Wewoka Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wewoka, Oklahoma.
- Location
- 1400 West First Street, Wewoka, Oklahoma 74884
- CMS Provider Number
- 375303
- Inspections on file
- 44
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 12 (6 serious)
Citation history
Health deficiencies cited at Wewoka Healthcare Center during CMS and state inspections, most recent first.
A resident with chronic pain and other conditions had an order for PRN oxycodone/APAP, with pharmacy records showing 120 tablets delivered, but facility documentation only accounted for a fraction of the medication and contained unexplained discrepancies between the controlled drug count sheet and the MAR. Staff reported forged signatures on the narcotic count sheet and stated that concerns were brought to the administrator and ADON, yet the administrator later denied being informed, and required reporting to state authorities and law enforcement, as outlined in the facility’s abuse and misappropriation policy, did not occur. Nursing staff, including a CMA, an LPN, and the ADON, described limited follow-up and unclear responsibility for reconciliation of controlled substances, resulting in a failure to implement and follow policies and procedures to prevent, detect, and report misappropriation of controlled narcotic medications.
The facility failed to prevent misappropriation of controlled medications for two residents with chronic pain and major depressive disorder. Pharmacy records showed full quantities of oxycodone/APAP and hydrocodone/APAP were delivered, but internal documentation, including receiving logs, narcotic count sheets, and MARs, did not account for all tablets. One resident reported taking only a single dose and then refusing further medication, while a CMA reported their signature had been forged on narcotic count sheets, with another staff member stating this was reported to administration despite the administrator denying awareness. For the second resident, reconciliation of count sheets and packing slips revealed missing tablets and an absent count sheet, and a search of locked medications did not locate the unaccounted doses.
The facility failed to maintain an effective system for receiving, documenting, and reconciling controlled narcotics, resulting in missing oxycodone/APAP and hydrocodone/APAP for two residents with chronic pain and major depressive disorder. Pharmacy records showed full quantities of controlled medications were delivered, but medication cards and count sheets for significant portions of these drugs could not be located, and the receiving logs did not reflect the deliveries. For one resident, the controlled drug count sheet showed doses documented as given that were not recorded on the MAR, while the resident reported taking only one dose and a CMA reported their signature had been forged on the count sheet. For the other resident, reconciliation of count sheets and packing slips revealed 30 tablets unaccounted for, with incomplete count sheets for the month. Staff interviews showed inconsistent reconciliation practices and acknowledged a period without a full-time DON during which these discrepancies occurred.
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of mouse droppings, chewed wall material, dead roaches, and live roaches in the kitchen, dining room, and a resident room, including inside an ice machine and a room refrigerator. A resident with dysphagia, hemiplegia, chronic pain, suprapubic catheter status, and an open buttocks wound, who was bed/chair bound and required moderate assistance with all ADLs, was found to have dead roaches and mouse droppings in the room and bathroom areas. The facility’s pest sighting log documented ongoing mice and roach activity in resident rooms and the dining room over several months and showed a preventive treatment date, but did not show that each recorded pest sighting was treated, despite a written policy stating the building would be kept free of insects and rodents.
A resident with traumatic brain injury, mood disorder, and intact cognition exhibited escalating behaviors including yelling, cursing, hoarding medications, attempting self-harm, threatening staff, and expressing suicidal intent, leading to an emergency discharge and police transport to a hospital. An immediate written discharge notice was completed and given to the resident, but the LPN who prepared the transfer packet sent only a face sheet, diagnosis list, and medication list, omitting the discharge notice. The administrator had assumed all discharge documents were sent, and the hospital case manager later confirmed the hospital did not receive the discharge notice until they contacted the facility about returning the resident, showing the facility failed to provide the required immediate written discharge notice to the receiving hospital.
A resident with intact cognition and multiple psychiatric and medical diagnoses was receiving several psychotropic medications, including Quetiapine and Trintellix. During a pharmacist’s monthly medication regimen review, the pharmacist requested gradual dose reductions for these medications. The physician marked that dose reductions were contraindicated but did not document any clinical rationale, despite facility policy requiring such documentation when GDR is declined. Nursing staff noted the physician’s response but did not obtain or document a rationale, and the ADON later confirmed the absence of this required documentation while also noting that many residents in the facility were on psychotropic medications.
Multiple incidents occurred in which a resident physically struck other residents, including one with intact cognition and another with hemiplegia, resulting in injuries such as a bruise and a small tear. In another case, a resident with moderate cognitive impairment was hit on the head during a dining room altercation. Staff and LPNs witnessed or responded to these events, but the facility did not prevent the physical abuse.
The facility did not ensure timely reporting of suspected abuse incidents to the State Agency, including a physical altercation between two residents that resulted in injury. Initial reports were submitted late, and final investigation reports were either not sent within the required timeframe or not successfully transmitted, as confirmed by fax logs and the State Agency's records. These failures involved multiple residents and reflected noncompliance with required abuse reporting protocols.
A resident with cognitive and mental health diagnoses reported being held down and subjected to unwanted kissing by another resident. The incident was not promptly reported or thoroughly investigated, and the affected resident experienced ongoing fear and isolation as the perpetrator continued to approach them in common areas. Facility staff failed to ensure immediate protection and proper documentation as required by policy.
A resident with full code status was found unresponsive, but staff were initially unable to confirm the code status because it was not listed in the electronic health record. This led to a delay in starting CPR, as staff had to consult the Kardex to verify the resident's wishes. CPR was eventually initiated, but EMS records indicated that resuscitation efforts were not started prior to their arrival, highlighting a delay in providing basic life support.
A resident with schizoaffective disorder, psychosis, and depression exhibited repeated threats of self-harm and aggression toward others, including physical assaults on staff and another resident. Despite these behaviors, the resident was not placed on behavior monitoring, did not receive a psychiatric evaluation or medication reconciliation, and lacked appropriate care plan interventions. Staff confirmed that no special monitoring or interventions were in place after re-admission, and the facility environment was not equipped to manage the resident's mental health needs.
A resident with a history of schizoaffective disorder, hallucinations, and depression threatened to harm themself and others while exhibiting aggressive behavior and reporting auditory hallucinations. Although the resident was placed on one-on-one monitoring and emergency services were contacted, there was no documentation that the physician or psychiatric provider was notified of the incident, as confirmed by staff interviews and record review.
