriction. Another cognitively intact resident with emphysema and COPD was newly admitted to hospice, but the care plan, last reviewed over a year earlier, did not include hospice services. A further resident on hospice with a prognosis of less than six months had a care plan last revised more than a year earlier and lacking documentation of hospice services or repeated unsafe smoking behaviors, including placing a cigarette in a pocket and later igniting a cigarette while on oxygen, which resulted in a burn treated with Silvadene. The DON acknowledged that care plans were supposed to be updated quarterly and that this had not been done for these residents.
Failure to Inform Residents of Medication Changes and Risks/Benefits
Penalty
Summary
The facility failed to ensure residents and/or their representatives were informed of changes to medication regimens and the associated risks and benefits, contrary to its Notification of Changes Policy requiring immediate sharing of such information. For one cognitively intact resident with schizophrenia who received antipsychotic medications, physician orders initiated clozapine 50 mg at bedtime and later haloperidol 5 mg twice daily, but nursing progress notes over the relevant periods contained no documentation that the resident had been informed of these new medications or their risks and benefits. The resident reported receiving mental health medications that were adjusted at times and was unsure whether they had been notified of the clozapine or haloperidol orders. An LPN stated that the charge nurse receiving a new medication order was responsible for notifying the resident or representative and documenting this in progress notes, but also stated they discussed only possible side effects, not risks and benefits. The DON acknowledged that charge nurses were supposed to document such notifications but that it was not common practice and confirmed that risks and benefits had not been discussed with this resident or their representative. Another cognitively intact resident with depression and schizoaffective disorder was receiving multiple psychotropic and opioid medications, including Rexulti, tramadol, trazodone, and buspirone, with care plan approaches to administer medications as ordered and monitor for side effects and effectiveness. Review of progress notes over several months did not show that the resident or representative had been notified of the risks and benefits of these medications. The DON stated that information on risks and benefits was provided by the physician before medications were given and documented in physician progress notes, but no such documentation was identified in the nursing progress notes reviewed. A third resident with moderate cognitive impairment and diagnoses including emphysema, heart failure, hypertension, and depression had new orders for Lantus insulin and levofloxacin for bacterial pneumonia, yet progress notes did not show that the resident or representative had been informed of the benefits and side effects of these medications. The DON again stated that charge nurses were to document notification of medication changes but that this was not common practice and confirmed that risks and benefits had not been discussed with this resident or their representatives.
Failure to Assist Cognitively Intact Resident With Advance Directive
Penalty
Summary
The facility failed to provide assistance to develop an advance directive for one resident reviewed for advance directives. Record review showed an Advance Directive Policy and Record form for Resident #15 dated 09/21/25 that indicated documents were not received and the facility was informed of the document, and that a POA was in place with initials from the resident’s responsible party. An admission assessment dated 09/28/25 documented that the resident had a BIMS score of 15, indicating they were cognitively intact for daily decision-making, and listed diagnoses including dementia. During an interview on 03/13/26 at 3:30 p.m., the DON stated that the business office manager typically reviewed the admission packet with all new admissions and acknowledged that this resident was not offered, did not decline, and did not accept assistance to formulate an advance directive.
Failure to Develop Comprehensive Smoking Care Plans for Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing residents’ smoking needs and behaviors. For one resident, the admission assessment dated 12/08/25 documented that the resident was a smoker, and the resident later stated they required someone to stay with them when they smoked because they could not push their own transport wheelchair. However, a care plan dated 12/13/25 contained no smoking concern, and the smoking care plan with interventions was not reflected until a version revised 12/15/25, which was only saved by the surveyor on 03/12/26. Quarterly Smoking Assessments dated 03/10/26 and 03/11/26 indicated the resident was safe to smoke with minimal supervision, but no other smoking assessments were found in the record. The DON stated the smoking care plan was implemented and added on 03/12/26 and acknowledged that care plans were to be reviewed and updated quarterly. For another resident, surveyors observed the resident smoking outside with other residents and staff. The resident had signed the facility’s Smoking and Vaping Policy on 10/24/24, and a Quarterly Smoking Assessment showed the resident was able to smoke with minimal supervision. Despite this, the care plan revised 01/31/25 did not document that the resident smoked, and no smoking care plan had been developed. The DON, who was responsible for overseeing the MDS coordinator to ensure comprehensive care plans were developed, reviewed this resident’s care plan and confirmed the resident had smoked since admission but did not know why a smoking care plan was not in place.
