Ranchwood Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yukon, Oklahoma.
- Location
- 824 South Yukon Parkway, Yukon, Oklahoma 73099
- CMS Provider Number
- 375229
- Inspections on file
- 44
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 21 (3 serious)
Citation history
Health deficiencies cited at Ranchwood Nursing Center during CMS and state inspections, most recent first.
A resident with multiple serious medical conditions, including acute kidney injury, sepsis, and diabetes, experienced repeated episodes of abnormal vital signs such as very low blood pressure, low oxygen saturation, and bradycardia. On more than one occasion, there was no documentation that the physician or NP was notified of these changes, nor that the NP evaluated the resident, despite facility policy requiring notification for significant changes in condition. The resident’s family reported they were not informed by the facility about the resident’s deteriorating condition and instead learned of it from the emergency room. The resident was later found unresponsive, transferred to the ER in critical condition, returned while actively dying, and subsequently died, with the death certificate citing protein calorie malnutrition, cognitive impairment disorder, acute kidney failure, and diabetes mellitus as contributing conditions.
A resident with DM2, acute kidney injury, and a recent history of hypoglycemia-related hospitalizations was admitted without care plan interventions for diabetes or kidney injury and without parameters for PRN Glutose or glucagon. Over several days, no finger stick blood sugars were documented despite ongoing use of Metformin and glimepiride. The resident developed critically abnormal VS, including hypotension, hypoxia, bradycardia, and unresponsiveness, with documentation gaps showing no or unclear provider notification and no recorded interventions for some abnormal readings. Staff later reported they believed they had notified the NP about low VS, but could not find documentation, and the NP stated they had not been notified of these changes and had expected routine blood glucose monitoring. The resident was ultimately found unresponsive with severe hypoglycemia and was transferred to the ED in critical condition, and the situation was cited as an IJ for failure to monitor and intervene for hypoglycemia and acute changes in condition.
The facility failed to develop and update comprehensive care plans for two residents with significant clinical needs. One resident admitted with DM2 and acute kidney injury had a care plan that did not include these diagnoses, despite later being found unresponsive and critically ill with severe hypoglycemia and hypotension, and having acute kidney failure and diabetes documented on the death certificate. Another resident with severe cognitive impairment, severe protein-calorie malnutrition, and notable weight loss had a nutrition therapy assessment and MD orders for weekly weights and specific nutritional interventions, but these were not incorporated into the care plan. The MDS coordinator and DON acknowledged that these conditions and interventions should have been reflected in the residents’ plans of care.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with orders for levothyroxine for hypothyroidism and divalproex for dementia did not receive multiple scheduled doses because the medications were not available in the building. Review of the MAR showed several early-morning levothyroxine doses and morning divalproex doses marked as held due to unavailability or lacking documentation. CMAs reported that medications were ordered when supplies were low and that unavailable medications were left on the MAR while notifying nursing staff, pharmacy, and the DON, while leadership stated medications should be reordered earlier and STAT if needed. These discrepancies in practice led to repeated missed doses of the resident’s prescribed medications.
An LPN left a treatment cart in a hallway with a laptop unlocked and the EMR visible while going into a resident room, leaving the screen facing the hallway. During this time, a resident approached the cart and faced the exposed screen while speaking to the LPN. Facility policy required resident health information to remain private and MAR or EMR information to be closed or covered when not in direct use, but the LPN reported not knowing how to lock the computer screen, resulting in resident medical information being visible in a public area.
A resident who was cognitively intact, occasionally incontinent, and dependent for bed mobility was found to have a bed with a visible urine wet ring on the mattress and wet linens placed on the floor, along with a strong urine odor and a saturated brief in the trash. A CNA reported the resident was wet when being gotten out of bed for therapy and that only the resident’s clothes were changed, not the bed linens. The DON stated staff were expected to check incontinent residents at least every two hours, provide perineal care, and change soiled linens as needed, and confirmed observing the wet linens and wet ring on the bed.
A treatment cart on one hall was left unlocked and unattended in the hallway while an LPN entered a resident room, despite facility policy requiring carts to be locked when out of sight and clearly visible when unlocked. During this time, a resident approached the front of the unattended cart and spoke with the LPN from the doorway while the LPN remained inside the room. In interviews, the LPN minimized the significance of leaving the cart unlocked, and facility leadership, including the regional consultant and DON, confirmed that policy required treatment/medication carts to be locked whenever staff were not in attendance.
A CNA failed to follow infection control and hand hygiene protocols while providing perineal care to a resident who was dependent for toileting, frequently incontinent, and had active UTI and septicemia. After cleaning stool, the CNA wiped feces from a gloved hand onto the bed pad and then continued care, touching the resident, linens, wipes package, and cleaning solution without changing gloves. The CNA then removed the soiled pad, dressed the resident, handled bed covers, and took out the trash without performing hand hygiene, contrary to facility policy requiring glove removal and hand hygiene after feces removal and before applying new gloves and clean linens.