A resident with severe cognitive impairment was inappropriately touched by another cognitively intact resident in a common area. Staff intervened immediately, but the incident had already occurred. The affected resident was unable to recall the event due to their condition, and facility policies required protection from such abuse and consent based on decision-making ability.
A resident with a history of physical aggression assaulted another severely cognitively impaired resident, causing injury that required emergency care. Facility staff did not immediately implement required one-on-one supervision for the aggressor or update care plans with new interventions after each incident, and failed to document witness statements, all in violation of facility policy.
A resident with a history of physical aggression assaulted another resident, resulting in injury and hospital evaluation. The facility did not conduct a thorough investigation, failed to document witness statements, did not immediately implement required one-on-one safety measures, and did not update the care plan with new interventions or coordinate with QAPI as required by policy.
A resident with severe cognitive impairment and neuropsychiatric conditions was physically assaulted by another resident, resulting in visible injuries and an ER visit. The facility did not document any witness statements from staff or other residents, and the administrator acknowledged that a thorough investigation was not completed, contrary to facility policy.
Two residents with cognitive impairment and behavioral health diagnoses were able to leave the facility unsupervised, with one found walking on a road and another located miles away in a construction zone, both without proper documentation or notification to leadership. Staff interviews revealed confusion about elopement risk identification and inconsistent communication. Additionally, an unwitnessed fall involving another resident was not documented, despite evidence of the incident.
A resident with multiple medical conditions and full dependence for ADLs was found to have roaches on their body, mouse droppings in their room, and a mouse trap near their bed. Despite repeated pest sightings documented in the facility's log and complaints from the resident, there was no evidence that the pest issues were addressed after being reported. Staff confirmed ongoing pest problems in the room.
A resident with Medicaid coverage and intact cognition was not notified when their trust account balance exceeded the $200 threshold below the Medicaid resource limit, as required. Documentation and interviews confirmed the lack of notification, and the BOM was unaware of the notification requirement.
Multiple residents were found living in unsanitary and uncomfortable conditions, including mold under a sink, cracked and stained flooring, pest infestations, soiled linens, and damaged walls. Staff and administration acknowledged the presence of these issues, and residents reported that their concerns about cleanliness and pests were not addressed.
A resident with dementia and impaired decision-making was found on the floor after an unwitnessed fall. An LPN took a photo of the resident, exposing their bottom, before providing assessment or care, and did not document the incident in the health record. The facility's policy prohibits taking demeaning or privacy-violating photos, and the incident was reported to the state health department.
A treatment cart was found unlocked and unattended near the nurses station, with an insulin pen for a resident stored inside. Facility policy requires all medications to be securely stored and accessible only to authorized personnel. An LPN confirmed the cart should have been locked and attended at all times.
A call light was found not working in one of the shower rooms, as observed and confirmed by staff. The administrator confirmed that call lights are expected to be operational in all shower rooms, but the maintenance supervisor reported no work orders had been submitted for this issue.
A resident with multiple diagnoses began receiving Cipro, an antibiotic, without a documented physician's order or entry in the MAR. Despite this, the medication was administered, as indicated by a count sheet. A CMA admitted to not documenting the administration, and the ADON confirmed that medications not listed on the MAR should not be given.
The facility did not maintain a consistent temperature log for the medication refrigerator, with missing entries for several days across multiple months. The responsibility for maintaining these logs was assigned to the night shift nurses, as confirmed by the DON.
A facility failed to update a fall care plan for a resident with rheumatoid arthritis, omitting the intervention of a low bed with a fall mat despite it being implemented. The MDS coordinator was unaware of this change due to a lack of communication processes.
The facility did not conduct scheduled activities for residents, as observed and reported by residents and staff. The activity calendar listed events like Dominoes and Bingo, but these were not held at the scheduled times. Residents expressed dissatisfaction with the lack of activities and the absence of an activity director. Staff acknowledged the issue, with discussions about sharing activity responsibilities but no implementation.
The facility failed to ensure safety in the smoking area, resulting in a resident with schizophrenia smoking without a proper assessment and another resident with depression receiving a burn hole in their jacket due to overcrowding. Staff confirmed the lack of assessments and supervision, and the administrator acknowledged the overcrowding issue.
A facility failed to develop a comprehensive care plan for a resident with schizophrenia, specifically regarding their smoking habits. Despite the resident's assessment documenting tobacco use, no care plan was completed by the required date. The resident was observed smoking with staff assistance, but there was no care plan addressing this behavior. The MDS coordinator admitted to being behind on care plans, leading to this omission.
A resident with psychotic disorders exhibited adverse behaviors, such as aggression and inappropriate urination, which were documented in nursing progress notes but not in the TAR. An LPN confirmed the omission, indicating a failure to maintain accurate medical records.
The facility failed to notify mental health physicians of resident-to-resident abuse incidents involving two residents with mental health diagnoses. Despite multiple aggressive incidents, there was no documentation of physician notification, and interviews confirmed the oversight.
A facility failed to accurately assess a resident's adverse behaviors, despite documented instances of aggression and inappropriate actions. The resident, diagnosed with hallucinations and psychotic disorders, exhibited behaviors such as urinating in inappropriate places and physical aggression. However, the MDS assessment did not reflect these behaviors, and several sections were incomplete or inaccurately documented. The MDS Coordinator acknowledged the inaccuracies after reviewing the resident's records.
The facility failed to update care plans with interventions to protect vulnerable residents from abuse and prevent further potential abuse. Two residents were assaulted by others, and a resident with psychotic disorders exhibited abusive behavior without preventative interventions documented in their care plan. The MDS Coordinator acknowledged the need for updates, highlighting a lapse in adherence to the facility's abuse policy.
The facility did not employ a full-time DON and failed to ensure RN coverage for eight consecutive hours daily. The administrator and interim DON confirmed the absence of a full-time DON since May, with timecard reports showing insufficient RN coverage on 20 days in both August and September.
The facility failed to consistently implement COVID-19 isolation procedures for residents who tested positive, as required by their policy. Despite being in outbreak status, there was no signage indicating positive cases, and staff were unclear about which residents were in isolation and for how long. Some residents were removed from isolation after only five days, contrary to the 10-day policy, leading to a deficiency identified by surveyors.