Failure to Complete Competency Assessments for Newly Hired CNAs
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had documented competencies to care for residents in a manner that maximizes each resident’s well-being, as evidenced by missing competency documentation in the files of four certified nurse aides (CNAs) hired within the past four months. Record review showed that CNA #3, hired on 11/22/25, CNA #4, hired on 01/28/26, CNA #5, hired on 01/08/26, and CNA #2, hired on 02/05/26, all lacked completed staff competency forms in their employee files. The facility’s undated “New Hire Process” policy stated that new employees are subject to TB testing, an employee physical, competencies, and three days of training on the floor at the DON’s discretion and schedule. During an interview, the DON reported that newly hired CNAs were trained by another CNA and that their competencies were to be documented on a check-off form, but acknowledged that these competency documents had not been completed due to recent staff turnover and stated that this requirement had “slipped through the cracks.” No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Lack of Annual Performance Review and Medication Administration Discrepancy
Penalty
Summary
The facility failed to ensure annual performance reviews were completed for a certified medication aide (CMA) who had been employed for more than 12 months, resulting in a deficiency related to staff performance oversight. Surveyors observed CMA #1 administering 50 mg of zinc by mouth to Resident #1, while the physician’s order dated 03/03/26 specified zinc 30 mg daily. Review of CMA #1’s employee file showed a hire date of 11/19/24 and no documentation of any performance review since hire. During interview on 03/13/26 at 9:39 a.m., the DON stated there was no system in place to ensure CNAs/CMAs had performance reviews completed at least every 12 months and confirmed they could not locate documentation showing CMA #1 had received a performance review.
Medication Security and Storage Deficiencies on Treatment Carts and Narcotic Storage
Penalty
Summary
Surveyors identified multiple failures related to medication security and storage. On two separate dates, the nurse treatment cart was observed unlocked and unattended at the nurse's station, despite containing medications. During one of these observations, both the administrator and a visitor walked past the unattended, unlocked cart before an LPN returned and opened the top drawer. RN #1 and the DON both stated that medication/treatment carts were to be kept locked when unattended, and the LPN stated they thought they had locked the cart before leaving it. Further inspection of the nurse treatment cart revealed several medication storage issues. One bottle of glucometer check strips was opened and not dated, and multiple insulin pens (Lantus, Novolog, and Lispro) for several residents were opened and not dated, preventing staff from knowing how long they had been in use. The cart also contained an albuterol inhaler and two bottles of nystatin powder with listed expiration dates in 2025. RN #1 stated they did not know how often the cart was monitored for expired medications or how long the undated insulin pens had been opened, while LPN #2 stated the pharmacist monitored the cart monthly for expired medications. The DON stated nurses were to date insulin pens when opened and that one LPN was responsible for monitoring the cart, but the DON did not verify that these audits were completed. Additionally, discontinued narcotics were stored in a drawer of a locked medication/treatment cart in the DON's office; the DON reported the narcotics were behind two locks (the office door and the cart lock), but the internal separately locked compartment could not be used because there was no key, and the cart itself was not permanently affixed.
Improper Use of Unpasteurized Eggs and Inadequate Food Labeling in Kitchen
Penalty
Summary
The facility failed to procure and handle food in accordance with professional standards when surveyors observed improper storage and use of food items in the kitchen and dining areas. During inspection of the cold storage refrigerator, surveyors found sliced cheese in an unsealed zip-close bag labeled with a prior date, as well as an unlabeled, undated clear plastic container holding an unknown liquid. Two flats of unpasteurized eggs were also observed in the refrigerator, with no other eggs available. At a subsequent breakfast meal observation, three residents were served and ate eggs cooked over easy. The Dietary Manager reported that the unpasteurized eggs were routinely used every morning for scrambled, over easy, and fried eggs, including that morning’s service, and acknowledged not knowing whether the eggs were pasteurized. The Dietary Manager also stated that the unlabeled container belonged to an employee despite staff having a separate refrigerator for personal food. No facility policy regarding food storage or the use of pasteurized versus unpasteurized eggs was provided to surveyors. The administrator later stated they were unaware that the eggs ordered from the supplier were not pasteurized and had assumed the supplier would provide products appropriate for a nursing facility. In total, the Dietary Manager identified eight residents who ate eggs over easy and 34 residents who consumed food prepared in the kitchen during the relevant meal service. These observations and interviews demonstrate that the facility did not ensure eggs served over easy were pasteurized and did not ensure all leftover foods in the refrigerator were properly labeled and dated, affecting multiple residents who consumed meals from the kitchen.
