Westhaven Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Stillwater, Oklahoma.
- Location
- 1215 South Western, Stillwater, Oklahoma 74074
- CMS Provider Number
- 375417
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Westhaven Nursing Home during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, dependent on staff for transfers and wheelchair use, was allegedly yanked from a wheelchair and dropped forcefully onto a couch by a CNA after being described as combative with care. A family member and an RN both believed the CNA’s actions were abusive. Although the facility’s abuse policy required immediate reporting of suspected abuse to the Administrator or DON, the RN delayed reporting the allegation until the following morning, resulting in a failure to promptly report the suspected abuse.
A resident with dementia, severely impaired cognition, and dependence on staff for transfers and wheelchair use was allegedly abused by a CNA during a night shift. The RN who witnessed or became aware of the abusive behavior did not know the facility’s abuse procedure, did not remove the CNA from duty, and delayed reporting the allegation to the DON until the following morning, allowing the CNA to complete the shift. This response conflicted with the facility’s abuse policy, which required suspension of an employee during an abuse investigation.
A resident admitted with malnutrition, GI hemorrhage, and dysphagia, and receiving tube feeding, experienced an 8.66% weight loss over about one month, as shown by weight records. Despite this, the admission MDS documented that the resident had not lost 5% or more body weight in the prior month. An LPN reported the resident was placed on five daily bolus feedings of Jevity 1.5 for a few days, and the MDS coordinator later acknowledged that the admission assessment should have reflected a weight loss greater than 5% in one month.
A resident with malnutrition, GI hemorrhage, dysphagia, and a feeding tube experienced significant weight loss over about one month, but the care plan was not updated to reflect this change or add specific interventions. The existing care plan only noted the need for tube feeding and periodic RD evaluation, despite physician orders for multiple daily bolus feedings of Jevity 1.5. During interviews, an LPN reported the resident received five bolus feedings daily for a few days, and the MDS coordinator acknowledged that the care plan should have documented the greater than 5% monthly weight loss and included measures to prevent further loss.
Surveyors found that daily nurse staffing information was consistently posted on a bulletin board down a hallway rather than in a prominent, easily visible area such as the main lobby or front entrance. The DON and administrator acknowledged that the posting location was not readily visible to all residents and visitors unless they already knew where to look, despite dozens of residents residing in the facility at the time.
Surveyors identified that the facility failed to remove expired medications and medical supplies from a medication supply room and a medication cart, despite a policy requiring constant review and rotation to prevent expiration. In the supply room, multiple expired wound care dressings and an opened Tubersol vial without an open date were found, and another Tubersol vial remained beyond the 30-day use period. On one hall’s medication cart, an expired box of Naloxone nasal spray was present. Nursing staff and the DON acknowledged that these expired items should have been removed and that opened vials should have been properly dated and discarded within the required timeframe.
A CNA failed to remove soiled gloves or perform hand hygiene after providing perineal care to a resident, then proceeded to handle clean items such as blankets and a bed remote, contrary to facility policy requiring glove removal and handwashing before touching clean areas.
The facility did not complete discharge summaries for three residents who were discharged. A review of their records showed the absence of these summaries, and the DON confirmed the oversight.
A facility did not ensure a pharmacy's medication regimen review recommendation was sent to a physician for a resident with diabetic neuropathy. The resident was prescribed Gabapentin 600 mg TID, but a review suggested a dose reduction due to renal function. No documentation showed the recommendation was acted upon, and the DON could not find the physician's response.
The facility failed to implement a 14-day stop date for as-needed lorazepam for a resident with anxiety and did not act on a Medication Regimen Review request for dose reduction of psychotropic medications for another resident with anxiety and depression. The oversight in medication management was acknowledged by staff, and the Director of Nursing could not locate a physician's response to the review request.
The facility failed to remove expired medications and supplies from the medication storage room, as observed during a tour with the DON. Expired items included Ipratropium Bromide and Albuterol Sulfate, collection and transport swab packets, Milk of Magnesia, and Narcan nasal spray. Additionally, a bottle of Lantus insulin was found opened and undated. The DON acknowledged the oversight.
A resident with Alzheimer's and dementia developed a new pressure ulcer, but the facility failed to notify the physician as required. The wound was documented and treated with calazime, but there was no record of physician notification. The DON confirmed the oversight during a wound care observation.
