The Highlands At Owasso
Inspection history, citations, penalties and survey trends for this long-term care facility in Owasso, Oklahoma.
- Location
- 10098 N 123 E Ave, Owasso, Oklahoma 74055
- CMS Provider Number
- 375558
- Inspections on file
- 28
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at The Highlands At Owasso during CMS and state inspections, most recent first.
A cognitively impaired resident with cardiovascular comorbidities was given another resident’s medications when a CMA, unfamiliar with the residents, relied solely on the resident’s verbal confirmation of identity instead of using proper identification methods. The resident did not receive 11 of their own ordered medications and instead was administered multiple antihypertensives and other drugs, including amlodipine, lisinopril, and labetalol, that were not prescribed for them. Shortly after the error, the resident became diaphoretic, lethargic, cyanotic, and unresponsive, with EMS documenting sinus bradycardia, shallow respirations, and initiating cardiac arrest protocol. Hospital records showed treatment for wrong-medication administration, diagnoses of hypotension, bradycardia, and asystole, and the resident was later pronounced deceased; the medical director indicated that the erroneously administered labetalol and other antihypertensives, in combination with epinephrine given by EMS, could have contributed to an acute cardiac event.
A resident with severe cognitive impairment, dependent for most ADLs and requiring a mechanical lift with two-person assistance for transfers, was improperly positioned in a lift sling by two CNAs. During a transfer from bed to chair, staff failed to secure the resident’s back far enough on the sling, leaving inadequate trunk support and causing the resident to slip from the sling, fall to the floor, and hit the head. The resident, who was on blood thinners, complained of head pain and was later found to have a small subdural hematoma requiring hospitalization, demonstrating a failure to follow the facility’s safe lifting policy and the resident’s care plan.
A resident who had been receiving furosemide 60 mg PO daily in the hospital was admitted with discharge instructions to continue that dose, but the facility’s physician order was entered as only 40 mg PO daily. The resident, who had moderate cognitive impairment and was documented as receiving a diuretic, reported the dose discrepancy, and the ADON later confirmed that the hospital discharge order specified 60 mg daily and that a nurse had mistakenly entered the lower dose.
A cognitively intact resident with a stage II pressure ulcer to the coccyx had a physician’s order for zinc oxide 20% paste to be applied topically every shift, but the medication was left unsecured at the bedside instead of in a locked compartment. Nursing documentation later showed the resident was found mixing the zinc oxide paste into their oatmeal and confirmed ingesting some of it. Facility staff acknowledged that the topical medication had been inappropriately left unattended at the bedside and could not identify who was responsible.
A resident’s guardian requested dental assessment and denture fitting, but the clinical record contained no documentation of these services despite external e-mails confirming impressions, delivery of upper and lower dentures, and later adjustment with care instructions. The resident was observed with a denture cup at bedside and reported their dentures were in the cup, while the social service director acknowledged the absence of dental documentation in the record and was unable to explain the prolonged delay before the resident ultimately received dentures.
A facility failed to follow proper infection control practices during medication administration for a resident with chronic pain syndrome and hypertension. A CMA was observed handling oxycodone with bare hands before placing it into a medication cup, contrary to protocol. Both an LPN and the ADON confirmed that medications should not be touched with bare hands.
A resident with heart failure and anxiety disorder reported that their call light had not worked for several months, requiring them to rely on their roommate for assistance. An LPN was unaware of the issue until it was demonstrated, and the maintenance supervisor admitted that the wireless call system, which required batteries, had ongoing issues with no routine testing or scheduled battery replacement.
A resident with chronic conditions experienced a delay in receiving medications due to transcription errors and communication issues between the facility and pharmacy. The resident's hospital discharge instructions for Xanax were incorrectly transcribed, and medications were not delivered until three days post-admission. Staff interviews highlighted a lack of proactive communication with the pharmacy, resulting in medication administration delays.
The facility failed to serve meals at safe and appetizing temperatures, affecting 99 residents. A resident reported meals were never hot and often improperly cooked, while another resident found the meals inedible. The dietary manager claimed temperatures were checked, but a meal cart's gauge read 100°F, and a test tray showed shrimp at 92°F, cold and flavorless. The dietary manager acknowledged the issue.
