Park Place Healthcare And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 1530 Ne Grand Blvd, Oklahoma City, Oklahoma 73117
- CMS Provider Number
- 375582
- Inspections on file
- 28
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Park Place Healthcare And Rehab during CMS and state inspections, most recent first.
A resident at risk for pressure ulcers, with impaired mobility and a sacral fracture, had a care plan calling for weekly skin assessments and a pressure-reducing mattress, but charge nurse assessments documented only redness and no open areas despite later identification of three stage 2 ulcers on the buttocks. During incontinent care, a CNA observed open areas and applied vitamin A&D ointment after reporting the issue to an RN, yet there were no physician orders for wound treatment and the wound care nurse initially did not have the resident on the wound list. The resident was also found on a regular mattress rather than the ordered pressure-relieving surface, while nursing staff and the DON gave conflicting accounts about whether such a mattress was in place and what constituted a pressure-relieving mattress.
A resident with generalized pain, gout, and liver cirrhosis had a care plan and physician order for oxycodone 5 mg every six hours as needed, but did not receive the ordered oxycodone on an overnight shift when pain was reported as severe. The MAR showed oxycodone was given on earlier shifts, yet there was no documentation of administration overnight. The resident reported being told there was no nurse available to give narcotics and was instead offered Tylenol, which they refused due to a liver condition and prior instructions from a transplant physician. The overnight LPN stated they were the only nurse on duty, refused to accept the narcotic lockbox keys, did not know where the keys were, and therefore did not administer oxycodone when requested. Facility leadership later confirmed that medications were to be administered as ordered and that the resident’s oxycodone should have been provided.
The facility failed to accurately report direct care staffing hours to CMS for multiple dates on the 3 p.m. to 11 p.m. shift, despite having higher actual hours documented in payroll records. For several days across two consecutive months, the Quality of Care report submitted to CMS showed substantially fewer direct care staffing hours than those reflected in the facility’s payroll detail, while the resident census remained in the mid-60s. During an interview, a corporate nursing officer confirmed that the staffing information submitted to CMS was not accurate.
A resident with diabetes and intact cognition had multiple FSBS readings above 350 mg/dL, for which 10 units of Humalog insulin were administered per sliding-scale orders that also required notifying the MD when FSBS was between 350 and 400. Review of progress notes and MAR showed no documentation that the MD was notified for any of these elevated readings. The resident reported their blood sugars had been well controlled prior to admission but had become significantly higher in the facility. An RN confirmed the notification requirement in the insulin order, acknowledged that no MD notification was documented for the elevated FSBS values, and the DON stated staff should notify the physician when orders direct them to do so.
A resident with documented left-sided weakness, renal failure, and heart failure was observed with a contracted left hand held in a fist and an inability to raise the left arm above shoulder level, yet the admission and comprehensive assessments recorded no upper extremity impairment despite the resident being cognitively intact. A CNA reported the resident could not use the left hand and had left arm weakness, and the MDS coordinator, who stated they gather assessment data by chart review and direct observation, acknowledged the assessment should have reflected the left-hand contracture and arm weakness but did not.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for several residents. One resident with left-sided weakness and a contracted hand had no care plan problem for limited ROM, no therapeutic devices, and no restorative or ROM interventions, despite staff recognizing the impairment. Another resident with protein-calorie malnutrition and significant documented weight loss had a care plan requiring meal replacement supplements when eating 50% or less of meals, but staff did not provide the ordered health shakes, and the resident reported not receiving supplements. A third resident, dependent for transfers and using a mechanical lift as confirmed by staff and observation, did not have lift use included in the care plan, even though the MDS coordinator stated such interventions should be documented.
Surveyors found multiple infection control failures during incontinent care. In one case, a CNA caring for a resident with dementia and bowel/bladder incontinence dropped a soiled pad on the floor and continued care and room adjustments without changing gloves, contrary to facility policy requiring soiled linen to be bagged at bedside. In another case, a CNA caring for a resident who was occasionally incontinent placed soiled wipes and a soiled brief on the bed, then handled the resident’s stuffed animal, clean linens, bedside table, bed controls, call light, and clean supplies while still wearing contaminated gloves. For a resident on EBP for a pressure ulcer and skin infection, a CNA performed high-contact care (brief change with fecal soiling) wearing gloves but no gown, and continued tasks after brief removal without an appropriate glove change, despite the EBP policy and care plan requiring gown and glove use for such activities.
A resident with left-sided weakness and a contracted left hand was observed with the hand tightly closed into a fist and unable to raise the left arm above shoulder height, without any therapeutic devices in place. The resident, who was cognitively intact, reported no use of the left hand and no therapies or devices to maintain or improve function. Facility records did not document upper extremity impairment or a hand contracture on admission, and staff, including CNAs and an LPN, confirmed there were no orders for therapeutic devices or ROM exercises and that the resident was not on restorative services. The DON stated that residents with limited ROM or contractures should be in therapy or the restorative program and acknowledged this had not occurred for this resident since admission.
A resident with protein-calorie malnutrition, pancytopenia, renal insufficiency, cirrhosis, and moderate cognitive impairment experienced significant weight loss while consuming only 25–50% of meals. The care plan required meal replacement supplements when 50% or less of a meal was eaten, and the dietician ordered health shakes three times daily with meals. Over an extended period, there was no documentation that these health shakes were provided, and staff confirmed the resident did not receive supplements despite poor intake and an untouched meal tray observed at the bedside.
A resident with a sacral fracture and mobility abnormalities, who was cognitively intact, had physician orders for weekly skin assessments. During incontinent care, three open areas were observed on the coccyx and buttocks, but a same-day weekly skin assessment documented no open areas and only noted redness. The following day, the wound care nurse identified three stage 2 pressure areas with specific measurements, and the resident had previously reported a small open area on their bottom. The DON confirmed the weekly assessment showed no open areas, and an LPN admitted not completing a full head-to-toe skin assessment or clearly visualizing the coccyx and buttocks, despite existing training that weekly skin checks must cover all skin areas.
A resident with a documented diagnosis of depression, prescribed fluoxetine and identified as cognitively intact, did not receive a psychiatric consultation despite facility criteria and a physician order indicating such a consult was needed when certain behaviors occurred. The resident was observed tearful, reported feeling too depressed to get out of bed and at risk of missing dialysis, and was described by staff as easily upset, socially withdrawn, and having refused dialysis multiple times. Activity records also showed no participation in activities during a full month, even though activities were noted as very important to the resident, and the DON acknowledged the resident met the facility’s criteria for psychiatric consultation, which was not obtained.
Surveyors found that the facility’s medication error rate exceeded 5% after two residents received incorrect medication doses during an observed med pass. One resident was given a single 25 mcg vitamin D3 tablet instead of the prescribed 50 mcg dose, and another resident received only one senna tablet instead of the ordered two tablets for constipation. CMAs later acknowledged they had not followed the physician orders, and the DON stated staff were expected to follow the rights of medication administration and the punch-initial-give method.
A resident with a sacral fracture, gait abnormalities, and intact cognition had physician orders for weekly skin assessments, but the required assessment was not completed accurately. During incontinent care, the resident was observed with three open areas on the coccyx and buttocks, while a weekly skin assessment documented the prior night by an LPN recorded no open areas and only coccyx redness. A subsequent assessment by the wound care nurse identified stage 2 open areas on the coccyx and both buttocks. The LPN later admitted not performing a complete head-to-toe skin assessment or visualizing the coccyx and buttocks, despite facility policy requiring objective, complete, and accurate documentation based only on observed findings.