The facility did not designate a qualified infection preventionist for its infection prevention and control program. The administrator identified the ADON as the infection preventionist, but there was no certification documentation. The interim DON, who had the certification, was on vacation, and the ADON had been handling duties without being formally assigned. The ADON attempted to manage COVID procedures but did not fulfill all required duties.
A resident with intact cognition missed a scheduled court hearing due to the facility's failure to communicate the hearing details to the appropriate staff. Despite informing the facility upon admission, the resident's attendance was not facilitated, leading to a delay in their guardianship proceedings.
A resident, dependent on staff for bathing due to conditions like edema and morbid obesity, did not receive scheduled baths as per the facility's shower schedule. The resident was supposed to be bathed three times a week, but there was no documentation of completed baths in the EHR. The resident reported receiving only three baths since admission. A CNA confirmed that bath completions and refusals should be documented, but the ADON found no such records.
The facility failed to investigate an alleged abuse incident involving two residents, one with cognitive communication deficit and another with aphasia and dementia. A witness reported seeing one resident force the other into a room and undress them. Despite discrepancies in staff accounts and police involvement, the incident was not documented in medical records or reported to the state health department.
A facility failed to prevent physical abuse of a resident who was severely cognitively impaired and dependent on staff for most ADLs. A CNA witnessed another CNA grab the resident's groin with force and yell at the resident during care, being rough during incontinent care. The facility's investigation substantiated the allegation of abuse.
A facility failed to report an alleged abuse incident within the required two-hour timeframe. A CNA witnessed potential abuse by another CNA towards a resident and reported it to the ADON. However, the incident, which occurred in the evening, was not reported to the OSDH until the following morning, exceeding the mandated reporting period.
The facility failed to maintain kitchen sanitation and food safety, affecting 74 residents. Observations included grease and food debris accumulation, warm hamburger meat in dirty water, and numerous cockroaches. Open garbage cans without lids and undated food packages were found, with a lack of temperature documentation for refrigerators and freezers. Staff shortages contributed to the unclean kitchen, and the DM was unaware of the conditions due to sick leave.
The facility failed to maintain an effective pest control program, with numerous cockroaches observed in the kitchen and dining areas. Staff and residents reported ongoing issues, including a resident finding a cockroach in their breakfast. The Dietary Manager acknowledged the problem, noting it remained a major concern despite some improvement.
A resident with a supra-pubic catheter experienced chronic pain due to the facility's failure to ensure a scheduled urology surgery was completed. The appointment was canceled because of transportation issues and lack of paperwork, and it was not rescheduled promptly due to inconsistent social services staffing. The interim DON admitted the oversight, and the resident expressed frustration over the continued need for the catheter.
The facility failed to ensure food was palatable and served at appetizing temperatures, as required by their policy. Observations revealed that food items were served below the required 135 degrees F, and residents reported dissatisfaction with the meals, describing them as cold and unappetizing. The Dietary Manager acknowledged the lack of temperature documentation and the oversight in maintaining proper food temperatures.
The facility did not cover garbage containers in the kitchen, contrary to their policy, leading to pest presence. Open garbage cans filled with food waste were observed, and the DM acknowledged the need for lids to prevent contamination and pests.
The facility did not follow the planned lunch menu, serving meat loaf instead of turkey pot pie without approval. The Dietary Manager was unaware of the substitution, and ingredients for the original meal were available. Additionally, a delay occurred when au gratin potatoes ran out, requiring mashed potatoes to be prepared for remaining residents.
Failure to Implement and Follow Policies for Controlled Narcotic Accountability and Misappropriation Reporting
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow policies and procedures to prevent and report misappropriation of a resident’s controlled narcotic medications. The facility had an undated Abuse Policy and Procedure stating residents have the right to be free from misappropriation of property and that the administrator would immediately report allegations to the Oklahoma State Department of Health and local police and conduct an immediate investigation. Resident #6 was admitted with diagnoses including chronic pain, hypertension, and major depressive disorder and had a physician’s order for oxycodone/APAP 10-325 mg, one tablet every six hours as needed, which was later discontinued. Pharmacy records showed 120 oxycodone/APAP tablets were delivered for this resident, but facility documentation only accounted for 30 tablets on the controlled drug count sheet, and the Medication Log of Receiving did not log the 12/15/25 delivery at all. The MARs for December and January showed only three documented doses, while the controlled drug count sheet reflected an additional 19 administered doses not documented on the MAR. Staff interviews revealed multiple failures to act on and report suspected misappropriation and documentation irregularities. CMA #1 reported that their name had been forged on the narcotic count sheet on multiple days and stated the resident did not request or take the medication beyond the first dose, and that they informed the administrator and were told it would be taken care of. Another CMA stated the issue was discovered during a cart count and that CMA #1 immediately reported it to the administrator. An anonymous staff member also stated they witnessed CMA #1 report the forged signatures to the administrator and ADON. However, the administrator later stated they were never informed of the issue and confirmed that neither the state agency nor law enforcement had been notified. LPN #1 acknowledged being told about the narcotic count sheet issue but did not follow up, believing it was the DON’s responsibility. The ADON stated they only ensured the count sheet and card matched before locking medications in the DON’s office and indicated RNs were usually responsible for reconciliation. The administrator stated reconciliation of the count sheet with the MAR should be done by the RN or charge nurse. LPN #2 denied administering any narcotics to the resident or signing the count sheet. Pharmacy staff confirmed that 120 tablets had been delivered, underscoring the discrepancy between delivered, documented, and administered doses and the facility’s failure to implement its own policies for reporting and investigating misappropriation of controlled medications.