Failure to Report Resident Abuse Allegations to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse to the Oklahoma State Department of Health (OSDH) as required by its own Abuse Prohibition Procedure. The policy stated that any suspected abuse or unexplained injury must be reported immediately to the charge nurse, DON, or administrator, and that the administrator or designee would immediately initiate an investigation and notify OSDH. Resident #4, who had a BIMS score of 15 indicating intact cognition and a diagnosis of schizophrenia, told other residents during a smoke break that they had been beaten and had bruises on their arms and back. This allegation was documented in a progress note by LPN #3, who later stated they had notified the administrator and DON of the allegation. Several days later, Resident #4 called 911 from a resident phone, reporting to police that staff were beating them with whips and chains. A police officer responded, and together with LPN #4 performed a full body assessment, with no bruising noted. LPN #4 stated they notified the DON of this allegation after the police officer left. The DON stated that allegations of abuse were immediately investigated by the MDS coordinator, the administrator, or themself, and that they were unsure if they had been notified of the first allegation but were aware of the second. The DON acknowledged that they investigated the allegation but did not report it to OSDH because the police had looked into it and had not substantiated the allegation. The administrator also stated they had not reported either of the resident’s abuse allegations to OSDH, relying on the lack of physical findings and the police officer’s investigation instead of following the requirement to report all allegations.
Failure to Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse made by a cognitively intact resident. Facility policy stated that any suspected abuse would be reported, investigated, and that the administrator or designee would immediately initiate an investigation and notify the state agency. Resident #4 had a BIMS score of 15, indicating intact cognition, and a diagnosis of schizophrenia. On 02/22/26, a progress note documented that the resident told other residents during a smoke break that they had been getting beaten and had bruises on their arms and back; this note was signed by an LPN. On 02/28/26, another progress note documented that the resident called 911 from a resident phone, reporting to police that staff were beating them with whips and chains. A full body assessment was completed by an LPN and a police officer, with no bruising noted, and this was documented in the record. Interviews confirmed that these allegations were reported to facility leadership but not investigated in accordance with policy. One LPN stated they notified the administrator and DON after the 02/22/26 allegation, and another LPN stated they notified the DON after the 02/28/26 allegation. The DON stated that allegations of abuse were to be immediately investigated by the MDS coordinator, the administrator, or the DON, but acknowledged having no evidence that the allegations from 02/22/26 or 02/28/26 had been investigated. The administrator stated that they did not investigate the 02/28/26 allegation because the police had unsubstantiated it, and did not investigate the 02/22/26 allegation because a shower aide reported no bruising and the resident later denied being abused. The administrator also stated they had never conducted an abuse investigation and had not documented their conversation with the resident, resulting in no formal investigation of the abuse allegations.
Failure to Document Key Elements of a Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the clinical record contained complete and required documentation for a resident’s discharge. A discharge return-not anticipated assessment showed that Resident #36 was admitted and then discharged home with hospice services, but review of the clinical record for the days leading up to and including the discharge did not show the reason for the discharge, the resident’s status upon discharge, a physician order for discharge, or what resources were required or provided upon discharge. The record from 12/23/25 through 12/29/25 lacked documentation of these key elements. During interviews, an LPN stated that the resident returned to their apartment with hospice services and left with medications and personal belongings. The DON stated that the physician had provided an order allowing the resident to be discharged home, but acknowledged that the clinical record did not contain a physician discharge order, documentation of the resident’s status at discharge, or documentation of the resources required or provided. The administrator reported that the discharge was planned, that the resident had improved, and that the resident left with personal belongings and medications with instructions, but did not know why this information was not documented. A family member confirmed that the resident chose to return to their apartment and left with medications and hospice services.
Failure to Complete Discharge Summary and Notify Ombudsman for Discharged Resident
Penalty
Summary
The facility failed to complete a discharge summary and notify the State Ombudsman office for a resident who was discharged home with hospice services. A discharge return-not anticipated assessment dated 12/29/25 showed that Resident #36 was admitted and then discharged to home, but review of the clinical record from 12/23/25 through 12/29/25 did not show any completed discharge summary or documentation that the State Ombudsman office had been notified of the discharge. LPN #2 reported that the resident returned to their apartment with hospice services and left the facility with medications and personal belongings. The DON stated that discharge summaries were to be completed by the MDS coordinator and filed under the "observations" section of the clinical record, but confirmed that no discharge summary was present for this resident after reviewing the record. The administrator stated they were responsible for notifying the State Ombudsman of discharges and acknowledged that they had not notified the Ombudsman office for this resident, explaining that they only notified the office in cases of involuntary discharge. Regional nurse #2 identified 13 residents who had been discharged in the past three months, but the cited deficiency specifically involved Resident #36, for whom the required discharge summary and Ombudsman notification were not completed or documented.