A resident did not receive multiple prescribed medications as ordered, with several missed doses documented as blanks on the MAR and no explanations provided. Facility staff confirmed that these medications were not administered or documented according to policy.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment was not maintained to minimize risks, and supervision protocols were insufficient.
Multiple residents with intact cognition were involved in verbal altercations, including threats of physical harm, and one resident produced a knife and attempted to jab it at a nurse. The facility did not consistently document 1:1 supervision, failed to update care plans after the incidents, and did not ensure all staff received required abuse and neglect training. Another resident reported being treated roughly and spoken to harshly by a CNA, leading to feelings of being unsafe. These failures resulted in deficiencies related to abuse, neglect, and inadequate supervision.
The facility did not notify law enforcement after an incident in which a resident made explicit threats of physical harm, including threats to set another resident on fire and use a weapon, and later brandished a knife at a nurse. Staff separated the involved residents and reported the incident to the state agency, but there was no documentation that law enforcement was contacted, as required by facility policy.
The facility did not update the care plans for two residents after incidents involving threats and aggressive behavior, including one resident producing a knife and making verbal threats, and another resident verbally threatening harm to others. Both residents had documented behavioral and mental health histories, but their care plans were not revised to address these incidents, despite facility policy and staff statements indicating that care plans should be updated following such events.
The facility did not determine if three residents wished to formulate an advance directive, as required by their policy. The business office manager stated that if residents were unsure or wanted to discuss with family, the form was left blank, indicating no current advance directives.
The facility failed to maintain safe flooring in the common area, with floor slats pulled away and corners sticking up, creating a tripping hazard for mobile residents, staff, and visitors. Maintenance was observed gluing slats down multiple times, and resident council members expressed concerns about the floor causing trouble even for those in wheelchairs. The administrator acknowledged the issue and provided documentation of bids to replace the flooring.
The facility failed to secure medication carts when not in use, as observed on two occasions. A medication cart was found unlocked and unattended by the nursing station, and another was observed unlocked on hall 600 with no staff present. Staff interviews confirmed that leaving carts unlocked was against policy, which mandates that all drugs be stored in locked compartments.
A facility failed to maintain infection control during medication administration to a resident with a PEG tube. An LPN did not wear a gown as required by the Enhanced Barrier Precautions policy, which mandates gown and glove use during high-contact care activities involving indwelling devices. The policy aims to reduce the transmission of multidrug-resistant organisms, and supplies were available outside the resident's room, but the protocol was not followed.
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling devices. A resident with a foley catheter and pressure wounds and another with a gastric tube were not provided with appropriate EBP. Staff used only gloves without gowns, and there was a lack of understanding of EBP among staff. No EBP signs were posted, and the DON and ADON could not identify residents needing EBP, indicating systemic issues in infection control.
The facility did not provide mail delivery to residents on Saturdays, contrary to their Resident Rights policy. Although mail was delivered on Saturdays, it was not distributed until Monday, as confirmed by the activities director and resident council members. The DON acknowledged this issue, affecting 47 residents.
A facility failed to notify a physician upon receiving culture and sensitivity results from a urinalysis for a resident with acute cerebrovascular insufficiency, communication deficit, and UTI. The facility's policy requires prompt physician consultation for treatment alterations. The resident was prescribed Cephalexin, but documentation lacked culture results and physician notification. The lab results were released and finalized, but the ADON confirmed no progress note indicated physician notification.
The facility did not complete baseline care plans within the required 48-hour timeframe for two residents. One resident, with multiple diagnoses including ESRD and cognitive impairment, had no baseline care plan upon readmission. Another resident's baseline care plan was completed late. Staff confirmed these oversights, indicating a failure to adhere to the facility's policy.
The facility failed to provide an activity program that meets residents' individual or group needs, leading to potential social isolation. The Activities Director noted residents' dislike for scheduled activities and used personal funds for crafts. Two residents with good cognitive functioning had unmet preferences for activities like being around animals and attending religious services. The DON acknowledged funding issues and plans to identify resident preferences.
An LPN left a medication cart unlocked while administering medication to a resident, contrary to facility policy requiring carts to be locked. The LPN admitted to being flustered, leading to the oversight. This incident was observed on one of the two medication/treatment carts in the facility, which houses 47 residents.
The facility failed to provide evening snacks to several residents who required them, despite having a policy to offer nourishing snacks at bedtime. Residents in a specific hall, who needed help leaving their rooms, were not offered snacks, and there was no documentation to show they were provided on multiple occasions. The DON was aware of the issue but it persisted.
A resident with multiple diagnoses was involved in an altercation with the facility administrator, who responded aggressively during a dispute over a camera. The resident's care plan was delayed, and the administrator was suspended pending investigation. Staff were uncertain about reporting abuse due to the absence of a current administrator.
A facility failed to complete a comprehensive assessment within 14 days of admission for a resident. The resident's 5-day/admission assessment was not completed by the required date, and it remained incomplete even after the deadline had passed.
A facility failed to implement a comprehensive care plan for a resident with ESRD and chronic kidney disease. The policy requires a person-centered care plan with measurable objectives, but no dialysis or nutrition care plan was found. The ADON confirmed the absence of these plans and acknowledged that the existing care plan did not meet the necessary requirements.
A facility failed to complete necessary dialysis orders and monitoring for a resident requiring such services. The Hemodialysis Policy required specific documentation and monitoring, which were not present in the resident's records. Staff interviews revealed a lack of awareness and adherence to the policy, with an LPN admitting to not assessing the resident's dialysis shunt and an undated bandage remaining on the resident's arm.
The facility did not ensure daily nurse staffing information was updated, with missing data for RNs, LPNs, CNAs, and CMAs on multiple days. The DON stated they were waiting to total actual hours worked before updating the sheet.
A facility failed to follow its antibiotic stewardship policy for a resident with a UTI, communication deficit, and cerebrovascular insufficiency. The resident was prescribed Cephalexin without reviewing culture and sensitivity results, which were not communicated to the physician. The DON admitted antibiotics were often prescribed before receiving C&S results, and the ADON confirmed no physician notification was documented, indicating a failure in the facility's process for appropriate antibiotic use.
A resident was unable to reach the call light while sitting in a wheelchair next to the bed, as the cord was too short. A CNA confirmed the call light was out of reach and mentioned that the policy is to have it within reach. The resident's roommate would use their call light if assistance was needed.
The facility failed to provide scheduled showers for two residents who required assistance with ADLs. One resident missed 22 days of showers, while another missed multiple scheduled baths over three months. Both the residents and staff confirmed the missed showers, and the DON acknowledged the lack of documentation.
The facility failed to complete ongoing assessments of a resident pre and post dialysis as required by their Hemodialysis policy. Documentation was missing for multiple dates in February, March, and April 2024. An LPN confirmed the lack of assessments after reviewing the records.
The facility failed to implement an antibiotic stewardship program and did not conduct ongoing monitoring. A resident had physician's orders for azithromycin and doxycycline hyclate, but there was no documentation of monitoring for these antibiotics. The DON and Infection Preventionist confirmed the lack of monitoring.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who received Part A skilled services and remained in the facility after discharge from these services. The MDS coordinator confirmed that the SNF ABN could not be located.
