Pocola Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Pocola, Oklahoma.
- Location
- 200 Home Street, Pocola, Oklahoma 74902
- CMS Provider Number
- 375188
- Inspections on file
- 22
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Pocola Health And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral disturbances repeatedly engaged in inappropriate sexual behaviors with other cognitively impaired residents. Despite staff interventions and the facility's policy requiring prevention and investigation of abuse, supervision was inconsistently applied, and documentation of one-on-one monitoring was missing for extended periods. Staff interviews confirmed lapses in monitoring, resulting in the facility's failure to protect residents from sexual abuse.
Surveyors found that the facility did not provide copies of its bed-hold policy to two residents when they were transferred to the hospital, including one with severe cognitive impairment and another with moderate cognitive impairment who was hospitalized for acute cystitis. Documentation showed the residents were sent to the ER and one was later readmitted, but there was no record of bed-hold policy notification at the time of transfer. An LPN stated they did not give residents the bed-hold policy when sending them to the hospital, and the DON confirmed that the policy was only reviewed at admission and not reissued during subsequent hospital transfers.
A resident with anxiety disorder and depression had a PRN order for Ativan 0.5 mg every 12 hours for anxiety that lacked an end date and was not limited to 14 days as required by facility policy. A pharmacy consultant identified the PRN psychoactive medication as potentially constituting a chemical restraint and requested physician documentation of rationale and a specific duration for any extension, but the physician chose to keep the PRN order without providing the required handwritten rationale or duration. A quarterly assessment showed the resident had intact cognition and was receiving an antianxiety medication, while an LPN and the DON both acknowledged that PRN psychotropic medications should be time-limited to two weeks unless a physician documents justification and duration, demonstrating noncompliance with the facility’s own standards.
A resident receiving continuous enteral nutrition via pump had a tube feeding bag running at 50 ml/hr on multiple observations without any label. A CMA and an LPN both reported they could not determine which resident the unlabeled bag was intended for or when it had been hung, and acknowledged that the bag should have been labeled. The DON also confirmed they could not identify the intended resident or the time and date the feeding was started because the bag lacked a label, despite stating that such bags should be labeled.
A resident with severe cognitive impairment and a history of vascular dementia was administered another resident's medications by a CMA, resulting in hospitalization for adverse reactions including hypotension and hyponatremia. Review of staff files and interviews revealed that CMAs had not received regular competency evaluations, and medication administration was not routinely observed by the DON. A similar medication error involving the same resident had previously occurred without effective follow-up.
A resident with severe cognitive impairment and multiple medical conditions was administered another resident's medications by a CMA who had not received regular competency evaluations. The error resulted in the resident being hospitalized for adverse reactions, including hypotension and hyponatremia. Review of staff files showed inconsistent or missing skills assessments for several CMAs, and the DON confirmed that annual competencies had not been completed consistently.
The facility failed to follow its abuse policy by not immediately reporting abuse allegations for two residents. One resident, with multiple diagnoses including schizophrenia, reported verbal abuse by an aide, while another resident with dementia and Alzheimer's Disease reported being physically mishandled. In both cases, the incidents were not reported to the OSDH within the required two-hour timeframe, and the DON was not promptly informed.
The facility failed to report allegations of abuse involving two residents to the OSDH within the required two-hour timeframe. One resident reported verbal abuse, while another reported physical mishandling. Both incidents were documented, but the state incident reports were faxed several hours later, exceeding the mandated reporting period. The DON confirmed the delay in reporting.
The facility failed to conduct thorough abuse investigations for two residents. One resident reported verbal abuse by an aide, while another reported being physically mishandled. Both investigations lacked critical documentation, including resident statements and details of interviews. The DON acknowledged the absence of documented interviews, as the investigations were conducted together due to the incidents involving the same staff member.
A CNA recorded and posted a video on social media mocking and verbally abusing a resident with Alzheimer's and other disorders. The resident appeared to be crying while the CNA laughed. The DON terminated the CNA and reported the incident to the state.
The facility failed to post the required staffing information in an easily accessible manner for residents and visitors. The information was placed on a bulletin board six feet from the floor, making it difficult to read, and did not include the census or staffing hours for each employee. The DON was unaware of the regulations regarding the accessibility of posted staffing information.
The facility failed to store food in accordance with professional standards, affecting all 53 residents who received meals from the kitchen. Observations included an unlocked ice machine, an uncovered trash can, improperly stored and dated food items, and unsanitary conditions in the ice machine. The Dietary Manager acknowledged these issues and admitted to lapses in hand hygiene and food safety practices.
The facility failed to follow infection control guidelines, with staff not performing hand hygiene during meal assistance and wound care, and the IP testing a resident for COVID-19 without proper PPE in a communal area.
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 13 employees. Payroll records confirmed these employees were permitted to work without the required checks, and the BOM and administrator were unaware of this oversight until the survey.
The facility failed to ensure residents were fully assessed for the use of side rails for four of the 35 sampled residents. Observations revealed that residents with various diagnoses were using bed rails without proper assessments documented in their EHRs. The DON acknowledged the lack of documentation and stated that bed rail assessments would start being documented routinely.
The facility failed to ensure DNR forms were complete and legal for two residents. One resident's DNR form lacked the required two witnesses, and another resident's DNR form was not dated. The DON confirmed these deficiencies during interviews.
The facility failed to ensure accurate MDS assessments for four residents, leading to incorrect documentation of medical conditions and care needs. Issues included misreporting anticoagulant use, hearing ability, fall incidents, and urinary incontinence.
The facility failed to notify OHCA of a resident with serious mental illness who stayed long-term. The resident had diagnoses including generalized anxiety disorder, major depressive disorder, and schizophrenia. A PASRR I screening indicated no need for PASRR II for a short stay, but the resident's care plan and annual assessment were inconsistent. The DON acknowledged the oversight.
The facility failed to develop a comprehensive care plan for a resident experiencing weight loss, despite physician's orders for nutritional supplements and health shakes. The MDS coordinator confirmed the absence of a care plan addressing the resident's weight loss.
The facility failed to ensure residents were not catheterized unless required by a clinical condition and did not assess the continued need for an indwelling urinary catheter for two residents. One resident had a catheter placed for isolation purposes due to ESBL, which is not a proper diagnosis for catheter use. Another resident had a catheter placed due to ESBL and E. coli in their urine, with no physician's orders for catheter care or changing the catheter. The infection preventionist confirmed there was no policy for catheterizing residents with UTIs.
The facility failed to ensure the physician documented a rationale on a consultant pharmacist recommendation for a resident with multiple diagnoses, including CHF and Alzheimer's. The MRR policy also lacked timeframes for the process steps, as confirmed by the DON.
The facility failed to ensure that a resident did not receive psychotropic medication unless for a specific diagnosed condition. The resident was prescribed Seroquel for Alzheimer's Disease, but a medication review later marked the diagnosis as mood disorder. The DON acknowledged the need for prompt diagnosis changes.
The facility failed to provide consistent dietitian services for a resident with multiple health issues, despite recommendations for nutritional supplements and health shakes. The last dietitian visit was in August 2023, and the care plan lacked documentation of these recommendations.
The facility failed to develop and implement a QAPI plan to identify and address problems. The QAPI meetings were sporadic, with the last meeting in September 2023. The DON confirmed that there was no formal policy and procedure for QAPI, and meetings were not held regularly. The DON mentioned that a QAPI meeting would likely be held after the current month due to a COVID outbreak in February.
