Sequoyah Manor, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Sallisaw, Oklahoma.
- Location
- 615 East Redwood, Sallisaw, Oklahoma 74955
- CMS Provider Number
- 375173
- Inspections on file
- 22
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sequoyah Manor, Llc during CMS and state inspections, most recent first.
Two residents were involved in separate resident-on-resident altercations in which one resident was struck on the head and another had their glasses knocked off, with both victims assessed as having no injuries. The aggressors and victims had differing cognitive statuses, including severe cognitive impairment, moderate cognitive impairment, Alzheimer’s disease, and intact cognition. CNAs witnessed both incidents, one of which was captured on camera, and the events were documented on incident reports and in nursing notes. Interviews with an LPN and the DON described that some residents were placed in memory care due to family concerns about confusion and elopement, and that behavioral concerns and resident altercations were ongoing topics of attention.
A resident with dementia and moderate cognitive impairment, who required set-up assistance with eating and drinking, was not consistently supervised while consuming hot coffee. This lack of supervision led to the resident spilling coffee and sustaining a second-degree burn on the inner thigh. Staff interviews confirmed that supervision and assistance with hot liquids were not provided prior to the incident.
A resident with dementia and moderate cognitive impairment, who required set-up assistance with eating and drinking, suffered a burn injury after spilling coffee due to the lack of care plan interventions addressing assistance with hot liquids. Facility staff confirmed the care plan should have included measures for hot beverage safety.
An IJ situation was identified in a memory care unit due to unsecured hazardous materials, including bug spray and bleach wipes, accessible to wandering residents. The facility's failure to adhere to policies on chemical safety and storage led to this deficiency, with staff unaware of the risks posed by unlocked storage areas.
The facility failed to provide baseline care plan summaries to three residents or their representatives, as required by policy. The baseline care plans for residents with Alzheimer's, obstructive and reflux uropathy, and Parkinson's disease lacked signatures and documentation of summary provision. The MDS coordinator confirmed the absence of documentation in the electronic health records.
The facility's medication error rate was 7.41%, exceeding the acceptable threshold of less than five percent. A resident received levothyroxine after their morning meal instead of before, and another resident received only one drop of Refresh eye drops in each eye instead of two. The DON attributed these errors to staff non-compliance.
A cook in the facility failed to maintain sanitary food handling practices by not changing gloves or washing hands between tasks while preparing meals for 64 residents. This was against the facility's policy on preventing foodborne illness, which requires gloves to be discarded after each task and hands to be washed between handling different food items and surfaces. Both the cook and the DM acknowledged the oversight.
The facility failed to ensure proper infection control during catheter care and medication administration. A resident with a catheter did not receive care with the required gown usage by CNAs, and another resident's catheter care lacked hand sanitation between glove changes. Additionally, a CMA did not sanitize hands during medication administration for four residents. The DON confirmed the expectations for infection control practices.
A resident with an indwelling urinary catheter was repeatedly observed with their catheter bag visible from the hallway, not covered by a dignity bag as required by the facility's policy. The resident expressed a desire for privacy, and both a CNA and an LPN confirmed the expectation to use privacy bags. The DON also stated that staff should cover catheter bags to maintain dignity.
A facility failed to ensure accurate assessments for a resident with hypertension, leading to a deficiency. The resident was documented as having a fall with major injury, but reviews of state-reported incidents and the electronic clinical record showed no evidence of such a fall. The resident confirmed they had not experienced a fall, and the MDS coordinator acknowledged the assessment was inaccurately coded.
A facility failed to develop a comprehensive care plan for a resident with a history of transient ischemic attack and range of motion impairment. The resident's care plan did not document their upper extremity impairment, despite an observation of a contracted right hand. The MDS coordinator admitted to missing the development of a care plan for the resident's limited range of motion, and the DON confirmed that such a plan should have been implemented.
A resident with a history of stroke and a contracture in their right hand did not receive appropriate range of motion (ROM) services. The care plan lacked documentation of the resident's ROM impairment, and no interventions were in place to address the contracture, despite facility policy requiring treatment to prevent further decrease in ROM. Observations and staff interviews confirmed the absence of necessary interventions.
A facility failed to maintain infection control for a resident with an indwelling urinary catheter. Observations showed the catheter tubing and bag were often on the floor, and the resident reported discomfort due to the catheter not being secured. Staff confirmed the absence of securement devices and inadequate documentation of catheter care, despite facility policies requiring these measures.
The facility failed to accurately assess bedrail use for two residents. One resident with hemiplegia was observed with half side rails, despite orders for quarter rails. Another resident with falls and altered mental status also had half side rails, contrary to the physician's order for quarter rails. The DON and MDS coordinator were unaware of the discrepancies.