The facility failed to ensure a resident's wall was in good repair, compromising the homelike environment. The resident, who was nonverbal and had cerebral infarction, had three deep scrapes on the wall by the head of the bed. Although a CNA was aware of the issue and reported it to another staff member, it was not communicated to maintenance, and the Maintenance Supervisor was unaware of the need for repair.
A resident with hypertension received hydralazine and carvedilol despite blood pressure readings below the ordered parameters. Both an LPN and the ADON confirmed the medications should have been held according to the physician's orders.
The facility failed to review a PRN lorazepam order after 14 days of use for a resident. The medication was prescribed with an indefinite end date and was administered multiple times over three months. The DON confirmed that PRN anti-psychotic orders should be re-evaluated every two weeks.
A CNA was observed transporting dirty pads without bagging them, briefly setting them on the floor before placing them in the soiled room. The CNA admitted to not following the facility's Handling Soiled Linen policy due to a lack of available bags.
Failure to Implement Skin Care Interventions and Provide Appropriate Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions to prevent skin breakdown and to provide appropriate treatment for existing pressure ulcers for one resident. The resident was admitted with diagnoses including an unspecified sacral fracture and abnormalities of gait and mobility, and was assessed as at risk for developing pressure ulcers, requiring assistance with rolling and perineal hygiene. The resident’s care plan, initiated on 02/05/26, included monitoring and documenting skin changes, using a pressure reducing/relieving mattress, and completing weekly skin assessments as ordered. However, skin assessments documented by the charge nurse on 02/05/26 and 02/12/26 indicated only coccyx redness and no open areas, despite subsequent findings of open wounds. On 02/12/26, during incontinent care, the resident was observed with three open areas on the coccyx and buttocks, and a CNA applied vitamin A&D ointment to the wounds. The CNA later stated they were aware of one open spot and reported the skin issue to an RN, and asked if there was anything else to use for treatment, being told to use vitamin A&D ointment. The RN stated they did not remember being informed of the wounds and believed the resident only had redness, with their last observation occurring the previous week. The resident reported not being aware of having three wounds. A wound care nurse’s skin assessment on 02/13/26 documented three stage 2 open areas on the right buttock, left buttock, and upper buttocks, and the wound care nurse initially stated the resident did not have a wound and was not on their wound care list. Physician orders for the month showed no wound treatment orders in place. The facility also failed to ensure the ordered pressure reducing mattress intervention was in place. On 02/13/26, the resident was observed lying on a regular mattress, and the CNA confirmed the resident did not have a pressure relieving mattress on the bed. The RN stated that all residents, including this resident, had pressure relieving mattresses, while the DON indicated that a pressure relieving mattress could mean pillows or wedges and was not aware the resident had wounds. Later, the resident was observed with a navy-blue pressure relieving mattress, and the wound care nurse clarified that the previous mattress had been a regular mattress and that not all residents had pressure relieving mattresses. The wound care nurse stated the resident’s wound would be considered facility-acquired and that having a pressure reducing mattress could have helped in preventing it.
Failure to Administer Ordered Oxycodone Due to Lack of Access to Narcotic Keys
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication as prescribed and to ensure access to ordered narcotics for a resident with generalized pain. Facility policies required medications to be administered in accordance with prescriber orders and emphasized appropriate assessment and treatment of pain. The resident’s care plan identified generalized pain with an intervention to administer analgesics as ordered, and a physician’s order prescribed oxycodone 5 mg every six hours as needed for pain. The resident had diagnoses including gout and liver cirrhosis and a BIMS score of 12, indicating moderate cognitive impairment. Medication administration records for the reviewed period showed the resident received oxycodone on the day and evening shifts on one date, with documented pain scores of 4/10 and 6/10, but there was no documentation that oxycodone was administered on the overnight shift. A nurse’s note documented that the resident requested oxycodone during the overnight shift and was told there was no primary nurse available to administer narcotics. The resident was offered Tylenol instead, but refused, stating they could not take Tylenol due to their liver condition and reporting that their liver transplant physician had advised against Tylenol. The resident later stated they hurt all over all the time, that they received oxycodone every six hours, and that they had been denied oxycodone due to no available staff. A CMA reported the resident frequently complained of pain and that oxycodone had been ordered as needed until it was changed to a routine every-six-hour schedule. The LPN on duty during the overnight shift stated they were the only nurse on duty, refused to accept the narcotic lockbox keys for the resident’s hall, did not know where those keys were, and therefore did not administer oxycodone when the resident, who rated their pain 10/10, requested it. The DON stated facility policy was to administer medications as ordered and that the resident’s oxycodone should have been given and an alternative to Tylenol should have been available.
Inaccurate PBJ Staffing Hours Reported to CMS
Penalty
Summary
The deficiency involves the facility’s failure to accurately report direct care staffing hours to CMS through the Payroll-Based Journal (PBJ)/Quality of Care reporting system for specific dates in December 2025 and January 2026. For the 3 p.m. to 11 p.m. shift in December 2025, the Quality of Care report submitted to CMS showed significantly lower direct care staffing hours than those documented in the facility’s payroll detail report. On 12/20, with a census of 62, 52.32 hours were reported to CMS while payroll showed 91.51 hours; on 12/24, with a census of 63, 37.40 hours were reported while payroll showed 63.27 hours; on 12/27, with a census of 63, 61.18 hours were reported while payroll showed 86.99 hours; and on 12/28, with a census of 61, 61.00 hours were reported while payroll showed 98.69 hours. A similar pattern occurred in January 2026 for the 3 p.m. to 11 p.m. shift, where the Quality of Care report again reflected inaccurate direct care staffing hours compared to the payroll detail. On 01/03, with a census of 65, 33.75 hours were reported versus 104.74 hours on payroll; on 01/20, with a census of 66, 38.21 hours were reported versus 64.10 hours; on 01/21, with a census of 66, 41.11 hours were reported versus 65.13 hours; on 01/24, with a census of 65, 72.50 hours were reported, which matched the payroll; on 01/27, with a census of 64, 37.83 hours were reported versus 75.80 hours; on 01/28, with a census of 64, 38.44 hours were reported versus 64.92 hours; and on 01/31, with a census of 64, 47.50 hours were reported versus 76.73 hours. During an interview on 02/18/26 at 12:05 p.m., the corporate nursing officer acknowledged that the facility had not accurately submitted staffing information to CMS. At the time, the administrator had identified that 63 residents resided in the facility.
Failure to Notify Physician of Elevated Blood Glucose per Insulin Order
Penalty
Summary
The facility failed to notify a physician when a resident’s finger-stick blood sugar (FSBS) exceeded 350 mg/dL, as required by the resident’s insulin order and the facility’s physician notification policy. The policy stated that licensed nurses are responsible for notifying medical staff of significant changes in condition and documenting the date, time, physician name, actions taken, and resident response. A physician’s order dated 12/31/25 for Humalog insulin directed staff to administer 10 units subcutaneously before meals for FSBS levels of 350–400 mg/dL and to notify the medical doctor. Record review for February showed multiple FSBS readings above 350 mg/dL for this resident, with corresponding administration of 10 units of Humalog insulin on several dates and times. Despite these elevated FSBS readings and the explicit order to notify the physician when FSBS was between 350 and 400, there was no documentation in the progress notes or medication administration record that the provider had been notified. The resident, who had a diagnosis of diabetes and intact cognition with a BIMS score of 14, reported that their blood sugar had been well controlled (around 100–200) prior to admission and that it had reached as high as 370 in the facility. During interviews, an RN confirmed that the process for insulin administration included obtaining and documenting FSBS and that physician notifications should be documented in progress notes. The RN acknowledged that the resident’s order required physician notification for FSBS of 350–400, could not locate any such documentation, and stated that the provider had not been notified for an FSBS of 375. The DON also stated that staff should notify the physician if the order stated to do so.
