Miami Nursing Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Miami, Oklahoma.
- Location
- 1100 East Street Northeast, Miami, Oklahoma 74354
- CMS Provider Number
- 375388
- Inspections on file
- 29
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 14 (2 serious)
Citation history
Health deficiencies cited at Miami Nursing Center, Llc during CMS and state inspections, most recent first.
The facility failed to accurately document and account for controlled medications, including Norco, Ativan, and tramadol, for several residents. For one resident receiving PRN Norco for pain, the narcotic count sheets repeatedly showed more doses signed out than were recorded as administered on the MAR, with no documentation that the extra tablets were destroyed. For another resident with a nightly Ativan order, the narcotic record often showed doses as given while the MAR documented refusals, and there were no destruction notations for the refused tablets; on one occasion the MAR showed a dose given with no corresponding narcotic sign-out. A third resident’s narcotic record showed tramadol doses administered on a day when the MAR showed none given and no destruction documented. CMAs and nursing staff acknowledged that the records were inaccurate and that refused controlled medications were not consistently brought to a nurse for joint destruction and co-signature as required.
A resident with cognitive impairment and behavioral challenges was physically restrained and verbally antagonized by an agency CNA during care, despite objections from other staff. The CNA pinned the resident's arms behind their back, dragged them to a chair, squeezed their wrist, and encouraged the resident to strike staff. The resident expressed pain and distress during the incident, which was witnessed and reported by other CNAs. The DON confirmed the abusive actions and noted missing orientation documentation for the agency CNA.
A resident with severe cognitive impairment, sharing a room with another resident in isolation for COVID-19, was observed without PPE or isolation signage and was allowed to move freely throughout the facility without a mask. Staff did not intervene or enforce infection control protocols, and no PPE supplies or isolation barriers were present in the room.
A resident with a history of behavioral disturbances and multiple medical conditions was required to eat meals alone in a separate room, after being told by the administrator that this was necessary to avoid disturbing others. The resident, who is cognitively intact, expressed feeling isolated and would have preferred to eat in the dining room. Staff interviews confirmed the decision was made due to repeated outbursts, resulting in involuntary seclusion.
A resident with severe cognitive impairment and multiple wounds was not assessed or treated for pain during repeated wound care procedures, despite exhibiting clear signs of distress and verbalizing significant pain. An LPN did not stop or address the pain during care, and staff interviews confirmed ongoing unaddressed pain. The DON was unaware of the lack of pain medication orders for the resident.
Surveyors found that opened beverage containers in the kitchen refrigerator were not labeled with the date they were opened, and the top of the oven and nearby walls were not kept clean as required by facility policy. A dietary aide confirmed the labeling requirement, while the dietary manager was unaware of it. Meals prepared in this kitchen were served to 65 residents.
A facility-wide assessment did not include information about residents with wounds or the training and competency required for staff to care for wounds, despite four residents with wounds being present. The administrator confirmed that these aspects were missing from the assessment.
The facility did not provide or document training and competency assessment for staff on wound care, even though several residents had wounds. The Facility-Wide Assessment omitted wound care training, and the DON could not confirm a process for verifying nurses' competency in wound identification and treatment.
A resident with neurogenic bladder and quadriplegia, who was cognitively intact, was not offered an advance directive as required. The clinical record lacked documentation or acknowledgement of this process, and the DON was unable to provide evidence that the opportunity to develop an advance directive had been offered.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room without prior notification to their representative, as required by facility policy. The move was made to accommodate another resident's request, and documentation of the notification was incomplete. The representative was only informed after the room change had already occurred.
A resident with dementia, anxiety disorder, and PTSD was administered both 1 mg and 0.5 mg doses of Risperdal after a dose reduction order was written but the original higher dose was not discontinued. The resident did not understand why the medication was being given and expressed a desire not to take it. The DON confirmed the unnecessary administration resulted from a failure to discontinue the previous order.
Nurses and nurse aides did not demonstrate competency in pain assessment and management during wound care for a resident. During a wound care procedure, a resident showed clear signs of pain, but the LPN did not stop or address the discomfort, and had not assessed for pain beforehand. There was no documentation of wound care training for staff, and the DON could not confirm a process to ensure nursing competency in wound care.
A resident with a suprapubic catheter did not consistently receive catheter care as ordered, with multiple missed care opportunities and incomplete documentation. The resident, who was cognitively intact, reported that only one nurse routinely provided catheter care, while others did not offer or perform it. An LPN admitted to documenting refusals without always offering care, and the DON confirmed that refusals should not be recorded if care was not offered.
Staff inaccurately documented catheter care for a resident with a suprapubic catheter, recording that care was provided on several occasions when it was not actually performed. Interviews revealed that CNAs documented the care without completing it, with one CNA assuming a nurse had done it. The DON confirmed that documentation should only reflect care actually provided.
A resident with severe cognitive impairment was moved to a different room without written notification being provided to the resident or their representative, as required by facility policy. The DON confirmed that no documentation of written notice was available.
A resident with an indwelling urinary catheter, who was cognitively intact, did not receive a chest x-ray as ordered due to a nurse failing to place the order. The x-ray, originally scheduled for one day, was delayed by two days until the order was completed and the imaging was performed, as confirmed by the DON.
