Senior Suites Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Broken Arrow, Oklahoma.
- Location
- 3501 W Washington Street, Broken Arrow, Oklahoma 74012
- CMS Provider Number
- 375528
- Inspections on file
- 26
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Senior Suites Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete Section C (cognitive patterns) of the MDS for four sampled residents, including on admission, quarterly, and annual assessments. Despite a written policy stating that MDS assessments would be conducted and submitted according to federal and state timeframes, these assessments were marked as "not assessed" in the cognitive section. During interviews, the MDS coordinator acknowledged that the cognitive sections should have been assessed and answered, and the DON was unable to explain why they were left incomplete, confirming they should have been completed.
Surveyors found that required MDS assessments were not electronically submitted to CMS within the required timeframe for two residents. Facility policy assigns responsibility to the assessment coordinator or designee to ensure timely submission of assessments in accordance with federal and state guidelines. Record review showed that one resident’s discharge assessment and another resident’s annual assessment had not been submitted, and the MDS coordinator confirmed that the RN who reviewed and signed these assessments did not complete the submission process.
The facility failed to conduct required quarterly care plan meetings with two cognitively intact residents and their representatives, contrary to its own policy and leadership expectations. One resident with multiple sclerosis and dementia had not had a care plan meeting since late the previous year and reported that care plan meetings were not being held. Another resident with a history of stroke and hypertension had not had a care plan meeting for many months, and a family member reported that a recently scheduled meeting was canceled due to lack of available staff, with no subsequent meetings held. The SSD acknowledged that quarterly care plan meetings were not being completed as required, and the DON stated that care plan meetings should occur on admission, quarterly, and as needed.
Surveyors found that the facility’s binding arbitration agreement did not clearly state that signing was not required for admission, despite facility policy stating arbitration is voluntary and not a condition of admission or care. The form used for multiple residents only indicated that signing was not a precondition to the “furnishing of services,” without explicitly addressing admission. During interview, the SSD acknowledged that this wording did not clearly communicate that admission was not dependent on signing the arbitration agreement.
Surveyors found that the facility’s binding arbitration agreements did not include required provisions for mutual selection of a neutral arbitrator or for a mutually convenient venue, despite the facility’s policy stating these elements must be present. For multiple residents, the arbitration forms either signed or presented for signature lacked any language about both parties choosing an arbitrator together and instead specified that, if no venue was agreed upon, arbitration would default to being held at the facility. During interview, the SSD confirmed they did not see any description of an arbitrator selection process in the agreement and understood the venue to default to the facility if mutual agreement could not be reached.
A resident with a PEG feeding tube and severely impaired cognition was cared for without required Enhanced Barrier Precautions (EBP) despite a facility policy stating that residents with indwelling medical devices, including feeding tubes, require gown and gloves for tube care and use. The resident’s room lacked EBP signage and readily accessible PPE, and the treatment administration record did not include an EBP order. On several occasions, an LPN and an RN performed PEG residual checks, tube feeding, medication administration, and a dressing change using only hand hygiene and gloves, without donning gowns, even though the DON later confirmed that gown and gloves were required for this resident’s PEG-related care.
A resident with moderate cognitive impairment was receiving a daily antidepressant (fluoxetine 10 mg) under a physician’s order, and the care plan directed staff to monitor and document medication side effects and effectiveness. Facility policy required proactive monitoring and documentation of side effects for all medications, including psychotropics. However, review of the treatment administration record over several months showed no documentation of side effect monitoring for this resident, and the DON confirmed that no such monitoring had occurred, despite many residents in the facility receiving psychotropic medications.
The facility failed to follow its F609 abuse reporting policy requiring that allegations of abuse be reported to state and local authorities within two hours. A family member informed staff of an alleged act of abuse involving a resident, but the DON did not notify the administrator until a later staff meeting, and the administrator did not submit reports to the state survey agency and local law enforcement until several days after staff first learned of the allegation. Both the administrator and DON acknowledged in interviews that the allegation should have been reported when staff were initially informed by the family.
A resident’s family reported an alleged act of abuse by a CNA to the DON during a care plan meeting, but the DON did not immediately initiate an investigation or remove the CNA from duty as required by facility policy. Facility records showed the CNA continued working several shifts after the allegation was known to the DON, and the administrator was not informed until later, at which point the CNA was suspended and the incident was reported to state authorities and law enforcement.
The facility failed to provide required written notices of transfer or discharge to residents or their representatives prior to transfers. The facility’s transfer/discharge policy did not include the requirement for written notification, and a resident sent to an acute care hospital for behaviors did not receive written notice before being transferred. An LPN reported never having heard of or provided written transfer notices, and the DON stated they were unaware of the requirement and confirmed that such notices had not been given, despite multiple resident discharges in the preceding months.
A resident was admitted and remained in the facility long enough to require a comprehensive, person-centered care plan per facility policy, but no such care plan was ever developed or documented in the EMR. The facility’s policy required completion of a comprehensive care plan within a set timeframe following the MDS admission assessment, yet both the MDS coordinator and the DON confirmed they could not locate any comprehensive care plan for this resident and acknowledged that it should have been completed within 14 days of the comprehensive assessment.
Surveyors found that the facility did not have a qualified activity director in place for a census of 74 residents, despite posted schedules for group activities such as coffee and conversations, bible study, and stretching. Residents were observed playing bingo with an automated bingo machine while a CMA sat at the table, rather than a qualified activities professional directing the program. A social worker reported that they or other staff assisted with activities and were unsure how long the facility had been without an activity director, and the administrator confirmed there had been no full-time activity director for several weeks, even though resident rights materials stated that a program of activities would be provided to meet residents’ needs and interests.
The facility failed to maintain and document required temperature monitoring for one of two medication refrigerators. During observation of a medication room with the DON, surveyors found a full-size refrigerator containing medications without a temperature log for the current month attached. Review of the facility’s Storage of Medications policy showed that medications must be stored under proper temperature controls. The DON stated they were unable to locate the missing temperature log and acknowledged that it should have been kept on the refrigerator and completed.
Surveyors found that a mini refrigerator in a medication room, which the DON stated was designated for resident food items, contained both food and a urine specimen. The refrigerator held bacon, protein shakes, ice cream, and mighty shakes, as well as a urine specimen cup half-filled with a yellow substance, sealed in a plastic lab bag, and labeled with the name of a former resident. The specimen was placed directly on top of the ice cream and mighty shakes. The DON acknowledged that the urine specimen should not have been stored in that refrigerator and identified this as an infection control issue, with 74 residents residing in the facility at the time.
A resident who required stand-by assist with ambulation did not have a functioning call light in their room and bathroom/bathing area. When the resident pressed the call light, the corridor light above the door did not activate and the room number did not appear on the nurses’ station monitor. The resident reported the call light had not worked even after the cord was replaced. Review of the maintenance logbook showed no prior entries for call light repairs until a CNA documented that this resident’s call light and another room’s call light were not working. Staff, including a CMA and CNA, reported that call lights and monitors did not always work and that problems occurred almost daily, while the DON acknowledged that issues had been reported verbally rather than documented as required by facility policy.
A computer displaying protected health information was left open and unattended on a medication/treatment cart at a nurses station, with no staff present. A CMA later closed the computer, and both the administrator and the assigned RN confirmed that the computer should not have been left open with resident information visible.
A medication/treatment cart was found unlocked and unattended at a nurses station, with medications left on top, contrary to facility policy requiring secure storage. The assigned RN was not present, and a CNA later locked the cart. Both the administrator and RN acknowledged the cart should have been secured to prevent access by residents or visitors.
A resident with atrial fibrillation missed multiple doses of amiodarone due to facility staff's misunderstanding of administration parameters. The CMA and LPNs had incorrect interpretations of when to withhold the medication, leading to significant missed doses. The DON later clarified the correct parameters with the physician.
