Montereau, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 6800 South Granite Avenue, Tulsa, Oklahoma 74136
- CMS Provider Number
- 375460
- Inspections on file
- 19
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Montereau, Inc. during CMS and state inspections, most recent first.
A resident who required significant assistance with daily activities and was at risk for falls experienced multiple prolonged waits for call light responses, including one instance where the call light was active for over three hours. The resident, who was cognitively intact and had several medical conditions, reported having to call out for help and being left unattended on the toilet, leading them to slide to the floor. Staff interviews revealed inconsistent expectations and practices regarding call light response times, with some staff acknowledging delays during busy periods and issues with accurately recording response times.
Surveyors found that two treatment carts containing medications and biologicals were left unlocked and unattended in the facility. Staff admitted to leaving keys in accessible locations and not following protocol to keep carts locked when out of sight. The DON confirmed that facility policy requires carts to be locked and keys to be kept on the nurse.
A resident with a history of heart failure and recurrent nosebleeds was discharged from the hospital with instructions to follow up with an ENT physician, but the facility failed to schedule the required appointment. The ADON, responsible for scheduling, did not identify the need for the ENT referral, and there was no documentation or monitoring process in place to ensure the appointment was made. The resident confirmed they were not notified of or sent to the ENT appointment during their stay.
A resident with severe cognitive impairment and a stage three pressure ulcer did not consistently receive a physician-ordered liquid protein supplement, with eight missed doses documented due to issues such as unavailability and lack of staff awareness. Staff interviews revealed confusion about ordering and administration responsibilities, resulting in the resident not receiving the prescribed nutritional support for wound healing.
A resident with heart failure, hypertension, and renal insufficiency did not receive Lasix at the physician-ordered times on multiple occasions. Audit reports showed several doses were administered late, and staff interviews revealed inconsistent adherence to the facility's medication timing protocol. The facility did not ensure medications were given as ordered, resulting in a deficiency related to timely medication administration.
A resident with a history of skin breakdown and high risk for pressure ulcers was admitted with moisture associated skin damage, but the facility failed to accurately assess, document, and care plan for the condition. There was a lack of timely wound care interventions, inconsistent documentation, and poor communication among staff, leading to the progression of a sacral wound to a stage IV pressure ulcer with severe infection and sepsis, ultimately resulting in the resident's death.
The facility failed to ensure enhanced barrier precautions were used during catheter care for two residents with indwelling urinary catheters. Despite the presence of PPE and signage, CNAs did not use gowns as required. Both CNAs admitted to not using gowns, and the DON and infection preventionist confirmed staff had been educated on PPE use.
A resident with dementia and dysphagia had their dietary needs publicly displayed on sheets of paper near the nurses' station, compromising their dignity. RN #1 acknowledged that this information should not be visible to the public and stated that staff could access dietary needs through the care plan and lunch tickets.
The facility failed to ensure residents were offered the choice to formulate an advance directive, as evidenced by the lack of documentation for three residents. One resident with dementia and dysphagia had no advance directive acknowledgment, another with Alzheimer's and sepsis had incomplete social service assessment, and a third resident's advance directive form was only signed on the day of the survey. The Social Services Director confirmed the absence of a form to document advance directives upon admission.
The facility failed to develop comprehensive care plans for four residents, including those with multiple sclerosis, hypertension, and Alzheimer's disease. The MDS assessments were completed, but the care plans were not fully developed as required. Additionally, a resident with Alzheimer's was not weighed as per their care plan, missing 31 out of 37 opportunities.
A resident with cognitive communication deficit and other conditions was abused by a CNA, who was witnessed and videotaped yelling and kicking the resident. The incident was not reported immediately due to the witnessing CNA's fear, violating the facility's abuse policy.
Failure to Provide Timely Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient staff to answer call lights in a timely manner for one of three sampled residents reviewed for call light response. Call light logs revealed multiple instances where the resident's call light remained active for extended periods, including durations of over an hour and, in one case, more than three hours. Documentation showed that the resident had to call out for help and was found on the bathroom floor after attempting to get assistance for an extended period. The resident reported having to wait 15 to 45 minutes on several occasions for staff to respond to their call light, sometimes resorting to calling the security desk for help at night. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including heart failure, hypertension, and renal insufficiency. The resident required substantial to maximum assistance with activities of daily living, including transfers and toileting, and was considered a fall risk. Despite these needs, the resident reported being left unattended on the toilet for at least 30 minutes, leading them to slide to the floor and crawl toward the door to seek help. Staff interviews confirmed that call light response times varied, with some staff indicating that response times could be longer during busy periods such as mealtimes. Interviews with facility staff, including the DON, LPNs, and CNAs, revealed inconsistencies in the expected and actual response times to call lights. While some staff stated that the expected response time was two minutes, others considered up to 15 minutes to be timely, especially during busy periods. The DON acknowledged that call light response times were monitored only randomly or in response to complaints and that there were issues with staff acknowledging but not turning off call lights, which could affect the accuracy of response time records.