A facility failed to ensure proper hand hygiene during catheter care for a resident with quadriplegia and neuromuscular dysfunction of the bladder. A CNA and an LPN were observed not changing gloves or performing hand hygiene when moving from soiled to clean areas during catheter care. Both staff members acknowledged their oversight, and the DON confirmed the requirement for glove changes during such procedures.
The facility failed to ensure privacy and dignity for residents, with issues such as missing privacy curtains in shared rooms and inadequate privacy measures for cognitively impaired residents. Additionally, meals were served in disposable containers due to insufficient dishware, impacting the residents' dining experience.
A facility improperly charged residents for services covered by Medicare/Medicaid and for administrative supplies. A resident was billed for room and board during periods covered by Medicaid and Medicare, and four residents were charged for checks drawn on the Residents' Trust account. The BOM attributed these errors to corporate instructions, acknowledging that the resident's account should have been credited for overpayments.
The facility failed to conduct timely skin assessments for two residents and did not obtain necessary orders for intravenous care for another resident. One resident with hypertension did not receive skin assessments as required, leading to untreated redness and odor under the breast. Another resident with a history of skin infections had open areas on the legs without dressings. Additionally, a resident with a PICC line returned from the hospital without orders for necessary care, and the dressing was not changed as per protocol.
A facility failed to provide routine catheter care for a resident with quadriplegia and neurogenic bladder. The resident reported inconsistent care, and interviews revealed confusion among staff about who was responsible for catheter care. The DON confirmed that both licensed nurses and CNAs were responsible for catheter care and documentation, but no records were found to support that care was provided.
The facility failed to monitor residents on psychotropic medications for behaviors and side effects, as shown by incomplete and inaccurate behavior flow sheets for three residents. One resident with schizophrenia had inconsistent monitoring for anxiety and agitation, while another with bipolar disorder lacked required AIMS assessments. A third resident's behavior documentation was inaccurate, as the resident regularly exhibited behaviors not reflected in the records. The DON admitted to insufficient monitoring of staff documentation practices.
The facility failed to secure medications properly, with carts left unlocked and unattended, and medications not dated when opened. Additionally, expired medications were found in the medication room. The DON admitted to not monitoring these practices effectively, relying on monthly pharmacist reviews.
The facility did not maintain a surety bond sufficient to cover the residents' personal funds in the facility trust. The bond was set at $90,000, but bank statements from April to June 2024 showed balances exceeding this amount, with a peak of $97,106.92. The administrator was unaware of the high balance, mistakenly believing it to be around $70,000.
Two residents in a facility were found to lack privacy curtains, compromising their visual privacy. One resident, sharing a room with two others, confirmed the absence of a curtain, which was corroborated by a CNA. Another resident, with dysphagia and incontinence, also lacked a curtain, as confirmed by staff. Maintenance noted the curtain track was inadequate, and the DON acknowledged the oversight.
A facility failed to update the care plan for a resident who returned from a hospital stay with a PICC line and an order for intravenous antibiotics. The care plan did not document the intravenous access, and the MDS coordinator admitted that the care plan had not been updated to reflect this change. The DON acknowledged the absence of a system to monitor care plan updates upon readmission or status changes.
A resident with dementia experienced significant weight loss due to the facility's failure to implement nutritional interventions. Despite a care plan requiring weight maintenance and meal consumption, the resident lost 11.65% of their weight over two months. The facility's policy mandated nutritional supplements if meals were less than 50% consumed, but records showed no supplements were offered. The DON acknowledged missing the weight loss and not notifying the physician or dietician.
A facility failed to conduct proper post-dialysis assessments for a resident with end-stage renal failure. The resident reported that while pre-dialysis checks were performed, post-dialysis assessments were not conducted unless requested. The resident had a recent port infection requiring antibiotics. A review of records showed missing documentation for post-dialysis assessments on several dates. Nursing staff confirmed the lack of a specific dialysis protocol, despite acknowledging the need for such assessments.
A resident experienced a significant weight loss of 11.65% over two months, dropping from 132.2 lbs to 116.8 lbs. Despite eating less than 50% of meals on several occasions, there was no documentation of supplemental nutrition being offered. The DON admitted to missing the weight loss and failing to notify the physician or dietician. The physician was informed during a monthly visit and ordered an appetite stimulant.
The facility did not comply with the requirement to post complete staffing information. Observations showed that the staffing schedule at the nurses' station was missing critical details like the resident census and nursing hours. The DON confirmed the presence of 73 residents, and the administrator admitted the omission of necessary information on the posted schedule.
A facility failed to administer clopridogrel as per physician orders for a resident with a history of transient ischemic attack. The resident was supposed to take clopridogrel daily, but the medication was not documented or administered upon admission. The DON was unaware of the oversight until reviewing the clinical record.
The facility failed to maintain a sanitary kitchen environment, with flies observed on food preparation areas and unsanitary conditions in the refrigerator, including undated and improperly stored food items. The ice machine was found to have algae, and the kitchen's open back door allowed flies to enter. Maintenance efforts to address these issues were inadequate.
The facility failed to implement enhanced barrier precautions during catheter and wound care for two residents, as required by their infection control program. One resident received catheter care without staff donning gowns, and another resident with multiple medical devices did not have appropriate signage or supplies for enhanced precautions. Additionally, a resident's urinary catheter dignity bag and tubing were observed dragging on the floor, contrary to facility protocol.
The facility failed to maintain the physical environment in good repair, as evidenced by a leaking roof in the dining area. A wet floor sign and a bucket containing water were observed, indicating the leak. Maintenance staff and the CDM confirmed the issue, and the Maintenance Supervisor noted the last roof repair was in September 2023. This affected the safety and comfort of 73 residents.