The facility failed to ensure that the QAA committee met at least quarterly, with the last documented meeting in September 2023. The DON confirmed that meetings were not held regularly and were only convened to address specific issues. A QAA meeting was anticipated due to a recent COVID outbreak.
Failure to Prevent and Monitor Sexual Abuse Among Residents
Penalty
Summary
The facility failed to adequately monitor and prevent sexual abuse involving a resident with severe cognitive impairment and behavioral disturbances. The resident, diagnosed with unspecified dementia and severe cognitive impairment, was repeatedly found in situations with another resident where inappropriate sexual behaviors were observed or alleged. Documentation shows that the resident was found in another resident's room, with both individuals on the bed and one resident's pants unzipped. There were also multiple reports of the resident making sexually suggestive gestures and engaging in inappropriate physical contact, such as holding hands and touching another resident's upper body. Staff and nursing notes indicate that these incidents were recurrent, with the resident being redirected or separated from others on several occasions. Despite these interventions, the inappropriate behaviors continued, and there were lapses in the implementation and documentation of one-on-one supervision. The facility's policy required thorough investigation and prevention of abuse, but the records show inconsistent monitoring and supervision, with periods where one-on-one documentation was missing for several days, even after the DON had indicated that such supervision was necessary until the behavior was resolved. Interviews with staff confirmed that the resident's behaviors were known and that supervision was inconsistently applied, with activity staff and nurses rotating responsibility for monitoring. The DON determined when to start and stop one-on-one supervision, but there was no clear or consistent protocol followed, and the resident continued to interact primarily with cognitively impaired residents. The failure to maintain consistent supervision and prevent further incidents resulted in the facility not protecting residents from sexual abuse as required by policy.
Failure to Provide Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide copies of its bed-hold policy to residents at the time of transfer to the hospital, as required. For one resident with renal failure, hypertension, and severe cognitive impairment (BIMS score of 2), a significant change assessment was completed in mid-April. A health status note documented that this resident was sent to the emergency room for evaluation, with the power of attorney notified and an ambulance called. However, there was no documentation that a copy of the facility’s bed-hold policy was provided at the time of this hospital transfer. In an interview, an LPN stated they did not give a copy of the bed-hold policy to residents when they were sent to the hospital. The DON stated that residents were given a copy of the bed-hold policy upon admission but not at the time of transfer to the hospital. For a second resident, a nurse’s progress note showed the resident was sent to the emergency room and admitted to the hospital for acute cystitis, with no documentation that the resident received a copy of the facility bed-hold policy at the time of transfer. The resident was later readmitted to the facility, and a subsequent quarterly assessment showed moderate cognitive impairment (BIMS score of 10). In interviews, the LPN again stated they did not provide residents with copies of the bed-hold policy when residents were sent to the hospital. The DON confirmed that the facility normally did not hand out the bed-hold policy after the initial admission and indicated that this resident had likely been informed about the bed-hold policy many years earlier, with the bed held since that time.
Failure to Limit and Re-Evaluate PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders were limited to 14 days and then re-evaluated, as required by its own pharmacy policy. The undated Pharmacy Service Policy stated that PRN orders for psychotropic drugs must be limited to 14 days unless the attending physician or prescribing practitioner documented a rationale in the medical record and indicated a specific duration for extending the order. For one resident, a physician’s order dated 02/22/25 directed administration of 0.5 mg Ativan by mouth every 12 hours as needed for anxiety, but the order did not include an end date. A Pharmaceutical Consultant Report dated 03/28/25 identified this resident as receiving an as-needed psychoactive medication that could be considered a chemical restraint and reiterated that any extension beyond 14 days required documented rationale and a specific duration. In response to the consultant’s review, the physician indicated that the report was reviewed and that no changes were desired, preferring the order to remain PRN unless directed otherwise in the future, but did not provide any handwritten rationale or specify a duration for the extended PRN order. A quarterly assessment dated 06/05/25 documented that the resident had anxiety disorder and depression, a BIMS score of 15 indicating intact cognition, and was receiving an antianxiety medication. During interviews, an LPN and the DON both stated that PRN antianxiety and psychotropic medications should only be ordered for two weeks unless a physician provided a rationale and duration, confirming that the standing PRN Ativan order without an end date or documented rationale was inconsistent with facility policy and regulatory expectations.
Unlabeled Enteral Tube Feeding Bag for Resident on Continuous Feeding
Penalty
Summary
The deficiency involves the facility’s failure to properly label an enteral tube feeding bag for a resident receiving continuous tube feeding. The DON identified one resident who received enteral nutrition via continuous pump. On two separate observations, the resident’s tube feeding was running at 50 ml/hr with no label on the feeding bag. During interviews, a certified medication aide stated they could not determine by looking at the bag which resident it was intended for or what time it was hung and acknowledged it should have had a label. An LPN also stated they could not identify which resident the tube feeding was for because the bag was not labeled and did not know why it was unlabeled. The DON confirmed they could not tell the time or date the bag was hung or which resident it was intended for due to the lack of a label and stated the bag should have been labeled, but did not know why it was not.
Failure to Ensure CMA Competency Leads to Medication Error and Hospitalization
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) were properly trained and competent to administer medications as ordered, resulting in a significant medication error. On one occasion, a CMA reported to a registered nurse that they may have given the wrong medications to a resident. Review of camera footage confirmed that the resident was administered another resident's medications. The resident, who had diagnoses including aphasia, vascular dementia, and cerebrovascular disease, was sent to the emergency room after the error was discovered. The resident was later admitted to the intensive care unit for adverse reactions, including hypotension and hyponatremia, after receiving multiple medications not prescribed to them. The resident involved had a care plan indicating a risk for hypotension and a recent assessment showing severe cognitive impairment. The medications administered in error included a diuretic, blood pressure medication, antidepressant, antianxiety medication, pain medication, and antiparkinsonian medication. The incident note documented a critically low blood pressure at the time paramedics arrived, and hospital records confirmed the resident required interventions to stabilize their blood pressure due to the medication error. Review of employee files revealed that several CMAs had not received regular skills evaluations or competency check-offs since their initial hire, with some files lacking any evidence of annual competency assessments. Interviews with the DON and CMAs confirmed that annual competencies had not been consistently completed for at least two years, and the DON acknowledged that medication administration was not routinely observed. Additionally, a similar medication error involving the same resident and another CMA had occurred previously, resulting in hospitalization, but no substantial interventions were implemented at that time.