The facility's kitchen environment and equipment were not maintained in a clean and safe condition, affecting meal preparation for 83 residents. Observations included a broken container used for pureeing food, standing water, dust, mold, and structural damage in the kitchen and dish machine room. Staff were aware of these issues but cited budget constraints for not addressing them.
A facility failed to assess a resident with dementia for bed rail use before installation. The resident's medical record lacked an assessment, and bed rails were observed on both sides of the bed. The administrator noted that the assessment page did not automatically populate, leading to the oversight.
A facility failed to follow its Enhanced Barrier Precautions policy during wound care for a resident with a sacral pressure ulcer. The policy required gowns and gloves for such care, but an RN and an LPN only wore gloves. The RN stated no additional measures were needed, and the LPN indicated gowns and masks were used only for MRSA cases. The administrator confirmed that gowns should have been worn.
The facility did not secure a surety bond with adequate coverage for the resident trust account, which had a balance of $18,330, while the bond covered only $10,000. The business office manager identified 15 residents with funds in the account. The corporate regional manager confirmed the bond's insufficiency and stated that the issue had been noticed the previous month, but it remained unresolved.
A facility failed to deposit a resident's personal funds exceeding $50 into an interest-bearing account separate from operational accounts. The resident had a credit balance of $1,471.00 in the facility's accounts receivable account, which was not transferred to the trust account. The corporate business office manager stated the funds were left in the operating system at the family's request, despite it not being interest-bearing. The corporate regional manager confirmed that resident funds should not be commingled with operating funds.
The facility failed to ensure timely availability of medications for a resident with acute kidney failure, resulting in a delay of over 24 hours in administering a prescribed antibiotic, contrary to facility policy requiring STAT orders to be fulfilled within four hours.
The facility failed to have an administrator of record between 11/23/23 and 01/18/24. The previous administrator left on 11/23/23, and the new administrator started on 01/18/24. The current administrator could not identify an interim administrator during this period, and no documentation was provided. This affected the management of the facility, which housed 76 residents.
Incomplete MDS Cognitive Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate and complete Minimum Data Set (MDS) assessments, specifically in Section C: Cognitive Patterns, for four of twenty-one sampled residents. A facility document titled “MDS Completion and Submission Timeframes,” dated October 2023, stated that the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. However, record review showed that a quarterly assessment for Resident #57 dated 11/01/25, an admission assessment for Resident #87 dated 11/21/25, an annual assessment for Resident #44 dated 12/11/25, and a quarterly assessment for Resident #69 dated 12/12/25 all had Section C marked as “not assessed” and left incomplete. During interviews on 02/12/26, the MDS coordinator acknowledged in each case that Section C should have been assessed and answered, and the DON stated they could not explain why Section C was not completed and confirmed it should have been assessed and answered correctly. These findings occurred in a facility where the administrator identified that 74 residents resided, and the deficiency was identified through record review and staff interviews focused on MDS accuracy for sampled residents.
Failure to Submit MDS Assessments to CMS Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit required Minimum Data Set (MDS) resident assessments to CMS within the mandated timeframe. Facility policy dated 10/01/23 states that the assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS’ Internet Quality Improvement Evaluation System in accordance with current federal and state guidelines, which require submission within 7 days of assessment. Record review showed that a discharge assessment for Resident #27, dated 11/07/25, and an annual assessment for Resident #13, dated 12/30/25, had not been submitted to CMS. During an interview on 02/10/26 at 1:55 p.m., the MDS coordinator confirmed that the MDS assessments for Resident #13 and Resident #27 were not submitted to CMS by the RN who reviewed and signed the assessments. The administrator reported that 74 residents resided in the facility at the time of the survey, and the two residents cited were part of the sample reviewed for MDS submission compliance.
Failure to Hold Required Quarterly Care Plan Meetings With Residents and Representatives
Penalty
Summary
The deficiency involves the facility’s failure to hold required quarterly care plan meetings with residents and/or their representatives, despite policy stating that residents and their representatives are encouraged to participate in the development and implementation of care plans. For one resident with multiple sclerosis and dementia, an annual assessment documented a BIMS score of 14, indicating the resident was cognitively intact, and the record showed the last care plan meeting occurred in November 2024. During interview, this resident stated the facility had not been having care plan meetings. The Social Services Director (SSD) acknowledged that quarterly care plan meetings had not been completed as required, and the DON stated that care plan meetings should occur upon admission, every quarter, and as needed. For another cognitively intact resident with a BIMS score of 13 and diagnoses including stroke and hypertension, the health record showed the last care plan meeting was held in early May 2024. The resident’s family member reported they had not had any care plan meetings and stated that a care plan meeting scheduled for the prior month was canceled because no staff were available to attend at the scheduled time. The family member further stated they were informed by staff that they were trying to get back to having regular care plan meetings. The SSD again confirmed that quarterly care plan meetings were not being held as required, and the DON reiterated that care plan meetings should be conducted upon admission, quarterly, and as needed.
Arbitration Agreement Lacked Clear Statement That Signing Was Not Required for Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure its binding arbitration agreement contained an explicit statement that signing the agreement was not a condition of admission, as required by its own policy and regulatory expectations. The facility’s Binding Arbitration Agreements policy dated 11/2023 stated that arbitration agreements are voluntary, that residents are not compelled, pressured, or coerced to enter into such agreements, and that it would be unambiguously communicated that arbitration is optional and not required as a condition of admission or to receive care. However, the actual arbitration agreement form used for three sampled residents included language stating only that execution of the arbitration agreement was not a precondition to the “furnishing of services” to the resident by the facility, without clearly addressing admission status. Record review showed that one resident’s representative signed the arbitration agreement, another resident’s representative refused to sign, and a third resident signed the agreement, all on the same form containing the “furnishing of services” language. For each of these residents, the agreement did not explicitly state that admission to the facility was not dependent on signing the arbitration agreement. During an interview, the SSD acknowledged that the portion of the binding arbitration agreement using the phrase “furnishing of services” did not clearly state that admission to the facility was not contingent on signing the agreement and stated that the wording was not clear enough. The administrator identified that 74 residents resided in the facility at the time of the survey.
Failure to Include Mutual Arbitrator and Venue Provisions in Arbitration Agreements
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its binding arbitration agreements contained required stipulations for the mutual selection of a neutral arbitrator and a mutually convenient venue, as outlined in its own Binding Arbitration Agreements policy dated 11/2023. The policy stated that arbitration agreements must provide for the selection of a neutral, impartial arbitrator agreed upon by both parties, and that the venue must be convenient to and agreed upon by both parties, with consideration of the resident’s ability to get to the venue. Record review showed that the facility’s standard arbitration agreement form did not include language about mutual selection of an arbitrator, and instead specified that if the parties could not agree on a venue, the arbitration would occur at the facility. For one resident, an arbitration agreement dated 04/02/25 was signed by the resident’s representative on 04/15/25 and lacked any stipulation regarding mutual selection of an arbitrator, while stating that if no venue was agreed upon, arbitration would take place at the facility. For another resident, an arbitration agreement dated 07/28/25, which the resident’s representative refused to sign, also lacked language on mutual arbitrator selection and contained the same default venue-at-the-facility clause. A third resident’s arbitration agreement, dated and signed on 01/07/26, similarly omitted any provision for mutual selection of an arbitrator and included the same venue default. During an interview on 02/12/26 at 12:34 p.m., the SSD, after reviewing the binding arbitration agreement, stated they did not read anything about the process of choosing an arbitrator and explained that while the venue would be selected mutually, if the parties could not agree, arbitration would occur at the facility.