Removal Plan
- Educate the administrator on policies and procedures that prohibit and prevent misappropriation of controlled medications
- Educate the administrator on investigating any allegations of misappropriation of controlled medications
- Ensure allegations of misappropriation of controlled medications are reported to the Oklahoma State Department of Health and law enforcement by the corporate administrator
- Re-educate all licensed nurses and CMAs on reporting requirements
- Re-educate all licensed nurses and CMAs on the controlled substance chain of command
- Re-educate all licensed nurses and CMAs on documentation requirements
Misappropriation and Poor Accountability of Controlled Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of controlled medications, resulting in unaccounted narcotics for two residents with chronic pain and major depressive disorder. For one resident, pharmacy records showed that 120 oxycodone/APAP tablets were delivered on 12/15/25, but facility documentation, including narcotic count sheets and medication logs, could only account for 30 of those tablets. The medication was not logged on the Medication Log of Receiving form, and the MAR for December 2025 and January 2026 showed only three documented doses administered. A controlled drug count sheet indicated 30 tablets received and 19 additional doses administered that were not reflected on the MAR. Staff interviews revealed discrepancies and possible forgery related to the controlled drug count sheet for this resident. One CMA reported that their name had been forged on the count sheet on multiple days and stated that the resident had only taken the first dose and then refused further doses because of how the medication made them feel. The resident confirmed they had not taken the oxycodone/APAP for approximately two months. Another CMA stated the issue was discovered during a cart count on 01/16/26 and that the first CMA immediately reported it to the administrator. However, the administrator stated they were never informed of the issue, and an anonymous staff member later reported witnessing the CMA report the forged signature to both the administrator and the ADON. Additional nursing staff indicated they did not administer narcotics to this resident and did not sign the count sheet. For a second resident with chronic pain and major depressive disorder, a physician’s order directed hydrocodone/APAP 7.5-325 mg three times daily. Pharmacy records showed that 90 tablets were delivered on 01/08/26, but the Medication Log of Receiving form did not show that this medication was logged in. When the resident’s controlled drug count sheets for several months were reconciled with packing slips, 30 tablets were found to be unaccounted for, and the ADON noted that one of the expected count sheets for January 2026 was missing. The DON reported that a search of all medications in lockup did not locate the missing hydrocodone/APAP. These documentation failures and missing medications for both residents constituted misappropriation of controlled substances.
Removal Plan
- Completed a full audit of all controlled substances by the on-site nurse consultant.
- Notified law enforcement and the physician.
- Educated the administrator on policies and procedures to prohibit and prevent misappropriation of controlled medications, investigate allegations, and report allegations to the Oklahoma State Department of Health and law enforcement.
- In-serviced all licensed nurses and CMAs that they are responsible for accepting medications from the pharmacy and signing verification of what was delivered.
- In-serviced all licensed nurses and CMAs to properly log controlled medications on narcotic count sheets, document administration on the MAR, verify count correctness at shift change, submit completed narcotic count sheets to the DON, and report any discrepancies to the administrator.
- Educated all licensed nurses and CMAs to turn in all medication receipts from the pharmacy, completed narcotic count sheets, and other drug records to the DON.
- Re-educated all licensed nurses and CMAs on controlled substance regulations and drug diversion.
- Provided ADON education on proper narcotic count procedures, documentation requirements, chain-of-custody, identifying and reporting drug diversion, reporting requirements for unusual occurrences, steps required when a discrepancy is found, and consequences of noncompliance.
Failure to Reconcile and Account for Controlled Narcotics for Two Residents
Penalty
Summary
The facility failed to maintain an effective system for the receipt, disposition, and reconciliation of controlled narcotic medications, resulting in unaccounted controlled drugs for two residents. Facility policy required a system for receipt, storage, administration, counting, reconciliation, investigation of discrepancies, and destruction of all controlled substances, including verification by two authorized staff upon delivery and documentation of the initial count. However, for one resident with chronic pain, hypertension, and major depressive disorder, a pharmacy packing slip showed that 120 oxycodone/APAP tablets were delivered, but count sheets and medication cards for 90 tablets could not be located. The controlled drug count sheet for this resident showed only 30 tablets received and documented 19 administered doses that were not recorded on the MAR. For this same resident, the Medication Log of Receiving did not reflect the oxycodone/APAP delivery, and the MAR for the relevant months showed only three administered doses, while the resident reported they had not taken the medication because they did not like how it made them feel and that the last dose was about two months prior. A CMA reported that their name had been forged on the narcotic count sheet on multiple days and stated the resident had only taken the first dose; this was reported to the administrator. Another CMA confirmed the issue was discovered during a cart count and that it was immediately reported to the administrator. Nursing staff, including an LPN, denied administering narcotics to this resident or signing the count sheet, and pharmacy staff confirmed the full quantity of 120 tablets had been delivered. For a second resident with chronic pain and major depressive disorder, a physician’s order prescribed hydrocodone/APAP three times daily, and a pharmacy packing slip showed 90 tablets were delivered. The Medication Log of Receiving did not show that this delivery was logged, and a count sheet and medication card for 30 tablets were missing. When the resident’s controlled drug count sheets and packing slips for several months were reconciled with the ADON, 30 hydrocodone/APAP tablets were found to be unaccounted for, and the ADON stated there should have been three count sheets for one month but only two were located. The administrator acknowledged the facility had been without a full-time DON for an extended period during the time these discrepancies occurred, and staff interviews indicated that reconciliation practices were limited to matching the count sheet and card, with RNs usually responsible for medication reconciliation.
Removal Plan
- The administrator and DON were in-serviced by the corporate administrator regarding the facility's controlled-substance reconciliation system, including mandatory reporting and record keeping requirements.
- All narcotic deliveries received would be verified against the pharmacy delivery receipt and signed into the controlled drug count sheets by a licensed nurse at the time of receipt.
- Delivery receipts would be attached to the unit's narcotic packet and routed to the DON by end of shift.
- The nurse consultant completed a full-scope audit of all units and verified medication availability for all residents with active orders.
- Access to controlled substances was restricted to licensed nurses only.
- CMAs would no longer receive or administer controlled substances.
- Medication storage for controlled substances was verified as double-locked and functional.
- End of shift dual signature counts by two licensed nurses were implemented.
- All licensed nurses and CMAs were re-educated by the ADON and LPN #4 on reconciliation, documentation, chain of custody, discrepancy escalation, and reporting expectations.