Three residents with significant physical or cognitive impairments did not consistently receive scheduled showers or baths, and staff failed to document bathing as required by facility policy. Interviews with residents, family members, and staff confirmed that bathing was not provided on scheduled days and that records were incomplete or missing, making it impossible to verify that care was delivered as planned.
Three residents experienced multiple missed doses of prescribed medications, including antihypertensives, insulin, anticonvulsants, and anticoagulants, with no explanations documented in the medical records. Facility staff confirmed that there was no way to verify if the medications were given, as proper documentation was not completed, resulting in a deficiency in pharmaceutical services.
A resident with intellectual disabilities and reduced mobility fell in the bathroom, sustained a head injury, and was transported to the hospital. Facility staff did not notify the resident's family or representative about the fall or hospital transfer, as required by policy. The family only learned of the incident when contacted by hospital staff, and facility staff cited confusion with the new EHR system as a reason for the failure to notify.
An LPN failed to follow infection control protocols during wound care for a resident with pressure ulcers, including not wearing a gown as required by Enhanced Barrier Precautions, and not performing hand hygiene or changing gloves after incontinent care and between wound sites. The resident had a history of pressure ulcers and malnutrition, and the LPN was not aware of the EBP requirements. The DON confirmed that proper infection control procedures were not followed.
A resident who required significant assistance with bathing did not have any documented evidence of receiving bathing services during their stay. Staff were unaware of the resident's bathing schedule, and the DON could not provide records to show that bathing was performed, resulting in a failure to meet the resident's care needs.
A resident with diabetes and renal disease reported missing doses of Ozempic, a medication they were prescribed weekly. The resident's medication pen, with two doses remaining, went missing after being left out to warm by an RN. The incident was reported to the DON, who did not initiate an investigation or inform the administrator. The administrator later confirmed they were unaware of the incident, leading to a deficiency in the facility's response to the alleged violation.
A resident admitted with type 2 diabetes and a stage 4 pressure ulcer did not have a comprehensive MDS assessment completed within the required time frame. The DON confirmed the absence of this assessment after reviewing the resident's clinical record.
A resident with pneumonia and deep vein thrombosis was mistakenly given medications intended for another resident due to improper identification methods by a CMA. The error involved administering aspirin, buspirone, linezolid, and potassium chloride. The DON acknowledged the incident but lacked documentation of a review or staff training to prevent recurrence.
The facility failed to maintain a homelike environment, with observations of torn carpets, damaged tiles, exposed wires, and strong urine odors. Residents expressed dissatisfaction, and the housekeeping supervisor confirmed the disrepair. The Regional Directors acknowledged the unsafe conditions and lack of adherence to the facility's policy.
The facility failed to ensure safe food handling practices by allowing unwrapped cereal bowls to be stacked on the tray line, leading to potential contamination. A kitchen aide noted that the bowls should have been wrapped, and the dietary manager confirmed the issue as an infection control concern, with no policy in place to address it. The DON reported that 101 residents received meals from the kitchen.
A facility failed to maintain a resident's dignity by not covering their catheter bag with a vanity bag, as required by policy. The resident, admitted with acute respiratory failure and cellulitis, had their catheter bag observed uncovered and visible from the hallway on two occasions. Staff interviews confirmed the policy breach, with a CNA and LPN acknowledging the requirement to cover the bag, while a corporate nurse was unsure of the policy details.
A facility failed to ensure a resident was offered the choice to formulate an advance directive. The policy requires the Director of Admission to complete and scan the Advanced Directive Acknowledgment Form into the resident's EMR during admission. However, a resident with multiple sclerosis and paraplegia had no documentation in their EMR indicating assistance with formulating an advance directive. Corporate Nurse #1 confirmed the absence of an acknowledgment after auditing the charts.
A resident with Hypertensive Chronic Kidney Disease and Anxiety Disorder reported an alleged abuse incident to a CMA, who failed to document it as required by the facility's policy. The incident was reported during a shift change, but no incident report was completed, as confirmed by the DON.
The facility failed to complete quarterly MDS assessments within the required 92-day period for two residents. One resident with morbid obesity and hypotension did not have an assessment completed by the due date following an ARD of 04/25/24. Another resident with epilepsy and major depressive disorder also missed the assessment deadline after an ARD of 04/06/24. A corporate nurse confirmed the oversight.
A facility failed to ensure accurate MDS documentation for a resident's discharge status. The MDS records incorrectly indicated a discharge to the hospital, while nursing notes and physician orders confirmed a discharge home. The MDS Coordinator acknowledged the coding error, and the Administrator noted the absence of a policy for handling such inaccuracies.
A resident with Parkinson's disease, dementia, and bipolar disorder fell due to a torn and frayed carpet in their room, resulting in a skin tear and pain. Despite the facility's policy to investigate and prevent future falls, the intervention plan only included educating the resident to use their walker and did not address the carpet issue. Observations confirmed the carpet had been in disrepair for at least a year, and maintenance was aware but did not complete repairs.