Failure to Ensure CMA Competency Leads to Significant Medication Error
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) were adequately trained and competent to administer medications as ordered, resulting in a significant medication error. On one occasion, a CMA reported to an RN that they may have given the wrong medications to a resident. Review of camera footage confirmed that the resident was administered another resident's medications. The resident, who had diagnoses including aphasia, vascular dementia, and cerebrovascular disease, was at risk for hypotension and had a severely impaired cognitive function as indicated by a BIMS score of 3. Following the medication error, the resident was sent to the emergency room after being found with a blood pressure of 146/21. The resident was admitted to the intensive care unit for adverse reaction to medication, hypotension, and hyponatremia. Documentation showed the resident had been given multiple medications not prescribed to them, including a diuretic, blood pressure medication, antidepressant, antianxiety medication, pain medication, and antiparkinsonian medication. The resident required interventions to stabilize their blood pressure while the effects of the incorrect medications wore off. Review of employee files revealed that several CMAs had not received regular skills evaluations or competency check-offs since their hire or for extended periods, with some having no record of annual skills assessments. The DON acknowledged that annual CMA competencies had not been completed consistently for the last two years and that medication administration was not routinely observed. It was also noted that a similar medication error involving the same resident had occurred previously, resulting in hospitalization, but only limited education was provided to the involved CMA and no further interventions were implemented.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy by not immediately reporting allegations of abuse for two residents. The policy requires that all alleged violations and abuse be reported to the charge nurse, who must then notify the Administrator and Director of Nursing (DON) immediately, and report to the appropriate agencies within a two-hour timeline. In the case of the first resident, who had diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia, an incident was reported where the resident was verbally abused by an aide. Although the incident was reported to the Assistant Director of Nursing (ADON) and the DON was investigating, the state incident report was not faxed to the Oklahoma State Department of Health (OSDH) until several hours later. For the second resident, who had diagnoses including a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease, an incident occurred where the resident reported being physically mishandled by a staff member. The DON was not made aware of this incident until later in the afternoon, and the state incident report was also delayed in being faxed to the OSDH. The DON confirmed that the staff did not notify them or the administrator of the allegations of abuse in a timely manner, and neither incident was reported to the OSDH within the required two-hour timeframe as per the facility's policy.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe. The facility's abuse policy mandates that all alleged violations and/or abuse reported to the charge nurse must be assessed and reported to the appropriate agencies within two hours. In the first incident, a resident with diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia reported verbal abuse by an aide. The incident was documented at 3:15 p.m., but the state incident report was not faxed to OSDH until 7:36 p.m., exceeding the two-hour requirement. In the second incident, a resident with a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease reported being physically mishandled by a staff member, causing back pain. This incident was documented at 9:30 a.m., but the state incident report was not faxed until 7:38 p.m. The Director of Nursing (DON) acknowledged during an interview that neither incident was reported within the required timeframe, indicating a failure to adhere to the facility's abuse reporting policy.
Incomplete Abuse Investigations for Two Residents
Penalty
Summary
The facility failed to conduct a thorough abuse investigation for two residents who were reviewed for abuse. The first resident, who had diagnoses including diabetes mellitus, morbid obesity, major depressive disorder, anxiety disorder, and schizophrenia, reported that an aide verbally abused them using offensive language. The incident was reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who initiated an investigation. However, the investigation lacked critical documentation, including a statement from the resident, statements from all involved staff, and details about the residents interviewed. Additionally, there was no documentation of the date, time, or number of residents interviewed. The second resident, with diagnoses including a fracture of the right tibia, anxiety disorder, dementia, and Alzheimer's Disease, reported being physically mishandled by a staff member, which caused them pain. The incident was reported, and the DON was aware and investigating. Similar to the first case, the investigation was incomplete, lacking documentation of resident interviews and statements from all involved staff. The DON stated that the investigations for both residents were conducted together due to the incidents involving the same staff member and occurring simultaneously, but acknowledged the absence of documented interviews.
Resident Abuse Incident Involving Social Media
Penalty
Summary
The facility failed to ensure a resident was free from abuse. A CNA recorded a video of a resident with Alzheimer's disorder, dementia, depression disorder, and anxiety disorder, mocking and verbally abusing the resident while they were sitting in their wheelchair. The resident appeared to be crying, and the CNA was laughing at them. This video was then posted on social media, which was discovered by the Director of Nursing (DON) shortly after it was posted. The DON immediately called everyone involved into their office and terminated the CNA responsible for the video. Another CNA who was aware of the recording but did not report it was given a written warning. The incident was reported to the state, and the video was retained for investigation purposes. The facility conducted an in-service training on abuse and reporting abuse for all employees following the incident.
Failure to Post Accessible Staffing Information
Penalty
Summary
The facility failed to post the required staffing information in a manner easily accessible to residents and visitors. On 03/06/24 at 10:00 a.m., the surveyor was unable to locate the posted staffing information. An RN indicated that the information was on a bulletin board on the 200 Hall outside the dining room entrance. The posted staffing information was observed on an 8.5 x 11 piece of copy paper pinned to a bulletin board approximately six feet from the floor, making it difficult to read unless directly in front of the board and looking up ten inches. Additionally, the posted staffing information did not document the census or staffing hours for each employee. The information remained in the same location and without the required details for the remainder of the survey. On 03/08/24 at 10:00 a.m., the DON questioned why residents couldn't tilt their heads up to read the information and was informed of the regulations regarding posted staffing requirements and accessibility for residents and visitors.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, affecting all 53 residents who received meals from the kitchen. During an observation, the ice machine in the dining room was found unlocked, and a large trash can by the hand washing sink was missing its lid, which was found on the floor behind the trash can. Additionally, the freezer contained bags of French fries and onion rings that were open to the air and not dated when they had been opened. The Dietary Manager (DM) acknowledged that these items should not be open to air and should be dated when opened. Further observations revealed that the ice machine had a brown/black substance on a clean cloth used to wipe it, and the DM admitted they did not know what the substance was. The DM also stated that the ice machine should be locked when not in use, but staff often failed to lock it. Additionally, the DM entered the kitchen without washing their hands and expressed concerns about contaminating their hands by touching the trash can lid. The DM mentioned that a surveyor from the previous year had advised that the trash only needed to be covered when being transported. The DM confirmed that staff entering the kitchen should wash their hands.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff followed infection control guidelines, leading to potential spread of communicable diseases. Observations revealed that a CNA assisting residents with eating did not perform hand hygiene after scratching their face, touching their clothing, or handling dirty dishes. Another CNA also failed to perform hand hygiene between assisting different residents. The Infection Preventionist (IP) confirmed that staff should use hand hygiene between residents and after touching something dirty while assisting residents to eat. Additionally, a registered nurse (RN) did not follow proper hand hygiene protocols during wound care. The RN washed their hands before care and applied gloves but did not perform hand hygiene after cleaning a resident who had a bowel movement. The RN also failed to perform hand hygiene between removing the old dressing, cleaning the wound, and applying skin prep. Furthermore, the IP was observed testing a resident for COVID-19 in a communal activity room without proper personal protective equipment (PPE), which could have potentially spread the infection to others in the facility.
Failure to Obtain Criminal Background Checks for Employees
Penalty
Summary
The facility failed to follow their abuse prevention policy by not obtaining criminal background checks upon hire for 13 of 74 employees hired between 2016 and 2024. The facility's Abuse Prevention Policy mandates that candidates for employment be screened for a potential history of abuse, neglect, or mistreatment before employment, including obtaining criminal background checks. However, the facility did not have criminal background checks for 13 employees, including CNAs, CMAs, and a laundry staff member. Payroll records confirmed that these employees were permitted to work without the required background checks, and the BOM and administrator were unaware of this oversight until it was brought to their attention during the survey. The BOM reported that criminal background checks could not be done for some employees because they had not been fingerprinted. Additionally, the BOM incorrectly believed that if an employee returned within three years of separation, a new background check was not required. The DON and administrator were also unaware of the lack of background checks for these employees. The facility's failure to adhere to its own abuse prevention policy and ensure that all employees had completed criminal background checks upon hire led to this deficiency.