Failure to Accurately Assess Resident’s Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively and accurately assess a resident’s physical condition, specifically upper extremity function, as required upon admission and periodically thereafter. Observation on 02/11/26 at 8:48 a.m. showed the resident’s left hand was contracted and completely closed into a fist, with no therapeutic devices in place, and the left arm could not be raised above shoulder height. The resident stated at that time that they had no use of their left hand and could not raise their left arm above their shoulders. A Physician’s Progress Note dated 11/14/25 documented left-sided weakness, and the resident’s admission assessment dated 11/23/25 showed admission with renal failure and heart failure. Despite these findings, the admission assessment documented no impairment to the upper extremities and showed a BIMS score of 14, indicating the resident was cognitively intact. Further interviews confirmed the discrepancy between the resident’s actual condition and the documented assessment. On 02/12/26 at 9:54 a.m., a CNA reported that the resident was unable to use their left hand and had left arm weakness. On 02/12/26 at 10:38 a.m., the MDS coordinator explained that comprehensive assessment information is collected by reading the chart and personally seeing the patient. When asked, the MDS coordinator acknowledged that the comprehensive assessment did not show any upper extremity impairments and stated that it should have reflected the resident’s left-hand contracture and left arm weakness. The facility had a policy titled Resident Assessments, dated 11/2019, indicating appropriate resident assessments were to be completed, but this was not followed for this resident’s upper extremity status.
Failure to Develop and Implement Comprehensive Care Plans for ROM, Nutrition, and Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for multiple residents. For one resident with left-sided weakness, surveyors observed a contracted left hand closed into a fist and limited ability to raise the left arm above shoulder height, with no therapeutic devices in place. The resident reported having no use of the left hand and no therapies or devices to maintain or improve function. Staff, including CNAs and an LPN, confirmed the resident had left-hand contracture and weakness, was not on restorative services, had no therapeutic devices, and did not receive range of motion exercises. The DON acknowledged that the resident had not been admitted to therapy or the restorative program since admission, despite having limited range of motion and contracture, and the MDS coordinator confirmed the care plan did not address the upper extremity impairment or related interventions. Another deficiency was identified for a resident with protein-calorie malnutrition and significant weight loss, whose care plan required staff to offer a meal replacement supplement when 50% or less of a meal was consumed. Weight records showed a decline from 170 pounds to 155 pounds over approximately two months, and a dietician’s note documented an 8.8% weight loss in one month and 15.3% in six months, with meal intake ranging from 25–50%. The dietician recommended health shakes three times daily with meals. The resident stated they were not receiving any meal supplements despite liking them, and a CNA confirmed the resident did not receive health shakes or additional supplements when eating 50% or less of meals. The DON stated the resident should have been receiving health shakes when 50% or less of meals were consumed. A further deficiency was found for a resident dependent on staff for transfers and with severe cognitive impairment, who was observed being transferred with a mechanical lift by staff. The significant change in status assessment documented dependence for transfers, and multiple staff members, including CNAs and the resident, reported that a lift was used for transfers and had been in use since the CNA’s employment at the facility. Despite this, the resident’s care plan, revised earlier in the month, did not include the use of a mechanical lift for transfers. The MDS coordinator, responsible for completing care plans, stated that lift use should be documented on the care plan when used, and acknowledged that this resident’s care plan did not address the use of a lift for transfers.
Inadequate glove use, linen handling, and EBP adherence during incontinent care
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control program related to incontinent care and enhanced barrier precautions. For one resident with dementia and senile degeneration of the brain who was incontinent of bowel and bladder, a CNA donned gloves and began incontinent care, placing a clean brief on the bedside table, removing a soiled brief with fecal matter, and cleaning the resident. The CNA then placed a new brief and pad under the resident, removed the old pad and dropped it on the floor, and continued to adjust the resident’s brief, bed, sheet, call light, and bedside table without changing gloves. The CNA later picked up the pad and trash bag from the floor and disposed of them before removing gloves and performing hand hygiene. The facility’s policy required soiled linen to be collected at the bedside and placed in a linen bag, and the CNA acknowledged they should not have placed the pad on the floor and should have changed gloves twice during incontinent care. For another resident who was occasionally incontinent and required staff assistance with perineal care, a CNA donned gloves, prepared clean supplies, and unfastened a urine-soiled brief. The CNA tucked the soiled brief between the resident’s legs, wiped the resident, and placed dirty wipes on the foot of the bed on top of the sheet. The CNA rolled the resident, tucked the soiled brief under them, applied a clean brief, and then removed the soiled brief and placed it at the foot of the bed on top of the sheet. While still wearing the same soiled gloves, the CNA handed the resident a stuffed animal, adjusted clean sheets, moved the bedside table, used the bed remote, and handed the call light to the resident. The CNA also reached into their jacket pocket with contaminated gloves to handle clean gloves and a trash bag roll before finally doffing gloves and exiting the room. The CNA later stated they should have changed gloves after touching the dirty brief and should not have placed soiled items on the bed or touched clean items and supplies with contaminated gloves. For a third resident on enhanced barrier precautions due to a pressure ulcer and other specified local skin infections, an EBP sign and PPE were present outside the room. A CNA used hand sanitizer, donned gloves, prepared a clean brief, and changed gloves before unfastening a brief and discovering feces. The CNA wiped the resident, tucked the soiled brief under them, and applied a clean pad and brief. After removing the soiled brief and disposing of it, the CNA pulled the clean brief into place and then doffed gloves. The CNA donned another pair of gloves from their jacket pocket, positioned a pillow, covered the resident with a blanket, lowered the bed, placed a fall mat, removed and replaced the trash bag, and then doffed gloves and washed their hands. The facility’s EBP policy required gown and glove use for high-contact care activities such as changing briefs, and the resident’s care plan specified PPE use throughout their stay or until wounds healed. The CNA later stated that EBP meant washing hands or using sanitizer, wearing gloves and a gown, and acknowledged they did not think about wearing a gown during incontinent care and should have changed gloves after removing the soiled brief. The DON stated the facility’s process required changing gloves between clean and dirty surfaces and wearing gloves and a gown for incontinent care for residents on EBP.
Failure to Provide ROM Interventions and Therapeutic Devices for Contracture
Penalty
Summary
The facility failed to provide range of motion (ROM) exercises and therapeutic devices to maintain or improve mobility for a resident with a left-hand contracture and left-sided weakness. On observation, the resident’s left hand was contracted and completely closed into a fist, with no therapeutic devices in place, and the left arm could not be raised above shoulder height. The resident reported having no use of the left hand and being unable to raise the left arm above the shoulders, and stated that no therapeutic devices or therapies were being used to maintain or improve function. The facility’s Restorative Nursing Services policy stated that residents would receive restorative nursing care as needed to promote optimal safety and independence. Record review showed the resident was admitted with renal failure and heart failure and had a physician’s note documenting left-sided weakness, but the admission assessment did not identify upper extremity impairment or a left-hand contracture, despite the resident being cognitively intact with a BIMS score of 14. Multiple staff interviews confirmed that the resident was not on restorative services, had no orders for therapeutic devices for the left-hand contracture, and was not receiving ROM exercises. The DON stated that residents with limited ROM or contractures should be admitted to therapy or the restorative program and acknowledged that this resident had not received restorative assistance since admission, despite needing interventions such as a rolled-up washcloth in the hand and passive ROM exercises.