Failure to Use Enhanced Barrier Precautions for PEG Tube Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) policy for a resident with a percutaneous endoscopic gastrostomy (PEG) feeding tube. The resident, who had severely impaired cognition, a feeding tube, and a diagnosis of transient ischemic attack, was observed in a room without EBP signage and without readily accessible personal protective equipment. Facility policy dated 04/01/25 specified that residents with indwelling medical devices, including feeding tubes, required EBP, with staff wearing a gown and gloves for feeding tube care or use. The treatment administration record for the resident for the month of February did not include any order for enhanced barrier precautions. On multiple observed occasions, licensed nursing staff did not follow the EBP requirements while providing PEG tube-related care to this resident. An LPN checked PEG tube residuals and flushed the tube using only hand hygiene and gloves, without donning a gown. On two separate occasions, an RN checked residuals, administered scheduled medications and feeding via the PEG tube, and later performed a dressing change to the PEG tube site, each time wearing gloves but not a gown. The DON confirmed that enhanced barrier precautions, including gown and gloves, should have been used for this resident during direct care, PEG tube feeding, and medication administration, and the RN acknowledged failing to wear a gown during these procedures.
Failure to Monitor and Document Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure ongoing side effect monitoring for a resident receiving a psychotropic medication. Facility policy on monitoring and reduction of unnecessary medications required staff to proactively monitor medication side effects, document findings, and collaborate with providers to adjust or discontinue medications when appropriate. A physician’s order dated 08/29/25 directed that Resident #19 receive fluoxetine 10 mg PO daily, and a quarterly assessment dated 12/12/25 documented that the resident, who had a BIMS score of 12 indicating moderate cognitive impairment, routinely received an antidepressant. The resident’s care plan, dated 12/31/25, included an intervention for depression specifying that medications were to be administered as ordered and that side effects and effectiveness were to be monitored and documented. However, review of the treatment administration record from 08/29/25 through 02/10/26 revealed no documentation of side effect monitoring, and on 02/11/26 the DON confirmed that no side effect monitoring had taken place for this resident. This deficiency involved one of five sampled residents reviewed for unnecessary medications, and the DON identified that 60 residents in the facility were receiving psychotropic medications.
Failure to Timely Report Alleged Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to timely report an allegation of abuse to the Oklahoma State Department of Health (OSDH) and local law enforcement within two hours of becoming aware of the allegation, as required by its Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation – F609 policy. The policy, dated 2001, stated that all reports of resident abuse, including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property, would be reported to local, state, and federal agencies as required by regulations, and that such reports would be made within two hours. An initial incident report showed that on 01/27/26 facility staff were informed by a family member of an alleged act of abuse against Resident #10, one of three sampled residents reviewed for abuse, in a facility with 74 residents. However, the incident report documented that the administrator did not report the allegation to OSDH and local law enforcement until 02/03/26. In interview, the administrator stated they first became aware of the allegation on 02/03/26 during a morning staff meeting when the DON reported learning of the incident on 01/27/26, and acknowledged the reports should have been made on 01/27/26 when staff were first informed by the family. The DON confirmed in interview that they informed the administrator of the alleged abuse at the staff meeting on 02/03/26 and acknowledged they should have reported it earlier.
Failure to Timely Investigate Abuse Allegation and Remove Alleged Perpetrator from Duty
Penalty
Summary
The deficiency involves the facility’s failure to timely investigate an allegation of abuse and to prevent the alleged perpetrator from working with the alleged victim in accordance with its abuse policy. The facility’s Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation – F609 policy required that all reports of resident abuse be thoroughly investigated by management, that the alleged perpetrator and victim be kept apart, and that the alleged perpetrator be placed on leave until the investigation was completed. An initial incident report documented that on 01/27/26, facility staff were informed by a family member of an alleged act of abuse against Resident #10, and that the family member identified CNA #1 as the alleged perpetrator. The Director of Nursing (DON) stated they learned of the accusation during a care plan meeting on 01/27/26. Despite this knowledge, facility records showed that CNA #1 continued to work at the facility on 01/29/26, 01/30/26, and 01/31/26, after the DON had been made aware of the allegation and before the administrator began the investigation on 02/03/26. The incident report also showed the administrator did not report the incident to the state survey agency and local law enforcement until 02/03/26. The administrator stated they first learned of the allegation against CNA #1 on 02/03/26 during a morning staff meeting with the DON, at which time they suspended CNA #1 and initiated the investigation. The DON later acknowledged that CNA #1 had not worked since 01/31/26 and stated they should have begun the investigation when they first learned of the allegation and immediately suspended the nurse aide.
Failure to Provide Required Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written notices of transfer or discharge to residents or their representatives prior to transfer, as evidenced by record review and staff interviews. The facility’s Transfer or Discharge policy dated April 2025 did not include the requirement to notify the resident or their representative in writing before a transfer or discharge. For one resident (Res #92) of three sampled for discharges, a nurse’s note dated 01/03/26 at 11:23 a.m. documented that the resident was sent to an acute care hospital for behaviors, but there was no written notice of transfer provided prior to this transfer. During an interview on 02/11/26 at 1:19 p.m., an LPN stated they had not heard of a written notice of transfer and had never given such a notice to any residents they had transferred or discharged. In a separate interview on 02/11/26 at 1:22 p.m., the DON stated they were unaware of the requirement for a written notice of transfer to be given to a resident or their representative prior to transfer or discharge and acknowledged that the facility had not been providing these notices to residents. The DON identified that 60 residents had been discharged during the three months prior to the survey, indicating that the lack of written transfer or discharge notices extended beyond the single sampled resident and reflected a broader practice consistent with the incomplete policy and staff unawareness of the requirement.
Failure to Develop Comprehensive Care Plan for Admitted Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable objectives and timetables for one resident, identified as #91, as required by its March 2022 Care Plans, Comprehensive, Person-Centered policy. The policy stated that comprehensive care plans must be completed within seven days of the required MDS assessment and no more than 21 days after admission. Admission records showed the resident was admitted on 10/07/25 and discharged on 11/23/25, and an admission assessment dated 10/14/25 confirmed the admission date. Review of the electronic medical record revealed that no comprehensive care plan had been developed for this resident during their stay. On 02/11/26 at 12:24 p.m., the MDS coordinator was unable to locate a comprehensive care plan for this resident in the electronic medical record and acknowledged that the resident had been in the facility long enough that a care plan should have been developed, stating it should have been completed no later than 14 days after the admission MDS assessment. At 12:48 p.m. the same day, the DON also confirmed they could not locate a comprehensive care plan for the resident and stated that both their expectation and facility policy required the comprehensive care plan to be developed within 14 days of completion of the resident’s comprehensive assessment.
Lack of Qualified Activity Director for Resident Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional, resulting in the absence of a full-time activity director for a census of 74 residents. On multiple observations, residents were seen participating in bingo games in the dining area, with an automated bingo machine calling numbers and a CMA present at the table, rather than a qualified activity director leading or overseeing the program. The posted activity board listed scheduled group activities such as coffee and conversations, bible study, and stretch sessions, but there was no indication of a qualified activities professional coordinating or conducting these programs. A Resident Rights poster stated the facility would provide a program of activities designed to meet residents’ needs and interests, yet the social worker reported that either they or another staff member would assist with activities and did not know how long the facility had been without an activity director. The administrator confirmed that the facility did not currently have a full-time activity director and that it had been “some weeks” since one was in place, acknowledging they were in the process of hiring but leaving the activities program without a qualified director during that period. No specific resident medical histories or clinical conditions were described in relation to this deficiency, only that 74 residents resided in the facility at the time of the survey.