Failure to Assess Bed Rail Use for Residents
Penalty
Summary
The facility failed to ensure residents were fully assessed for the use of side rails for four of the 35 sampled residents. Resident #11, who had diagnoses including CHF, chronic kidney disease, and Alzheimer's Disease, was observed multiple times with bed rails up on both sides of the bed. The resident's EHR did not contain bed rail assessments, and the LPN confirmed that bed rail assessments had only recently started without a proper template. The resident's POA was informed of the risks but still wanted the bed rails to prevent the resident from trying to get out of bed, despite the resident not having the strength to do so. Resident #22, diagnosed with generalized anxiety disorder, major depressive disorder, diabetes mellitus with diabetic neuropathy, CHF, and schizophrenia, was also observed using bed rails without proper assessments documented in the EHR. The resident stated they used the bed rails for positioning and had never fallen out of bed. The LPN confirmed that bed rail assessments for this resident had not been completed. Resident #42, with diagnoses including CHF, Alzheimer's Disease, anxiety disorder, and insomnia, was observed with bed rails up and a bed alarm in place. The EHR did not contain assessments for bed rails, although a waiver was signed by the resident's POA. Similarly, Resident #45, with diagnoses including unspecified osteoarthritis, COPD, and primary osteoarthritis of both shoulders, was observed using bed rails and an air mattress without documented assessments. The DON stated that nurses assess the side rails daily but do not document these assessments in the chart, and they would start utilizing a bed rail assessment form routinely.
Incomplete and Illegal DNR Forms
Penalty
Summary
The facility failed to ensure DNR forms were complete and legal for two residents. One resident with diagnoses including CHF, chronic kidney disease, and Alzheimer's Disease had a DNR form signed by the resident's POA but lacked the required two witnesses. Another resident with diagnoses including major depressive disorder, anxiety disorder, and osteoarthritis had a DNR form signed by the POA but it was not dated. The DON confirmed these deficiencies during interviews.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of MDS assessments for four residents. One resident with a history of deep vein thrombosis was incorrectly documented as not being on an anticoagulant, despite physician orders and care plans indicating otherwise. Another resident, who was blind and hard of hearing, was inaccurately assessed as having adequate hearing. Additionally, a resident who experienced two falls, one resulting in a subdural hematoma, had these incidents omitted from their significant change assessment. Lastly, a resident with a Foley catheter due to urinary retention was incorrectly documented as always incontinent of urine, despite observations and statements confirming the presence of the catheter. These inaccuracies in MDS assessments were identified through observations, record reviews, and interviews with staff and family members. The discrepancies highlight a failure in the facility's assessment process, leading to incorrect documentation of residents' medical conditions and care needs. This failure could potentially impact the quality of care provided to the residents, as accurate assessments are crucial for developing appropriate care plans and interventions.
Failure to Notify OHCA of Resident with Serious Mental Illness
Penalty
Summary
The facility failed to notify the Oklahoma Health Care Authority (OHCA) of a resident with a serious mental illness who stayed in the facility long-term. The resident had diagnoses including generalized anxiety disorder, major depressive disorder, and schizophrenia. A PASRR I screening dated 06/26/14 indicated the resident had a serious mental illness, and it was documented that a PASRR level II was not required for a short stay for therapy. However, the resident's care plan, revised 08/26/22, noted ongoing concerns related to schizophrenia and the use of psychotropic medications. An annual assessment dated 09/19/23 incorrectly documented that the resident was not considered to have a serious mental illness. The Director of Nursing (DON) later acknowledged that another staff member failed to conduct a new PASRR I when the resident stayed long-term in the facility.
Failure to Develop Comprehensive Care Plan for Weight Loss
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident experiencing weight loss. The resident had diagnoses including diabetes mellitus type 2, abdominal hernia, and major depressive disorder. Physician's orders were documented for nutritional supplements, health shakes, and protein powder to address the resident's weight loss. Despite these orders, a care plan dated 02/04/24 did not document the resident's weight loss. The MDS coordinator confirmed on 03/07/24 that there was no care plan for the resident's weight loss, indicating a lapse in the facility's care planning process.
Improper Use of Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure residents were not catheterized unless required by a clinical condition and did not assess the continued need for an indwelling urinary catheter for two residents. Resident #29 was admitted with multiple diagnoses including stage 3 kidney disease and dementia. Despite having a urinary tract infection with ESBL, there was no documentation of a catheter in the care plan. The DON acknowledged that the catheter was used for isolation purposes, which is not a proper diagnosis for catheter use. The care plan was not updated to reflect the presence of the catheter, and the DON admitted that ESBL was not a valid reason for catheterization. Resident #25, diagnosed with chronic kidney disease stage 4 and dementia, had a 16 Fr indwelling urinary catheter placed due to ESBL and E. coli in their urine. There were no physician's orders for catheter care or changing the catheter. The infection preventionist confirmed there was no policy or protocol for catheterizing residents with urinary tract infections and admitted that catheterizing for a UTI likely does not meet criteria. The DON stated that catheters were used for residents who were difficult to keep in their rooms for isolation, but acknowledged that ESBL was not a proper diagnosis for catheter use.
Failure to Document Rationale for Medication Regimen Review
Penalty
Summary
The facility failed to ensure the physician documented a rationale on a consultant pharmacist recommendation for a resident whose medications were reviewed. The resident had diagnoses including CHF, Alzheimer's Disease, anxiety disorder, and insomnia. A medication regimen review (MRR) requested a reduction in several medications, but the physician documented to continue the current use of medications without providing a rationale. Additionally, the facility's MRR policy did not contain timeframes for the steps in the MRR process. The Director of Nursing (DON) confirmed that the policy lacked timeframes and stated that physicians usually document their decisions on the MRRs.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents did not receive psychotropic medication unless for a specific diagnosed condition. This was identified for one of five residents reviewed for unnecessary medication. The facility's policy stated that drug regimens should be free from unnecessary drugs and that psychotropic medications should only be used when necessary to treat a specific condition documented in the clinical record. A resident with diagnoses including CHF, Alzheimer's Disease, anxiety disorder, and insomnia was prescribed Seroquel 25mg twice a day for Alzheimer's Disease. A medication review requested an appropriate diagnosis for the use of Seroquel, and the physician later marked the diagnosis as mood disorder. The resident's care plan documented the use of Seroquel for Alzheimer's Disease. The Director of Nursing acknowledged that the diagnosis should be changed promptly upon receiving the medication review request from the physician.
Inconsistent Dietitian Services and Documentation
Penalty
Summary
The facility failed to provide consistent services from a registered dietitian for one of the two residents reviewed for nutrition. The resident had diagnoses of diabetes mellitus type 2, abdominal hernia, and major depressive disorder. Despite multiple recommendations from a registered dietitian for nutritional supplements and health shakes, the facility did not document these recommendations in the resident's care plan. Additionally, the facility's business manager stated that the last visit from a registered dietitian was in August 2023, despite the facility contracting for monthly visits. This inconsistency in dietitian services and lack of documentation led to the deficiency.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) plan to identify and address problems within the facility. Record review and interviews revealed that the facility did not have a policy and procedure for QAPI. The QAPI meetings were held sporadically, with the last meeting occurring in September 2023. On March 11, 2024, the Director of Nursing (DON) confirmed that QAPI meetings were not implemented regularly and that there was no formal policy and procedure to follow for QAPI. The DON stated that when issues arose, the administrator, DON, Assistant Director of Nursing (ADON), Minimum Data Set (MDS) coordinator, and Infection Preventionist would meet to address the problems. The DON also mentioned that a QAPI meeting would likely be held after the current month due to a COVID outbreak in February.
Failure to Hold Quarterly QAA Committee Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly, as required. A review of the QAA committee meetings revealed that the last documented meeting was in September 2023. There was no documentation of meetings in October, November, and December 2023, nor in January or February 2024. The Director of Nursing (DON) confirmed that QAA meetings were not held regularly and stated that meetings were only convened when specific problems needed to be addressed. The DON mentioned that a QAA meeting would likely be held after the current month due to a COVID outbreak in February.