The facility failed to adhere to prescribed menus and portion sizes, as observed during a survey. A cook was unsure of the correct portion size for breaded chicken, serving 1.5 ounces instead of the required three ounces. The DM was unaware of the correct weight and substituted corn for peas and carrots due to a shortage. The entire meal served was actually the menu for the next day, and sandwich bread was used instead of buns due to a shortage. The administrator stated that dietary staff should follow recipes and menus, with changes approved by a dietitian.
The facility failed to regularly inspect bed frames and side rails for two residents, leading to discrepancies between physician orders and observed conditions. One resident with hemiplegia was observed with incorrect side rails, while another with hemiparesis had a side rail in the wrong position. Conflicting statements from staff revealed a lack of awareness about the requirement for regular inspections.
A facility failed to report an allegation of abuse involving a resident to local law enforcement within the required time frame. The incident, involving a housekeeper, occurred in the afternoon, but law enforcement was not notified until the following day. The ADON admitted to forgetting the notification, despite knowing it should have been done within two hours, as per facility policy.
A resident with cerebral palsy was verbally abused by another resident with bipolar disorder, but the incident was not reported to the administrator or investigated as required by the facility's abuse policy. The facility's policy, which stated a 24-hour reporting timeframe for abuse allegations, was outdated and not aligned with the current two-hour requirement, highlighting the need for policy revision.
A resident with intellectual disabilities was verbally abused by another resident with bipolar disorder, but the incident was not reported or investigated as required. The LPN documented the event but failed to notify the administrator, and both the ADON and DON were unaware of the incident despite regular reviews of progress notes.
The facility failed to ensure person-centered care plans for two residents. One resident's care plan did not document the representative's preference to redirect male residents, despite staff awareness. Another resident's care plan lacked details on behaviors to monitor after a new Depakote order, following verbal abuse incidents. The MDS coordinator and DON acknowledged these oversights.
Failure to Protect Residents From Abuse During Resident-on-Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse when resident-on-resident altercations occurred. In the first incident, a certified nursing assistant (CNA) witnessed one resident strike another resident on the top of the head. Documentation showed the resident who was struck was assessed and found to be free of injury. The resident who committed the act had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment, while the resident who was struck had a BIMS score of 12, indicating moderate cognitive impairment. The incident was reported on an OSDH incident report form, and nursing notes documented the aggressor’s status and supervision level following the event. In the second incident, another CNA witnessed a resident knock the glasses off another resident’s face. The resident whose glasses were knocked off was assessed and found to be free of injury and had an Alzheimer’s diagnosis and was described as unaware of their own actions. The resident who committed the act had a BIMS score of 15, indicating they were cognitively intact. The incident was captured on camera and documented on an OSDH incident report form. Interviews with an LPN and the DON indicated that the cognitively intact resident had been placed in memory care due to family concerns about elopement and that the other involved residents had varying levels of cognitive impairment and behavioral concerns. These events formed the basis of the finding that the facility failed to protect residents from abuse.
Failure to Supervise Resident with Dementia Results in Burn from Hot Liquid
Penalty
Summary
The facility failed to provide adequate supervision to prevent burns from hot liquids for a resident with dementia and moderate cognitive impairment. The resident had a BIMS score of 12, indicating moderate impairment in daily decision-making, and required set-up assistance with eating and drinking. Despite this, the resident was not always supervised while drinking coffee. On one occasion, the resident spilled coffee on themselves, resulting in a second-degree burn with a reddened area and blister on the right inner thigh. Interviews with staff confirmed that prior to the incident, the resident was not consistently assisted or supervised with hot liquids or meals. The resident's need for increased assistance had been noted, but supervision practices had not been adjusted accordingly before the burn occurred. Documentation and staff statements indicated that changes to supervision and assistance were only implemented after the incident.
Failure to Update Care Plan for Hot Liquid Assistance
Penalty
Summary
The facility failed to develop and implement a care plan addressing the need for assistance with hot liquids for a resident with dementia and moderate cognitive impairment. The resident, who required set-up assistance with eating and drinking, experienced an incident where they spilled coffee on themselves, resulting in a reddened area and a blister on their right inner thigh. Despite documented evidence of the resident's decline and increased need for assistance, the medical record did not include any care plan interventions related to hot liquids. Facility staff, including an LPN, the ADON, and the minimum data set coordinator, acknowledged that the care plan should have been updated to address this need.