The facility failed to report allegations of abuse, neglect, and resident-to-resident altercations to the OSDH for seven residents. Incidents involving mistreatment by staff and inappropriate behavior were not documented or reported within the required time frames, leading to a significant deficiency in compliance with regulations.
The facility failed to investigate multiple allegations of abuse and neglect reported by residents, including incidents involving staff treatment and resident altercations. Despite documentation of these complaints, the facility did not conduct thorough investigations as required by their policies.
Failure to Notify Physician and Family of Significant Change in Condition and Abnormal Vital Signs
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and the resident’s family of significant changes in condition, including abnormal vital signs, for a resident who ultimately died. The resident was admitted with multiple serious diagnoses, including hypertension, acute kidney injury, multidrug-resistant organisms, urinary tract infection, sepsis, diabetes mellitus, and later was assessed for dehydration with an order for IV normal saline. On one date, the vital sign log documented a blood pressure of 73/47 and oxygen saturation of 84% on room air, but there was no documentation in the health record that the physician was notified of these abnormal findings, and there was no documentation that the nurse practitioner saw the resident that day. Subsequently, nursing documentation showed the resident was unable to be aroused, with a blood pressure of 81/59, pulse of 41, 3+ pitting edema to both arms, and cold, purple fingers. At that time, the physician was notified and ordered a 500 cc normal saline bolus and possible transfer to the emergency room if there was no improvement. On a later date, the vital sign log showed a pulse of 48, but again there was no documentation that the nurse practitioner saw the resident that day or that the physician was notified of this abnormal pulse. A nurse later stated they had notified the nurse practitioner of the low pulse and documented it, but they were unable to locate any such documentation in the chart. The resident was later found unresponsive with a pulse of 28 and was sent to the emergency room, where records showed critically low blood pressure, hypothermia, and a blood glucose level of less than 20, with the resident verbally and physically unresponsive and critically ill. The resident subsequently returned to the facility while actively dying and passed away the following day. The death certificate listed protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure as causes of death, with diabetes mellitus as a contributing condition. The facility’s own change of condition policy required contacting families or appropriate representatives when there is a significant change in condition, yet the resident’s family member reported receiving no communication from the facility about the resident’s physical condition and stated they were first notified of the resident’s condition by the emergency room.
Failure to Monitor and Intervene for Diabetic Resident With Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess, identify, monitor, and intervene when a resident with diabetes mellitus type 2 and acute kidney injury experienced an acute emergent change in condition. The resident had a known history of diabetes, hypoglycemia, and recent hospitalizations for hypoglycemia, including a documented emergency room visit where their finger stick blood sugar was 36 and a subsequent hospital stay for hypoglycemia. Despite these known conditions, the comprehensive admission assessment and care plan did not include interventions for diabetes mellitus type 2 or acute kidney injury. The resident was prescribed Metformin and glimepiride, both blood sugar–lowering medications, as well as PRN Glutose gel and glucagon for low blood sugar, but there were no parameters in the orders specifying at what blood glucose level these PRN medications should be administered. An undated vital sign log showed there was no finger stick blood sugar monitoring for the resident over a multi-day period, even though the resident had diabetes and a recent history of hypoglycemia-related hospitalizations. The DON later acknowledged there were no physician orders to monitor the resident’s finger stick blood sugar, but stated monitoring should have been done because of the diabetes diagnosis. Nursing staff interviews further showed that an LPN did not recall monitoring the resident’s finger stick blood sugar, and the nurse practitioner stated they expected the facility to monitor the resident’s blood sugars given the diagnosis and prior hypoglycemic events. The nurse practitioner also reported that the only notifications of changes in the resident’s condition they received were on days when the resident was seen in person, and they did not recall being notified of abnormally low vital signs on the critical dates. The facility also failed to appropriately respond to and document interventions for the resident’s abnormal and critical vital signs. A vital sign log documented a blood pressure of 73/47 and oxygen saturation of 84% on room air, with no corresponding documentation of any intervention in the health record. Later, a nurse’s note recorded that the resident was unable to be aroused, with a blood pressure of 81/59, pulse of 41, 3+ pitting edema in both arms, and cold, purple fingers; the physician was notified and ordered a 500 cc normal saline bolus with instructions to send the resident to the emergency room if there was no improvement. Another vital sign entry showed a pulse of 48, but there was no documentation that the physician was notified of this abnormal pulse. The LPN stated they would notify a provider for a pulse less than 60 and claimed to have notified the nurse practitioner about the pulse of 48, but could not locate any documentation of this notification and did not notify the family. Subsequently, a nurse’s note documented that the resident was found unresponsive with a pulse of 28 and was sent to the emergency room, where they were found to have a blood pressure of 71/44, temperature of 88.2°F, blood glucose less than 20, and were described as ill-appearing, verbally and physically unresponsive, critically ill with low blood pressure, and with a high likelihood of death. The resident was later identified as actively dying, returned to the facility, and expired, with the death certificate listing protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure as the cause of death, and diabetes mellitus as a significant contributing condition. The facility’s own Change of Condition policy defined an acute change of condition as a sudden, clinically important deviation from baseline that, without intervention, may result in complications or death, and required staff to clearly document symptoms, condition changes, physician notifications, actions taken, and patient responses. However, the record review showed multiple instances where abnormal vital signs and significant changes in condition were either not followed by documented interventions or not accompanied by documented provider notification. The ADON stated they would report a blood pressure less than 110/60 and oxygen saturation less than 90% to a provider and claimed to have notified the nurse practitioner about the resident’s blood pressure of 73/47 and oxygen saturation of 84%, but could not recall whether they spoke directly or left a message and could not recall any resulting orders, and there was no documentation of this notification. These documented omissions and inconsistencies in monitoring, assessment, and communication regarding the resident’s diabetes, hypoglycemia risk, and abnormal vital signs formed the basis of the deficiency. The situation was determined by the state survey agency to constitute immediate jeopardy related to the facility’s failure to adequately monitor finger stick blood sugars and intervene for a resident with diabetes mellitus type 2 who was found unresponsive with hypoglycemia, and also related to the failure to monitor and intervene when the resident experienced a change in condition with abnormal vital signs. The immediate jeopardy determination was based on the facility’s alleged failures in monitoring, assessment, and intervention for this resident’s hypoglycemia and abnormal vital signs, as well as the lack of appropriate documentation and communication with the medical provider regarding these critical changes in condition.