Failure to Provide Ordered Nutritional Supplements to Resident With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements and to follow the resident’s care plan interventions to prevent avoidable weight loss. A resident with protein-calorie malnutrition had a care plan dated 10/10/25 directing staff to offer a meal replacement supplement whenever 50% or less of a meal was consumed. The resident’s weight log showed a decline from 170 pounds on 12/05/25 to 158.5 pounds on 01/05/26, and further to 155 pounds on 02/04/26. A dietician’s note dated 01/20/26 documented significant weight loss of 8.8% in one month and 15.3% in six months, with meal intake ranging from 25–50% of meals. The dietician recommended health shakes three times daily with meals, but there was no documentation that these health shakes were provided on multiple consecutive days. During observation on 02/11/26 at 9:16 a.m., the resident was seen lying in bed with eyes closed and an untouched breakfast tray on their walker seat. The resident’s admission assessment dated 12/20/25 showed diagnoses including pancytopenia, renal insufficiency, and cirrhosis of the liver, and a BIMS score of 12 indicating moderate cognitive impairment. On interview, the resident stated they did not receive any meal supplements and expressed that they liked them but did not know why they were no longer provided. CNA #2 confirmed the resident did not receive health shakes or additional supplements when consuming 50% or less of meals, noting the resident never ate much and had little appetite. The DON later stated the resident should have been receiving health shakes when 50% or less of meals were consumed, confirming that the ordered nutritional interventions were not implemented.
Incomplete Weekly Skin Assessment Leads to Missed Stage 2 Pressure Areas
Penalty
Summary
The facility failed to ensure accurate completion of a weekly skin assessment for one resident, resulting in missed identification of multiple open areas on the coccyx and buttocks. The resident had diagnoses including an unspecified fracture of the sacrum and abnormalities of gait and mobility, and was cognitively intact with a BIMS score of 15. A physician order dated 01/23/26 required a weekly skin assessment every Thursday on the night shift. On 02/12/26 at 10:40 a.m., the resident was observed during incontinent care with three open areas on the coccyx and buttocks. However, a skin assessment documented later that same day at 10:58 p.m. by the charge nurse indicated there were no open areas and only noted a reddened coccyx. Subsequent documentation and interviews confirmed the discrepancy. A wound care nurse’s skin assessment on 02/13/26 identified three stage 2 open areas: one on the right buttock measuring 1.5 cm by 1.5 cm, one on the left buttock measuring 1.5 cm by 1.5 cm, and one on the upper buttocks measuring 1 cm by 0.5 cm. The resident had also stated on 02/10/26 that they had a small open area on their bottom. The DON acknowledged that the 02/12/26 weekly skin assessment showed no open areas, and LPN #1 later stated they did not perform a complete head-to-toe skin assessment and, to their knowledge, did not visualize the coccyx and buttocks during the weekly skin assessment, despite facility training that weekly skin assessments must include all areas of the skin.
Failure to Provide Required Behavioral Health Services for Depressed Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with identified depression. The resident’s admission assessment documented a diagnosis of depression, indicated that participation in activities was very important to them, and showed they were cognitively intact with a BIMS score of 14. A physician’s order dated 11/11/25 directed that the resident receive a psychiatric consultation for mental health needs if criteria were met, and another order dated 12/20/25 prescribed fluoxetine 20 mg daily for depression. Despite these orders and the resident’s diagnosis, review of physician progress notes showed no psychiatric consultations, and an activity note indicated the resident did not participate in any activities during December 2025. Surveyor observations and staff interviews further demonstrated unmet behavioral health needs. On 02/11/26, the resident was observed tearful in their room and reported feeling depressed to the point of not wanting to get out of bed and potentially missing dialysis because of their depression. A CNA stated the resident was easily upset and isolated in their room, and an LPN reported the resident was not social, stayed in their room, and had refused dialysis several times. The DON stated that residents on antidepressants who exhibited behaviors such as refusing dialysis, isolating in their room, and refusing care met the criteria for psychiatric consultation, and acknowledged that this resident should have been seen for such a consultation, which had not occurred.
Medication Error Rate Exceeds 5% Due to Incorrect Dosing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 7.41% during a medication pass observation involving four sampled residents, with two residents receiving incorrect doses. For one resident, a CMA administered one tablet of vitamin D3 25 mcg from house stock instead of the prescribed vitamin D3 50 mcg, and later acknowledged that two 25 mcg tablets should have been given to follow the physician’s order. For another resident, a CMA administered one tablet of senna despite a physician’s order for two tablets once daily for constipation, and subsequently confirmed that only one tablet had been given instead of the ordered two. The DON stated that staff were expected to follow the rights of medication administration, use the punch-initial-give method, and adhere to physician orders. The administrator reported that 63 residents resided in the facility at the time of the survey, and the identified errors during the observed medication pass contributed to the facility’s overall medication error rate exceeding the 5% threshold.
Inaccurate Weekly Skin Assessment and Documentation for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate weekly skin assessments were documented for a resident with pressure-related skin issues, resulting in a discrepancy between nursing documentation and the resident’s actual skin condition. A physician’s order directed that the resident receive a weekly skin assessment every Thursday on night shift. The resident’s admission assessment documented diagnoses including an unspecified fracture of the sacrum and abnormalities of gait and mobility, and indicated intact cognition with a BIMS score of 15. During an incontinent care observation, the resident was seen with three open areas on the coccyx and buttocks. However, a weekly Skin Assessment by the charge nurse completed the previous night documented no open areas and only redness to the coccyx, while a subsequent skin assessment by the wound care nurse the next day identified stage 2 open areas on the coccyx and both buttocks. The LPN who completed the weekly skin assessment acknowledged that, contrary to facility policy requiring complete and accurate documentation and a head-to-toe assessment, they did not perform a complete skin assessment and, to their knowledge, did not visualize the coccyx and buttocks, and the DON stated nurses were to document only observed findings on the skin assessment. The wound care nurse identified that there were 12 residents with wounds in the facility, and Resident #26 was one of three sampled residents reviewed for pressure ulcers and skin conditions in whom this documentation failure was identified.