Failure to Secure Medications in Unattended Treatment Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were secured in accordance with professional standards. On two separate occasions, treatment carts containing medications such as insulin, Narcan, lidocaine patches, and various antiseptics were found unlocked and unattended. On the second floor, a treatment cart was left unlocked next to the nurses' station while staff were present but not attending to the cart. The key to the cart was found in an open compartment, and staff admitted to leaving it there for easy access, contrary to facility protocol. The cart remained unlocked and unattended for several minutes, with staff unable to provide a reason for this lapse. A similar incident occurred on the first floor, where another treatment cart was observed unlocked and unattended around the corner from the nurses' desk. Staff walked past the cart without securing it, and a CNA accessed supplies from the cart. When questioned, staff acknowledged that the cart should not have been left unlocked and stated it was an oversight. The Director of Nursing confirmed that facility policy required carts to be locked when out of sight and that keys should be kept on the nurse, not left in or near the cart.
Failure to Schedule Required ENT Follow-Up Appointment
Penalty
Summary
A deficiency occurred when the facility failed to schedule a follow-up appointment with an ENT physician for a resident who had been evaluated in the emergency room for a recurrent nosebleed. The resident, who was cognitively intact and had a diagnosis of heart failure, was discharged from the hospital with instructions to follow up with an ENT within five to seven days. Upon return to the facility, there was no documentation in the clinical record or appointment log indicating that the required ENT appointment had been scheduled. Interviews with facility staff revealed that the ADON was responsible for scheduling resident appointments and reviewing hospital records for necessary referrals. The ADON confirmed that, at the time of the resident's readmission, they did not identify the need for an ENT follow-up. The DON stated that there was no known monitoring process in place to ensure that appointments and referrals were scheduled, and could not explain why the ENT appointment was missed. The resident reported not being notified of or attending an ENT appointment during their stay.
Failure to Administer Ordered Nutritional Supplement for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that nutritional supplements ordered for the treatment of a pressure ulcer were consistently administered to a resident with severe cognitive impairment and multiple medical diagnoses, including coronary artery disease, hypertension, and Alzheimer's disease. The resident was assessed as having increased protein needs due to a stage three pressure ulcer, and a physician's order was in place for liquid protein to be given twice daily. However, review of medication administration records revealed that the supplement was not given on eight occasions out of thirty opportunities, with several missed doses lacking documented reasons or being attributed to the supplement not being available or on order from the pharmacy. Interviews with nursing staff indicated confusion regarding the ordering and administration process for the supplement, with one LPN stating that medications were ordered electronically and should be administered upon arrival, and the ADON noting that the supplement should have been available as house stock. Despite these protocols, the supplement was not administered as ordered, and staff were unable to provide consistent explanations for the missed doses, indicating a breakdown in ensuring the resident received the prescribed nutritional intervention for pressure ulcer care.
Failure to Administer Medications at Ordered Times
Penalty
Summary
The facility failed to ensure that medications were administered at the ordered times for one of three sampled residents reviewed for medication administration. According to the facility's policy, medications are to be administered by licensed nurses or other authorized staff as ordered by the physician, following the six rights of medication administration, including the right time. For a resident with diagnoses of heart failure, hypertension, and renal insufficiency, physician orders specified that Lasix was to be administered twice daily at 7:00 a.m. and 2:00 p.m. However, medication administration audit reports showed multiple instances where Lasix was not given at the ordered time, with doses being administered significantly later than scheduled on several dates. Interviews with staff revealed inconsistencies in following the facility's protocol regarding medication timing. An LPN stated that there was a one-hour window before and after the ordered time for administration, but acknowledged that some doses were given outside this window and could not explain the delays. The DON confirmed the protocol and stated that nurses should report late administrations, but there was no indication that this occurred. The documentation and staff interviews demonstrate that the facility did not consistently adhere to its own medication administration policies, resulting in late administration of prescribed medications.