Failure to Maintain Temperature Log for Medication Refrigerator
Penalty
Summary
The facility failed to ensure proper monitoring of medication refrigerator temperatures in one of two medication storage refrigerators, as required for safe storage of drugs and biologicals. During observation of medication room [ROOM NUMBER] with the DON, surveyors noted a full-size refrigerator containing medications that did not have a temperature record log attached for February 2026. Review of the facility’s Storage of Medications policy, dated 2001, showed that drugs and biologicals were to be stored under proper temperature controls. In an interview, the DON reported that they searched but were unable to locate the missing temperature log for the medication refrigerator in medication room [ROOM NUMBER] and stated that the log should have been kept on the refrigerator and completed in full. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Urine Specimen Improperly Stored in Refrigerator Used for Resident Food
Penalty
Summary
Surveyors observed that a mini refrigerator in medication room [ROOM NUMBER], designated for storing resident food items, contained both food and a urine specimen, in violation of infection control and food safety standards. On 02/10/26 at 9:33 a.m., the refrigerator was found to hold a box of bacon, two protein shakes, one individual-sized ice cream, and two mighty shakes, along with a urine specimen cup that was half-filled with a yellow substance and sealed in a plastic lab bag. The specimen cup, labeled with the name of a former resident, was placed directly on top of the ice cream and mighty shakes containers. At 9:37 a.m., the DON confirmed that the mini refrigerator in medication room [ROOM NUMBER] was intended solely for resident food storage and acknowledged that the urine specimen should not have been stored there, identifying it as an infection control issue. The facility administrator reported that 74 residents resided in the facility at the time of the survey. The report does not provide additional clinical details or medical history about the former resident whose name appeared on the urine specimen cup, nor does it describe the condition of any specific resident at the time of the deficiency.
Failure to Maintain Operational Call Light System for Resident Room and Bathroom
Penalty
Summary
The facility failed to ensure that the call light system was operational for a resident’s room and bathroom/bathing area, as required by its policy and resident care needs. During observation, the resident identified as #94 activated their call light, but the corridor light above the door did not illuminate or sound, and the call light system monitor at the nurses’ station did not display the room number. The resident reported that the call light had not been working, stating that maintenance had replaced the cord but the system still did not function. The resident’s baseline care plan indicated a need for stand-by assistance with ambulation, yet the resident had no functioning call light or bell available at the time of the initial observation. Further observations and interviews showed that the issue with nonfunctioning call lights was ongoing and not documented in the maintenance logbook. On review of the maintenance logbook, there were no entries indicating call lights needing repair until a CNA documented that the call light in this resident’s room and another room were not working. Staff interviews revealed that the call light system’s lights and monitors did not always work, and a CNA reported experiencing issues with call lights not working almost daily. The DON stated that there was no prior written documentation of call light problems because staff had been reporting them verbally rather than through the logbook, despite the facility’s policy requiring defective call lights to be reported to maintenance or administration to be addressed promptly.
Unattended Computer Displayed PHI on Medication Cart
Penalty
Summary
A deficiency occurred when a computer displaying protected health information was left open and unattended on top of a medication/treatment cart at nurses station 3. This was observed on the morning of 05/30/25, with the computer showing resident information and no staff member present at the cart. When a certified medication aide (CMA) arrived, they closed the computer but were unaware of the nurse assigned to the cart's whereabouts. The administrator and the registered nurse assigned to the cart both confirmed that the computer should not have been left open with resident information visible. The facility had 95 residents at the time of the incident. No specific residents were identified as being directly affected in the report, and no medical history or condition of residents was mentioned in relation to the deficiency.
Unattended Unlocked Medication Cart with Medications Left Accessible
Penalty
Summary
A medication/treatment cart on station 3 was observed to be unlocked and unattended at the nurses station, with a bottle of Hysept wound cleanser and a medicine cup containing an unidentified gel left on top. The facility's policy requires all compartments containing medications and biologicals to be locked when not in use and for carts to not be left unattended if open or accessible. At the time of the observation, the nurse assigned to the cart was not present, and a CNA subsequently locked the cart. Both the administrator and the assigned RN confirmed that the cart should have been locked and that medications should not have been left on top, acknowledging that residents or visitors could have accessed the medications. The facility had 95 residents at the time of the incident.
Failure to Administer Cardiac Medication as Prescribed
Penalty
Summary
The facility failed to administer a cardiac medication, amiodarone, as prescribed for a resident diagnosed with atrial fibrillation. The physician's order required the resident to receive 100 milligrams of amiodarone daily, with monitoring of blood pressure and heart rate. However, the resident missed a significant number of doses over a period from September to November, with six out of 18 doses missed in September, 11 out of 31 in October, and four out of seven in early November. On a specific day in November, a Certified Medication Aide (CMA) did not administer the medication, citing incorrect instructions regarding blood pressure parameters. Interviews with facility staff revealed a lack of understanding and consistency in administering the medication. The CMA and two Licensed Practical Nurses (LPNs) had varying interpretations of when to withhold the medication based on blood pressure and heart rate readings, none of which aligned with the physician's order. The Director of Nursing (DON) acknowledged the absence of specific instructions in the order and the significance of the missed doses. The DON later clarified the correct parameters with the physician, who specified holding the medication only if the heart rate was below 50 beats per minute, not based on blood pressure readings.
Kitchen Environment and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-repaired kitchen environment, which affected the preparation and serving of meals to 83 residents. Observations revealed that a cook was using a cracked and broken container to puree pork, which required manual pressure to keep it in place during use. The kitchen environment was found to have several issues, including standing water on the floor, a dusty box fan blowing air across food preparation areas, and a ceiling vent covered in dust. Additionally, there was visible light penetration around the exterior door, which could allow vermin access, and various stains and holes in the ceiling and walls of the kitchen and dish machine room. Further inspection showed peeling paint, missing drywall, and a black substance identified as mold around the ice machine. The kitchen had dirt, food particles, and expired insects along the baseboards, and grease stains on the walls of the dry storage room. The kitchen staff and maintenance personnel were aware of these issues, including the broken container and the poor drainage contributing to standing water, but cited budget constraints as a reason for not addressing them. The presence of mold and other unsanitary conditions in the kitchen environment posed a risk to food safety and hygiene.
Failure to Assess Bed Rail Use for a Resident
Penalty
Summary
The facility failed to ensure that residents were assessed for the use of bed rails prior to their installation, specifically for one resident who was reviewed for bed rails. This deficiency was identified through observation, interview, and record review. The resident in question had a diagnosis that included dementia. Upon reviewing the resident's medical record, it was found that there was no assessment conducted for the use of bed rails. During an observation, bed rails were noted to be up on both sides of the resident's bed. The facility's administrator acknowledged that the bed rail assessment page did not automatically populate in their system, requiring nurses to manually access it, which did not occur for this resident.
Failure to Adhere to Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy during wound care for a resident with a sacral pressure ulcer. The facility's policy required the use of gowns and gloves for high-contact resident care activities, such as wound care. However, during an observation, a registered nurse (RN) and a licensed practical nurse (LPN) sanitized their hands and donned gloves but did not wear gowns while treating the resident's pressure ulcer. When questioned, the RN stated that no additional infection control measures were necessary before starting the wound care. The LPN later mentioned that gowns and masks were only worn if the resident had MRSA. The facility administrator confirmed that gowns should have been worn during the wound care as per the facility's EBP policy.
Insufficient Surety Bond Coverage for Resident Trust Account
Penalty
Summary
The facility failed to secure a surety bond with sufficient coverage for the resident trust account balance. A review of the current surety bond revealed that it had coverage of only $10,000, while the resident trust account's monthly bank statement showed a balance of $18,330. The business office manager identified 15 residents with money in the trust account who were current residents. The corporate regional manager confirmed that the surety bond was insufficient and acknowledged that they had noticed the discrepancy the previous month and contacted the insurance company, but the issue had not been corrected.
Failure to Properly Manage Resident Personal Funds
Penalty
Summary
The facility failed to comply with regulations regarding the management of resident personal funds. Specifically, the facility did not deposit personal funds exceeding $50 into an interest-bearing account separate from the facility's operational accounts for one resident. A review of the resident's account revealed a credit balance of $1,471.00 in the facility's accounts receivable account, which was not transferred to the facility's trust account. The corporate business office manager acknowledged that the funds were left in the operating system at the family's request, despite the operating system not being an interest-bearing account. Additionally, the corporate regional manager confirmed that resident funds should not be commingled with operating funds.