Latest citations in Oklahoma
Surveyors found that staff failed to follow Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. Facility policy required targeted gown and glove use for high-contact care under EBP, and the resident had physician orders for catheter care every shift and placement on EBP. During an observation, two CNAs provided catheter care without wearing gowns. Both CNAs later acknowledged that gowns should have been used, and the DON confirmed that gowns are required for catheter care for residents on EBP. The resident, who was cognitively intact, reported that staff usually did not wear gowns during catheter care.
The facility did not update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed licensed nursing staff. The written assessment specified one RN for one day shift per week and projected a need for 10 LPNs across 24 hours, with detailed LPN coverage by shift, and stated it should be reviewed and updated as needed to guide staffing decisions. At the time of survey, the DON reported 36 residents in the facility, acknowledged that resident acuity was higher than when the assessment was completed, and stated that the actual pattern was two LPNs on the floor for the day shift and two LPNs for the night shift, with the DON, ADON, and MDS coordinator available only during weekday business hours. The DON identified a total of seven licensed staff available and stated that more staff were needed to work directly with residents, confirming that the facility assessment no longer reflected current resident needs or staffing resources.
A resident with a pressure ulcer received wound care during which an LPN and CNAs failed to follow basic infection control practices. The overbed table was not sanitized before wound supplies were placed, gloves were not changed after contact with feces, and the resident was repositioned onto a clean bed pad while still soiled. The LPN used the same contaminated gloves to handle personal items, suction equipment, wound care supplies, and to cleanse the resident’s skin and pressure ulcer, including applying collagen paste and calcium alginate with gloved fingers. Hand hygiene was not performed between glove changes, and the resident’s open wound came into contact with a cloth bed pad or pillow after cleansing and medication application but before the final dressing was applied.
A deficiency was cited for failure to prevent elopement and recurrent falls due to inadequate supervision, unsecured exits, and incomplete care planning. A newly admitted resident assessed as at risk for elopement and wandering had no related interventions on the baseline care plan, despite moderately impaired cognition and psychiatric and seizure diagnoses. This resident later left the building, was found several blocks away after falling and sustaining abrasions, and was subsequently observed at times without the one-on-one supervision that had been ordered, while a dining room exit door and perimeter gate remained unlocked and accessible. Another resident with vascular dementia, muscle weakness, and a history of multiple falls experienced several unwitnessed falls over months, culminating in two right hip fractures requiring surgical repair, yet fall-prevention interventions were not added to the care plan, and staff relied on verbal instructions and vague "close observation" rather than documented, individualized fall-prevention measures.
A resident with atrial fibrillation on Eliquis, with documented orders and a care plan to monitor and report signs of bleeding, experienced multiple episodes of active rectal bleeding while on the toilet, accompanied by anxiety, complaints of not being able to breathe, pain, pallor, and shivering. An ACMA and an LPN observed and documented that the toilet was full of blood and that the resident repeatedly refused transfer to the ER, but the LPN did not contact the physician or the family and instructed staff to continue monitoring. ACMA staff later attempted to follow instructions to contact family but reported no family contact information in the medical record, did not notify the physician, and ultimately called EMS only when the resident became pale and shivering; EMS found the resident unconscious amid evidence of a significant hemorrhagic event. Progress notes contained no documentation of physician or family notification during the change in condition, and the family, listed as POA and emergency contact in admission paperwork, reported they were not informed of the change in condition and learned of the resident’s death hours later.
A resident with recent abdominal aortic aneurysm repair and a history of circulatory surgery was on multiple anticoagulant and antiplatelet agents (Eliquis, aspirin, Plavix) and had care plans directing staff to monitor for and report abnormal labs and signs of bleeding, including black or bloody stools. A critical hemoglobin of 6.3 g/dL was reported by the lab, which documented unsuccessful attempts to reach nursing staff; the result was later signed by facility staff, but the DON confirmed the physician was never notified and no intervention was documented. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding with screaming, shortness of breath, and anxiety while on the toilet; an ACMA notified an LPN, who did not promptly assess the resident and instead instructed continued monitoring and attempts to convince the resident to go to the hospital. Nursing notes and EMS documentation showed a significant hemorrhagic event with extensive blood in the room and on the resident, yet there was no evidence of ongoing assessment, monitoring, or timely physician notification for the change in condition or the critical lab, leading surveyors to cite a deficiency under F684 for failure to provide appropriate treatment and care according to orders and the resident’s condition.
A resident with a history of circulatory surgery, an aortocoronary bypass graft, and on anticoagulant therapy experienced an acute onset of profuse rectal bleeding and shortness of breath during a night shift. An ACMA was functioning as charge on one hall while an LPN covered the other hall; the ACMA reported the resident’s bleeding and distress, and the LPN came once to the room but did not provide ongoing assessment or monitoring, later stating they were behind on work and relying on the ACMA to monitor. EMS later found the room with evidence of a significant hemorrhagic event and the resident unconscious on the toilet. Progress notes lacked documentation of significant change in condition, assessments, or interventions for the bleeding and respiratory distress, and the facility failed to notify the medical provider of a critical Hgb of 6.3 or of the acute bleeding. The facility also could not produce annual competency records for the LPN or ACMA, and the resident’s family was not notified of the change in condition or death until later.
A resident with a history of abdominal aortic aneurysm repair and on anticoagulant therapy had a critically low Hgb on lab testing, but the lab’s critical results were not successfully communicated to a nurse and the physician was not notified. Later, the resident developed anxiety, SOB, screaming, and profuse rectal bleeding while on the toilet. An LPN was notified of these symptoms and received a photo showing a large amount of blood but did not perform an assessment or ongoing monitoring, relying instead on an ACMA despite acknowledging this was not standard procedure. There was no documentation of a significant change in condition or interventions in the progress notes. EMS was eventually called and found evidence of a major hemorrhagic event in the room before transporting the resident, and the incident was identified by the regional nurse consultant as neglect.
Surveyors found multiple food safety deficiencies involving approximately 80 residents, including unlabeled and undated stored food items, and an ice machine with visible pink and brown residue on the chute above the ice. The dietary manager acknowledged that food should be labeled and noted visible dirt when wiping the ice machine. A cook was observed preparing pureed food with one gloved and one ungloved hand, using the same gloved hand to handle both ready-to-eat food and kitchen surfaces without changing gloves or performing hand hygiene until after taking equipment to the dishwasher. The DON reported there was no policy for food storage or ice machine maintenance, and only prior-year invoices were available to show servicing of the ice machine, with no recent documentation provided.
A resident with moderately impaired cognition who required partial to moderate assistance with ADLs expired in an ambulance, but staff documentation did not accurately reflect the resident’s status. A nursing progress note describing severe anxiety, complaints of inability to breathe, and blood in the toilet was entered without being identified as a late entry. Task logs showed ADL assistance documented as completed after the resident’s death, instead of being marked as not available or not applicable. Staff interviews confirmed that tasks should not be documented as completed when a resident is no longer in the facility or has died, indicating a failure to follow the facility’s nursing documentation policy.
Failure to Use Gowns During Catheter Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during catheter care. The facility’s Infection Control policy dated 04/01/24 required targeted gown and glove use during high-contact resident care activities under EBP. Physician orders showed that Resident #7 had an indwelling catheter with catheter care ordered every shift as of 01/07/26 and was placed on EBP as of 01/16/26. A quarterly assessment dated 03/27/26 documented that Resident #7 had intact cognition, with a Brief Interview for Mental Status score of 15, and an indwelling catheter. On 04/29/26 at 11:03 a.m., CNA #1 and CNA #2 were observed providing catheter care to Resident #7 without wearing gowns, despite the resident being on EBP and the facility’s policy requiring gown use for such care. CNA #1 acknowledged that gowns should have been worn under EBP, and CNA #2 stated they had forgotten to put on a gown. Resident #7 reported that staff usually did not wear gowns during catheter care, and on 04/30/26 the DON confirmed that gowns should be worn when providing catheter care to residents on EBP.