Failure to Maintain Effective Pest Control in Kitchen, Dining, and Resident Areas
Penalty
Summary
Failure to maintain an effective pest control program was identified based on multiple observations of mice and roach activity in food service and resident care areas. During a tour of the kitchen and dining room, surveyors observed a pile of mouse droppings mixed with chewed wall particles on the floor under the dishwasher, dead roaches along the baseboards in the kitchen and dining room, and dead roaches inside the ice machine. Live roaches were also seen crawling on the floors and walls around tables storing coffee cups and near the ice machine. On a later observation, live roaches were again seen around the ice machine and on the walls and floors in the dining room. The facility’s pest sighting log documented mice and roach sightings in resident rooms and the dining room over several months, and showed the last preventive treatment date, but did not document that every pest sighting recorded on the log was treated. In a resident room, surveyors observed dead roaches and mouse droppings on the floor and sticky traps in the closets and bathroom, as well as a live roach crawling inside the room refrigerator. The resident in that room had been admitted with dysphagia, hemiplegia, sequelae of cerebral infarction, chronic pain syndrome, suprapubic catheter status, and an open wound of the buttocks, and was care planned as bed/chair bound and requiring moderate assistance with all ADLs, with a BIMS score indicating intact cognition. The facility had a written pest control policy stating it would maintain an ongoing program to keep the building free of insects and rodents. Staff interviews confirmed awareness of a roach and mouse problem, and the pest sighting log and staff statements showed that pest activity had been ongoing and not consistently addressed in accordance with the facility’s stated pest control program.
Failure to Send Immediate Written Discharge Notice With Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide an immediate written notice of discharge to the receiving hospital when a resident was emergently transferred and discharged. The facility’s Emergency Transfer or Discharge policy required that, when an emergency transfer or discharge occurs, the receiving facility be notified that the transfer is being made and that a transfer form be prepared and sent with the resident. Resident #24 was admitted with traumatic brain injury with loss of consciousness and a mood disorder, was cognitively intact with a BIMS score of 14, and had documented behaviors including rejecting care and exhibiting physical and verbal behaviors. Nursing notes documented that the resident became increasingly upset, yelling and cursing at staff, hoarding medications, attempting to throw themself from the bed, attempting to hit staff, and threatening suicide if not allowed to leave. An immediate discharge written notice was completed, citing drastic violent episodes that endangered the health and safety of others and indicating that police intervention was required for removal. On the date of the incident, the LPN reported providing the immediate written discharge notice to the resident and explaining its contents, after which the resident discarded the notice. The resident was then transported to the hospital by police following threats of self-harm and continued requests to leave the facility. The administrator later stated they assumed all medical transfer forms, including the immediate discharge notice, had been sent with the resident. However, another LPN stated that only a face sheet, medical diagnosis list, and medication list were sent, and that a copy of the immediate discharge notice was not included with the transfer documentation. The hospital case manager confirmed that the hospital did not receive the immediate discharge notice at the time of transfer and only obtained it later when contacting the facility about discharging the resident back, demonstrating that the required immediate written discharge notice was not provided to the receiving hospital at the time of transfer.
Lack of Physician Rationale for Declined GDR of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a physician documented a clinical rationale when declining gradual dose reduction (GDR) requests for psychotropic medications, as required by facility policy and CMS guidance. The facility’s undated "Gradual Dose Reduction (GDR) Policy-Oklahoma Nursing Facility" stated that residents prescribed psychotropic medications should receive appropriate GDRs and non-pharmacologic interventions, and that the physician would document a rationale if a reduction was contraindicated. A consultant pharmacist completed a monthly medication regimen review on 12/31/25 for a resident admitted on 10/16/23 with diagnoses including paranoid schizophrenia, chronic pain, restless leg syndrome, paraplegia, major depressive disorder, obsessive compulsive disorder, hypertension, catheter status, and anxiety. The resident’s quarterly MDS dated 12/16/25 showed a BIMS score of 15, indicating intact cognition, and listed multiple medications, including Depakote for behavior management, Trazodone for sleep, Trintellix and Desvenlafaxine for depression, Meloxicam for arthritis, Olanzapine and Quetiapine for schizophrenia, Fesoterodine for neurogenic bladder, and several PRN medications. During the 12/31/25 medication regimen review, the consultant pharmacist requested consideration of a dose reduction in Quetiapine 300 mg at bedtime and Trintellix 20 mg daily, asking if a reduction in Quetiapine to 250 mg at bedtime was appropriate. On the review form, the physician checked "no, a reduction is contraindicated due to:" for both Quetiapine and Trintellix but did not document any rationale in the space provided. The Assistant Director of Nursing later verified that the GDR request for these medications was signed by the physician, that the physician had declined the dose reduction requests, and that no rationale was documented. The ADON also confirmed that the GDR request was noted by a nurse and there was no documentation that nursing staff sought or obtained a rationale from the physician for declining the GDR requests. The ADON identified that 47 residents in the facility were receiving psychotropic medications.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. In one instance, a resident with intact cognition and diagnoses including depression, schizophrenia, and bipolar disorder was physically struck on the arm by another resident who entered their room uninvited, resulting in a bruise. The incident was witnessed by staff and reported, with documentation indicating that the aggressor was moved and placed on one-to-one supervision. Another event involved a resident with hemiplegia and limited mobility who was confronted in their room by the same resident. Despite attempts to redirect the aggressor, a physical altercation ensued, resulting in a small tear on the resident's left arm. Staff and other residents reported hearing the commotion and observed the physical contact, with the aggressor swinging at the resident and making contact. A third incident occurred in the dining room, where a resident with moderate cognitive impairment and a history of physical and verbal aggression was struck on the head by the same resident during a verbal altercation. Staff intervened and separated the residents, and the affected resident was assessed for injuries, with no visible harm noted. These events demonstrate a pattern of resident-to-resident abuse that was not effectively prevented by the facility.
Failure to Timely Report and Document Abuse Allegations to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse incidents to the State Agency as required by its Abuse Prevention Program policy. Specifically, an incident involving a physical altercation between two residents resulted in one resident sustaining a small tear on the left arm. The incident occurred at 12:10 p.m., but the initial state reportable incident form was not submitted until 3:36 p.m., exceeding the two-hour reporting requirement. Additionally, there was no documentation that a final report was received by the State Agency within five business days for this incident. Interviews with staff and the administrator revealed inconsistencies regarding the time of notification and submission of reports, and the administrator acknowledged the report was not submitted in a timely manner if the incident occurred at the documented time. Further review identified another incident involving two residents in the dining room, which was reported initially, but the final incident report was not successfully transmitted to the State Agency. The administrator provided a fax transmission log indicating an unsuccessful attempt to send the final report, as denoted by a code indicating failed communication. The State Agency's database did not show receipt of the final report for this incident. These failures affected three residents and demonstrated noncompliance with both the facility's policy and state requirements for timely reporting and documentation of abuse allegations and investigation results.