Failure to Ensure Timely Availability of Medications
Penalty
Summary
The facility failed to ensure medications were available for a resident who required them. The resident, diagnosed with acute kidney failure, returned from a local hospital with a discharge order for the antibiotic cefepime to be administered every 12 hours. However, the medication was not administered until over 24 hours later, despite facility policy stating that emergency or STAT medication orders should be fulfilled within four hours. The Assistant Director of Nursing (ADON) confirmed that antibiotics are considered STAT orders and should be available within the specified timeframe. The Administrator also acknowledged that the new order for antibiotics should have been available within four hours.
Failure to Maintain Administrator Coverage
Penalty
Summary
The facility failed to have an administrator of record for a period between 11/23/23 and 01/18/24. The previous administrator left their position on 11/23/23, and the new administrator began on 01/18/24. During an interview on 02/26/24, the current administrator was unable to identify who, if anyone, served as the interim administrator during this period. By the end of the survey, the facility did not provide any documentation related to administration coverage for the interim period. This deficiency affected the management and operation of the facility, which housed 76 residents at the time of the survey.
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Surveyors found that staff failed to follow Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. Facility policy required targeted gown and glove use for high-contact care under EBP, and the resident had physician orders for catheter care every shift and placement on EBP. During an observation, two CNAs provided catheter care without wearing gowns. Both CNAs later acknowledged that gowns should have been used, and the DON confirmed that gowns are required for catheter care for residents on EBP. The resident, who was cognitively intact, reported that staff usually did not wear gowns during catheter care.
The facility did not update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed licensed nursing staff. The written assessment specified one RN for one day shift per week and projected a need for 10 LPNs across 24 hours, with detailed LPN coverage by shift, and stated it should be reviewed and updated as needed to guide staffing decisions. At the time of survey, the DON reported 36 residents in the facility, acknowledged that resident acuity was higher than when the assessment was completed, and stated that the actual pattern was two LPNs on the floor for the day shift and two LPNs for the night shift, with the DON, ADON, and MDS coordinator available only during weekday business hours. The DON identified a total of seven licensed staff available and stated that more staff were needed to work directly with residents, confirming that the facility assessment no longer reflected current resident needs or staffing resources.
A resident with a pressure ulcer received wound care during which an LPN and CNAs failed to follow basic infection control practices. The overbed table was not sanitized before wound supplies were placed, gloves were not changed after contact with feces, and the resident was repositioned onto a clean bed pad while still soiled. The LPN used the same contaminated gloves to handle personal items, suction equipment, wound care supplies, and to cleanse the resident’s skin and pressure ulcer, including applying collagen paste and calcium alginate with gloved fingers. Hand hygiene was not performed between glove changes, and the resident’s open wound came into contact with a cloth bed pad or pillow after cleansing and medication application but before the final dressing was applied.
A deficiency was cited for failure to prevent elopement and recurrent falls due to inadequate supervision, unsecured exits, and incomplete care planning. A newly admitted resident assessed as at risk for elopement and wandering had no related interventions on the baseline care plan, despite moderately impaired cognition and psychiatric and seizure diagnoses. This resident later left the building, was found several blocks away after falling and sustaining abrasions, and was subsequently observed at times without the one-on-one supervision that had been ordered, while a dining room exit door and perimeter gate remained unlocked and accessible. Another resident with vascular dementia, muscle weakness, and a history of multiple falls experienced several unwitnessed falls over months, culminating in two right hip fractures requiring surgical repair, yet fall-prevention interventions were not added to the care plan, and staff relied on verbal instructions and vague "close observation" rather than documented, individualized fall-prevention measures.
A resident with atrial fibrillation on Eliquis, with documented orders and a care plan to monitor and report signs of bleeding, experienced multiple episodes of active rectal bleeding while on the toilet, accompanied by anxiety, complaints of not being able to breathe, pain, pallor, and shivering. An ACMA and an LPN observed and documented that the toilet was full of blood and that the resident repeatedly refused transfer to the ER, but the LPN did not contact the physician or the family and instructed staff to continue monitoring. ACMA staff later attempted to follow instructions to contact family but reported no family contact information in the medical record, did not notify the physician, and ultimately called EMS only when the resident became pale and shivering; EMS found the resident unconscious amid evidence of a significant hemorrhagic event. Progress notes contained no documentation of physician or family notification during the change in condition, and the family, listed as POA and emergency contact in admission paperwork, reported they were not informed of the change in condition and learned of the resident’s death hours later.
A resident with recent abdominal aortic aneurysm repair and a history of circulatory surgery was on multiple anticoagulant and antiplatelet agents (Eliquis, aspirin, Plavix) and had care plans directing staff to monitor for and report abnormal labs and signs of bleeding, including black or bloody stools. A critical hemoglobin of 6.3 g/dL was reported by the lab, which documented unsuccessful attempts to reach nursing staff; the result was later signed by facility staff, but the DON confirmed the physician was never notified and no intervention was documented. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding with screaming, shortness of breath, and anxiety while on the toilet; an ACMA notified an LPN, who did not promptly assess the resident and instead instructed continued monitoring and attempts to convince the resident to go to the hospital. Nursing notes and EMS documentation showed a significant hemorrhagic event with extensive blood in the room and on the resident, yet there was no evidence of ongoing assessment, monitoring, or timely physician notification for the change in condition or the critical lab, leading surveyors to cite a deficiency under F684 for failure to provide appropriate treatment and care according to orders and the resident’s condition.
A resident with a history of circulatory surgery, an aortocoronary bypass graft, and on anticoagulant therapy experienced an acute onset of profuse rectal bleeding and shortness of breath during a night shift. An ACMA was functioning as charge on one hall while an LPN covered the other hall; the ACMA reported the resident’s bleeding and distress, and the LPN came once to the room but did not provide ongoing assessment or monitoring, later stating they were behind on work and relying on the ACMA to monitor. EMS later found the room with evidence of a significant hemorrhagic event and the resident unconscious on the toilet. Progress notes lacked documentation of significant change in condition, assessments, or interventions for the bleeding and respiratory distress, and the facility failed to notify the medical provider of a critical Hgb of 6.3 or of the acute bleeding. The facility also could not produce annual competency records for the LPN or ACMA, and the resident’s family was not notified of the change in condition or death until later.
A resident with a history of abdominal aortic aneurysm repair and on anticoagulant therapy had a critically low Hgb on lab testing, but the lab’s critical results were not successfully communicated to a nurse and the physician was not notified. Later, the resident developed anxiety, SOB, screaming, and profuse rectal bleeding while on the toilet. An LPN was notified of these symptoms and received a photo showing a large amount of blood but did not perform an assessment or ongoing monitoring, relying instead on an ACMA despite acknowledging this was not standard procedure. There was no documentation of a significant change in condition or interventions in the progress notes. EMS was eventually called and found evidence of a major hemorrhagic event in the room before transporting the resident, and the incident was identified by the regional nurse consultant as neglect.
Surveyors found multiple food safety deficiencies involving approximately 80 residents, including unlabeled and undated stored food items, and an ice machine with visible pink and brown residue on the chute above the ice. The dietary manager acknowledged that food should be labeled and noted visible dirt when wiping the ice machine. A cook was observed preparing pureed food with one gloved and one ungloved hand, using the same gloved hand to handle both ready-to-eat food and kitchen surfaces without changing gloves or performing hand hygiene until after taking equipment to the dishwasher. The DON reported there was no policy for food storage or ice machine maintenance, and only prior-year invoices were available to show servicing of the ice machine, with no recent documentation provided.