Failure to Update Facility Assessment to Reflect Increased Resident Acuity and Staffing Needs
Penalty
Summary
The facility failed to update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed nursing resources. The written facility assessment dated 10/15/25 stated that one RN was needed for one day shift per week, including weekends, and projected a total of 10 LPNs needed to provide care in a 24-hour period. The assessment further specified that seven LPNs were needed for the day shift, five for the evening shift, and four for the night shift. The assessment document itself stated that it was to be reviewed annually and updated as needed, and that it was to be used to evaluate the resident population and determine the resources necessary to care for residents competently during day-to-day operations and emergencies, and to drive staffing decisions. At the time of the survey, the DON identified that 36 residents resided in the facility and reported that the acuity level of the residents was higher than it had been in October 2025 when the facility assessment was completed. The DON stated that the projected need for ten LPNs in a 24-hour period was not correct and described the actual staffing pattern as two LPNs working on the floor from 7 a.m. to 7 p.m. and two LPNs working on the floor from 7 p.m. to 7 a.m., with the DON (RN), assistant DON (RN), and MDS coordinator (LPN) available to assist with resident needs during business hours, five days a week. The DON counted a total of seven licensed staff members available and acknowledged that more staff were needed to work directly with residents given the current higher acuity, demonstrating that the facility assessment had not been updated to reflect the current resident population and resource needs.
Improper Infection Control During Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care in a manner that prevented contamination and potential infection for one resident with a pressure ulcer. During an observed dressing change, an LPN entered the resident’s room, pushed personal items aside, and placed plastic trash bags and wound care supplies on the overbed table without sanitizing the surface. The LPN and CNAs provided incontinent care during which feces remained on the resident’s legs and buttocks, and at least one CNA did not change gloves after wiping feces and before placing a clean cloth bed pad under the resident. The resident was repositioned onto the new pad while still soiled with feces. Wearing the same gloves used during incontinent care, the LPN handled the resident’s personal items, oral suction yankauer, and suction machine, and prepared wound care supplies, including soaking gauze in a cleansing solution. The LPN then used the same contaminated gloves to obtain wet gauze from the cleansing solution and clean feces from the resident’s legs and buttocks before proceeding to remove the old dressing and packing from the pressure ulcer. Some packing fell onto the cloth bed pad, and the resident’s back and buttocks, including the open pressure ulcer area after cleansing and medication application but before placement of the absorbent dressing, came into contact with the cloth bed pad or pillow. The LPN applied a collagen paste to the wound bed by inserting gloved fingers into a cup of white paste and then applied calcium alginate with the same gloved fingers, without using an applicator. The LPN discarded the gloves but did not perform hand hygiene before donning a new pair of gloves stored on the overbed table. During a post-observation interview, the LPN acknowledged feeling nervous, recognized that their gloves and multiple items and surfaces may have been contaminated by contact with feces, and stated that the resident’s bed pad and wound bed were likely contaminated during the dressing change.
Failure to Prevent Elopement and Recurrent Falls Due to Inadequate Supervision and Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to elopement risk and fall prevention. One resident identified as a new admission was evaluated on 02/28/26 as being at risk for elopement and wandering, with documentation that the resident wandered around the facility and into rooms. Despite this evaluation, the baseline care plan dated the same day did not include any interventions for wandering or elopement risk. An admission assessment dated 03/06/26 documented moderately impaired cognition with a BIMS score of 09 and diagnoses including schizophrenia and seizure disorder. On 03/07/26, the resident was reported missing from their room around 11:20 a.m., and an incident report and progress note showed the resident was found a couple of blocks from the facility, having tripped and fallen outside and sustaining abrasions to the hand and knee that required first aid. Following the elopement, documentation showed the resident was placed on one-on-one staff supervision and the care plan was updated; however, subsequent observations revealed lapses in supervision. On 03/11/26, the resident was observed in bed with a staff member seated outside the door, and the resident stated they were not allowed to leave the facility alone. On 03/12/26, the resident was observed in bed with no staff supervision, then walking out of the room toward the dining room without staff present, until an unidentified staff member later noticed the resident in the hall and alerted the charge nurse. Interviews indicated that prior to the elopement the resident had not been on frequent checks because staff did not consider them an elopement risk, despite the earlier evaluation. The ADON later stated the baseline care plan lacked elopement/wandering interventions because they had failed to communicate with the weekend RN who completed the elopement evaluation and were unaware the resident was at risk. Environmental observations on 03/13/26 showed the dining room exit door and the outside perimeter gate in the smoking area were unlocked and accessible to residents, and the DON and administrator acknowledged the dining room exit door was not secured and that the resident likely exited through the unlocked door and perimeter gate. The deficiency also includes the facility’s failure to provide adequate supervision, reassess fall risk, investigate root causes, and implement fall-prevention interventions for a resident with a history of multiple falls. Facility records identified this resident as having several falls without injury on 06/04/25, 06/05/25, 06/18/25, 06/30/25, and 07/31/25, with no fall-prevention interventions documented for any of these events. A fall on 09/25/25 resulted in severe right leg pain and an emergency room visit, with a subsequent nurse’s note documenting a right hip fracture requiring surgical repair. Review of the care plan dated 07/31/25 showed no fall-prevention interventions in place for the 09/25/25 fall, and a later care plan dated 10/06/25 documented the resident’s diagnoses, including vascular dementia and muscle weakness, and the prior falls, but still showed no interventions for those falls. A nurse’s note dated 10/20/25 documented another fall on 10/19/25 that resulted in a second right hip fracture, again with no documentation of interventions in place to prevent that fall. Observations and interviews further demonstrated the lack of systematic fall-prevention planning for this resident. On 03/12/26, the resident was observed sitting in a geriatric chair near the nurse’s station with a fall mat at bedside and was later assisted to stand and ambulate with a walker. The resident reported falling frequently and not knowing why, and stated that staff followed them everywhere to prevent falls but were unsure what specific interventions were in place. An LPN stated the resident had frequent falls and that interventions included a fall mat at bedside and keeping the resident under close observation, but could not clarify what “close observation” entailed and acknowledged that interventions were communicated verbally rather than being reflected in the care plan. Another LPN stated they relied on the care plan to know fall-prevention interventions and, if not listed, had to depend on other staff for guidance. The MDS coordinator stated all falls, regardless of injury, should result in care plan interventions to prevent recurrence and did not know why this resident’s falls lacked interventions, and the DON confirmed there were no interventions on the care plan for the resident’s falls despite the expectation that such interventions should have been in place. Facility policies reviewed by surveyors underscored the deficiencies. An undated wandering policy stated that the facility would ensure the safety of residents who wander and that the MDS nurse would complete a wandering assessment on admission and work with the care plan team to develop, maintain, and update a care plan for each resident who wanders. A Falls – Clinical Protocol dated 03/2018 stated that staff and the physician would identify pertinent interventions to prevent subsequent falls and address the risks of clinically significant consequences of falling. A Care Plan Completion policy stated the facility would develop a comprehensive person-centered care plan for each resident that includes measurable objectives, timeframes, and services to meet medical, nursing, mental, and psychosocial needs. Despite these policies, the facility did not ensure that the elopement risk assessment for the first resident was communicated and incorporated into the baseline care plan, did not secure exit doors and perimeter fencing to prevent elopement, and did not consistently implement or document individualized fall-prevention interventions for the second resident after multiple falls and two hip fractures.