A facility failed to ensure safe medication administration when a resident was observed with two medication cups left on their bedside table while eating breakfast. Despite the policy requiring staff to stay with residents until medications are swallowed, an RN left the medications with the resident, who intended to take them later, violating the facility's guidelines.
A facility failed to implement Enhanced Barrier Precautions (EBP) during incontinent and indwelling catheter care for a resident. Despite a policy requiring gowns and gloves for high-contact activities, staff did not wear gowns while providing care. The CNA and CMA involved were unsure if EBP should be used during such care, indicating a lack of adherence to infection control protocols.
Failure to Immediately Report Alleged Abuse of a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an allegation of abuse was immediately reported as required by its policy. The facility’s undated “Patient Abuse” policy stated it was strictly prohibited for any employee to fail to immediately report an incident of patient abuse to the Administrator or DON. Resident #1, admitted on 01/25/26, had severely impaired cognition with a BIMS score of 03, diagnoses including dementia, and was dependent on staff for transfers and required substantial/maximal assistance for wheelchair use. An incident report dated 02/12/26 documented an allegation of abuse that occurred on 02/11/26 at approximately 11:00 p.m., when RN #1 observed CNA #1 behave in an abusive manner toward Resident #1. Family member #1 reported they had been called to the facility around 10:30 p.m. to 11:00 p.m. because Resident #1 was being combative with care and requested the resident be transferred to a couch where they had been sleeping recently. Family member #1 stated CNA #1 yanked the resident up from the wheelchair and dropped them down on the couch with force, and they felt the CNA’s actions were abusive. RN #1 stated they had asked CNA #1 to transfer Resident #1 from the wheelchair to the couch in the common area, and that CNA #1 was mad and aggressively transferred the resident. RN #1 stated they and family member #1 both felt the CNA’s actions were abusive, but RN #1 did not report the incident to the DON until 6:00 a.m. the next morning, rather than immediately. The administrator stated they reported the abuse allegation and started an investigation as soon as they were made aware of the incident by RN #1, and the DON stated the incident should have been reported to them or the administrator immediately by RN #1.
Failure to Immediately Remove Alleged Perpetrator After Abuse Allegation
Penalty
Summary
The facility failed to immediately protect a resident from potential further abuse after an allegation against a CNA. An admission assessment for Resident #1, who had dementia, severely impaired cognition with a BIMS score of 03, and was dependent on staff for transfers and wheelchair use, documented the resident’s condition. An incident report showed that on 02/11/26 at approximately 11:00 p.m., an allegation of abuse by CNA #1 toward Resident #1 occurred, but RN #1 did not report the allegation to the DON until 6:00 a.m. on 02/12/26. During this time, CNA #1 was not removed from duty and was allowed to continue working, as confirmed by a timesheet showing CNA #1 clocked out at 6:15 a.m. on 02/12/26. The facility’s undated Patient Abuse policy stated that to protect the resident during an abuse investigation, the employee would be suspended during the investigation process. RN #1 stated they did not send CNA #1 home after witnessing the abusive behavior and did not know the facility’s abuse procedure, waiting until the next morning to report the allegation. The DON stated CNA #1 should have been sent home immediately and should not have been allowed to finish the shift. This sequence of events demonstrates that the facility did not follow its own abuse policy and failed to immediately remove the alleged perpetrator from resident care after an abuse allegation involving Resident #1.
Inaccurate MDS Assessment of Significant Weight Loss
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for one resident when the admission MDS did not reflect a significant weight loss that had occurred prior to and at the time of admission. Record review showed the resident, admitted with malnutrition, gastrointestinal hemorrhage, and dysphagia and requiring nutrition via feeding tube, weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26, with an admission assessment weight of 195 pounds on 01/23/26. This represented an 8.66% weight loss between 12/24/25 and 01/23/26. However, the admission MDS documented that the resident had not experienced a weight loss of 5% or more in the last month. During interview, an LPN reported the resident had been placed on five daily bolus feedings of Jevity 1.5 for a few days, and the MDS coordinator, after reviewing the weight summary, acknowledged that the admission assessment should have indicated a weight loss of over 5% in one month.