The facility failed to implement a comprehensive care plan for a resident with stage three pressure wounds, as required weekly wound care documentation was missing before a specified date. Interviews with staff confirmed the lack of documentation.
The facility failed to provide and document pressure ulcer care as ordered by the physician, complete weekly wound observations, and document refusals in the nursing notes for a resident with quadriplegia and chronic pain syndrome. Interviews with nursing staff and the DON revealed that care was provided but not documented correctly, leading to deficiencies in pressure ulcer care.
Inaccurate Documentation and Handling of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication administration records (MARs) and controlled drug count sheets accurately reflected the disposition of controlled medications for multiple residents. Facility policy required that each dose of medication be properly recorded on the MAR and that when a CMA was unable to administer a medication, the charge nurse be notified immediately. For one resident with an order for Norco 10-325 mg every four hours as needed for pain, comparisons between the February MAR and the individual narcotic record from late January to late February showed repeated discrepancies: on multiple dates, the narcotic record reflected more doses signed out than were documented as administered on the MAR, with no notation that the unaccounted tablets were destroyed. The resident reported they kept their own notes on pain pill use and, when compared to the facility’s narcotic records, found the records were not accurate. A second resident had an order for Ativan 1 mg at bedtime. Review of the February MAR and the corresponding narcotic record showed that on numerous dates the narcotic record indicated a dose was administered, while the MAR documented that the dose was refused. There was no documentation on the narcotic record that the refused tablets were destroyed. On another date, the MAR showed the medication was administered, but no dose was signed out on the narcotic record. An additional undated narcotic entry, located after a late-February entry, showed a dose as administered while the MAR documented a refusal for that same time frame, again without any destruction notation. A third resident had an order for tramadol 50 mg, two tablets every six hours as needed for pain. For this resident, the narcotic record showed two tablets administered on a specific February date, while the MAR showed no tramadol doses given that day and there was no documentation that the tablets were destroyed. During interviews, CMAs and nursing staff acknowledged that the MARs and narcotic records for these residents were inaccurate and showed pills signed out without documentation of administration or destruction. Staff described that refused controlled medications were supposed to be taken to the charge nurse and destroyed together with both parties initialing the count sheet, but one CMA reported they had been destroying refused medications alone without notifying the nurse, contrary to the described procedure. The DON stated that some CMAs had not been following the procedure to alert charge nurses of refused narcotics and to jointly destroy and document them.
Resident Subjected to Physical and Verbal Abuse by Agency CNA
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, non-Alzheimer's dementia, depression, and hoarding disorder was subjected to physical and verbal abuse by a certified nursing assistant (CNA) employed through an agency. The resident, who was known to display verbal and physical behaviors and to reject care, was being assisted by three CNAs to prepare for bed. During the interaction, the resident became combative and grabbed one CNA by the neck. In response, another CNA restrained the resident by pinning their arms behind their back and dragging them to a chair, despite objections from the other staff present. The same CNA also grabbed and squeezed the resident's wrist and verbally antagonized the resident by encouraging them to strike out at staff. Witness statements from the other CNAs present confirmed that the agency CNA repeatedly used physical force to restrain the resident, even after being told to stop by colleagues. The resident was heard yelling for help and expressing pain, and staff noted that the resident's behavior escalated while the agency CNA was present but calmed after the CNA left the room. The incident included both physical restraint and verbal provocation, with the resident being encouraged to hit staff members. The resident initially complained of arm pain but later denied discomfort and refused further assessment. Interviews with the involved CNAs and the Director of Nursing (DON) confirmed that the actions of the agency CNA were considered abusive. The DON stated that the agency CNA had worked at the facility for about a month and that the facility provided orientation materials and abuse prevention training to all staff, including agency personnel. However, the facility was unable to locate the completed orientation packet for the agency CNA involved in the incident.
Failure to Implement Infection Control Measures for COVID-19 Exposure
Penalty
Summary
The facility failed to minimize the risk of spreading infection by not implementing appropriate infection prevention and control measures for a resident exposed to COVID-19. Observation revealed that a resident who shared a room with another resident in isolation for COVID-19 was not provided with or observed using personal protective equipment (PPE) such as masks, gowns, or gloves. There were no isolation signs or PPE supplies at the entrance to the room, and no barriers were present between the two residents. The resident, who was severely cognitively impaired and required supervision for decision-making, was seen leaving the room and walking through common areas without a mask. Staff did not intervene or encourage the resident to wear a mask or return to their room, and staff themselves were not observed wearing isolation masks in the hallway. Record review indicated that the resident had a history of removing isolation signage and PPE supplies from their room, and staff were aware of this behavior. The resident had tested negative for COVID-19 but chose to remain in the room with the COVID-19 positive roommate. Despite being informed of the need to wear a mask when leaving the room, the resident was allowed to move freely throughout the facility without adherence to infection control protocols, and staff did not enforce or support these measures.