Failure to Notify Physician and Family of Significant Bleeding Episode in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and family of a significant change in condition. The resident had a history of atrial fibrillation and was on Eliquis, with physician orders and a care plan directing staff to monitor and report signs of bleeding such as blood in urine or stool, black tarry stools, and other symptoms. The resident’s cognition was moderately impaired, with a BIMS score of 11, and they required supervision with ambulation and transfers and partial to moderate assistance with toileting hygiene. The admission contract identified a family member as the emergency contact and POA, with contact information provided. On the night of the incident, staff observed multiple episodes of active bleeding while the resident was on the toilet. Around 1:15 a.m., the resident was on the toilet and bleeding, with the toilet full of blood, and was reported to be screaming that they could not breathe. ACMA staff notified the LPN, left the blood in the toilet for the LPN to observe, and reported that the resident refused to go to the ER. The LPN assessed the resident at approximately 1:32 a.m., documented increased anxiety, complaints of not being able to breathe, and that most of the toilet contents were blood, and noted that the resident refused transfer to the emergency department. The LPN instructed ACMA staff to continue monitoring the resident and did not contact the physician or the family at that time. The resident continued to have episodes of bleeding while on the toilet around 2:00 a.m. and again around 2:50 a.m., with reports of pain, pallor, and shivering, and continued refusals to go to the hospital and to take pain medication. ACMA staff reported they were instructed by text to contact the family to encourage the resident to go to the ER but stated no family contact was listed in the medical record and did not call the physician. EMS was eventually called by ACMA staff when the resident became pale and shivering; EMS arrived to find the resident unconscious on the toilet with evidence of a significant hemorrhagic event in the room, including saturated towels and blood on the floor and on the resident. Progress notes did not show any contact with the physician or family during the change in condition, and the family member later stated they were not notified of the change in condition and did not learn of the resident’s death until several hours later. The facility’s failure to notify the physician and family of the resident’s serious change in condition was cited as an Immediate Jeopardy deficiency.
Failure to Respond to Critical Lab and Acute Bleeding in Anticoagulated Post-Surgical Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess, identify, and intervene when a resident with a recent abdominal aortic aneurysm repair experienced an acute change in condition, including profuse bleeding from an unknown source and a critically low hemoglobin level. The resident had diagnoses including encounter for surgical aftercare following circulatory system surgery and presence of an aortocoronary bypass graft, and was receiving multiple anticoagulant and antiplatelet medications (Eliquis twice daily, aspirin daily, and Plavix daily), along with psyllium and Imodium for diarrhea. Facility policies required nurses to assess acute condition changes, obtain and report pertinent information to the physician, and promptly notify the physician in emergencies, as well as to review and act on lab and diagnostic test results based on the seriousness of abnormalities. The resident’s care plan directed staff to monitor for and report abnormal lab results and signs of bleeding, including black or bloody stools and significant changes in vital signs, and to avoid aspirin use with anticoagulant therapy. A laboratory report for the resident showed a critically low hemoglobin of 6.3 g/dL, with a normal reference range of 13.7–17.5 g/dL. The lab documented attempts to call the facility at 3:35 p.m. and again, with no answer and inability to reach a nurse, and the report was released later that afternoon. The report bore a staff signature dated several days later and a stamped physician signature without a date. The DON confirmed that the physician was not notified of this critical result and stated that the physician should have been notified immediately per facility procedure. Despite the resident’s anticoagulant therapy and care plan instructions to report abnormal labs, there was no evidence that the critical hemoglobin value was communicated to the physician or that any clinical intervention occurred in response to this lab finding. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding while on the toilet, accompanied by screaming, shortness of breath, increased anxiety, and refusal to go to the hospital. An ACMA reported to an LPN around 1:15–1:32 a.m. that the resident was having bloody stool and distress, but the LPN did not immediately assess the resident and instead instructed the ACMA to monitor and convince the resident to go to the hospital. The nursing progress note later documented that the resident’s toilet contents were mostly blood and that the resident was educated about the need to go to the ED but refused. EMS records indicated that when they arrived, the resident’s room showed signs of a significant hemorrhagic event, with towels saturated with blood and blood on the floor, legs, socks, and in the toilet. The nursing documentation showed no ongoing assessment, monitoring, or intervention for the resident’s shortness of breath, screaming, blood in the toilet, or refusal of transfer during the period before EMS was called. The facility’s failure to identify, monitor, and provide continuing assessments for the resident’s change in condition, to notify the medical provider of the critical hemoglobin result, and to promptly notify the provider and intervene for the acute onset of profuse bleeding constituted the cited deficiency. The report also notes that staff interviews revealed gaps in practice and understanding related to change in condition and bleeding. The LPN acknowledged being concerned the resident was “bleeding out” and stated they were traumatized by the amount of blood, yet did not perform an immediate assessment when first notified of bloody stool and pain, relying instead on the ACMA to monitor and attempt to persuade the resident to accept transfer. The LPN further stated they typically remained on one side of the building and did not routinely go to the other side unless needed, and that they did not visually see the resident in distress until later. A CNA reported having seen dark, clumped stool earlier in the week and indicated they had only minimal education on signs and symptoms of bleeding. These documented actions and inactions, in the context of the resident’s high-risk status and existing policies and care plans, led surveyors to determine that the facility failed to provide appropriate treatment and care according to orders, the resident’s condition, and established protocols for change in condition and critical lab results. The resident’s family reported that the resident had ongoing diarrhea with horrendous odor and black color since before admission, and that staff were aware of the stool characteristics. Another CNA described the resident’s stool as dark black and mixed solid/liquid, resembling stool from someone taking iron, though they only observed it once and did not report red blood. The care plan specifically directed staff to monitor for black tarry stools and other signs of bleeding in the context of anticoagulant therapy, and to report such findings to the physician. Despite these documented risk factors, symptoms, and care plan directives, the record lacked evidence that staff recognized and escalated these signs as potential bleeding or that they communicated them to the physician prior to the acute hemorrhagic event. This pattern of missed recognition, lack of timely assessment, and failure to notify the physician of both critical lab results and acute bleeding formed the basis of the deficiency under F684 (Quality of Care).