Failure to Secure Hazardous Materials in Memory Care Unit
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified in a locked memory care unit due to the facility's failure to secure chemicals away from wandering residents. An unlocked closet was found with gauze stuffed in the door latch, preventing it from closing. This closet contained hazardous items such as bug spray, paint, and personal care items labeled to be kept out of reach of children. At the time of the observation, three residents were seen wandering aimlessly in the hall, and it was noted that five out of nine residents on the unit wandered independently. The Director of Nursing (DON) was unaware of the issue with the lock and acknowledged the presence of hazardous items that should have been secured. Further observations revealed that a soiled linen closet on another hall was also unlocked and contained a container of bleach wipes, which were labeled to be kept out of reach of children. The facility's policy on hazardous areas and chemical safety required such items to be stored securely and away from resident access. Despite these policies, multiple areas within the facility were found to have unsecured hazardous materials, posing a risk to residents, particularly those who wandered. Interviews with staff, including Certified Nursing Assistants (CNAs) and the DON, confirmed that there was a lack of awareness and adherence to the facility's policies regarding the storage of hazardous materials. The CNAs reported that they were the only staff assigned to the memory unit, which limited their ability to monitor wandering residents effectively. The DON admitted that chemicals should be locked and stored properly, and the failure to do so was a significant oversight that contributed to the deficiency.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that a copy of the baseline care plan was provided to the resident and/or resident representative for three of the 19 sampled residents. The facility's policy, dated March 2022, requires that a written summary of the baseline care plan be provided in a language that the resident or representative can understand. However, for Resident #2, diagnosed with Alzheimer's disease, the baseline care plan dated 04/29/24 did not have a signature from the resident or representative, and there was no documentation in the clinical record indicating that the summary was provided. Similarly, Resident #15, with diagnoses including obstructive and reflux uropathy, had a baseline care plan dated 04/27/24 that lacked a signature and documentation of the summary being provided. The resident stated they did not think they received the summary upon admission. For Resident #29, diagnosed with Parkinson's disease, the baseline care plan dated 03/12/24 also lacked a signature and documentation of the summary being provided. The MDS coordinator confirmed that there was no documentation in the electronic health records indicating that the summaries were provided to the residents or their representatives.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 7.41% for two of the 27 residents reviewed for medication administration. One incident involved a resident who received levothyroxine 125 mcg after their morning meal, contrary to the physician's order to administer it before the meal. Another incident involved a resident who was supposed to receive two drops of Refresh eye drops in both eyes four times daily, but only received one drop in each eye. The errors were attributed to staff non-compliance, as stated by the Director of Nursing (DON).
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner, as observed during a meal service for 64 residents. A cook, identified as [NAME] #1, was seen handling a resident's menu sheet, obtaining a clean plate, using various serving utensils, and reaching into a bag of sandwich bread to obtain slices of bread, all while wearing the same pair of gloves. The cook also placed a slice of cheese on breaded chicken using their gloved hand without changing gloves or washing hands between tasks. This was contrary to the facility's policy on preventing foodborne illness, which requires gloves to be discarded after completing a task and hands to be washed between handling raw meats and ready-to-eat foods, as well as between handling soiled and clean dishes. Both the cook and the Dietary Manager (DM) acknowledged that the gloves should have been changed and hands washed to prevent cross-contamination.
Infection Control Deficiencies in Catheter Care and Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures during catheter care and medication administration. For Resident #15, who had a diagnosis of malignant neoplasm of the prostate, CNAs #5 and #4 did not wear gowns as required for catheter care, despite the resident being on enhanced barrier precautions. CNA #5 admitted to not doing anything different for Resident #15, while CNA #4 acknowledged forgetting to wear gowns. LPN #1 confirmed that staff should wear gloves and gowns for catheter care, and the DON stated that staff were educated to use enhanced barrier precautions for residents with devices. For Resident #4, who had paraplegia and urinary retention, CNA #2 did not sanitize their hands between glove changes during catheter care, although they claimed to have used hand sanitizer. RN #1 stated that hand hygiene should be performed between glove changes to maintain infection control. Additionally, during medication administration for four residents, CMA #1 failed to sanitize their hands before and after checking blood pressure and administering medications. The DON confirmed that staff were expected to sanitize their hands between each resident during medication administration.