The facility failed to maintain an effective pest control program, as evidenced by the presence of roach droppings, dead roaches, and live roaches in various areas during an environmental tour. The corporate administrator noted that the exterminator visited monthly but was unsure if recommendations were reviewed, indicating a deficiency in the pest control program.
A resident with Chronic Lymphocytic Leukemia was found with a large bruise on their arm, which they could not explain. Despite the facility's policy requiring prompt reporting of injuries of unknown origin, the incident was not reported until it was brought up as an abuse allegation. The regional administrator admitted the failure to notify the incident as required.
Fatal Medication Error Due to Failure to Correctly Identify Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically failing to correctly identify a resident before administering medications. A cognitively impaired resident with a history of atherosclerotic heart disease, hyperlipidemia, hypertension, and traumatic brain injury was admitted with orders that included amlodipine 5 mg for hypertension, to be held if systolic blood pressure was less than 115 or heart rate was less than 50. A quarterly assessment documented significantly impaired cognition with a brief mental illness score of 03, use of multiple psychotropic and other medications, and no indication that the resident rejected care. Vital signs taken the morning of the incident showed a blood pressure of 147/76 and pulse of 83 beats per minute. On the morning in question, a CMA administered medications intended for the resident’s roommate to this resident after asking the resident if they were the roommate and accepting the resident’s incorrect verbal confirmation as sufficient identification. The CMA reported being unfamiliar with the residents and relied on the resident’s verbal response rather than using other identification methods such as the photo in the health record, despite the resident’s known cognitive and hearing impairments. As a result, the resident did not receive 11 medications that were prescribed for them and instead received multiple medications prescribed for the roommate, including amlodipine 10 mg, lisinopril 40 mg, and labetalol 300 mg, all ordered with parameters to hold for low systolic blood pressure and/or low heart rate. Shortly after the medication error, nursing notes documented that the resident became diaphoretic, lethargic, pale, cyanotic around the lips, with labored breathing and unresponsiveness. EMS records indicated the facility reported that the resident had been given amlodipine, aldactone, aspirin, baclofen, cyanocobalamin, fluoxetine, glimepiride, labetalol, lamotrigine, lisinopril, metformin, and potassium chloride in error, and EMS found the resident lethargic with sinus bradycardia, shallow respirations, and initiated cardiac arrest protocol. Hospital records showed the resident was treated for having been administered the wrong medications and was diagnosed with hypotension, bradycardia, and asystole, and was pronounced expired later that morning. The medical director stated that labetalol 300 mg administered in error could have caused the resident to expire and that labetalol, amlodipine, and lisinopril all lower blood pressure, and further noted that epinephrine administered by EMS in the presence of labetalol could have caused an acute cardiac event. The resident’s representative stated the resident expired as a result of the medication administration error.
Removal Plan
- Conducted a QAPI meeting where the IDT reviewed the facility’s medication administration policies and procedures to ensure they would keep residents safe
- Provided in-service education by the DON and ADON for all staff administering medications covering medication administration policies and procedures, including correct resident identification during medication pass
- Implemented bi-weekly visual audits of staff administering medications to ensure compliance with medication administration policies and procedures
- Observed staff administering medications to verify they were identifying the correct resident during medication pass
- Verified medication aide certifications
- Completed medication aide skills check-offs
- Reviewed nursing licenses
- Suspended a medication aide
- Observed and interviewed medication aides and nursing staff across multiple shifts to confirm they had the skills and knowledge to correctly identify residents during medication pass and administer medications as prescribed
Improper Mechanical Lift Sling Positioning Leads to Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a mechanical lift in accordance with its own policy and the resident’s care plan. The facility’s Safe Lifting and Movement of Residents policy required that only staff with documented training use mechanical lifts and that residents be properly positioned in slings, with enough appropriate slings available. Resident #2’s quarterly assessment documented severe cognitive impairment with a BIMS score of 5 and dependence on others for most ADLs, including positioning and transfers. The resident’s care plan required the assistance of two or more staff members and the use of a mechanical lift for transfers. On 12/06/25, during a mechanical lift transfer from bed to chair, Resident #2 slipped from the sling and fell. A nurse’s progress note documented that the resident routinely received blood thinners, complained of head pain after the fall, and was transferred to the hospital. The progress note and state reportable incident indicated that two CNAs were present, witnessed the fall, and reported that the resident hit their head on the floor. The incident report stated that the CNAs were attempting to ambulate/transfer the resident in the lift and failed to secure the resident’s back far enough on the sling per facility policies and procedures, resulting in the resident falling from the top right of the sling and hitting their head on the ground. Further description from the ADON indicated that, upon reenactment of the transfer, it was immediately apparent that the CNAs had not properly positioned the sling, leaving the resident without trunk support. Because Resident #2 could not hold themselves up while in the sling, the improper sling positioning led to the resident falling from the sling. A subsequent nurse’s progress note documented that the resident sustained a small subdural hematoma requiring hospitalization. At the time of later observation on 01/07/26, the resident was noted sitting in a recliner, dressed, with the call light in reach, but the deficiency centers on the earlier transfer event in which staff failed to properly secure and position the resident in the mechanical lift sling as required by policy and the care plan.