A resident with moderately impaired cognition who required partial to moderate assistance with ADLs expired in an ambulance, but staff documentation did not accurately reflect the resident’s status. A nursing progress note describing severe anxiety, complaints of inability to breathe, and blood in the toilet was entered without being identified as a late entry. Task logs showed ADL assistance documented as completed after the resident’s death, instead of being marked as not available or not applicable. Staff interviews confirmed that tasks should not be documented as completed when a resident is no longer in the facility or has died, indicating a failure to follow the facility’s nursing documentation policy.
Failure to Use Gowns During Catheter Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during catheter care. The facility’s Infection Control policy dated 04/01/24 required targeted gown and glove use during high-contact resident care activities under EBP. Physician orders showed that Resident #7 had an indwelling catheter with catheter care ordered every shift as of 01/07/26 and was placed on EBP as of 01/16/26. A quarterly assessment dated 03/27/26 documented that Resident #7 had intact cognition, with a Brief Interview for Mental Status score of 15, and an indwelling catheter. On 04/29/26 at 11:03 a.m., CNA #1 and CNA #2 were observed providing catheter care to Resident #7 without wearing gowns, despite the resident being on EBP and the facility’s policy requiring gown use for such care. CNA #1 acknowledged that gowns should have been worn under EBP, and CNA #2 stated they had forgotten to put on a gown. Resident #7 reported that staff usually did not wear gowns during catheter care, and on 04/30/26 the DON confirmed that gowns should be worn when providing catheter care to residents on EBP.
Failure to Update Facility Assessment to Reflect Increased Resident Acuity and Staffing Needs
Penalty
Summary
The facility failed to update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed nursing resources. The written facility assessment dated 10/15/25 stated that one RN was needed for one day shift per week, including weekends, and projected a total of 10 LPNs needed to provide care in a 24-hour period. The assessment further specified that seven LPNs were needed for the day shift, five for the evening shift, and four for the night shift. The assessment document itself stated that it was to be reviewed annually and updated as needed, and that it was to be used to evaluate the resident population and determine the resources necessary to care for residents competently during day-to-day operations and emergencies, and to drive staffing decisions. At the time of the survey, the DON identified that 36 residents resided in the facility and reported that the acuity level of the residents was higher than it had been in October 2025 when the facility assessment was completed. The DON stated that the projected need for ten LPNs in a 24-hour period was not correct and described the actual staffing pattern as two LPNs working on the floor from 7 a.m. to 7 p.m. and two LPNs working on the floor from 7 p.m. to 7 a.m., with the DON (RN), assistant DON (RN), and MDS coordinator (LPN) available to assist with resident needs during business hours, five days a week. The DON counted a total of seven licensed staff members available and acknowledged that more staff were needed to work directly with residents given the current higher acuity, demonstrating that the facility assessment had not been updated to reflect the current resident population and resource needs.
Improper Infection Control During Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care in a manner that prevented contamination and potential infection for one resident with a pressure ulcer. During an observed dressing change, an LPN entered the resident’s room, pushed personal items aside, and placed plastic trash bags and wound care supplies on the overbed table without sanitizing the surface. The LPN and CNAs provided incontinent care during which feces remained on the resident’s legs and buttocks, and at least one CNA did not change gloves after wiping feces and before placing a clean cloth bed pad under the resident. The resident was repositioned onto the new pad while still soiled with feces. Wearing the same gloves used during incontinent care, the LPN handled the resident’s personal items, oral suction yankauer, and suction machine, and prepared wound care supplies, including soaking gauze in a cleansing solution. The LPN then used the same contaminated gloves to obtain wet gauze from the cleansing solution and clean feces from the resident’s legs and buttocks before proceeding to remove the old dressing and packing from the pressure ulcer. Some packing fell onto the cloth bed pad, and the resident’s back and buttocks, including the open pressure ulcer area after cleansing and medication application but before placement of the absorbent dressing, came into contact with the cloth bed pad or pillow. The LPN applied a collagen paste to the wound bed by inserting gloved fingers into a cup of white paste and then applied calcium alginate with the same gloved fingers, without using an applicator. The LPN discarded the gloves but did not perform hand hygiene before donning a new pair of gloves stored on the overbed table. During a post-observation interview, the LPN acknowledged feeling nervous, recognized that their gloves and multiple items and surfaces may have been contaminated by contact with feces, and stated that the resident’s bed pad and wound bed were likely contaminated during the dressing change.
Failure to Prevent Elopement and Recurrent Falls Due to Inadequate Supervision and Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to elopement risk and fall prevention. One resident identified as a new admission was evaluated on 02/28/26 as being at risk for elopement and wandering, with documentation that the resident wandered around the facility and into rooms. Despite this evaluation, the baseline care plan dated the same day did not include any interventions for wandering or elopement risk. An admission assessment dated 03/06/26 documented moderately impaired cognition with a BIMS score of 09 and diagnoses including schizophrenia and seizure disorder. On 03/07/26, the resident was reported missing from their room around 11:20 a.m., and an incident report and progress note showed the resident was found a couple of blocks from the facility, having tripped and fallen outside and sustaining abrasions to the hand and knee that required first aid. Following the elopement, documentation showed the resident was placed on one-on-one staff supervision and the care plan was updated; however, subsequent observations revealed lapses in supervision. On 03/11/26, the resident was observed in bed with a staff member seated outside the door, and the resident stated they were not allowed to leave the facility alone. On 03/12/26, the resident was observed in bed with no staff supervision, then walking out of the room toward the dining room without staff present, until an unidentified staff member later noticed the resident in the hall and alerted the charge nurse. Interviews indicated that prior to the elopement the resident had not been on frequent checks because staff did not consider them an elopement risk, despite the earlier evaluation. The ADON later stated the baseline care plan lacked elopement/wandering interventions because they had failed to communicate with the weekend RN who completed the elopement evaluation and were unaware the resident was at risk. Environmental observations on 03/13/26 showed the dining room exit door and the outside perimeter gate in the smoking area were unlocked and accessible to residents, and the DON and administrator acknowledged the dining room exit door was not secured and that the resident likely exited through the unlocked door and perimeter gate. The deficiency also includes the facility’s failure to provide adequate supervision, reassess fall risk, investigate root causes, and implement fall-prevention interventions for a resident with a history of multiple falls. Facility records identified this resident as having several falls without injury on 06/04/25, 06/05/25, 06/18/25, 06/30/25, and 07/31/25, with no fall-prevention interventions documented for any of these events. A fall on 09/25/25 resulted in severe right leg pain and an emergency room visit, with a subsequent nurse’s note documenting a right hip fracture requiring surgical repair. Review of the care plan dated 07/31/25 showed no fall-prevention interventions in place for the 09/25/25 fall, and a later care plan dated 10/06/25 documented the resident’s diagnoses, including vascular dementia and muscle weakness, and the prior falls, but still showed no interventions for those falls. A nurse’s note dated 10/20/25 documented another fall on 10/19/25 that resulted in a second right hip fracture, again with no documentation of interventions in place to prevent that fall. Observations and interviews further demonstrated the lack of systematic fall-prevention planning for this resident. On 03/12/26, the resident was observed sitting in a geriatric chair near the nurse’s station with a fall mat at bedside and was later assisted to stand and ambulate with a walker. The resident reported falling frequently and not knowing why, and stated that staff followed them everywhere to prevent falls but were unsure what specific interventions were in place. An LPN stated the resident had frequent falls and that interventions included a fall mat at bedside and keeping the resident under close observation, but could not clarify what “close observation” entailed and acknowledged that interventions were communicated verbally rather than being reflected in the care plan. Another LPN stated they relied on the care plan to know fall-prevention interventions and, if not listed, had to depend on other staff for guidance. The MDS coordinator stated all falls, regardless of injury, should result in care plan interventions to prevent recurrence and did not know why this resident’s falls lacked interventions, and the DON confirmed there were no interventions on the care plan for the resident’s falls despite the expectation that such interventions should have been in place. Facility policies reviewed by surveyors underscored the deficiencies. An undated wandering policy stated that the facility would ensure the safety of residents who wander and that the MDS nurse would complete a wandering assessment on admission and work with the care plan team to develop, maintain, and update a care plan for each resident who wanders. A Falls – Clinical Protocol dated 03/2018 stated that staff and the physician would identify pertinent interventions to prevent subsequent falls and address the risks of clinically significant consequences of falling. A Care Plan Completion policy stated the facility would develop a comprehensive person-centered care plan for each resident that includes measurable objectives, timeframes, and services to meet medical, nursing, mental, and psychosocial needs. Despite these policies, the facility did not ensure that the elopement risk assessment for the first resident was communicated and incorporated into the baseline care plan, did not secure exit doors and perimeter fencing to prevent elopement, and did not consistently implement or document individualized fall-prevention interventions for the second resident after multiple falls and two hip fractures.