Failure to Develop and Update Comprehensive Care Plans for Diabetes, AKI, and Weight Loss
Penalty
Summary
The facility failed to develop and implement complete care plans addressing all identified needs for two residents. For one resident with documented diagnoses of diabetes mellitus type 2 and acute kidney injury on the comprehensive admission assessment, the care plan dated 01/22/26 did not include these conditions as problems to be managed. Subsequent clinical events showed the resident was found unresponsive with a pulse of 28 and transferred to the emergency room, where the physician documented hypotension, hypothermia, a blood glucose level of less than 20, and critical illness with a high likelihood of death. The Certificate of Death later listed protein calorie malnutrition, cognitive impairment disorder, and acute kidney failure as causes of death, with diabetes mellitus noted as a significant contributing condition. The DON acknowledged that this resident should have had a care plan for monitoring kidney injury/failure and diabetes mellitus type 2. The facility also failed to incorporate recommended nutritional interventions and weight monitoring into the care plan for another resident experiencing weight loss. A Nutrition Therapy Assessment dated 03/25/26 recommended encouraging fluid intake with meals and snacks, providing a frozen nutrition treat, and obtaining weekly weights, and a physician order directed weekly weights on day shift for four weeks or until stable. However, the resident’s care plan did not include these recommended interventions. A weight report showed an 8.5% weight loss over six months, and a quarterly assessment documented severe cognitive impairment (BIMS score of 3) and a diagnosis of severe protein calorie malnutrition. The MDS coordinator stated that care plans were updated when there was a 10% change in weight and acknowledged that the interventions from the nutrition therapy assessment were appropriate but were not added to the care plan.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Ensure Availability of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available and administered as prescribed for one resident. Facility policy dated 01/2024 required medications to be administered as prescribed in accordance with manufacturers’ specifications and good nursing practices. Physician orders for the resident included divalproex 125 mg by mouth every 12 hours for unspecified dementia and levothyroxine 150 mcg by mouth in the early morning for hypothyroidism. Review of the resident’s February 2026 MAR showed multiple instances where levothyroxine doses were held due to unavailability on 02/07, 02/08, 02/14, 02/15, and 02/16 at 6:00 a.m., and one instance on 02/12 at 6:00 a.m. with no documentation. The MAR also showed divalproex doses held on 02/15 and 02/16 at 9:00 a.m. due to unavailability. During interviews, CMA #2 stated the process to ensure medications were available was to order medications daily, typically when the supply was down to five days or less, and to call the pharmacy and notify the nurse if a medication was not in the building. CMA #2 also stated that when a medication was not available, they left the medication up on the MAR and notified the nurse, pharmacy, and then the DON. The DON and regional consultant stated medications should be ordered when down to a seven-day supply and, if not available, the physician and DON should be notified and the medication ordered STAT from the pharmacy. CMA #1 confirmed that an “H” on the MAR indicated a hold and verified that the resident’s levothyroxine and divalproex doses on the specified February dates were held because the medications were unavailable and needed to be ordered STAT, indicating the medications were not in the building at those times.