Failure to Maintain Resident Dignity with Urinary Catheter
Penalty
Summary
The facility failed to ensure the dignity of a resident with an indwelling urinary catheter. The resident, who had diagnoses including obstructive and reflux uropathy, was observed multiple times with their urinary catheter bag visible from the hallway, not covered by a dignity bag as required by the facility's Dignity policy dated February 2021. The resident expressed a desire for their catheter bag to be covered, indicating that staff were supposed to keep it in a bag to prevent it from being seen. Both a CNA and an LPN confirmed that catheter bags should be placed in privacy bags to maintain dignity. The Director of Nursing also stated that staff were expected to use privacy bags to cover catheter bags to uphold the resident's dignity.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure accurate assessments for a resident, leading to a deficiency. A resident with a diagnosis of hypertension was documented in a quarterly assessment as being moderately impaired in cognition for daily decision-making and having experienced a fall with major injury since the prior assessment. However, a review of state-reported incidents and the electronic clinical record did not reveal any evidence of such a fall. Furthermore, the resident themselves confirmed they had not experienced a fall with major injury. The MDS coordinator acknowledged that the clinical record review showed no fall with major injury, indicating that the assessment dated 10/30/24 was inaccurately coded.
Failure to Develop Comprehensive Care Plan for Resident with Range of Motion Impairment
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident with a history of transient ischemic attack and range of motion impairment. The resident's significant change assessment documented impairment to one side of their upper body and both sides of their lower body. However, the care plan, revised later, did not include the resident's upper extremity impairment. During an observation, the resident was found in bed with a contracted right hand, which they stated had been contracted since a stroke years ago. The MDS coordinator acknowledged missing the development of a care plan addressing the resident's limited range of motion. The DON confirmed that a care plan should have been developed to include interventions for the resident's right hand contracture.
Failure to Provide ROM Services for Resident with Contracture
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) services to a resident with limited ROM, specifically to one resident who had a contracture in their right hand. The resident had a history of transient ischemic attack and had been experiencing a contracture since a stroke several years ago. Despite this, the care plan did not document the resident's ROM impairment in the upper extremity, and there were no interventions in place to address the contracture. Observations and interviews revealed that the resident's right hand was contracted, and the facility typically applied hand rolls for residents with contractures. However, the electronic clinical record lacked any interventions for the resident's condition. Both the MDS coordinator and the DON confirmed that there were no interventions in place for the resident's contracture or limited ROM, indicating a failure to adhere to the facility's policy on providing treatment and services to prevent further decrease in ROM.
Inadequate Catheter Care and Infection Control
Penalty
Summary
The facility failed to maintain infection control standards for indwelling urinary catheters, as evidenced by the improper handling and documentation of catheter care for a resident with obstructive and reflux uropathy. Observations revealed that the resident's catheter tubing and drainage bag were frequently in contact with the floor or fall mat, contrary to the facility's policy which mandates that these items be kept off the floor to prevent infection. Additionally, the resident reported discomfort due to the catheter not being secured, and staff confirmed that securement devices were not used because they were unavailable on their hall. Further investigation showed that catheter care was not documented in the resident's clinical record as required by the care plan, which specified catheter care every shift. Interviews with CNAs and the LPN indicated a lack of adherence to the facility's policy regarding the use of securement devices and proper documentation. The DON acknowledged the absence of documentation and was unaware of the lack of securement devices for the resident's catheter, despite having them available in the facility.
Inaccurate Bedrail Assessment for Two Residents
Penalty
Summary
The facility failed to ensure that residents were accurately assessed for bedrails, as evidenced by the cases of two residents. Resident #30, who had diagnoses including pain and left-sided hemiplegia, was observed with half side rails in the up position, despite a physician's order and consent form indicating the use of quarter side rails. The discrepancy was noted by the Director of Nursing (DON) and the MDS coordinator, who were unaware of why the resident had half side rails instead of the ordered quarter rails. Similarly, Resident #48, with diagnoses including falls and altered mental status, was also observed with half side rails, contrary to the physician's order and consent form that specified quarter side rails for bed mobility and repositioning. The DON and MDS coordinator acknowledged the inconsistency but could not explain why the resident had half side rails instead of the quarter rails documented in the physician's order and consent form.
Failure to Follow Prescribed Menus and Portion Sizes
Penalty
Summary
The facility failed to follow the prescribed menus for residents, as observed during a survey. On the evening of December 18, 2024, the cook preparing the pureed diet was unsure of the correct portion size for the breaded chicken, which was supposed to weigh three ounces per serving according to the recipe. Instead, the chicken weighed only 1.5 ounces. The Dietary Manager (DM) was unaware of the required weight and only knew that the menu called for one piece of chicken. Additionally, the vegetable for the evening meal was supposed to be peas and carrots, but corn was substituted due to a lack of the specified vegetables. The entire meal served was actually the menu planned for the following day, indicating a switch in the menu schedule. Furthermore, sandwich bread was used instead of a bun for the breaded chicken sandwich because all buns had been used during lunch. The DM confirmed this substitution. The facility administrator acknowledged that dietary staff should adhere to recipes and menus, and any changes or substitutions should be approved by a dietitian.