Failure to Administer Medications as Ordered and Document on MAR
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one of three residents sampled for medication administration. Review of the resident's Medication Administration Record (MAR) for September 2025 revealed multiple missed doses of prescribed medications, including atorvastatin, doxepin, mirtazapine, Singulair, Zyprexa, carvedilol, buspirone, gabapentin, carafate, and hydrocodone-acetaminophen. There were blanks on the MAR for these medications on specific dates, and no explanations for the missed doses were documented in the medical record. Interviews with facility staff confirmed that blanks on the MAR indicated that the medications were either not in the facility or not given, and that the medications in question did not appear to have been administered as ordered. The certified medication aide and the Assistant Director of Nursing (ADON) both acknowledged that the medications had not been signed out or given according to the facility's policy and physician orders. The resident involved was noted to have intact cognition at the time of the deficiency.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse, Neglect, and Inadequate Supervision
Penalty
Summary
The facility failed to ensure residents were free from verbal abuse, implement interventions to protect residents from potential physical abuse, and prevent neglect. Multiple residents with intact cognition were involved in a series of verbal altercations, including threats of physical harm. One resident made repeated verbal threats to another, including threats to set them on fire and have them shot, while another resident responded with threats of physical violence. These altercations escalated to the point where one resident produced a knife and attempted to jab it at a nurse, demonstrating a clear risk of physical harm. Documentation revealed that, although the facility reported separating the involved residents and placing them on one-on-one (1:1) supervision, there was no consistent documentation to confirm that 1:1 supervision was provided for each shift during the investigation. Additionally, care plans for the residents involved were not updated to reflect the interventions taken in response to the incidents. Staff interviews indicated a lack of clarity regarding who was responsible for 1:1 supervision during certain shifts, and there was no evidence that all staff had received the required in-service training on abuse, neglect, and misappropriation as claimed in the facility's incident report. Another incident involved a resident who reported being treated roughly and spoken to harshly by a CNA, including being told they would only be changed every two hours and experiencing pain during care. The resident expressed feeling unsafe with the CNA, and the facility's investigation led to the CNA's termination. However, staff interviews indicated that not all staff were aware of the incident or the findings of the investigation. The facility's failure to provide adequate documentation, update care plans, and ensure staff training contributed to the deficiencies identified by surveyors.
Failure to Report Resident Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse involving three residents to local law enforcement, as required by its own abuse, neglect, and exploitation policy. The incident involved verbal threats of physical harm among residents during a smoking break, with one resident making explicit threats to set another on fire and have them shot, and another resident responding with threats of physical violence. Staff intervened by separating the residents and placing two of them on one-to-one observation for the duration of the investigation. The incident was reported to the state agency, but there was no documentation that law enforcement was notified, despite the facility's policy stating that law enforcement should be contacted when applicable. Resident assessments indicated that all three residents involved had intact cognition, with relevant diagnoses including depression, anxiety disorder, schizophrenia, heart failure, hypertension, aphasia, parkinsonism, and a history of traumatic brain injury. During the incident, one resident retrieved a small knife from their purse and attempted to jab a nurse while simultaneously handing over the knife, after being informed that possessing a knife on the property was illegal. This resident was subsequently sent out for a psychiatric evaluation due to continued aggressive and violent behavior, as documented in behavioral health hospital records. Interviews with staff and the administrator confirmed that the residents were separated and placed on one-to-one observation, and that the incident was reported internally and to the state agency. However, the administrator stated that law enforcement would only be notified if a resident agreed to it, and could not provide documentation that residents declined law enforcement involvement. Staff accounts corroborated the sequence of events, including the verbal threats and the incident involving the knife. The lack of notification to law enforcement constituted a failure to follow the facility's abuse reporting policy.
Failure to Update Care Plans After Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to update the care plans for two residents after incidents of abusive and aggressive behavior were observed. Specifically, after an altercation involving threats of physical harm between residents, including one resident making verbal threats and another responding with threats of their own, both individuals were placed on 1:1 supervision for the duration of the investigation. Despite documentation in the facility's incident report that care plans would be updated as appropriate, there were no updates made to the care plans of either resident to address the incidents or the observed behaviors. One resident, with a history of depression, anxiety disorder, and schizophrenia, was involved in an incident where they made verbal threats to another resident and later produced a small knife, refusing to surrender it to the DON and attempting to jab the nurse with it. This resident continued to display verbal outbursts and was eventually admitted to a behavioral health hospital due to being a danger to others and exhibiting increased aggression and violent behavior. The care plan for this resident did not reflect the incident involving the knife or the threats made to others. Another resident, with diagnoses including hypertension, aphasia following cerebral infarction, parkinsonism, and a history of traumatic brain injury, was reported to have verbally threatened another resident with bodily harm. The resident was separated from others and later evaluated by a mental health provider, who documented the resident's account of the incident and their understanding of the consequences of their behavior. However, the care plan for this resident was not updated to address the threats made. Interviews with facility staff revealed a lack of clarity and consistency regarding the process for updating care plans following such incidents.
Failure to Determine Residents' Advance Directive Preferences
Penalty
Summary
The facility failed to determine if residents wished to formulate an advance directive for three of the thirteen sampled residents whose advance directive acknowledgements were reviewed. The facility's undated Advanced Directives policy requires that upon admission, it should be identified if a resident has an advance directive and if not, determine if the resident wishes to formulate one. However, for Resident #27, the advance directive was not signed, nor did it indicate whether they had or wanted an advance directive. For Residents #46 and #49, their advance directives were signed but did not indicate whether they had or wanted an advance directive. The business office manager stated that during admission, they discuss the advance directive with residents and representatives and upload the directive and acknowledgment into the computer. If the resident is unsure or wants to discuss it with family, the form is left blank, which the manager stated would correctly document that they have no advance directives currently.
Unsafe Flooring in Common Area
Penalty
Summary
The facility failed to provide a safe flooring environment in the common area where all halls connect, posing a potential tripping or injury hazard. Observations revealed that two floor slats were completely pulled away from the floor near the nurses' station, and maintenance was seen gluing them down and holding them with boxes while the glue dried. Multiple other floor slats had been previously glued back down, with corners sticking up, creating a hazard for mobile residents, staff, and visitors. Resident council members expressed concerns about the floor causing trouble even for those in wheelchairs. The administrator acknowledged that the floor had been spot-fixed multiple times and provided documentation of bids obtained to replace the flooring, recognizing it as a potential injury hazard.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were secured when not in use, as observed on two separate occasions. On February 10, 2025, at 4:44 p.m., the medication cart for halls 100 and 200 was found unlocked and unattended by the nursing station, with keys still in the lock. On February 13, 2025, at 7:55 a.m. and again at 9:37 a.m., the medication cart on hall 600 was observed to be unlocked with no staff present. The facility's Medication Storage policy, dated January 8, 2024, mandates that all drugs and biologicals be stored in locked compartments under proper temperature controls. Interviews with staff, including an LPN and a certified medication aide, confirmed that leaving the carts unlocked was against policy, and they acknowledged their failure to comply with the policy. The administrator also confirmed that the policy required medication carts to be locked unless within sight of the nurse or medication aide.
Infection Control Breach During PEG Tube Medication Administration
Penalty
Summary
The facility failed to maintain infection control and follow evidence-based practices (EBP) during medication administration to a resident with a percutaneous endoscopic gastrostomy (PEG) tube. During an observation, an LPN was seen administering crushed medications through the PEG tube without wearing a gown, which is required under the facility's Enhanced Barrier Precautions policy. Although the LPN washed their hands and wore gloves, they did not adhere to the full EBP protocol, which mandates the use of a gown and gloves during high-contact care activities involving indwelling medical devices. The facility's Enhanced Barrier Precautions policy, which aims to reduce the transmission of multidrug-resistant organisms (MDROs), specifies that gowns and gloves should be worn during care activities involving indwelling devices, such as feeding tubes, even if the resident is not known to be infected or colonized with an MDRO. The LPN acknowledged the requirement to wear a gown but did not do so, and the Director of Nursing confirmed that the policy requires staff to wear gowns and gloves for residents with indwelling devices. Supplies for these precautions were available outside the resident's room, but the protocol was not followed during the observed medication administration.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling medical devices, as observed in two cases. Resident #39, who had a foley catheter and pressure wounds, was not provided with appropriate EBP. During observations, staff members were seen using only regular gloves without gowns when performing care activities such as transferring, bathing, and wound care. The staff, including a CNA and an LPN, demonstrated a lack of understanding of EBP, with one staff member mistakenly believing it referred to a cream application. Additionally, there were no EBP signs posted on the resident's door, indicating a lack of communication and adherence to the facility's EBP policy. Similarly, Resident #40, who had a gastric tube, was also not provided with the necessary EBP. An LPN administering enteral feeding and flushing urinary catheters used only hand sanitizer and gloves, without additional PPE. The LPN admitted to being unsure about what EBP entailed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the absence of EBP signage and were unable to identify which residents required EBP, highlighting a systemic issue in the facility's infection prevention and control program.