Involuntary Seclusion of Resident During Meals Due to Behavioral Issues
Penalty
Summary
A deficiency occurred when a resident was involuntarily secluded from other residents during meal times. The resident, who is cognitively intact with a BIMS score of 15 and has diagnoses including lymphedema, dementia with agitation, depression, epilepsy, type 2 diabetes, and asthma, was observed eating alone at a table facing the wall in the day room, away from other residents. The resident reported being told by the administrator that they had to eat alone in the day room to avoid disturbing others, and expressed feeling like a child being chastised, preferring to eat in the dining room instead. Staff interviews revealed that the resident had a history of outbursts and causing disturbances in the dining room, leading to the decision to move the resident to a separate room for meals. The administrator and nursing staff acknowledged that the resident was disruptive during meal times and stated that the move was intended to find a compromise for all involved. However, the action resulted in the resident being separated from others without their consent, constituting involuntary seclusion.
Removal Plan
- The DON and Care plan coordinator met with resident #1 and advised her that she would be offered 3 locations for her meals: main dining room, smaller dining room, or her room.
- An alert has been added to the EMR for resident #1 that she will be able to choose where she would like to take meals.
- Staff will ask resident #1 prior to each meal where she would like her meal served.
- Care plan will be updated to reflect that resident is able to choose her dining locations.
- Resident #1's dietary card has been updated to reflect that meals may be taken at the location of resident's choice.
- Facility will not ask any other resident to receive meals in the small dining room unless the resident requests to do so.
- The facility has reviewed all current residents and no other residents were identified as being secluded in any manner.
- In the future, the facility will not seclude a resident exhibiting behavior problems that may be detrimental to other residents.
- If resident #1 or any other resident exhibits disruptive behaviors, staff will attempt to de-escalate the situation.
- If a resident is removed from an area, a staff member will remain with them until behaviors have resolved.
- All nursing staff will receive in-service training on the above.
- If any nursing staff is unable to be present in person, they will receive in-service via phone.
Failure to Assess and Manage Pain During Wound Care
Penalty
Summary
The facility failed to assess, monitor, and intervene for pain management during wound care for one resident with multiple medical conditions, including type 2 diabetes, Alzheimer's disease, peripheral vascular disease, and hypertension. The resident, who was severely cognitively impaired, had wound care orders for multiple sites and was observed during a wound care procedure to be in visible pain, grimacing, stiffening, and verbally expressing discomfort. Despite these clear signs of pain, the LPN performing the wound care did not stop the procedure or address the resident's pain, and stated afterward that they had not assessed the resident for pain prior to the procedure and were unaware of any pain medication orders for the resident. Further review revealed that from the start of the wound care order through the date of the incident, there were 35 missed opportunities to assess the resident for pain during wound care. Interviews with CNAs confirmed that the resident regularly exhibited signs of pain during wound care, such as clenching teeth, moaning, tensing up, and verbalizing that the procedure was painful. The resident also reported experiencing significant pain, rating it as an 8 out of 10 during wound care. The DON acknowledged not knowing why pain medication had not been ordered for the resident.
Removal Plan
- A pain assessment was completed on Resident #27.
- Primary care physician for Resident #27 was contacted and a new order for Tramadol, an analgesic, was obtained.
- Staff will offer PRN pain medication prior to wound care.
- Care plan for Resident #27 will be updated accordingly.
- For all other residents a new pain assessment will be completed.
- All employees will be in-serviced on pain management including recognition of pain (verbal and non-verbal signs).
- If employee is unable to come in person for training they will receive training over the phone and then in person training prior to the beginning of their next shift.
Failure to Label Opened Food Containers and Maintain Kitchen Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to ensure that opened containers of beverages, including orange drink, grape juice, prune juice, and thickened lemon water, stored in the reach-in refrigerator were properly labeled with the date they were opened. Additionally, the top of the oven was found to be covered with debris, and the walls above the oven were coated with a sticky brown substance. Facility policies required that opened packaged foods be dated and that the oven and surrounding walls be cleaned weekly. During interviews, a dietary aide confirmed that opened items should be labeled, while the dietary manager, who was new, was unaware of the labeling requirement and acknowledged that the oven and its surrounding area should be thoroughly cleaned. The Director of Nursing identified that 65 residents received meals prepared in the kitchen where these deficiencies were observed.
Facility Assessment Lacked Wound Care and Staff Competency Evaluation
Penalty
Summary
The facility failed to ensure that its facility-wide assessment addressed the needs of residents with wounds and the necessary staff training and competency to care for these residents. Record review showed that four residents with wounds were present in the facility, but the assessment reviewed on 07/30/25 did not include information about these residents or the required wound care training and competency for staff. During an interview, the administrator acknowledged that the assessment did not address wounds or wound training.
Failure to Ensure Staff Training and Competency in Wound Care
Penalty
Summary
The facility failed to provide training and ensure competency for staff regarding wound care. Record review showed that the Facility-Wide Assessment did not address training or competency for wound care, despite the presence of four residents with wounds. Employee records lacked documentation of wound care training and competency. During an interview, the DON was unable to confirm whether there was a specific process to determine nurses' competency in identifying and treating wounds.
Failure to Offer Advance Directive to Cognitively Intact Resident
Penalty
Summary
The facility failed to ensure that an advance directive was offered to a resident who was cognitively intact, as evidenced by a BIMS score of 15 on a quarterly assessment. The resident had diagnoses including neurogenic bladder and quadriplegia. Review of the clinical record revealed there was no documentation or acknowledgement indicating the resident had been offered the opportunity to develop an advance directive. When requested, the Director of Nursing was unable to provide an advance directive acknowledgement for this resident, and none was provided by the end of the survey.