Unsecured Computer Screen Exposed Resident Medical Records
Penalty
Summary
The facility failed to maintain privacy and confidentiality of residents' medical records when a laptop on a treatment cart in hall 8 was left unlocked with the electronic medical record visible while unattended. During observation, an LPN left the treatment cart positioned in front of a resident room with the computer screen facing the hallway and went inside the room, leaving the screen exposed and displaying resident medical information. While the LPN was inside the room, a resident approached the cart, faced the computer, and spoke to the LPN from the doorway, with the medical record still visible on the screen. The facility’s Medication Administration policy stated that resident health information must remain private and that MAR pages containing resident health information must remain closed or covered when not in direct use. The LPN stated they did not think leaving the screen exposed was a big deal because they returned quickly and also stated they were unsure how to lock the computer screen. The regional consultant and DON later stated that the policy and procedure for securing computers was to minimize or close the screen when not actively in use by staff. The administrator identified that 105 residents resided in the facility at the time of the survey, and the deficiency was cited for 1 of 1 treatment cart observed with an unsecured computer displaying medical records in a public hallway area.
Failure to Provide Timely Incontinent Care and Change Soiled Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and change soiled linens for a resident who required assistance with activities of daily living. Surveyors observed a strong urine odor and an overly urine-saturated brief in the trash can in the resident’s room in the early afternoon. The resident’s bed had a visible wet ring in the center of the mattress, and the blanket, sheet, and cloth pad that had been removed from the bed and placed on the floor were wet. The facility’s perineal care policy required staff to provide perineal care in accordance with standards of practice to prevent skin breakdown and infection, dispose of used supplies, perform hand hygiene, and apply a new brief and change linens as needed. The resident’s admission assessment showed the resident was cognitively intact, occasionally incontinent of bladder, required partial/moderate assistance with toileting, and was dependent for bed mobility. The resident stated they were not soiled and reported staff had gotten them out of bed just before lunch. A CNA reported that when they went to the room around 1:00 p.m. or earlier to get the resident out of bed for therapy, the resident was wet, and the CNA changed the resident’s clothes but did not make the bed afterward. The CNA verified the sheet and linens were wet. The DON stated that staff were expected to check incontinent residents at least every two hours, clean and dry them if soiled, and change linens as needed when soiled, and confirmed observing the wet linens and wet ring on the resident’s bed.
Unattended Unlocked Treatment Cart Left Accessible in Hallway
Penalty
Summary
The facility failed to ensure a treatment cart on hall 8 was secured when staff were not in attendance, contrary to facility policy requiring medication carts to be closed and locked when out of sight of the medication nurse. On 03/04/26 at 12:26 p.m., an LPN left the treatment cart unlocked in the hallway and went inside a resident room, positioning the cart slightly sideways near the wall with the front of the cart facing the hallway. At 12:27 p.m., an unidentified resident approached the front of the unattended, unlocked treatment cart and spoke to the LPN from the doorway while the LPN remained inside the room. The facility’s Medication Administration policy, dated 01/2024, stated that during medication administration the cart must be kept closed and locked when out of sight and must be clearly visible to the personnel administering medications when unlocked. When interviewed at 12:29 p.m., the LPN stated they did not think leaving the cart unlocked was a big deal because they returned quickly. Later, at 2:32 p.m., the regional consultant and the DON confirmed that the policy and procedure for treatment/medication cart storage required carts to be locked anytime staff were not in attendance of the cart. The administrator identified that 105 residents resided in the facility at the time of the survey.
Failure to Follow Hand Hygiene and Glove Protocol During Perineal Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices, specifically hand hygiene and glove use, during perineal care for one resident. During an observation of incontinent care, a CNA performed perineal care on a resident who was dependent for toileting and bed mobility and frequently incontinent of bowel and bladder. After the resident had a bowel movement, the CNA wiped stool from the resident and was observed wiping stool from their gloved hand onto the pad under the resident. Without changing gloves, the CNA then placed a clean brief under the resident, touched the wipes package, placed it on the resident's table, turned the resident, and continued to touch the resident, the wipes package, and a cleaning solution with the same contaminated gloves. The CNA continued the care by fastening the clean brief, removing the soiled pad and placing it at the foot of the bed, and putting clean pants on the resident, all without changing gloves. The CNA then touched the resident's covers and draw sheet with the same gloved hands. At the end of care, the CNA removed their gloves, took the trash, and left the room without performing hand hygiene after glove removal or before handling the trash. There was no observation that hand hygiene was performed at any point. The facility's perineal care policy required staff to remove feces, dispose of gloves and used supplies, perform hand hygiene, and then apply new gloves before placing a new brief and changing linens. The resident involved had active diagnoses of urinary tract infection and septicemia. In a subsequent interview, the CNA stated that gloves were supposed to be changed after cleaning stool and after completing incontinent care and acknowledged they did not think they changed their gloves because they were nervous.