Incorrect Transcription of Hospital Furosemide Order
Penalty
Summary
The facility failed to ensure medications were administered as ordered when a resident did not receive the correct furosemide dose following hospital discharge. A hospital discharge medication list for Resident #16, dated 01/09/26, directed continuation of furosemide 60 mg by mouth daily, but the corresponding physician’s order entered at the facility on the same date specified only 40 mg by mouth daily. An admission assessment dated 01/16/26 documented that the resident had a BIMS score of 12, indicating moderate cognitive impairment, and was receiving a diuretic medication. On 01/22/26 at 10:00 a.m., the resident reported that they had been taking 60 mg of furosemide daily in the hospital and had only been receiving 40 mg daily since admission to the facility. At 12:20 p.m. the same day, the ADON confirmed that the hospital discharge order called for 60 mg daily, but the nurse had mistakenly entered an order for 40 mg daily. This discrepancy between the hospital discharge medication list and the facility physician’s order, along with the resident’s report and the ADON’s acknowledgment of a nurse’s entry error, demonstrates that the facility did not provide pharmaceutical services in accordance with the prescribed medication regimen for this resident.
Unsecured Topical Medication Left at Bedside and Ingested by Resident
Penalty
Summary
The deficiency involves the facility’s failure to secure and properly store medications, resulting in a cognitively intact resident having access to zinc oxide paste at the bedside. A physician’s order directed that zinc oxide 20% external paste be applied topically to the resident’s sacrum and buttocks every shift for skin integrity, and nursing documentation noted a stage II pressure ulcer on the coccyx with surrounding redness that was treated with zinc cream and a padded dressing. Despite this being a topical medication, it was left unattended at the resident’s bedside rather than stored in a locked compartment as required. A subsequent nurse’s progress note documented that when the nurse entered the resident’s room, the resident was observed mixing zinc oxide paste into their oatmeal and confirmed having eaten some of the mixture. The resident’s comprehensive assessment showed a BIMS score of 15, indicating they were cognitively intact, and noted the use of ointment or medication applied to body areas other than the feet. Facility staff, including the MDS coordinator and ADON, later acknowledged that zinc oxide paste had been left at the bedside and that it was inappropriate to leave medications unattended for this resident, and they were unable to determine which staff member had left the cream there.
Failure to Document and Timely Coordinate Denture Services
Penalty
Summary
The facility failed to provide medically appropriate dental services by not ensuring complete and timely documentation and follow-through of denture services for one resident. The resident was observed in bed with a denture cup at the bedside, and a social service progress note documented that the resident’s guardian had provided contact information and requested that the resident be assessed and fitted for dentures. However, review of the clinical record did not show that the resident had been assessed and fitted for dentures, despite this request. E-mails from the dental provider, supplied by the social service director, showed that impressions for upper and lower dentures were made, that the resident received upper and lower dentures with no adjustments initially needed, and that the dentures were later adjusted for comfort with instructions given on denture care. The resident stated their dentures were in their denture cup. The social service director, who began working at the facility months after the initial request, reported there was no documentation in the clinical record regarding these dental services, even though they found e-mail communications from the dental provider. The social service director also stated they did not know why the information was not included in the clinical record or why it took more than a year before the resident received dentures.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident diagnosed with chronic pain syndrome and hypertension. A physician's order required the resident to receive oxycodone 20 mg every 6 hours as needed for breakthrough pain. During an observation, a Certified Medication Aide (CMA) was seen administering the resident's oxycodone by punching the medication out of the card into their bare hand before placing it into a medication cup. The CMA later acknowledged that the medication should have been punched directly into the cup without being touched. Both a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) confirmed that medications should not be handled with bare hands and should be punched directly into the medication cup.