Failure to Assess, Monitor, and Intervene for Pressure Ulcer Risk and Treatment
Penalty
Summary
A deficiency was identified when the facility failed to properly assess, monitor, and intervene for a resident with a history of skin breakdown and at high risk for pressure ulcers. Upon admission, the resident was documented as having moisture associated skin damage to the right gluteus, but there was no documentation of a deep tissue injury or other wounds. Despite this, there was a lack of accurate and timely documentation regarding the resident's skin condition, and the baseline care plan did not address any skin issues or concerns. The facility also failed to initiate appropriate treatment orders for the skin damage present on admission, and there was no evidence of wound care interventions until a pressure ulcer was later identified. Throughout the resident's stay, multiple nursing notes, skin checks, and care plan reviews continued to document the presence of moisture associated skin damage, but did not identify or address the development of a pressure ulcer. The Braden scale assessments initially indicated a low risk for pressure ulcers, and there was inconsistency in the documentation of the resident's skin status. The care plan eventually noted the resident was at risk for skin breakdown due to incontinence, but did not specifically address the presence or treatment of a pressure ulcer. Weekly wound tracking and physician notes later documented the progression of a sacral wound from suspected deep tissue injury to a stage IV pressure ulcer, with significant necrotic tissue and exudate, and additional wounds on the right heel and left foot. Communication failures were evident, as changes in the resident's skin condition were not consistently reported to the care team or reflected in the care plan. There was a delay in obtaining and following physician orders for wound care, and discrepancies existed between the frequency of ordered dressing changes and what was scheduled in the electronic medical record. The lack of timely and coordinated interventions contributed to the deterioration of the resident's skin condition, ultimately resulting in severe infection, sepsis, and death due to complications from an infected sacral decubitus ulcer.
Failure to Utilize Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were utilized during indwelling urinary catheter care for two residents. Both residents had diagnoses of obstructive and reflux uropathy and were on enhanced barrier precautions due to the presence of indwelling urinary catheters. Despite the presence of personal protective equipment (PPE) bins and signage indicating enhanced barrier precautions outside the residents' doors, the certified nursing assistants (CNAs) providing care did not use gowns as required. CNA #1 and CNA #2 both acknowledged that they were supposed to use gowns and gloves during catheter care but admitted to not doing so during their respective observations. The Director of Nursing (DON) and the infection preventionist confirmed that staff had been educated on the use of PPE for residents on enhanced barrier precautions, yet the CNAs failed to adhere to these protocols during the observed care activities.
Resident Dignity Compromised by Public Display of Dietary Information
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as observed in the case of a resident with dementia and dysphagia. The resident was admitted with a physician's order for a regular pureed texture diet with nectar thick consistency liquids. During an observation, the resident was seen sitting near the nurses' station with two 8 x 10 sheets of paper displaying their dietary requirements, including their name and the need for nectar thick liquids. These signs were visible to the public, which was acknowledged by RN #1 as inappropriate, stating that such information should not be publicly displayed. RN #1 also mentioned that staff could access the resident's dietary needs through the care plan and lunch tickets available during meal times.
Failure to Offer Advance Directive Choices
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate an advance directive, as evidenced by the lack of documentation for three residents. Resident #7, who was admitted with dementia and dysphagia, had a physician's order and care plan indicating full code status, but there was no advance directive acknowledgment or social services assessment documenting the resident's choice. Similarly, Resident #40, admitted with Alzheimer's and sepsis, had a care plan indicating DNR status, yet the social service assessment lacked information regarding the resident's choice to accept or decline an advance directive. Resident #208's case further highlights the deficiency, as their social service history and initial assessment did not contain any information regarding advance directives. During an interview, the Social Services Director admitted that there was no form to document whether a resident had advance directives upon admission. It was revealed that the forms provided to the survey team were newly created on the day of the survey, and Resident #208's form was signed on the same day, despite the resident being admitted earlier.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, as required by their policy. Resident #50, diagnosed with cellulitis of the abdominal wall and multiple sclerosis, did not have a comprehensive care plan completed after the admission MDS assessment was finalized on May 18, 2024. Similarly, Resident #41, with diagnoses including hypertension, a fracture of the left femur, and a transient ischemic attack, also lacked a comprehensive care plan following the completion of their admission MDS assessment on April 25, 2024. In both cases, the MDS Coordinator confirmed that the care plans were not fully completed. Resident #111, who had cerebral infarction, congestive heart failure, and heart failure, was admitted without a comprehensive care plan after their MDS assessment was completed on June 17, 2024. Additionally, Resident #40, diagnosed with Alzheimer's disease and morbid obesity, had a care plan that required weekly weight monitoring due to malnutrition risk. However, the facility failed to obtain the resident's weight on 31 out of 37 opportunities. The MDS Coordinator acknowledged that Resident #40 was not being weighed according to their care plan.
Failure to Immediately Report Abuse
Penalty
Summary
The facility failed to implement their abuse policy by not immediately reporting an incident of abuse. A resident with diagnoses including cognitive communication deficit, displaced intertrochanteric fracture, and depression was subjected to abuse when a CNA was witnessed and videotaped yelling and kicking the resident. The incident occurred at approximately 5:30 a.m. and was not reported to the administrator until 2:30 p.m. the same day. The delay in reporting was due to the witnessing CNA's fear of the abusive CNA. The facility's policy requires immediate reporting of abuse, which was not followed in this case.
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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