Failure to Notify Physician and Family of Significant Bleeding Episode in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and family of a significant change in condition. The resident had a history of atrial fibrillation and was on Eliquis, with physician orders and a care plan directing staff to monitor and report signs of bleeding such as blood in urine or stool, black tarry stools, and other symptoms. The resident’s cognition was moderately impaired, with a BIMS score of 11, and they required supervision with ambulation and transfers and partial to moderate assistance with toileting hygiene. The admission contract identified a family member as the emergency contact and POA, with contact information provided. On the night of the incident, staff observed multiple episodes of active bleeding while the resident was on the toilet. Around 1:15 a.m., the resident was on the toilet and bleeding, with the toilet full of blood, and was reported to be screaming that they could not breathe. ACMA staff notified the LPN, left the blood in the toilet for the LPN to observe, and reported that the resident refused to go to the ER. The LPN assessed the resident at approximately 1:32 a.m., documented increased anxiety, complaints of not being able to breathe, and that most of the toilet contents were blood, and noted that the resident refused transfer to the emergency department. The LPN instructed ACMA staff to continue monitoring the resident and did not contact the physician or the family at that time. The resident continued to have episodes of bleeding while on the toilet around 2:00 a.m. and again around 2:50 a.m., with reports of pain, pallor, and shivering, and continued refusals to go to the hospital and to take pain medication. ACMA staff reported they were instructed by text to contact the family to encourage the resident to go to the ER but stated no family contact was listed in the medical record and did not call the physician. EMS was eventually called by ACMA staff when the resident became pale and shivering; EMS arrived to find the resident unconscious on the toilet with evidence of a significant hemorrhagic event in the room, including saturated towels and blood on the floor and on the resident. Progress notes did not show any contact with the physician or family during the change in condition, and the family member later stated they were not notified of the change in condition and did not learn of the resident’s death until several hours later. The facility’s failure to notify the physician and family of the resident’s serious change in condition was cited as an Immediate Jeopardy deficiency.
Failure to Respond to Critical Lab and Acute Bleeding in Anticoagulated Post-Surgical Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess, identify, and intervene when a resident with a recent abdominal aortic aneurysm repair experienced an acute change in condition, including profuse bleeding from an unknown source and a critically low hemoglobin level. The resident had diagnoses including encounter for surgical aftercare following circulatory system surgery and presence of an aortocoronary bypass graft, and was receiving multiple anticoagulant and antiplatelet medications (Eliquis twice daily, aspirin daily, and Plavix daily), along with psyllium and Imodium for diarrhea. Facility policies required nurses to assess acute condition changes, obtain and report pertinent information to the physician, and promptly notify the physician in emergencies, as well as to review and act on lab and diagnostic test results based on the seriousness of abnormalities. The resident’s care plan directed staff to monitor for and report abnormal lab results and signs of bleeding, including black or bloody stools and significant changes in vital signs, and to avoid aspirin use with anticoagulant therapy. A laboratory report for the resident showed a critically low hemoglobin of 6.3 g/dL, with a normal reference range of 13.7–17.5 g/dL. The lab documented attempts to call the facility at 3:35 p.m. and again, with no answer and inability to reach a nurse, and the report was released later that afternoon. The report bore a staff signature dated several days later and a stamped physician signature without a date. The DON confirmed that the physician was not notified of this critical result and stated that the physician should have been notified immediately per facility procedure. Despite the resident’s anticoagulant therapy and care plan instructions to report abnormal labs, there was no evidence that the critical hemoglobin value was communicated to the physician or that any clinical intervention occurred in response to this lab finding. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding while on the toilet, accompanied by screaming, shortness of breath, increased anxiety, and refusal to go to the hospital. An ACMA reported to an LPN around 1:15–1:32 a.m. that the resident was having bloody stool and distress, but the LPN did not immediately assess the resident and instead instructed the ACMA to monitor and convince the resident to go to the hospital. The nursing progress note later documented that the resident’s toilet contents were mostly blood and that the resident was educated about the need to go to the ED but refused. EMS records indicated that when they arrived, the resident’s room showed signs of a significant hemorrhagic event, with towels saturated with blood and blood on the floor, legs, socks, and in the toilet. The nursing documentation showed no ongoing assessment, monitoring, or intervention for the resident’s shortness of breath, screaming, blood in the toilet, or refusal of transfer during the period before EMS was called. The facility’s failure to identify, monitor, and provide continuing assessments for the resident’s change in condition, to notify the medical provider of the critical hemoglobin result, and to promptly notify the provider and intervene for the acute onset of profuse bleeding constituted the cited deficiency. The report also notes that staff interviews revealed gaps in practice and understanding related to change in condition and bleeding. The LPN acknowledged being concerned the resident was “bleeding out” and stated they were traumatized by the amount of blood, yet did not perform an immediate assessment when first notified of bloody stool and pain, relying instead on the ACMA to monitor and attempt to persuade the resident to accept transfer. The LPN further stated they typically remained on one side of the building and did not routinely go to the other side unless needed, and that they did not visually see the resident in distress until later. A CNA reported having seen dark, clumped stool earlier in the week and indicated they had only minimal education on signs and symptoms of bleeding. These documented actions and inactions, in the context of the resident’s high-risk status and existing policies and care plans, led surveyors to determine that the facility failed to provide appropriate treatment and care according to orders, the resident’s condition, and established protocols for change in condition and critical lab results. The resident’s family reported that the resident had ongoing diarrhea with horrendous odor and black color since before admission, and that staff were aware of the stool characteristics. Another CNA described the resident’s stool as dark black and mixed solid/liquid, resembling stool from someone taking iron, though they only observed it once and did not report red blood. The care plan specifically directed staff to monitor for black tarry stools and other signs of bleeding in the context of anticoagulant therapy, and to report such findings to the physician. Despite these documented risk factors, symptoms, and care plan directives, the record lacked evidence that staff recognized and escalated these signs as potential bleeding or that they communicated them to the physician prior to the acute hemorrhagic event. This pattern of missed recognition, lack of timely assessment, and failure to notify the physician of both critical lab results and acute bleeding formed the basis of the deficiency under F684 (Quality of Care).