Failure to Notify Representative of Room Change for Cognitively Impaired Resident
Penalty
Summary
The facility failed to notify a resident's representative of a room change, as required by its own policy and procedure for notification of change. On observation, a resident with severe cognitive impairment, as indicated by a BIMS score of 00 and diagnoses including heart failure, hypertension, cerebrovascular accident, and seizure disorder, was found to have been moved to another room. Review of clinical progress notes showed no documentation that the resident's representative was notified prior to the move. The facility's form for room or roommate change was incomplete, lacking a documented reason for the move and containing only a scribble mark for the resident's signature, with the nurse's printed name below it. The Director of Nursing confirmed that the resident was moved over the weekend to accommodate another resident's request due to a roommate issue, and acknowledged that notification should have been made and documented before the move. The resident's representative reported not being informed of the room change until after it had occurred, stating that the facility called them after the move had already taken place and did not seek their input beforehand.
Failure to Discontinue Unnecessary Psychotropic Medication Order
Penalty
Summary
The facility failed to prevent the administration of unnecessary psychotropic medication to a resident who was admitted with diagnoses including dementia, anxiety disorder, and post-traumatic stress disorder. Upon admission, the resident was prescribed Risperdal 1 mg at bedtime for dementia with behavioral disturbance. Subsequently, a new order was written to decrease the Risperdal dose to 0.5 mg at bedtime for 14 days, with an end date specified. However, the original 1 mg order was not discontinued, resulting in the resident receiving both the 1 mg and 0.5 mg doses over a weekend. The resident expressed a lack of understanding regarding the reason for taking Risperdal and indicated a desire not to receive the medication. The DON confirmed that the resident had come from a geriatric psychiatric hospital and that the facility intended to discontinue Risperdal due to an inaccurate diagnosis. The DON acknowledged that the continued administration of Risperdal 1 mg was unnecessary and resulted from a failure to discontinue the previous order when the dose was reduced.
Failure to Assess and Address Pain During Wound Care
Penalty
Summary
Nurses and nurse aides failed to demonstrate appropriate competencies in pain assessment and management during wound care for a resident with wounds. During an observed wound care procedure, the resident exhibited clear signs of pain, including grimacing, body stiffening, and verbal expressions of discomfort, yet the LPN performing the care did not stop the procedure or address the resident's pain. The LPN admitted to not assessing the resident for pain prior to the procedure and was unaware of any pain medication orders for the resident. Review of employee files revealed no documentation of completed wound care training. The Director of Nursing was unable to confirm any specific process in place to ensure nursing staff competency in identifying and treating wounds.
Failure to Provide Ordered Catheter Care and Inaccurate Documentation
Penalty
Summary
The facility failed to provide catheter care as ordered for one resident with a suprapubic catheter. A physician's order required staff to cleanse the area around the catheter and tubing every shift, but review of the treatment administration record showed that catheter care was not completed as ordered, with 20 missed opportunities out of 51 in the first 17 days of May. Documentation indicated that the resident refused care 16 times, but there were also shifts with no documentation of care or refusal. The resident, who was cognitively intact, reported that CNAs never performed catheter care and that only one nurse routinely provided it, while others did not even ask if care was wanted. An LPN stated they documented refusals without always offering care, and the DON confirmed that refusals should not be documented if care was not offered.
Inaccurate Documentation of Catheter Care
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one resident who had a suprapubic catheter. Physician orders required catheter care to be performed every shift, and documentation indicated that two CNAs had recorded providing this care on multiple dates. However, both CNAs later stated in interviews that they did not perform the catheter care as documented, with one CNA admitting to assuming the nurse had completed the care and documenting it as done. The resident involved was cognitively intact and had an indwelling urinary catheter at the time of the deficiency. The Director of Nursing confirmed that staff should not document care that was not performed.
Failure to Provide Written Notice of Room Change
Penalty
Summary
The facility failed to provide written notice of a room change for one resident with severe cognitive impairment, as required by facility policy. The policy states that residents and their legal representatives or interested family members must be notified in writing within 48 hours of a change in room or roommate assignment. Record review showed that the resident was moved to a different room, but there was no documentation in the medical record indicating that the resident or their representative received written notification of this change. During an interview, the DON confirmed that there was no documentation of written notice being given.
Delay in Providing Ordered Chest X-ray
Penalty
Summary
The facility failed to provide timely imaging services as ordered for one resident. A physician's order dated 12/29/24 indicated that the resident was to have a chest x-ray on 12/29/24. However, nurse documentation from 12/29/24 revealed that the resident reported not receiving a chest x-ray that was supposed to be performed on 12/27/24. The administrator confirmed that the x-ray was indeed scheduled for 12/27/24. The resident, who was cognitively intact with a BIMS score of 15 and had an indwelling urinary catheter, stated on 05/20/25 that the chest x-ray was not performed until 12/29/24. The DON confirmed that the x-ray order was not placed by the nurse, resulting in a two-day delay in obtaining the imaging service.
Inadequate Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during catheter care for one of the three residents reviewed. The resident involved had diagnoses including quadriplegia and neuromuscular dysfunction of the bladder. During an observation, a CNA donned gloves, cleansed around the catheter area, and then touched the resident's table and computer keyboard without changing gloves or performing hand hygiene. Similarly, an LPN was observed to cleanse the catheter area, dispose of a soiled dressing, and then apply a clean dressing without changing gloves or performing hand hygiene. Both staff members acknowledged their failure to change gloves and perform hand hygiene when moving from soiled to clean areas. The DON confirmed that gloves should be changed during catheter care when transitioning from dirty to clean tasks.