Failure to Protect Resident from Resident-to-Resident Sexual Abuse
Penalty
Summary
A deficiency was identified when the facility failed to protect a resident from abuse, specifically resident-to-resident sexual abuse. The incident involved a cognitively intact resident with a history of anoxic brain damage, major depressive disorder, and anxiety disorder, who reported being pushed down on a bed, held down, and subjected to unwanted kissing by another resident. The resident stated they told the perpetrator to stop and eventually left the room after a few minutes. The incident was not immediately reported to the appropriate authorities, and the resident indicated that after the event, the perpetrator continued to approach them in common areas, causing the resident to feel afraid and to isolate themselves in their room for approximately two weeks. The facility's policy required thorough investigation and documentation of all alleged or actual incidents of abuse, including obtaining detailed accounts from the resident and assessing for mood or behavioral changes. However, the report shows that the initial allegation was not promptly or thoroughly investigated. The resident stated they had reported the incident to staff, but staff interviewed by police denied knowledge of the abuse. Documentation indicates that the administrator was eventually informed, and a care plan was developed identifying the resident as at risk for unwanted physical contact, but this occurred after a significant delay from the time of the incident. Records also show that the facility did not immediately notify the appropriate authorities or conduct a timely assessment of the resident's well-being following the allegation. The resident's statements and subsequent interviews revealed that the incident had a negative impact on their sense of safety and emotional state. The facility's failure to promptly investigate, document, and protect the resident from further unwanted contact constituted a deficiency in ensuring residents are free from abuse.
Delay in CPR Initiation Due to Unclear Code Status Documentation
Penalty
Summary
The facility failed to prevent a delay in care when a resident was found unresponsive. According to the facility's policy, if a resident's Do Not Resuscitate (DNR) status is unclear, CPR should be initiated until a DNR or physician's order is confirmed. In this incident, the resident had a care plan indicating full code status and a wish to have CPR performed. However, when the resident was found unresponsive, staff were initially unsure of the resident's code status because it was not listed in the electronic health record under the resident's name. Staff had to consult the resident's Kardex to determine the code status, which led to a delay in initiating CPR. Nursing notes indicated that the resident was found unresponsive with no respirations, pulse, or heart sounds. Although CPR was eventually started and continued until emergency services arrived, the EMS report showed that the facility did not start resuscitation efforts prior to their arrival. The EMS was called at 5:06 a.m. and arrived at 5:12 a.m., but the timeline provided by staff interviews suggested that CPR may have only been started around the time EMS arrived, rather than immediately upon finding the resident unresponsive. Interviews with staff revealed confusion and lack of clarity regarding the process for determining a resident's code status, as well as the timing of when CPR should be initiated. The Assistant Director of Nursing (ADON) and Certified Nursing Assistants (CNAs) confirmed that the code status was not readily available in the electronic health record at the time of the incident, contributing to the delay in care. The deficiency was identified as an Immediate Jeopardy situation due to the failure to provide timely basic life support to a resident who was a full code.
Removal Plan
- Review all residents' code status, update electronic records, and update care plans.
- Maintain a list of all residents' current code status at each nurse's station.
- In-service all staff on calling 911 when a resident is found unresponsive regardless of code status and maintain a resident code status list at each nurse's station.
- In-service all licensed nurses on initiating CPR on any resident that is a full code and continuing until emergency services arrive.
- Make any employee who cannot be reached for in-service inactive and remove from the schedule until education is provided.
Failure to Provide Necessary Care and Treatment for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with multiple mental health disorders, including schizoaffective disorder, psychosis, and depression, who exhibited behaviors such as threatening self-harm and harm to others. Documentation showed that the resident had episodes of screaming, cussing, and threatening to kill themself and others, as well as hearing voices and being aggressive toward staff. Despite these behaviors, there was no evidence that the resident was placed on behavior monitoring or received a psychiatric evaluation or medication reconciliation following these incidents. Nursing notes indicated that after a significant incident where the resident threatened self-harm and aggression, one-on-one monitoring was initiated and emergency services were contacted, but the resident was not transferred to the emergency room. Subsequent documentation revealed further aggressive behavior, including physically assaulting a nurse and another resident. Staff interviews confirmed that the resident was not on any special monitoring after re-admission and that no interventions for self-harm or aggression were in place. The care plan did not reflect the necessary interventions for the resident's mental health needs. Staff, including LPNs and the ADON, acknowledged that the resident should have received a higher level of care and that the facility environment was not equipped to manage such behaviors. There was no documentation of timely notification to psychiatric providers or adjustments to the resident's medication regimen after the incidents. The lack of appropriate assessment, monitoring, and intervention for the resident's mental health and behavioral issues led to the deficiency.
Removal Plan
- A review of all resident records was conducted to identify those with mental health disorders that may exhibit behaviors related to those disorders. All residents identified will have care plans updated to reflect mental health disorder/behavior. PCP and mental health will be aware of the identified residents to ensure all are evaluated and referred for services.
- All staff in-serviced that a current list of residents with mental health disorders is maintained at each nurse's desk.
- All staff in-serviced that when a resident displays that he/she is a harm to themselves or others and to report behavior immediately to nurse supervisor/administrator.
- Nursing staff will be in-serviced to notify the physician and mental health provider of the harmful behaviors immediately.
- The nursing staff will be in-serviced to request medication reconciliation with the physician and mental health provider following harmful/ mental health behaviors.
- Department supervisors are responsible for ensuring all in-services are completed.
- Employees who are unable to be reached will be required to in-service upon return to the facility.