Failure to Assess, Monitor, and Notify Provider for Resident With Profuse Bleeding and Critical Lab Value
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and competent nursing staff to assess, monitor, and intervene for a resident with a known high-risk medical history who experienced an acute onset of profuse bleeding. The resident had a history of surgical aftercare following surgery on the circulatory system, including the presence of an aortocoronary bypass graft, and was receiving anticoagulant therapy (Eliquis) for atrial fibrillation. The resident’s care plan and physician orders directed staff to monitor for specific signs of bleeding and adverse reactions to anticoagulant therapy, such as blood in the stool or urine, changes in mental status, shortness of breath, and other symptoms. The facility also had an Acute Condition Changes – Clinical Protocol policy requiring baseline assessments, monitoring, and timely physician notification for acute changes in condition. On the night of the incident, assignment sheets showed that an ACMA was the charge nurse on one hall (South hall) for the 7:00 p.m. – 7:00 a.m. shift, while an LPN was the charge nurse on the other hall (North hall). EMS records documented that they were dispatched in the early morning hours after facility staff reported that the resident had blood in the stool starting about three hours earlier and was recovering from abdominal aortic aneurysm surgery. When EMS arrived, they observed the resident’s room with signs of a significant hemorrhagic event, including towels saturated with blood and blood on the floor, and found the resident unconscious on the toilet with blood on their socks, legs, and in the toilet. Progress notes for that date did not show documentation of a significant change in condition, nor did they show assessments, monitoring, or interventions for the resident’s shortness of breath, screaming, blood in the toilet, or refusal to be transported to the hospital. Interviews revealed that the LPN was the only licensed nurse in the building on the weekend and did not obtain a full report on the South hall because the ACMA was functioning as the charge for that hall. The LPN stated that the ACMA reported the resident was screaming, hurting, having a bowel movement, and there was blood, and that the resident had a history of abdominal aortic aneurysm surgery, raising concern about bleeding. The LPN instructed the ACMA to send the resident to the hospital, but the resident refused, and the LPN did not perform ongoing assessments or monitoring, citing being behind on work and relying on the ACMA to monitor and report. The ACMA reported that the resident was on the toilet and bleeding around 1:15 a.m., with vital signs within normal limits, and refused to go to the ER; the ACMA contacted the LPN, who came once at about 1:32 a.m. to check on the resident while the resident was back in bed, with blood left in the toilet for the LPN to see. The ACMA stated that later, as the resident continued to pass blood, became pale and shivering, and remained in pain while refusing pain medication and hospital transfer, they eventually called 911 when the resident’s condition worsened. The facility was unable to produce annual skills competencies for either the LPN or the ACMA, and a family member reported they were not notified of the resident’s change in condition or of the resident’s death until later, despite the resident’s room being on the South hall where the events occurred. The report also notes that the facility failed to notify the medical provider of a critical hemoglobin lab value of 6.3 (normal reference range 13.7–17.5) and failed to notify the medical provider of the acute onset of profuse bleeding. There is no documentation that the physician was contacted regarding the critical lab result or the resident’s active bleeding, despite facility policy requiring timely physician notification for acute changes in condition and the resident’s known risk factors and anticoagulant therapy. Additionally, the facility’s own policy required that direct care staff, including nursing assistants, be trained to recognize and report significant changes, and that phone calls to physicians be made by adequately prepared nurses with organized, pertinent information; however, the documented events and interviews show that the ACMA was functioning as charge on one hall and that the LPN did not consistently assess or directly manage the resident’s rapidly changing condition. These combined failures to assess, monitor, intervene, and notify the medical provider for a resident with profuse bleeding and a critical hemoglobin value constituted the cited deficiency.
Failure to Assess and Respond to Resident’s Significant Bleeding and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident experiencing a significant change in condition and profuse bleeding was assessed and monitored by a licensed nurse. The facility had an Acute Condition Changes - Clinical Protocol requiring nurses to assess and document vital signs, neurological status, pain, level of consciousness, cognitive and emotional status, onset and severity of symptoms, and other clinical information, and to promptly contact the physician for emergencies. The resident had a history of abdominal aortic aneurysm repair and was on anticoagulant therapy for atrial fibrillation, with care plans directing staff to monitor and report signs and symptoms of cardiovascular issues and adverse reactions to anticoagulants, including blood in stool and shortness of breath. A physician’s order required weekly CBC and CMP labs while on skilled services. A lab report for the resident showed a critically low hemoglobin level of 6.3 g/dl, but the lab’s attempts to call the facility at 3:35 p.m. and again later were unsuccessful, and the physician was not notified of the results. Subsequently, during the night, the resident experienced increased anxiety, was screaming that they could not breathe, was on the toilet with most of the contents being blood, and refused to go to the emergency department. LPN #1 was notified at 1:32 a.m. of the resident’s condition, including shortness of breath, screaming, and blood in the toilet, but did not perform an assessment or ongoing monitoring, and there was no documentation of a significant change in condition or interventions for these symptoms in the progress notes. LPN #1 reported typically being the only licensed nurse in the building on weekends and stated they did not go to the resident’s hall for a full report, relying instead on an ACMA to monitor residents and report concerns. LPN #1 acknowledged being told that the resident was screaming, hurting, having bloody stool, and had a recent abdominal aortic aneurysm, and expressed concern about the resident bleeding out. LPN #1 received a texted picture of the blood at 2:25 a.m. and described being traumatized by the amount of blood, but still did not assess or monitor the resident, citing being behind on work and relying on the ACMA, despite stating that it was not standard procedure for an ACMA to assess, monitor, and send a resident to the hospital. EMS was finally contacted at 3:12 a.m., arrived to find evidence of a significant hemorrhagic event with blood-saturated towels and blood on the floor, and transported the resident, who expired in the ambulance shortly thereafter. The regional nurse consultant stated the incident was considered neglect.
Improper Food Storage, Ice Machine Sanitation, and Glove Use in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food storage and ice handling practices during kitchen observations. In one kitchen tour, they observed a white paper bowl containing orange ice cream wrapped in plastic wrap that was unlabeled and undated, as well as an opened bag of hamburger buns that was also unlabeled and undated. The ice machine had a pink substance on the white plastic chute directly above the ice, which, when wiped with a clean paper towel, resulted in a pink and brown speckled residue. The dietary manager acknowledged that the food items should have been labeled and stated they saw dirt on the towel used to wipe the ice machine chute. The DON reported there was no policy for food storage or the ice machine, and stated that ice machine maintenance was based on the machine’s indicator and then calling an outside company, with invoices available only for servicing dates in the prior year and no documentation provided for recent cleaning or maintenance. Additional deficiencies were observed in food handling and glove use by kitchen staff. One cook was seen working with one hand gloved and one hand ungloved, using the gloved hand to place cornbread into a blender, then touching the blender, a utensil, and returning to touch the cornbread without changing gloves or performing hand hygiene between contact with food and other surfaces. The cook later took the blender to the dishwasher and only then removed the glove and washed their hands. When interviewed, the cook stated their process for changing gloves was when changing the type of food and after touching utensils, and acknowledged they did not change gloves after touching the cornbread. The dietary manager stated the process for changing gloves was to change when staff touched something or something was dirty. The administrator identified that 80 residents resided in the facility at the time of the survey.
Inaccurate Post-Death Documentation and Failure to Follow Nursing Charting Policy
Penalty
Summary
The facility failed to ensure accurate and timely documentation in the medical record for a resident who died. Facility policy on nursing documentation required staff to chart as soon as possible after care, to enter the actual date and time of charting, and to clearly label any late entries with the date and time being documented. The admission assessment for the resident showed moderately impaired cognition with a BIMS score of 12 and a need for partial to moderate staff assistance with most ADLs. An EMS report documented that the resident expired in the ambulance at 3:40 a.m. on a specified date. A progress note for that same date, timed at 1:32 a.m., described the nurse being notified that the resident was on the toilet, screaming that he could not breathe, with oxygen saturation at 98% and most of the toilet contents being blood; this note was not identified as a late entry despite the timing and circumstances. Task logs for the resident showed that staff documented completion of ADL assistance after the resident’s death. Specifically, the task log reflected that the resident received ADL assistance at 10:08 a.m. on the date of death, and additional ADL assistance entries at 6:54 a.m., 8:32 a.m., and 11:59 p.m. on another date, even though the resident had already expired. During interviews, a CNA stated that if a resident was not in the facility, the scheduled ADL task should be documented as the resident not being available. The RNC confirmed that if a resident had passed away, staff should not document task completion for that resident and that any remaining scheduled tasks should be documented as not applicable. These findings showed that staff documentation did not accurately reflect the resident’s status or comply with the facility’s documentation policy.
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