Privacy and Dignity Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide adequate privacy and dignity for several residents. Resident #55, who had dysphagia, was in a three-bed room without a privacy curtain for the middle bed, leaving them exposed to their roommates during episodes of incontinence. Similarly, Resident #4, diagnosed with PTSD and depression, also lacked a privacy curtain in their three-bed room, leading to a lack of privacy and distress due to roommates frequently yelling. Resident #50, with severe cognitive impairment due to anoxic brain damage, was observed with a sign on their door to keep it open at all times, and their privacy curtain was inadequately pinned, leaving them exposed. Resident #26, who had dementia and frequent falls, also had a sign to keep their door open, which the DON acknowledged could be a dignity issue. Additionally, the facility did not provide enough dishware, resulting in meals being served in disposable containers. Cook #1 noted that some residents received meals in styrofoam containers and used plasticware due to behavioral issues, such as marking up dishware or poking others with cutlery. The dietary manager confirmed the lack of sufficient bowls and the high cost of lids, leading to the use of styrofoam containers for side items. These actions and inactions contributed to the deficiencies observed during the survey.
Improper Billing for Covered Services and Administrative Supplies
Penalty
Summary
The facility failed to ensure that residents were not charged separately for services covered by Medicare or Medicaid. Specifically, Resident #174 was charged for room and board during periods that should have been covered by Medicaid and Medicare. The facility's billing statements and trust transaction history revealed that Resident #174 was charged $2015.00 for a Medicaid pending stay in January 2024, despite Medicaid covering all charges for that month. Additionally, the resident was charged for room and board in March 2024, even though Medicare covered the skilled nursing stay from February 2, 2024, to April 3, 2024. The Business Office Manager (BOM) and Administrator #2 acknowledged the billing errors, which were attributed to instructions from corporate. The BOM stated that the resident's account should have been credited for any overpayments once the actual amounts were determined. However, the billing errors persisted, and the resident was incorrectly charged for services during their skilled nursing stay. The BOM also mentioned that the billing errors were entered at the corporate level, and the facility's accounting of the resident's trust was correct based on the information received. Furthermore, the facility charged four residents, including Resident #174, for administrative supplies, specifically $3.25 for the purchase of checks drawn on the Residents' Trust account. The BOM explained that the cost of ordering checks was divided among all residents with monies in the trust. This practice resulted in residents being charged for administrative supplies, which should not have been billed to them.
Failure to Conduct Skin Assessments and Obtain IV Care Orders
Penalty
Summary
The facility failed to conduct timely skin assessments for two residents and did not obtain necessary orders for intravenous care for another resident. Resident #42, who had a diagnosis of hypertension, was supposed to have weekly skin assessments as per the care plan. However, no skin assessments were conducted between the admission date and a later date when redness with a foul odor was noted under the resident's left breast, leading to a new order for treatment. Similarly, Resident #3, with a history of erysipelas and cellulitis, was observed with superficial open areas on the lower legs without any dressings, despite the care plan requiring weekly skin inspections. The areas were not addressed until a later date when a treatment was finally ordered. Additionally, Resident #8, who had a diagnosis of atrial fibrillation, returned from a hospital stay with a PICC line in place. The facility did not have any orders for PICC line care, such as flushing or dressing changes, upon the resident's readmission. The dressing on the PICC line had not been changed since the resident's return from the hospital, and the facility's protocol for intravenous care was not followed. The DON acknowledged the lack of orders and the failure to perform necessary care for the PICC line.
Failure to Provide and Document Routine Catheter Care
Penalty
Summary
The facility failed to provide routine catheter care for a resident with quadriplegia and neurogenic bladder. The resident reported that only one nurse consistently provided catheter care, and when that nurse was off, they did not receive the care. Interviews with CNAs revealed that they did not provide catheter care, believing it was the responsibility of the nurses. Conversely, LPNs stated that catheter care was assigned to the CNAs. The Director of Nursing (DON) confirmed that catheter care was the responsibility of both licensed nurses and CNAs and should be documented every shift. However, upon reviewing the clinical records, the DON found no documentation of catheter care for the resident, indicating that even if care was provided, it was not recorded.
Inadequate Monitoring of Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor residents receiving psychotropic medications for behaviors and side effects, as evidenced by the incomplete and inaccurate documentation on behavior flow sheets for three residents. Resident #3, diagnosed with schizophrenia, had a care plan requiring monitoring for anxiety, tearfulness, and agitation every shift. However, the behavior flow sheets for May, June, and July 2024 showed that behaviors were monitored inconsistently, with no specific behaviors indicated on the sheets. Similarly, Resident #44, with a diagnosis of bipolar disorder, had a care plan that required AIMS assessments upon admission and quarterly, but no such assessments were found in the clinical record. The behavior flow sheets for this resident also lacked specific behavior indications and were inconsistently completed. Resident #28, also diagnosed with schizophrenia, had behavior flow sheets that were inconsistently filled out, with no specific behaviors indicated. The DON acknowledged that the behavior sheets used a code system to identify behaviors, but was unable to specify what behaviors were monitored for Resident #28. The DON admitted that the behavior monitoring sheets were not accurate, as the resident regularly exhibited behaviors contrary to the documentation. The DON also stated that there was a lack of monitoring to ensure staff were documenting behaviors and side effects properly, including the completion of AIMS assessments.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications across several areas, leading to multiple deficiencies. Observations revealed that medications were not secured on the North hall medication cart, which was left unlocked and unattended on multiple occasions. This was confirmed by CMA #1, who admitted to forgetting to lock the cart. Additionally, medications were found to be opened but not dated on the North hall, North Main, and treatment carts, despite policies requiring such dating. The DON acknowledged that medications should be secured and dated but admitted to not monitoring these practices effectively. Furthermore, the facility did not adequately monitor for expired medications. During an inspection of the medication room, expired medications, including an influenza vaccine and hydrocort, were found. The DON stated that the pharmacist reviewed the medication/treatment carts monthly but did not personally monitor for expired medications. This lack of oversight contributed to the presence of expired medications in the facility, further highlighting the deficiencies in medication management and storage practices.