Failure to Notify Physician After Resident Threatened Self-Harm and Harm to Others
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician after a resident, with diagnoses including schizoaffective disorder bipolar type, hallucinations, psychosis, and depression, verbalized threats to harm themself and others. The resident, who had intact cognition and a history of hallucinations and delusions, was observed at the nurses' station exhibiting aggressive behavior, threatening self-harm and harm to others, and reporting auditory hallucinations. Although the resident was placed on one-on-one monitoring and 911 was called, there was no documentation that the physician or psychiatric provider was notified of the incident, as confirmed by staff interviews and record review.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A resident with severe cognitive impairment, including a diagnosis of focal traumatic brain injury and frontotemporal neurocognitive disorder, was not protected from sexual abuse by another resident. The cognitively impaired resident, who had a BIMS score of 7 indicating severe impairment, was observed sitting in a common area when another resident, who was cognitively intact, sat beside them and engaged in inappropriate sexual touching. Staff immediately intervened and separated the two residents, but the incident had already occurred. The cognitively impaired resident was unable to recall or participate in an interview about the event due to their condition, and a family member confirmed that the resident was not capable of consenting to sexual advances. The facility's abuse policy and sexual consent policy both require protection of residents from abuse and specify that consent must be based on intact decision-making ability. Despite these policies, the incident occurred in a common area, and the resident at risk was not adequately protected from inappropriate contact. The event was documented in nursing notes and reported to the state health department. Prior to the incident, there was no indication of a relationship or interaction between the two residents beyond casual greetings.
Failure to Protect Resident from Abuse Due to Inadequate Supervision and Policy Implementation
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse, specifically resident-to-resident physical aggression. On one occasion, a resident with a history of aggressive behaviors physically assaulted another resident, resulting in the victim sustaining a facial injury that required emergency medical evaluation. The aggressor had a documented history of multiple prior incidents of physical aggression toward both peers and staff, as noted in their care plan and facility records. Despite the aggressor's known behavioral risks, the facility did not implement immediate one-on-one safety observations as required by its own policy following the incident. Documentation failed to show that the aggressor was placed on one-on-one supervision immediately after the event, and there were no documented witness statements from residents or staff regarding the incident. Additionally, the care plan for the aggressor was not updated with new interventions after each aggressive episode, contrary to facility policy. The victim was severely cognitively impaired and had no prior documented history of aggressive behaviors. The aggressor was also severely cognitively impaired and had a pattern of physical aggression. The facility's failure to follow its abuse prevention and monitoring policies, including timely implementation of supervision and care plan updates, directly contributed to the occurrence and inadequate response to the abuse incident.
Failure to Implement Abuse Policy and Investigative Procedures
Penalty
Summary
The facility failed to implement its abuse policy in response to an incident where a resident with a history of physical aggression, related to dementia and other psychiatric diagnoses, physically assaulted another resident. The incident resulted in the victim sustaining a red discharge from the nose and swelling to the head, requiring emergency room evaluation. Documentation showed that the aggressor had a documented history of multiple physical aggression incidents toward both peers and staff, yet the care plan did not reflect new interventions after each event, and the intervention of one-on-one observation had been repeatedly used without documented updates or changes. The facility did not provide evidence of a complete and thorough investigation, as there were no documented witness statements from residents or staff regarding the incident. Additionally, the facility failed to immediately implement one-on-one safety measures as required by policy, and there was no documentation of coordination with QAPI or the implementation of new interventions to prevent recurrence. The administrator confirmed that required documentation and QAPI review were not completed following the incident.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with severe cognitive impairment and multiple neuropsychiatric diagnoses. According to facility policy, investigations of resident-to-resident abuse require interviews with cognitive residents and witnesses, as well as head-to-toe assessments for non-cognitive residents if necessary. An incident report documented that the resident was punched in the face by another resident, resulting in a red discharge from the nose, swelling to the head, and a subsequent emergency room visit. Despite these events, there were no documented witness statements from staff or other residents regarding the incident, and the administrator confirmed that a thorough investigation was not completed.
Failure to Prevent Elopement and Document Falls
Penalty
Summary
The facility failed to prevent elopement and document falls for multiple residents, resulting in deficiencies related to supervision and accident prevention. One resident with moderate cognitive impairment and a history of falls was able to leave the facility unsupervised and was found walking down the road by a visitor, who notified staff. The resident was picked up by a CNA and returned to the facility, but there was no documentation of the elopement in the resident's health record, and staff were unclear about which residents were at risk for elopement. Another resident, identified as high risk for elopement and with a history of schizo-affective disorder, was able to leave the facility without staff knowledge and was found three miles away on a state highway in a construction zone by an off-duty staff member. This resident had previously attempted to elope multiple times and was returned to the facility covered in mud and fecal matter, but again, there was no documentation of the elopement in the health record. Staff interviews revealed confusion and inconsistency regarding the identification and supervision of residents at risk for elopement. Some staff relied on verbal communication from charge nurses to determine which residents could leave unsupervised, while others were unaware of any formal assessment or list. The DON and administrator were not notified of the elopements, and there was no documentation or incident reporting for these events. The care plans for residents at risk for elopement did not include appropriate interventions to prevent elopement, and staff were not consistently aware of or following facility policy regarding elopement prevention and response. Additionally, the facility failed to document an unwitnessed fall for another resident with a history of traumatic brain injury and dementia. An anonymous email with a photo showed the resident on the floor, but there was no documentation of the fall in the health record. The charge nurse admitted to finding the resident on the floor and assessing them but did not document the incident, mistakenly believing the resident was care planned to be on the floor. These failures in supervision, documentation, and communication contributed to the deficiencies cited by surveyors.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest management program as evidenced by multiple observations of pests and pest evidence in a resident's room. On several occasions, surveyors observed a roach on a resident, mouse droppings along the walls and in the resident's dresser, and a mouse trap at the head of the bed. Additional observations included live and dead roaches behind the refrigerator and further mouse droppings in the room. The facility's pest control policy stated that an ongoing program would be maintained to keep the building free of insects and rodents. However, the pest sighting log documented sightings of mice and roaches in the same room and other areas, with no evidence that these sightings were addressed after being recorded. The last preventative pest treatment was documented nearly two months prior to the most recent sightings. The resident involved had diagnoses including dysphagia and major depressive disorder, was dependent for all activities of daily living, and had intact cognition. The resident reported frequent issues with roaches crawling on them and stated that repeated complaints to staff were not addressed. Facility staff, including housekeeping and the administrator, confirmed the presence of roaches, mouse droppings, and traps in the resident's room. The maintenance supervisor acknowledged that roaches were still present in the facility, though their numbers had decreased.