Failure to Deliver Mail on Weekends
Penalty
Summary
The facility failed to provide mail delivery to residents on Saturdays, as required by their Resident Rights policy. The policy stated that mail would be delivered by facility staff, and on weekends, it would be delivered by the RN supervisor. However, interviews with eight members of the resident council revealed that mail was not distributed on weekends. Additionally, the activities director confirmed that while mail was delivered on Saturdays, it was not passed out until Monday. This discrepancy in mail distribution was acknowledged by the Director of Nursing (DON), who identified that 47 residents resided in the facility.
Failure to Notify Physician of Urinalysis Results
Penalty
Summary
The facility failed to notify the physician upon receiving culture and sensitivity results from a urinalysis for a resident reviewed for unnecessary medication. The facility's Notification of Changes policy, dated February 2023, mandates prompt consultation with the resident's physician under circumstances requiring treatment alteration. The resident had diagnoses including acute cerebrovascular insufficiency, communication deficit, and urinary tract infection. The antibiotic stewardship book and documentation lacked the culture and sensitivity results with the urinalysis. Progress notes did not document physician notification of the culture results. A physician's order dated August 14, 2024, prescribed Cephalexin 500 mg twice daily for seven days. An infection note dated August 20, 2024, indicated the resident continued on Cephalexin for a UTI. The lab results were first released on August 14, 2024, and finalized on August 18, 2024. On August 23, 2024, the ADON confirmed the absence of a progress note indicating physician notification.
Failure to Complete Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were completed in a timely manner for two residents out of a sample of 13. According to the facility's policy, a baseline care plan should be developed within 48 hours of a resident's admission. Resident #27, who was readmitted with diagnoses including metabolic encephalopathy, chronic kidney disease, end-stage renal disease (ESRD), and cognitive impairment, did not have a baseline care plan located. The Assistant Director of Nursing (ADON) confirmed that a baseline care plan had not been completed for this resident, and the current care plan was only initiated on 07/09/24. Similarly, Resident #147, who was admitted on an unspecified date, had a baseline care plan documented with a completion date of 08/20/24, which was not within the required 48-hour timeframe. A nurse consultant acknowledged that the baseline care plan for Resident #147 was not initiated in a timely manner.
Inadequate Activity Program for Residents
Penalty
Summary
The facility failed to ensure that an ongoing activity program was designed to meet the individual or group needs of residents, which increased the potential for social isolation and adverse effects on residents' well-being. On a specific date, the Activities Director was observed walking around the nurses' station and stated that no residents wanted to participate in the scheduled word search activity. The Activities Director mentioned that residents expressed dislike for what they referred to as 'kid games' and that they were following the activity schedule set by the previous Activities Director. The current Activities Director also noted that they had been using personal funds to purchase crafts that residents enjoy, due to a lack of facility funding. The report highlights specific residents whose activity preferences were not being met. One resident, with a BIMS score indicating good cognitive functioning, expressed preferences for being around animals, listening to music, participating in group activities, and attending religious services. Another resident, also with good cognitive functioning, preferred being around animals and keeping up with the news. The Director of Nursing (DON) acknowledged the lack of adequate funding for sufficient activity options and mentioned plans to identify resident preferences and schedule religious services, with a staff member willing to assist if external services could not be arranged.
Medication Security Lapse
Penalty
Summary
The facility failed to ensure the security of medications during an observation of medication administration. On August 22, 2024, at 9:20 a.m., an LPN was observed leaving a medication/treatment cart unlocked while entering a resident's room to administer medication. This incident occurred on Hall 500, one of the two medication/treatment carts observed. The LPN later explained on September 22, 2024, at 9:24 a.m., that the cart was left unlocked because they were flustered, acknowledging that the facility's policy requires carts to be locked. The facility houses 47 residents, and this lapse in protocol was identified during the survey.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to ensure that evening snacks were offered to four of the eleven sampled residents who required them. The facility's policy stated that residents should be offered a nourishing snack at bedtime according to their needs, preferences, and requests. However, residents residing in hall 100, who required extensive help to leave their rooms, were not offered snacks. The Director of Nursing (DON) identified 46 residents who received meals from the kitchen, and the Dietary Manager (DM) stated that snacks were prepared before the kitchen closed and left at the nurses' station for distribution. Despite this, residents complained about not receiving snacks, and there was no documentation to indicate that snacks were offered on multiple dates. Interviews with residents revealed that they consistently were not offered evening snacks, with some residents stating they never received them. The DON acknowledged that this was a known issue in the past and claimed to have addressed it, but the problem persisted. The lack of documentation and the residents' statements indicate a failure in the facility's process to ensure snacks were delivered as per the policy, particularly affecting those who needed assistance to access them.
Failure to Protect Resident from Abuse by Administrator
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving the administrator and a resident. The resident, who had diagnoses including hemiplegia, schizoaffective disorder, and epilepsy, was involved in an altercation with the administrator. The incident occurred when the resident was in the human resources office expressing concerns about their camera being removed. The administrator responded aggressively by slamming their hands on the desk and challenging the resident to repeat their words. This incident was documented in an Initial and Final State Reportable Incident form, indicating a failure to ensure the resident was free from abuse. The resident's care plan had not been initiated until several days after the incident, and their admission assessment was incomplete. The Director of Nursing (DON) explained that the camera was removed because the administrator believed the resident was not allowed to have audio, despite the family having signed consent for both audio and video. The administrator was suspended pending investigation, and the Assistant Director of Nursing (ADON) took statements from staff and witnesses. Staff members were in-serviced on abuse policies and procedures, but there was confusion among staff about reporting abuse, as they were unsure of the current administrator's role.
Incomplete Admission Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days of admission for a resident. The resident was admitted on an unspecified date, and the 5-day/admission assessment had a reference day set for August 9, 2024. However, by August 21, 2024, it was noted that the admission assessment should have been completed by August 18, 2024. As of August 23, 2024, the admission assessment remained incomplete.
Failure to Implement Comprehensive Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with end-stage renal disease (ESRD) and chronic kidney disease. The facility's policy mandates the development of a person-centered care plan with measurable objectives and timeframes based on the resident's comprehensive assessment. However, upon review, it was found that there was no dialysis or nutrition care plan for the resident. The Assistant Director of Nursing (ADON) confirmed the absence of these care plans and acknowledged that the existing fluid volume overload care plan did not meet the requirements for assessing and monitoring nutrition for a dialysis resident.