Failure to Provide and Document Scheduled Bathing for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents dependent on staff for bathing received scheduled showers or baths, as required by their care plans and facility policy. For each of the three residents reviewed, there was a lack of documentation showing that showers or baths were provided on the scheduled days across multiple weeks in February, March, and April. The facility's policy required staff to provide bathing services and document any refusals or missed baths, but records were incomplete or missing. Interviews with residents and family members confirmed that showers were not consistently provided as scheduled, and staff were unable to produce documentation to verify that bathing occurred as required. The residents involved had significant care needs, including hemiplegia, hemiparesis, intellectual disabilities, reduced mobility, heart failure, and muscle weakness. Assessments indicated that these residents required partial to maximum assistance with bathing and were cognitively intact or moderately impaired. Despite these needs, the facility did not maintain adequate records or ensure that scheduled bathing was completed, as confirmed by the DON, staffing coordinator, and administrator, who acknowledged the lack of documentation and inability to verify that care was provided as scheduled.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for three residents who were sampled for timely medication administration. Review of the facility's policy indicated that medications should be given within a defined window of time, and any missed doses should be documented with an explanation. However, medication administration records for all three residents showed multiple missed doses of various prescribed medications, with no explanations documented in the medical records for these omissions. For one resident with diagnoses including hypertensive chronic kidney disease and type II diabetes mellitus, missed doses included antihypertensives, insulin, and other critical medications over several days. Another resident with a history of convulsions, encephalitis, and edema had missed doses of anticonvulsants, diuretics, and statins, again with no documentation explaining the missed doses. A third resident with chronic kidney disease, atrial fibrillation, and insomnia also had several missed doses of anticoagulants, diuretics, and other medications, with no recorded reasons for the omissions. Interviews with facility staff, including the corporate nurse consultant and the DON, confirmed that there was no way to determine if the missed doses were actually administered, as staff were not documenting appropriately on the medication records. The lack of documentation and unexplained missed doses directly contravened facility policy and physician orders, resulting in a deficiency related to pharmaceutical services and medication administration.
Failure to Notify Resident's Representative After Hospital Transfer Due to Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative after the resident experienced a fall that resulted in a head injury and required transport to the hospital. The resident, who had intellectual disabilities, reduced mobility, and was cognitively intact, fell in the bathroom, sustained a swollen area above the left eye, and was subsequently sent to the emergency room for evaluation. The facility's policy required notification of family or representatives in the event of significant injury or transfer to another healthcare setting. Despite this policy, the resident's family was not informed by the facility about the fall or the hospital transfer. Instead, the family was contacted by hospital emergency room staff to pick up the resident after evaluation. Interviews with facility staff revealed confusion regarding the location of emergency contact information in the new EHR system, with multiple staff members assuming others had notified the family. The DON confirmed that staff were looking in the wrong area of the EHR and acknowledged that the family should have been notified according to policy.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to follow infection prevention and control protocols during wound care for a resident with pressure ulcers. The LPN performed hand hygiene and donned gloves prior to starting, but did not wear a personal protective gown as required under Enhanced Barrier Precautions (EBP) for residents with wounds. During the procedure, the resident was found to be incontinent of bowel, and the LPN cleaned the area but did not perform hand hygiene or change gloves before proceeding with wound care on the resident's left lower back and sacrum. The LPN also touched personal items, wrote on wound dressings, applied a new brief, and repositioned the resident without changing gloves or performing hand hygiene between these activities. Facility policies required the use of gowns and gloves during high-contact care activities, such as wound care, under EBP, and specified hand hygiene before and after care, especially when hands become soiled. The resident involved had a history of pressure ulcers and protein-calorie malnutrition, with physician orders for specific wound care procedures. The LPN later acknowledged not being educated on EBP and was unaware of the need for a gown during wound care for residents with pressure ulcers. The Director of Nursing confirmed that EBP should have been followed and that the LPN's actions did not meet infection control standards.
Failure to Provide and Document Bathing Assistance
Penalty
Summary
The facility failed to provide bathing services for a resident who required substantial to maximum assistance with bathing, as documented in their admission assessment. The facility's policy required staff to provide bathing services within standard practice guidelines. During the resident's stay, a CNA was unaware of the resident's shower schedule, and the interim DON was unable to locate any documentation indicating that bathing was provided. This lack of documentation and staff awareness resulted in the failure to ensure the resident received necessary bathing care as required by facility policy and the resident's assessed needs.
Failure to Investigate Missing Medication Doses
Penalty
Summary
The facility failed to conduct a thorough investigation after receiving an allegation of missing doses of medication for a resident diagnosed with type 2 diabetes mellitus and end-stage renal disease. The resident was prescribed Ozempic 2mg via subcutaneous injection every Wednesday. According to the Medication Administration Record (MAR), the medication was administered as ordered in December and early January. However, the resident reported issues with receiving the correct dosage for three weeks in December and mentioned not receiving the medication at all for one week. Additionally, the resident reported that their Ozempic pen, which had two doses remaining, went missing after being left out to warm by a registered nurse (RN). The RN confirmed that the pen was missing and reported the incident to the Director of Nursing (DON), who attempted to locate the pen but did not initiate an investigation or report the incident to the administrator. The pharmacist corroborated that there should have been two doses remaining in the pen based on the prescription fill dates. When questioned, the administrator stated they were unaware of the incident and acknowledged that an investigation should have been initiated. This lack of action and communication led to a deficiency in the facility's handling of the alleged violation.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required time frame for a resident. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, an admission assessment must be completed no later than the 14th day of the resident's admission. A resident, who was admitted with diagnoses including type 2 diabetes mellitus and a stage 4 pressure ulcer of the sacral region, did not have a comprehensive MDS assessment documented in their electronic health record (EHR). The Director of Nursing (DON), upon reviewing the resident's clinical record and consulting with the MDS coordinator, acknowledged that no comprehensive MDS assessment had been completed since the resident's admission.