Non-Functioning Call Light System for Resident
Penalty
Summary
The facility failed to ensure the call light system was functioning for a resident with heart failure and anxiety disorder. The resident reported that their call light had not worked for several months, and they relied on their roommate to activate their call light if they needed help. During an observation, the resident pressed the button to activate their call light, but the light outside their door did not illuminate. An LPN was shown the non-functioning call light and stated they were unaware of the issue and would inform maintenance. The maintenance supervisor acknowledged that call lights had been an ongoing issue in the facility, noting that the wireless call system required batteries. They admitted that there was no routine testing of the call system or scheduled replacement of the batteries, contributing to the deficiency.
Medication Transcription and Delivery Errors
Penalty
Summary
The facility failed to accurately transcribe admission orders and acquire medications within the required timeframe for a resident with chronic obstructive pulmonary disease, depressive episodes, and dementia with mood disturbance. The hospital discharge instructions indicated that the resident was to take alprazolam (Xanax) 1mg as needed every six hours, but the facility's admission orders incorrectly documented it as a routine medication. Additionally, the medications Xanax and Nuvigil were not delivered to the facility until three days after the resident's admission, resulting in a delay in administration. Interviews with facility staff revealed a lack of communication and verification processes between the facility and the pharmacy. The Certified Medication Aide (CMA) and Licensed Practical Nurse (LPN) stated that they often did not know a medication required a written script until it was not delivered. The facility's Director of Nursing (DON) confirmed the transcription error and acknowledged the delay in medication delivery. The staff relied on the pharmacy to notify them of any issues, which led to residents not receiving medications as ordered.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve hot foods at an appealing temperature, affecting 99 residents who ate meals prepared in the kitchen. On December 11, 2024, Resident #4 reported that meals served in their room were never hot and rarely warm, with some meals being either undercooked or overcooked. Resident #6 expressed that the meals tasted bad and suspected that the kitchen staff knowingly served inedible food. The dietary manager claimed that food temperatures were checked before serving and upon delivery to the residents' hall. However, an observation of the meal cart's temperature gauge showed it reading 100 degrees Fahrenheit, despite the heating dial being set to 145 degrees Fahrenheit. A test tray revealed that the temperature of popcorn shrimp was 92 degrees Fahrenheit, with the shrimp feeling cold, chewy, and covered in damp breading, lacking flavor. The dietary manager acknowledged the issue, stating that the food was hot when it left the kitchen.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations made during an environmental tour on the 400 hall. Roach droppings and dead roaches were found along baseboards, near and under the refrigerator, on glue traps located in the corners of the room, storage drawers, and closets. Live roaches were also observed in the corners nearest the bathroom door and near the heat/air unit in rooms 412 and another unspecified room. The corporate administrator acknowledged that the exterminator visited the facility monthly but was unsure if the administrator reviewed the recommendations left on the exterminator's invoices. Despite the exterminator's responsiveness to concerns, the presence of pests indicated a deficiency in the pest control program.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident diagnosed with Chronic Lymphocytic Leukemia of B-cell type. The resident was found with a large bruise on their right arm, which they could not explain. Initially, the resident did not report any pain, but later expressed discomfort, prompting a consultation with the wound nurse and an x-ray, which showed no fractures or abnormalities. Despite these findings, the facility did not immediately report the incident as an injury of unknown origin. The facility's policy required that all injuries of unknown source be reported promptly to local, state, and federal agencies. However, the incident was only reported as an abuse allegation after a family member inquired about the bruise, and the facility realized the reporting oversight. The regional administrator acknowledged the failure to notify the incident as an injury of unknown origin, indicating a lapse in following the established reporting procedures.
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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