Failure to Complete Dialysis Orders and Monitoring
Penalty
Summary
The facility failed to ensure that orders for dialysis were completed for a resident who required such services. The facility's Hemodialysis Policy, dated February 2023, outlined the necessary care and treatment for residents receiving hemodialysis, including specific documentation and monitoring requirements. However, for the resident in question, there were no orders for monitoring or assessing the dialysis shunt, nor were there details about the dialysis schedule or location. This lack of documentation was confirmed during an interview with the Assistant Director of Nursing (ADON), who noted the absence of necessary orders in the resident's electronic medical record. Observations and interviews with staff revealed further deficiencies in the care provided to the resident. A Certified Nursing Assistant (CNA) mentioned the resident's dialysis schedule but did not provide details about the care required for the dialysis shunt. An LPN admitted to not having assessed the resident's shunt on the day of observation and was unable to explain why the resident still had an undated bandage from dialysis. These findings indicate a failure to adhere to the facility's policy and ensure proper care and monitoring for the resident receiving dialysis.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted and updated. On August 21, 2024, at 11:17 a.m., the staffing sheet was observed to be completed for August 19, 2024, but only partially completed for August 20, 2024, missing the actual hours worked for RNs, LPNs, CNAs, and CMAs. Additionally, there was no staffing information available for August 21, 2024. By August 22, 2024, at 9:35 a.m., the staffing sheet had not been updated to include information for August 21 or August 22. It was only at 10:50 a.m. on August 22, 2024, that the staffing sheet was fully updated. The Director of Nursing (DON) explained that they had been waiting to total the actual hours worked for the staff before updating the sheet.
Failure to Follow Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program policy for a resident diagnosed with a urinary tract infection (UTI), communication deficit, and cerebrovascular insufficiency. The policy required that antibiotics be prescribed and administered under the guidance of the program, with culture and sensitivity (C&S) results communicated to the prescriber to determine the appropriateness of antibiotic therapy. However, the facility did not follow this protocol. The resident was prescribed Cephalexin 500 mg twice daily for seven days without the C&S results being reviewed or communicated to the physician. The culture was obtained on August 14, 2024, and received on August 18, 2024, but the results were not included in the antibiotic stewardship documentation. The Director of Nursing (DON) admitted that the facility often prescribed antibiotics before receiving C&S results and acknowledged that the prescribed Cephalexin was not listed on the culture and sensitivity report. The resident received the antibiotic from August 15, 2024, through August 21, 2024, and was later sent to the hospital due to behaviors. The Assistant Director of Nursing (ADON) confirmed that there was no progress note indicating physician notification, and the antibiotic stewardship policy was not followed. This oversight highlights a failure in the facility's process for ensuring appropriate antibiotic use, as required by their policy.
Inadequate Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that the emergency call cords were long enough to be reached by a resident when lying in bed. During observations, it was noted that the call light was on the floor and out of reach of a resident who was sitting in a wheelchair next to the bed. The resident was unable to reach the call light to request assistance to be put back to bed. A CNA confirmed that the call light cord was too short to reach the bed and mentioned that the policy is to have the call light within reach. The CNA also stated that the resident's roommate would use their call light if assistance was needed.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide showers for two residents who required assistance with activities of daily living (ADL). Resident #15, diagnosed with multiple sclerosis and morbid obesity, reported that their last bath was on 04/08/24, and records showed no documentation of a shower for 22 days between February 24, 2024, and March 18, 2024. The Director of Nursing (DON) confirmed the lack of documentation for this period. Resident #4, diagnosed with lack of coordination, muscle wasting, and atrophy, also did not receive scheduled baths. Their quarterly assessment indicated they required moderate assistance for bathing. Records showed that Resident #4 missed eight out of 13 scheduled baths in February 2024, nine out of 14 in March 2024, and three out of eight in April 2024. Both the resident and CNA #2 confirmed the missed baths, and the DON acknowledged the absence of documentation for these dates.
Failure to Complete Ongoing Dialysis Assessments
Penalty
Summary
The facility failed to complete ongoing assessments of a resident pre and post dialysis for one of the sampled residents reviewed for dialysis services. The Hemodialysis policy, revised on 10/01/23, required ongoing assessment and oversight of the resident before, during, and after dialysis treatment. However, the dialysis communication records for February, March, and April 2024 showed no documentation of pre, during, and post dialysis assessments for multiple dates. An LPN confirmed that these assessments were not completed for the specified dates after reviewing the resident's dialysis communication records and progress notes.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for one of five sampled residents reviewed for unnecessary medications and did not conduct ongoing monitoring of the program. The facility's policy, revised on 10/01/23, required an antibiotic stewardship program as part of the infection prevention and control program. However, there was no documentation of antibiotic use monitoring for several months in 2023 and 2024. Specifically, a resident had physician's orders for azithromycin and doxycycline hyclate, but there was no documentation of monitoring for these antibiotics in September 2023 and March 2024. The Director of Nursing (DON) and the Infection Preventionist confirmed the lack of monitoring during a review on 04/17/24.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who received Part A skilled services. The resident was admitted to Part A skilled services on November 22, 2023, and discharged from these services on November 30, 2023, but remained in the facility. There was no documentation indicating that the SNF ABN was provided to the resident. On April 16, 2024, the MDS coordinator confirmed that they could not locate the SNF ABN for the resident.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a resident's wall was in good repair, compromising the homelike environment for one of the 16 sampled residents. The resident had diagnoses including cerebral infarction and abnormalities of gait and mobility and was nonverbal. On observation, the resident's wall had three deep scrapes by the head of the bed. A CNA acknowledged awareness of the scrapes since February and reported them to another staff member, but it was unclear if the issue was communicated to maintenance. The Maintenance Supervisor confirmed they were unaware of the need for repair in the resident's room.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for a resident with a diagnosis of hypertension. The resident had physician's orders for hydralazine and carvedilol, both with specific parameters to hold the medication if the systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate was less than 60. The April 2024 Medication Administration Record (MAR) documented that hydralazine was administered on two occasions when the resident's blood pressure was below the specified parameters. Similarly, carvedilol was also administered on the same two occasions despite the resident's blood pressure being below the ordered parameters. Both an LPN and the Assistant Director of Nursing (ADON) confirmed that the medications should not have been administered on those dates according to the physician's orders.
Failure to Review PRN Lorazepam Order After 14 Days
Penalty
Summary
The facility failed to review a PRN lorazepam order after 14 days of use for one resident. According to the facility's policy on the use of psychotropic medication, PRN orders for such drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration of 14 days. If the attending physician or prescribing practitioner believes that the PRN order should be extended beyond 14 days, they must document their rationale in the resident's medical record and indicate the duration for the PRN order. A physician order dated 02/23/24 prescribed lorazepam 0.5 mg to be given every 8 hours as needed for anxiety, insomnia, and restlessness, with an indefinite end date. The medication was administered once in February, twelve times in March, and eleven times in April. On 04/19/24, the Director of Nursing (DON) confirmed that PRN anti-psychotic orders should be re-evaluated every two weeks.
Improper Transport of Dirty Linen
Penalty
Summary
The facility failed to ensure dirty linen was transported in a manner to prevent cross-contamination. The Handling Soiled Linen policy, revised in October 2023, specified that linen should not touch the uniform or floor and should be collected and placed in a linen bag or designated receptacle. On April 17, 2024, at 6:38 a.m., a CNA was observed walking by the nurse's station with pads and a trash bag in his gloved hands. The CNA briefly set the pads on the floor by three blue bins before picking them up again and placing them in the soiled room. The CNA admitted to setting the dirty pads on the floor and acknowledged that the pads were supposed to be bagged during transport but stated there were not enough bags available.
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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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