Medication Administration Error Due to Improper Resident Identification
Penalty
Summary
The facility failed to ensure that a resident did not receive the wrong medications, affecting one of the three sampled residents reviewed for medication administration. The incident involved a resident with diagnoses of pneumonia and deep vein thrombosis, who was mistakenly given medications intended for another resident. The medications administered in error included aspirin, buspirone, linezolid, and potassium chloride. This error was documented in an incident report and a nurse's note, both dated December 25, 2024. The Director of Nursing (DON) acknowledged the incident but did not provide documentation that the Quality Assurance and Performance Improvement (QAPI) committee reviewed the incident or that staff, including the Certified Medication Aide (CMA) involved, received in-service training to prevent recurrence. The CMA responsible for the error stated that residents are identified using pictures in the Electronic Health Record (EHR), names posted outside doors, and personal familiarity over time. However, this method failed to prevent the medication error.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment, as observed during a survey. The observations revealed several deficiencies, including torn and raised carpets, missing and damaged tiles, peeling wallpaper, exposed wires, and strong odors of urine. These issues were noted in multiple rooms and hallways, indicating a widespread problem. The facility's Resident Room Cleaning policy aimed to provide a clean and safe environment, but the maintenance work order log showed that repairs were not completed, and some issues had persisted for at least a year. Residents expressed dissatisfaction and concern about the unsafe and unclean conditions, with one resident reporting a fall due to the carpet tear. The housekeeping supervisor acknowledged the disrepair and stated that maintenance was aware of the issues but had not effectively addressed them. The Regional Director of Plant Operations and the Regional Director of Operations confirmed the unsafe conditions and admitted that the facility did not maintain a homelike environment, as required by their policy.
Unsafe Food Handling Practices in Tray Line
Penalty
Summary
The facility failed to ensure safe food handling practices during meal preparation and distribution, specifically regarding the sanitary condition of cereal bowls on the tray line. On September 3, 2024, it was observed that bowls of cereal were unwrapped, stacked, and stored in a manner that allowed the bottom of the bowls to come into contact with the cereal product. This practice was contrary to the expected standard, as reported by Kitchen Aide #1, who stated that the bowls were supposed to be wrapped and not stacked on each other. On September 10, 2024, the Dietary Manager acknowledged that the handling of the cereal bowls was an infection control issue and confirmed that there was no existing policy to address this specific issue. The Director of Nursing (DON) indicated that 101 residents received nutritional meals from the kitchen, highlighting the potential impact of this deficiency on a significant number of residents.
Failure to Cover Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of a resident by not covering a catheter bag with a vanity bag, as required by their policy. This deficiency was observed in the case of a resident who was admitted with acute respiratory failure with hypoxia and cellulitis. The facility's policy, revised on January 12, 2023, mandates that drainage bags should be covered with a privacy bag as necessary. However, during two separate observations, the resident's catheter bag was found uncovered and visible from the hallway, which was against the facility's policy. Interviews with staff members, including a CNA, an LPN, and a corporate nurse, confirmed the visibility of the uncovered catheter bag from the hallway. The CNA and LPN acknowledged that the facility's policy required the catheter bag to be covered with a vanity bag to maintain the resident's dignity. The corporate nurse, however, was unsure if the policy required the bag to be covered while in the resident's room. This inconsistency in policy understanding and implementation led to the deficiency in maintaining the resident's dignity.
Failure to Offer Advance Directive Formulation
Penalty
Summary
The facility failed to ensure that residents were offered the choice to formulate an advance directive, as evidenced by the case of one resident among a sample of 32 whose advance directive acknowledgments were reviewed. The facility's policy, revised on March 27, 2023, mandates that the Director of Admission complete and scan the Advanced Directive Acknowledgment Form into the resident's electronic medical record (EMR) during the admission process. However, for a resident admitted with diagnoses including multiple sclerosis and paraplegia, there was no documentation in the EMR indicating assistance with formulating an advance directive. During an interview, Corporate Nurse #1 confirmed that an audit of the charts revealed the absence of an advanced directive acknowledgment for this resident.
Failure to Document Alleged Abuse Incident
Penalty
Summary
The facility failed to document an alleged abuse incident involving a resident diagnosed with Hypertensive Chronic Kidney Disease and Anxiety Disorder. The facility's policy, dated 06/23/17, requires that all incidents of alleged abuse or neglect be documented on incident reports and forwarded to the Abuse Counselor. However, on 09/20/24, it was found that there was no record of an initial report for the alleged abuse reported by the resident. An LPN reported that a CMA had received the allegation from the resident on 09/06/24 during a shift change but failed to document it. The Director of Nursing confirmed that the company policy mandates the person receiving the allegation to complete an incident report, which was not done in this case.