Failure to Update Care Plan for Significant Weight Loss in Tube-Fed Resident
Penalty
Summary
The facility failed to update and implement a comprehensive care plan to address significant weight loss for one resident who received nutrition via a feeding tube. Record review showed the resident weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26, an 8.66% loss between 12/24/25 and 01/23/26, yet the existing care plan dated 12/29/25 only reflected that the resident required tube feeding and included an intervention for the registered dietitian to evaluate quarterly and as needed, with no update documenting the significant weight loss or additional interventions. A physician’s order dated 01/17/26 directed bolus feedings of Jevity 1.5 five times daily, and the admission MDS documented diagnoses including malnutrition, gastrointestinal hemorrhage, and dysphagia, with tube feeding required and no prior 5% or greater weight loss in the last month. During interview, an LPN stated the resident was placed on five bolus feedings daily for a few days, and the MDS coordinator, after reviewing the weight summary, acknowledged the care plan should have reflected the resident’s greater than 5% monthly weight loss and included interventions to prevent further weight loss. This deficiency involved the facility’s inaction in revising the care plan despite documented significant weight loss and existing clinical information indicating the resident’s nutritional risk, as well as reliance on assessments for weight information without ensuring that the care plan was updated to address the change in condition.
Failure to Post Daily Nurse Staffing Information in a Prominent Location
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a prominent location readily accessible to residents, staff, and visitors. On two separate observations, the daily nurse staffing information sheet was found posted on a bulletin board partway down hall 4, rather than in a clearly visible area such as the main lobby or front entrance. During these observations, the posting was not clearly visible to all visitors and residents. The DON acknowledged that the daily nurse staffing information sheet was not posted in the main lobby area and would not be visible to all residents and visitors who did not know where it was located, stating it had always been kept down hall 4 on the bulletin board. The administrator similarly confirmed that the daily nurse staffing information sheet was not posted at the front entrance and was not visible to all residents and visitors who did not know where to look. At the time of the survey, the DON identified that 62 residents resided in the facility. These observations and interviews demonstrate that the facility did not comply with the requirement to post nurse staffing information in a prominent, readily accessible place for all residents, staff, and visitors.
Expired Medications and Supplies Not Removed From Storage and Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure expired medications and medical supplies were removed from storage areas and a medication cart, as required by professional standards and the facility’s own policy on expired medications. In the medication supply room, multiple wound care products were observed to be past their expiration dates, including several packages of IoFlex iodophor foam dressings, Maxorb II alginate wound dressings, Sorbalgon calcium alginate dressings, Tegaderm film dressings, Zetuvit Plus silicone border dressings, and an Optifoam heel foam non-adhesive dressing. Additionally, one Tubersol vial was opened and dated, and another Tubersol vial was opened with no date indicating when it was opened, contrary to expectations that such vials be dated and discarded after 30 days. On a medication cart for one hall, surveyors observed a box of Naloxone hydrochloride nasal spray with an expiration date indicating it should already have been removed. Staff interviews confirmed that the expired medications and supplies should have been removed from the medication/storage room and that the Tubersol vial should have been dated and discarded after 30 days. Another staff member acknowledged that the Naloxone should have already been removed from the cart. The DON also stated that the expired medications and supplies should have been removed, confirming that the facility did not follow its policy to rotate and review medications on a constant basis to prevent expired items from remaining available for use.
Failure to Follow Infection Control Practices During Incontinent Care
Penalty
Summary
During an observation of incontinent care provided to one resident, two CNAs entered the resident's room to perform perineal care. CNA #1 was observed removing blankets and a pillow, assisting the resident to their side, and cleaning the perineal area with disposable wipes, using each wipe only once before discarding. After completing the cleaning, CNA #1 replaced the pillow, pulled up the blankets, and used the bed remote, all while still wearing the same gloves used during the perineal care. CNA #1 did not remove the soiled gloves or sanitize their hands before touching clean items and areas, contrary to the facility's perineal care policy, which requires glove removal and hand hygiene before handling clean items. CNA #1 later acknowledged not following the glove removal policy prior to touching clean areas.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete discharge summaries for three residents who were discharged from the facility. Resident #60 was discharged on August 22, 2024, Resident #67 on May 29, 2024, and Resident #69 on May 31, 2024. Upon review of their records, it was found that none of these residents had a discharge summary documenting their stay. The Director of Nursing (DON) confirmed on August 28, 2024, that the discharge summaries were not completed for these residents.