Failure to Regularly Inspect Bed Rails and Frames
Penalty
Summary
The facility failed to ensure that beds and side rails were regularly inspected as part of a maintenance program for two residents who were reviewed for side rails. One resident had diagnoses including pain and left-sided hemiplegia, with a physician's order to use quarter side rails bilaterally for repositioning. However, the resident was observed with half side rails in the up position bilaterally. Another resident, diagnosed with hemiplegia and hemiparesis, had a physician's order to use one side rail for bed mobility and transfers, but was observed with a quarter side rail in the up position on the right side of the bed. The maintenance supervisor, housekeeping supervisor, and DON provided conflicting statements regarding who was responsible for conducting safety checks on resident beds and side rails. Ultimately, the maintenance supervisor admitted they were unaware of the requirement to regularly monitor and inspect the residents' beds and side rails for safety.
Failure to Timely Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to local law enforcement within the mandated time frame. The incident involved a housekeeper allegedly abusing a resident, which was documented to have occurred at approximately 2:15 p.m. on November 5, 2024. The facility's policy on abuse investigation and reporting requires that all alleged violations involving abuse be reported to various authorities, including law enforcement, within a specific time frame. However, the initial incident report did not document the notification of law enforcement, and the final report indicated that law enforcement was not notified until the following day at 10:53 a.m. The Assistant Director of Nursing (ADON) acknowledged conducting the investigation on the day of the incident but admitted to forgetting to notify law enforcement until the next day. The ADON was aware that the notification should have occurred within two hours of the allegation, as per the facility's policy. This oversight resulted in a failure to adhere to the established reporting time frames for suspected abuse, as outlined in the facility's policy dated July 2017.
Failure to Implement Abuse Policy and Outdated Reporting Timeframes
Penalty
Summary
The facility failed to implement its abuse policy for a resident with cerebral palsy and unspecified intellectual disabilities, who was verbally abused by another resident with bipolar disorder. The incident involved the abusive resident calling the other resident derogatory names in public areas, causing visible distress. Despite the incident being documented in a progress note by an LPN, the administrator was not notified, and no incident report was filed. The LPN admitted to notifying the ADON and the physician but failed to report the incident as verbal abuse or initiate an investigation. Additionally, the facility's abuse policy was outdated, stating a 24-hour timeframe for reporting allegations of abuse/neglect to the Oklahoma State Department of Health (OSDH), contrary to the ADON's understanding of a two-hour requirement. The DON confirmed the policy's 24-hour reporting timeframe and acknowledged the need for an update, as the policy had not been reviewed for the current year. The administrator also recognized the discrepancy and the necessity to revise the policy to align with current reporting requirements.
Failure to Report and Investigate Verbal Abuse Incident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving two residents. One resident, diagnosed with cerebral palsy and unspecified intellectual disabilities, was verbally abused by another resident with a diagnosis of bipolar disorder. The abusive behavior included being called derogatory names loudly in common areas, which visibly upset the victim. Despite the incident being documented in a progress note by an LPN, it was not reported to the administrator or investigated as required by the facility's policy. The facility's policy mandates immediate reporting of any suspected abuse to the administrator, but this protocol was not followed. The LPN involved acknowledged the failure to report the incident as verbal abuse. Additionally, the ADON and DON were unaware of the incident, despite regular reviews of event report progress notes. The administrator also confirmed they were not informed of the incident until much later, indicating a breakdown in communication and adherence to the facility's abuse reporting procedures.
Deficiencies in Person-Centered Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were person-centered for two residents. Resident #1, diagnosed with Rett's syndrome, had a care plan that did not document the preferences of their representative, specifically the request to redirect male residents from interacting with them. Despite the staff being aware of this preference, it was not included in the care plan. The MDS coordinator acknowledged the oversight, stating that the preference was known shortly after admission but was not added to the care plan. The DON confirmed that the preference was known before the last care plan meeting and should have been updated. Resident #2, diagnosed with bipolar disorder, had a care plan that did not address specific behaviors to monitor following a new order for Depakote. The resident had been verbally abusive to another resident, which led to the medication order. However, the care plan only noted the medication order without detailing the behaviors to be monitored. The MDS coordinator admitted to not reviewing the clinical record to determine the behaviors that warranted the medication, and the DON stated that the care plan should have been revised to reflect the reasoning for the order and the specific behaviors to monitor.
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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