Failure to Complete Timely Quarterly Assessments
Penalty
Summary
The facility failed to ensure that quarterly assessments for residents were completed within the required 92-day timeframe. Specifically, two residents, identified as Resident #1 and Resident #25, did not have their Minimum Data Set (MDS) assessments completed within the stipulated period. Resident #1, who was admitted with diagnoses including morbid obesity and hypotension, had a quarterly assessment with an Assessment Reference Date (ARD) of 04/25/24, but no subsequent assessment was completed by 07/25/24. Similarly, Resident #25, admitted with conditions such as epilepsy and major depressive disorder, had an ARD of 04/06/24, but no assessment was completed by 07/05/24. Corporate Nurse #1 confirmed the absence of these assessments upon review, acknowledging the oversight.
Inaccurate MDS Discharge Documentation
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) records accurately reflected the resident's discharge status. Specifically, the MDS assessment records incorrectly documented that the resident was discharged to the hospital, while nursing notes and physician orders indicated that the resident was discharged home. This discrepancy was identified during a review of the resident's records, which included a phone call arrangement for the resident to be discharged home and physician orders confirming the discharge home. The MDS Coordinator acknowledged the error in coding the resident's discharge status. Additionally, the facility's Administrator reported that there was no existing policy for addressing inaccurate MDS documentation.
Failure to Maintain Safe Environment Leads to Resident Fall
Penalty
Summary
The facility failed to maintain a safe environment for its residents, resulting in a fall incident involving a resident with Parkinson's disease, dementia, and bipolar disorder. The resident, who was cognitively intact and used a walker for ambulation, fell due to uneven flooring and not using their walker. The incident report noted a skin tear and pain in the resident's left arm as a result of the fall. Despite the facility's Fall Management policy, which requires immediate investigation and intervention to prevent future falls, the intervention plan only included educating the resident to use their walker and did not address the torn and frayed carpet that contributed to the fall. Observations and interviews revealed that the carpet in the resident's room was torn and frayed, with strings and raised areas, and the bathroom tiles were missing or damaged. The housekeeping supervisor confirmed the carpet had been in disrepair for at least a year, and maintenance was aware of the issue. However, the Director of Plant Operations was unaware of the damaged carpet and acknowledged that the work order for repairs was not completed. The failure to repair the carpet and ensure a safe environment directly contributed to the resident's fall.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure allegations of abuse were reported to the Oklahoma State Department of Health (OSDH) for seven residents. The facility's policy required timely investigation and reporting of abuse allegations to state and local agencies, but this was not adhered to. For instance, Resident #1 had multiple incidents where abuse was alleged, including being held down against their will and having their mouth covered by a staff member. These incidents were not reported within the required time frames, and some were not reported at all. Additionally, Resident #1's claims of being mistreated by staff were not followed up with proper investigations or timely reports to the OSDH. Resident #10 reported that a therapy staff member was not being nice, which was not reported to the OSDH. Similarly, Resident #11 mentioned that staff sometimes took a long time to answer call lights, especially in the evening and night, but this was also not reported. Resident #4 had multiple incidents, including making threats to another resident, leaving the facility without notifying anyone, and displaying inappropriate behavior in the dining room. These incidents were not reported to the OSDH as required. Other residents, including Resident #7, Resident #3, and Resident #9, also reported concerns about staff treatment and interactions with other residents. These allegations were not documented or reported to the OSDH. The Director of Nursing (DON) and Corporate RN acknowledged that these incidents should have been reported but were not. The facility's failure to report these allegations of abuse, neglect, and resident-to-resident altercations within the required time frames constitutes a significant deficiency in compliance with federal and state regulations.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to fully investigate allegations of abuse for nine of eleven sampled residents. The facility's policy on Abuse, Neglect, and Exploitation requires timely investigations upon receiving an allegation, but this was not adhered to in multiple instances. For example, Resident #1's complaints of being held down and having their mouth covered by a CNA were not investigated, and there was no documentation of an investigation into the resident's disruptive behavior to ensure other residents were not fearful. Similarly, Resident #10's and Resident #11's complaints about staff treatment were not investigated, despite being documented in incident reports. Resident #2, who had severe cognitive impairment, reported through a hospital liaison that a nurse had slapped them twice, but the facility only interviewed the resident's family and did not conduct a thorough investigation involving other residents or staff. Resident #4, who had moderate cognitive impairment, made threats to another resident and left the facility without notifying anyone, but these incidents were not investigated. Additionally, Resident #4's altercations with other residents in the dining room were not investigated. Other residents, including Resident #7, Resident #3, and Resident #9, also reported concerns about staff treatment and interactions with other residents, but these allegations were not investigated. The Director of Nursing (DON) and Corporate RN acknowledged that these incidents should have been investigated but were not. The lack of thorough investigations into these allegations of abuse and neglect indicates a significant deficiency in the facility's adherence to its own policies and regulatory requirements.
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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