Failure to Act on Pharmacy Recommendation for Medication Adjustment
Penalty
Summary
The facility failed to ensure that a Medication Regimen Review (MRR) pharmacy request was sent to the physician for action regarding a resident's medication. The resident, who had a diagnosis of diabetic neuropathy, was prescribed Gabapentin 600 mg three times daily. A MRR conducted on 06/11/24 recommended a dose reduction based on the resident's renal function, suggesting a maximum dosage of 700 mg twice daily. However, there was no documentation in the resident's clinical record indicating that the recommendation had been acted upon. The Director of Nursing (DON) was unable to locate the physician's response to the MRR pharmacy recommendation letter.
Failure to Implement Psychotropic Medication Protocols
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications. For one resident with a diagnosis of anxiety, the facility did not implement a 14-day stop date for as-needed lorazepam orders. The orders were documented with a re-evaluation date instead of a set stop date, leading to the continuation of the medication without proper review. This oversight was acknowledged by a corporate nurse who stated that the orders should have been entered with a set stop date. Another resident, diagnosed with anxiety and depression, was prescribed lorazepam and bupropion. A Medication Regimen Review (MRR) requested a gradual dose reduction of these medications, as per state and federal guidelines. However, the facility failed to act on this request, as the Director of Nursing (DON) could not locate a physician's response to the MRR. This inaction indicates a lapse in following up on medication reviews and ensuring appropriate medication management for the resident.
Expired Medications and Supplies Found in Medication Storage Room
Penalty
Summary
The facility failed to ensure the removal of expired medications and supplies from the medication storage room, as observed during a tour with the Director of Nursing (DON). Several expired items were found, including boxes of Ipratropium Bromide and Albuterol Sulfate with use-by dates ranging from April to November 2024, collection and transport swab packets expired since February 2024, and multiple bottles of Milk of Magnesia with use-by dates from March to August 2024. Additionally, a bottle of Lantus insulin was found opened and undated, and Narcan nasal spray boxes with expiration dates as far back as November 2013 were present. The DON acknowledged that the insulin should have been dated when opened and that expired medications and supplies should have been removed before their use-by dates.
Failure to Notify Physician of New Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician of a new pressure ulcer for a resident diagnosed with Alzheimer's disease and dementia. The resident developed an open area measuring 0.5 cm by 0.5 cm with red-tinged drainage, as documented in a progress note dated 07/27/24. The wound was cleaned, patted dry, and calazime barrier cream was applied, but there was no documentation indicating that the physician was notified of the new wound. On 08/27/24, during an observation of wound care, the Director of Nursing (DON) confirmed that the physician should have been notified on the day the wound was discovered, but there was no evidence of such notification.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for one of the six sampled residents reviewed for medications. During an observation, a resident was seen sitting in their room eating breakfast with two medication cups on their bedside table. One cup contained two white tablets, and the other contained 12-15 tablets/capsules. When questioned, RN #1 stated that the policy for administering medications involved checking the physician's orders, punching the medications out, initialing the MAR, and staying with the resident until they swallowed the medications. However, RN #1 left the medication cups on the resident's bedside table after the resident expressed a desire to take them after breakfast, contrary to the facility's policy and inservice education guidelines that medications should not be left in residents' rooms.
Failure to Implement Enhanced Barrier Precautions During Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during incontinent care and indwelling catheter care for one of the five sampled residents reviewed for infection control. The Director of Nursing identified nine residents with Foley catheters and 23 with EBP in place. An undated policy on EBP indicated that staff must wear gowns and gloves during high-contact resident care activities, such as changing briefs and urinary catheter care. An EBP sign was posted on the outside of the resident's door, instructing staff to wear gloves and a gown during transfers and urinary catheter activity. On the morning of the observation, a resident was seen sitting in a wheelchair with a lift sling under them, and a urinary drain bag was hooked under the wheelchair. Two staff members, a CNA and a CMA, cleaned their hands and donned gloves before transferring the resident to their bed using a lift. The CMA provided peri care and indwelling catheter care, while the CNA provided incontinent care. However, neither staff member wore gowns during these procedures. When asked about the EBP policy, the CMA mentioned that EBP should be used for residents with specific conditions but was unsure if it should be implemented during incontinent and urinary catheter care.
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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