Facility Fails to Maintain Adequate Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a surety bond in an amount sufficient to cover the residents' personal funds deposited in the facility trust. The business office manager identified that there were 38 residents with funds in the facility trust. The surety bond, dated October 7, 2022, was documented to cover a balance of $90,000. However, the bank statements from April to June 2024 showed that the daily balances exceeded this amount, reaching as high as $97,106.92. On July 19, 2024, the administrator admitted to being unaware of the high balance in the trust, mistakenly believing it to be around $70,000, and acknowledged the need to increase the bond to cover the higher balance.
Lack of Privacy Curtains for Residents
Penalty
Summary
The facility failed to provide adequate privacy curtains to ensure full visual privacy for two residents. Resident #4, who shared a room with two other roommates, did not have a privacy curtain, which was confirmed by both the resident and a CNA. The CNA mentioned that during incontinent care, they would pull the curtains around the two roommates and shut the door, but there was no curtain available to provide full visual privacy for Resident #4. This lack of privacy was acknowledged by the resident, who expressed a desire for a curtain. Similarly, Resident #55, who had a diagnosis of dysphagia and experienced episodes of incontinence, also lacked a privacy curtain. The resident reported that while the staff closed the door, there was no curtain to ensure visual privacy from the two roommates. A CNA confirmed that the curtains were pulled around the other beds but not for the middle bed, where Resident #55 was located. Maintenance staff noted that the ceiling track for the privacy curtain was insufficient, and the DON admitted to not noticing the absence of privacy curtains for the middle beds in rooms with three residents.
Failure to Update Care Plan for Resident with PICC Line
Penalty
Summary
The facility failed to revise the care plan for a resident who had returned from a hospital stay with a midline placed in the left arm and an order for an intravenous antibiotic. The care plan, updated shortly after the resident's return, did not document the presence of intravenous access. Observations later confirmed that the resident had a PICC line in the left upper arm. The MDS coordinator acknowledged that care plans were supposed to be updated quarterly, with significant changes, new orders, and upon readmission from the hospital, but admitted that the care plan for this resident had not been updated to reflect the PICC line. The DON stated there was no system in place to monitor care plans to ensure they were updated upon readmission or with a change in a resident's status.
Failure to Prevent Unnecessary Weight Loss
Penalty
Summary
The facility failed to implement interventions to prevent unnecessary weight loss for a resident diagnosed with dementia. The resident's care plan, dated May 2, 2024, indicated a nutritional problem or potential for one, with a goal to maintain weight within 5% of the current weight and consume at least 50% of three daily meals. However, between May 2, 2024, and July 3, 2024, the resident experienced a significant weight loss of 11.65%, dropping from 132.2 lbs to 116.8 lbs. Observations noted the resident appeared emaciated and was not consistently redirected to meals, as seen when the resident wandered the halls instead of eating. The facility's policy required that if a resident consumed less than 50% of a meal, a nutritional supplement, such as a house shake, should be provided and documented. Despite this, the resident's electronic medical record showed multiple instances where the resident ate less than 50% of their meals, with no documentation of a house shake being offered. Interviews with CNAs and the DON confirmed the protocol for providing supplements, yet there was no record of compliance. The DON admitted to missing the significant weight loss and failing to notify the physician or dietician in a timely manner.
Failure to Conduct Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure proper post-dialysis assessments for a resident with end-stage renal failure. The resident, who was cognitively intact, reported that while their blood pressure and temperature were checked before dialysis, they did not see a nurse upon returning unless they requested assistance. The resident also mentioned a recent infection in their port, which required antibiotics due to a blood infection. A review of the resident's electronic medical record revealed a lack of documentation for post-dialysis assessments, including vital signs, weight, and fistula/port assessments on multiple dates. Interviews with nursing staff confirmed the absence of a specific dialysis protocol, although they acknowledged the need for pre and post-dialysis assessments.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss for a resident, which was identified during a record review and interview. The resident's weight dropped from 132.2 lbs to 116.8 lbs over two months, marking an 11.65% weight loss. Despite the resident eating less than 50% of their meals on multiple occasions, there was no documentation of a house shake being offered as a supplement in the last 30 days. The LPN and CMA stated that a health shake should be offered if a resident eats less than 50% of a meal, and this should be reported to the charge nurse. However, the DON admitted to not noticing the significant weight loss and failing to notify the physician or dietician. The physician, who visits the facility monthly, was only informed of the weight loss on July 19, 2024, and subsequently ordered an appetite stimulant for the resident. The DON acknowledged the oversight and the lack of communication with the physician regarding the resident's condition. The physician confirmed that they were notified of the weight loss during their visit and reviewed the resident's chart and condition at that time.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to post the required staffing information as mandated. Observations on multiple dates revealed that the staffing schedule displayed at the nurses' station did not include the necessary details such as the resident census or the nursing hours. The Director of Nursing (DON) confirmed that there were 73 residents in the facility. On July 22, 2024, the administrator acknowledged that the posted schedule lacked the nursing hours and resident census.