Failure to Complete and Document Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that required pre- and post-dialysis assessments were completed and documented for a resident receiving dialysis. Resident #10, who had a BIMS score of 11 indicating moderately impaired cognition and a diagnosis of end stage renal disease, had physician orders for dialysis three times weekly on Monday, Wednesday, and Friday and a care plan reflecting the need for dialysis. Review of Dialysis Communication forms and progress notes from 03/02/26 through 03/13/26 showed no documentation that nurses conducted pre- or post-dialysis assessments on 03/02/26 or 03/09/26. An LPN stated that such assessments should be documented on Dialysis Communication forms or in progress notes, but the DON confirmed they could not locate any documentation of these assessments for the two identified dates and did not know why they had not been completed or what monitoring was in place to ensure they were done. This deficiency centers on the absence of documented pre- and post-dialysis assessments for Resident #10 on specific dialysis treatment days despite existing orders and care plan directives, and the lack of an identified monitoring process by facility leadership to ensure these assessments were consistently completed.
Failure to Assess Bedrail Safety and Document Required Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document required safety assessments for the use of a bedrail for one resident. Surveyors observed the resident in bed with an enabler-style bedrail in the up position on the right side of the bed, and the resident reported using the bedrail to assist with getting out of bed. A physician order dated 12/22/25 authorized use of an enabler-style bedrail for positioning, and the care plan revised 12/27/25 referenced a transfer bar evaluation with demonstration for safe repositioning and transfers in and out of bed. However, review of the observation section and progress notes from 12/25/25 through 03/13/26 showed no evidence that the resident had been assessed for safety with the use of the bedrail, despite facility expectations that residents with bedrails be assessed when bedrails are ordered and then quarterly. The DON stated they were not aware the resident had a bedrail and confirmed there was no documentation of a safety assessment for the bedrail’s use. The facility’s policy requires that before using a bedrail, staff must assess the resident for safety risk, review risks and benefits with the resident or representative, obtain informed consent, and correctly install and maintain the bedrail. In this case, although the bedrail was in use and ordered by a physician, the required safety assessment and related documentation were not completed or available for review.
Failure to Ensure TB Testing and Annual Flu/Pneumonia Immunizations
Penalty
Summary
The facility failed to ensure required TB testing and annual flu and pneumonia immunizations were completed and documented for two of five sampled residents reviewed for immunizations. One resident, admitted on 09/21/25 with an admission assessment dated 09/28/25 showing a BIMS score of 15 (cognitively intact) and diagnoses including dementia, had no documentation of a TB test on admission or of annual flu and pneumonia vaccinations in their immunization record. Another resident, with a quarterly assessment dated 02/12/26 showing a BIMS score of 15 and diagnoses including right lower lobe lung cancer, and who had been re-admitted to the facility, had no documentation of a TB test upon admission in their immunization record. During the survey, the DON initially indicated that TB test and vaccination information should be in the electronic health record, then later stated that the documentation was in the administration office, and confirmed that TB tests were to be completed on admission; however, immunization and TB test documentation for these two residents was not provided by the end of the survey. The administrator identified that 34 residents resided at the facility, and the deficiency was identified through record review and staff interview when surveyors requested and did not receive the required TB and immunization documentation for the sampled residents.
Ineffective Pest Control and Environmental Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by the presence of roaches and various environmental deficiencies. During an initial tour of the kitchen, surveyors observed roaches in and around the low temperature dish machine, missing baseboards, standing water under the dish machine, missing floor tiles, buckled flooring, peeling wallpaper, and a 50-gallon trash can without a lid. Additionally, the rear kitchen door could not be easily secured, allowing light to be visible around the door frame, and a mop bucket with standing liquid and dead bugs was found outside the rear kitchen door. The outside commercial trash container was also not covered with lids. The pest control service notification indicated that roaches had been reported in the break room and dining room, but the technician did not observe any live activity at the time of service. The technician treated various areas with liquids and inspected exterior bait stations. However, the maintenance supervisor acknowledged that staff had reported seeing roaches in the dining room and that the pest control company had been out to spray, but they had not noticed the roaches in the dish machine. The maintenance supervisor stated they would collaborate with the dish machine technician and pest control company to address the issue.
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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