Failure to Assess, Monitor, and Notify Provider for Resident With Profuse Bleeding and Critical Lab Value
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and competent nursing staff to assess, monitor, and intervene for a resident with a known high-risk medical history who experienced an acute onset of profuse bleeding. The resident had a history of surgical aftercare following surgery on the circulatory system, including the presence of an aortocoronary bypass graft, and was receiving anticoagulant therapy (Eliquis) for atrial fibrillation. The resident’s care plan and physician orders directed staff to monitor for specific signs of bleeding and adverse reactions to anticoagulant therapy, such as blood in the stool or urine, changes in mental status, shortness of breath, and other symptoms. The facility also had an Acute Condition Changes – Clinical Protocol policy requiring baseline assessments, monitoring, and timely physician notification for acute changes in condition. On the night of the incident, assignment sheets showed that an ACMA was the charge nurse on one hall (South hall) for the 7:00 p.m. – 7:00 a.m. shift, while an LPN was the charge nurse on the other hall (North hall). EMS records documented that they were dispatched in the early morning hours after facility staff reported that the resident had blood in the stool starting about three hours earlier and was recovering from abdominal aortic aneurysm surgery. When EMS arrived, they observed the resident’s room with signs of a significant hemorrhagic event, including towels saturated with blood and blood on the floor, and found the resident unconscious on the toilet with blood on their socks, legs, and in the toilet. Progress notes for that date did not show documentation of a significant change in condition, nor did they show assessments, monitoring, or interventions for the resident’s shortness of breath, screaming, blood in the toilet, or refusal to be transported to the hospital. Interviews revealed that the LPN was the only licensed nurse in the building on the weekend and did not obtain a full report on the South hall because the ACMA was functioning as the charge for that hall. The LPN stated that the ACMA reported the resident was screaming, hurting, having a bowel movement, and there was blood, and that the resident had a history of abdominal aortic aneurysm surgery, raising concern about bleeding. The LPN instructed the ACMA to send the resident to the hospital, but the resident refused, and the LPN did not perform ongoing assessments or monitoring, citing being behind on work and relying on the ACMA to monitor and report. The ACMA reported that the resident was on the toilet and bleeding around 1:15 a.m., with vital signs within normal limits, and refused to go to the ER; the ACMA contacted the LPN, who came once at about 1:32 a.m. to check on the resident while the resident was back in bed, with blood left in the toilet for the LPN to see. The ACMA stated that later, as the resident continued to pass blood, became pale and shivering, and remained in pain while refusing pain medication and hospital transfer, they eventually called 911 when the resident’s condition worsened. The facility was unable to produce annual skills competencies for either the LPN or the ACMA, and a family member reported they were not notified of the resident’s change in condition or of the resident’s death until later, despite the resident’s room being on the South hall where the events occurred. The report also notes that the facility failed to notify the medical provider of a critical hemoglobin lab value of 6.3 (normal reference range 13.7–17.5) and failed to notify the medical provider of the acute onset of profuse bleeding. There is no documentation that the physician was contacted regarding the critical lab result or the resident’s active bleeding, despite facility policy requiring timely physician notification for acute changes in condition and the resident’s known risk factors and anticoagulant therapy. Additionally, the facility’s own policy required that direct care staff, including nursing assistants, be trained to recognize and report significant changes, and that phone calls to physicians be made by adequately prepared nurses with organized, pertinent information; however, the documented events and interviews show that the ACMA was functioning as charge on one hall and that the LPN did not consistently assess or directly manage the resident’s rapidly changing condition. These combined failures to assess, monitor, intervene, and notify the medical provider for a resident with profuse bleeding and a critical hemoglobin value constituted the cited deficiency.
Failure to Assess and Respond to Resident’s Significant Bleeding and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident experiencing a significant change in condition and profuse bleeding was assessed and monitored by a licensed nurse. The facility had an Acute Condition Changes - Clinical Protocol requiring nurses to assess and document vital signs, neurological status, pain, level of consciousness, cognitive and emotional status, onset and severity of symptoms, and other clinical information, and to promptly contact the physician for emergencies. The resident had a history of abdominal aortic aneurysm repair and was on anticoagulant therapy for atrial fibrillation, with care plans directing staff to monitor and report signs and symptoms of cardiovascular issues and adverse reactions to anticoagulants, including blood in stool and shortness of breath. A physician’s order required weekly CBC and CMP labs while on skilled services. A lab report for the resident showed a critically low hemoglobin level of 6.3 g/dl, but the lab’s attempts to call the facility at 3:35 p.m. and again later were unsuccessful, and the physician was not notified of the results. Subsequently, during the night, the resident experienced increased anxiety, was screaming that they could not breathe, was on the toilet with most of the contents being blood, and refused to go to the emergency department. LPN #1 was notified at 1:32 a.m. of the resident’s condition, including shortness of breath, screaming, and blood in the toilet, but did not perform an assessment or ongoing monitoring, and there was no documentation of a significant change in condition or interventions for these symptoms in the progress notes. LPN #1 reported typically being the only licensed nurse in the building on weekends and stated they did not go to the resident’s hall for a full report, relying instead on an ACMA to monitor residents and report concerns. LPN #1 acknowledged being told that the resident was screaming, hurting, having bloody stool, and had a recent abdominal aortic aneurysm, and expressed concern about the resident bleeding out. LPN #1 received a texted picture of the blood at 2:25 a.m. and described being traumatized by the amount of blood, but still did not assess or monitor the resident, citing being behind on work and relying on the ACMA, despite stating that it was not standard procedure for an ACMA to assess, monitor, and send a resident to the hospital. EMS was finally contacted at 3:12 a.m., arrived to find evidence of a significant hemorrhagic event with blood-saturated towels and blood on the floor, and transported the resident, who expired in the ambulance shortly thereafter. The regional nurse consultant stated the incident was considered neglect.
Improper Food Storage, Ice Machine Sanitation, and Glove Use in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food storage and ice handling practices during kitchen observations. In one kitchen tour, they observed a white paper bowl containing orange ice cream wrapped in plastic wrap that was unlabeled and undated, as well as an opened bag of hamburger buns that was also unlabeled and undated. The ice machine had a pink substance on the white plastic chute directly above the ice, which, when wiped with a clean paper towel, resulted in a pink and brown speckled residue. The dietary manager acknowledged that the food items should have been labeled and stated they saw dirt on the towel used to wipe the ice machine chute. The DON reported there was no policy for food storage or the ice machine, and stated that ice machine maintenance was based on the machine’s indicator and then calling an outside company, with invoices available only for servicing dates in the prior year and no documentation provided for recent cleaning or maintenance. Additional deficiencies were observed in food handling and glove use by kitchen staff. One cook was seen working with one hand gloved and one hand ungloved, using the gloved hand to place cornbread into a blender, then touching the blender, a utensil, and returning to touch the cornbread without changing gloves or performing hand hygiene between contact with food and other surfaces. The cook later took the blender to the dishwasher and only then removed the glove and washed their hands. When interviewed, the cook stated their process for changing gloves was when changing the type of food and after touching utensils, and acknowledged they did not change gloves after touching the cornbread. The dietary manager stated the process for changing gloves was to change when staff touched something or something was dirty. The administrator identified that 80 residents resided in the facility at the time of the survey.
Inaccurate Post-Death Documentation and Failure to Follow Nursing Charting Policy
Penalty
Summary
The facility failed to ensure accurate and timely documentation in the medical record for a resident who died. Facility policy on nursing documentation required staff to chart as soon as possible after care, to enter the actual date and time of charting, and to clearly label any late entries with the date and time being documented. The admission assessment for the resident showed moderately impaired cognition with a BIMS score of 12 and a need for partial to moderate staff assistance with most ADLs. An EMS report documented that the resident expired in the ambulance at 3:40 a.m. on a specified date. A progress note for that same date, timed at 1:32 a.m., described the nurse being notified that the resident was on the toilet, screaming that he could not breathe, with oxygen saturation at 98% and most of the toilet contents being blood; this note was not identified as a late entry despite the timing and circumstances. Task logs for the resident showed that staff documented completion of ADL assistance after the resident’s death. Specifically, the task log reflected that the resident received ADL assistance at 10:08 a.m. on the date of death, and additional ADL assistance entries at 6:54 a.m., 8:32 a.m., and 11:59 p.m. on another date, even though the resident had already expired. During interviews, a CNA stated that if a resident was not in the facility, the scheduled ADL task should be documented as the resident not being available. The RNC confirmed that if a resident had passed away, staff should not document task completion for that resident and that any remaining scheduled tasks should be documented as not applicable. These findings showed that staff documentation did not accurately reflect the resident’s status or comply with the facility’s documentation policy.
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