Failure to Administer Medication Per Physician Orders
Penalty
Summary
The facility failed to ensure medications were administered per physician orders for a resident who was reviewed for unnecessary medications. The resident had a diagnosis of transient ischemic attack and was supposed to continue taking clopridogrel 75 mg daily as per the hospital discharge summary. However, the Order Recap Report did not document that clopridogrel had been started upon the resident's admission to the facility. The resident, who was cognitively intact, reported not receiving the medication while at the facility. The Director of Nursing (DON) stated that admission orders were obtained from the hospital discharge orders but was unaware that clopridogrel had not been ordered upon admission. Upon reviewing the clinical record, the DON acknowledged failing to continue the clopridogrel order.
Sanitation Deficiencies in Kitchen and Ice Machine
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by multiple observations of unsanitary conditions. Flies were seen landing on food preparation tables, cookware, and dishware, and two ceiling vents over food preparation areas were covered with grease, dust, and debris. Additionally, the kitchen refrigerator contained several open food items, such as apple juice, Pepsi, Coke, sliced luncheon meat, omelettes, waffles, shredded lettuce, cheese slices, chicken noodle soup, cranberry juice, and canned pineapple, all without open or preparation dates. The kitchen staff acknowledged the requirement to label and date foods and stated that leftovers should be discarded within 48 hours. Personal drinks were also found in the refrigerator, which staff knew was against policy. The facility also failed to maintain a clean ice machine, as a slimy black substance identified as algae was found in and around the water reservoir. The maintenance supervisor admitted to not knowing how often the ice machine was cleaned and was not qualified to determine its cleanliness. A technician from the contracted cleaning company confirmed the presence of algae and noted difficulty in keeping the machine clean. Furthermore, the kitchen's back door was left open to improve airflow, allowing flies to enter, which had been a persistent issue for months. Maintenance efforts to address the fly problem, such as caulking around the kitchen window, were ineffective. Additionally, maintenance staff acknowledged the dirtiness of the ceiling vents and planned to clean and paint them.
Inadequate Infection Control and Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program by not implementing enhanced barrier precautions during catheter and wound care for two residents. One resident with neuromuscular dysfunction of the bladder received catheter care from CNAs who did not don gowns, contrary to the facility's policy for transmission-based precautions. The Director of Nursing (DON) acknowledged that enhanced barrier precautions had not been initiated, despite new guidelines indicating their necessity during high-contact care activities. Another resident with quadriplegia, open wounds, a urinary catheter, and a colostomy did not have signage or supplies for enhanced barrier precautions in their room. The resident reported that only an LPN provided wound and catheter care, using gloves but not a mask or gown. Observations confirmed that the LPN did not use enhanced barrier precautions during wound care. Additionally, the facility failed to prevent cross-contamination by allowing the urinary catheter dignity bag and tubing of a resident to drag on the floor, which was against the facility's protocol.
Failure to Maintain Physical Environment in Good Repair
Penalty
Summary
The facility failed to ensure the physical environment was maintained in good repair. A yellow wet floor sign and a blue bucket containing approximately one half cup of water were observed on the floor in the middle of the dining area near the serving window. Maintenance staff indicated that the bucket was placed to prevent people from slipping and falling, and it appeared that the water was coming from the ceiling. The Certified Dietary Manager (CDM) confirmed that the roof leaks when it rains. The Maintenance Supervisor stated that the roof had last been repaired in September 2023. This deficiency affected the safety and comfort of the 73 residents residing in the facility.
Failure to Implement Comprehensive Care Plan for Pressure Wounds
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with stage three pressure wounds. The care plan, dated 02/16/24, required weekly treatment documentation, including measurements and observations of the wounds. However, there was no documentation of wound care being provided before 03/17/24. Interviews with an LPN and the DON confirmed the lack of documented wound observations prior to this date, despite the care plan's requirements.
Failure to Document and Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care as ordered by the physician, complete weekly wound observations and measurements, and document refusals in the nursing notes. The policy and procedure for the prevention and treatment of pressure ulcers required the facility to provide care and services necessary to promote healing, prevent infection, and document any refusals in the resident's clinical record. However, the facility did not adhere to these guidelines for Resident #1, who had diagnoses including quadriplegia and chronic pain syndrome. The treatment administration records (TAR) for February, March, and April 2024 showed multiple instances where the prescribed treatments were either not documented or marked as refused without proper documentation in the clinical record. Additionally, there were no documented wound observations prior to March 17, 2024, despite the requirement for weekly evaluations. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the care was being provided but not documented correctly. LPN #2 confirmed that refusals should be charted in the clinical record, and LPN #1 explained that a blank on the TAR meant the treatment was not provided, while specific numbers indicated refusal or other reasons, which should have been accompanied by a progress note. The DON acknowledged the lack of weekly wound documentation and admitted that the admit screener's documentation was insufficient. This lack of proper documentation and adherence to the care plan led to the identified deficiencies in pressure ulcer care for Resident #1.
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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