Failure to Notify Resident of Trust Account Balance Near Medicaid Limit
Penalty
Summary
The facility failed to notify a resident when their trust account balance was within $200 of the Medicaid resource limit of $2000, as required. Record review showed that the resident, who had Medicaid as a payer source, an intact BIMS score of 15, and was dependent for all activities of daily living, had a trust account balance of $2353.44. There was no documentation in the resident's health record indicating that notification was provided when the balance approached the Medicaid limit. The resident confirmed they were not notified, and the Business Office Manager stated they were unaware of the requirement to provide such notification.
Failure to Maintain Clean, Sanitary, and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary and unsafe conditions in resident rooms. In one instance, a resident's room was found to have black and green mold spots under the sink cabinet, with the affected area measuring approximately 20 inches along the back wall and spots ranging from 0.5 to 3 inches in size and 7 to 11 inches in height. The flooring under the sink was cracked and stained. The maintenance supervisor confirmed the presence of mold due to water damage and stated there were no work orders for this issue, indicating a lack of timely response to maintenance needs. Another resident's room was observed to have soiled bed linens, a baby roach on the resident, damaged and stained walls, cracked and dirty floor tiles with brown residue, and a window sill with visible dirt and debris. The resident, who was cognitively intact but dependent for all activities of daily living, reported frequent issues with roaches and dissatisfaction with the room's cleanliness, stating that staff had not addressed their concerns. Housekeeping and administrative staff acknowledged the presence of pests, dirt, and the need for cleaning and repairs. Facility policies require a clean, sanitary, and homelike environment, but these standards were not met in the observed cases.
Failure to Prevent Abuse and Protect Resident Privacy
Penalty
Summary
A facility failed to prevent abuse for a resident with a history of traumatic brain injury and dementia, who was moderately impaired for decision making and required supervision for mobility. The resident was identified as being at risk for falls. An anonymous email was sent to the state health department containing a picture of the resident lying on the floor with their hospital gown exposing their bottom, after an unwitnessed fall. The picture showed the resident looking at the camera and unable to prevent the photo from being taken. The LPN on duty admitted to taking the picture of the resident after finding them on the floor, before assessing the resident. The LPN stated they did not document the fall in the health record, believing the resident was care planned to be on the floor. The facility's abuse policy specifically prohibits taking demeaning or privacy-violating pictures of residents, considering such actions as abuse. The LPN attempted to obscure the resident's buttocks in the image but still took and retained the photo, in violation of facility policy.
Unattended and Unlocked Treatment Cart with Insulin Found
Penalty
Summary
A treatment cart located on the East side of the nurses station in the Southwest hall was observed to be unlocked and unattended. Inside the first drawer of the cart, a Lantus SoloStar Subcutaneous Pen-injector (insulin glargine) prescribed for a resident was found. Facility policy, revised in January 2018, requires that medications and biologicals be stored safely, securely, and properly, and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During an interview, an LPN confirmed that the treatment cart was supposed to be locked and attended at all times, in accordance with facility policy.
Non-Functioning Call Light in Shower Room
Penalty
Summary
A deficiency was identified when a call light was found not working in one of the three shower rooms used by residents, specifically the shower room on the East side of the middle hall. This was observed during a facility visit, and confirmed by an advanced certified medication aide who stated the call light in that shower room was not operational. The administrator acknowledged that call lights were supposed to be functional in all shower rooms. Review of the facility's maintenance policy indicated that the Maintenance Department is responsible for ensuring all equipment is safe and operable at all times. However, the maintenance supervisor reported that there were no work orders submitted regarding the non-functioning call light.
Failure to Document Antibiotic Order and Administration
Penalty
Summary
The facility failed to ensure that a resident's chart was updated with a new antibiotic order. A resident, who was admitted with diagnoses including overactive bladder, hypertension, and anxiety, began receiving Cipro, an antibiotic, at a dosage of 500 mg twice a day. However, the physician's orders did not document this antibiotic order, and the medication administration record (MAR) also lacked documentation of the order. Despite this, a count sheet indicated that the first dose of Cipro was administered. When questioned, a Certified Medication Aide (CMA) admitted to not documenting the administration of the antibiotic on the MAR. The Assistant Director of Nursing (ADON) confirmed that if the medication was not on the MAR, it should not have been administered.
Failure to Maintain Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to maintain a consistent temperature log for the medication refrigerator in the medication room, as required by professional principles. During a tour of the medication room, it was observed that there was no temperature log for December 2024, and the logs for November and October 2024 had significant gaps, with 21 and 8 days of missing temperatures, respectively. CMA #1 indicated that the nurses were responsible for maintaining these logs. LPN #1 further clarified that the night shift nurses were specifically tasked with this responsibility. The Director of Nursing (DON) confirmed that the temperature logs were supposed to be completed daily, highlighting a lapse in the facility's protocol for monitoring medication storage conditions.
Failure to Update Fall Care Plan with New Interventions
Penalty
Summary
The facility failed to update a fall care plan with necessary interventions for a resident diagnosed with rheumatoid arthritis. The resident's fall care plan, dated August 6, 2023, included interventions such as using a wheelchair for mobility, referring to a restorative program if functional changes were noted, and monitoring for changes in condition that might require increased supervision or assistance. An incident report from November 2, 2024, indicated that the facility planned to implement a low bed with a fall mat at the bedside for the resident. However, the care plan initiated on November 6, 2024, did not document the low bed with mat as a fall intervention. On December 9, 2024, the resident was observed in bed with the bed in the lowest position and a fall mat at the bedside, yet the resident denied any recent falls. The MDS coordinator later stated there was no established process to communicate new interventions to their department, and they were unaware of the low bed with mat placement.
Failure to Conduct Scheduled Activities for Residents
Penalty
Summary
The facility failed to ensure scheduled activities were conducted for its residents, as observed and reported by both residents and staff. The activity calendar for November 2024 listed activities such as Dominoes and Bingo on specific dates, but these activities were not observed to be in progress at the scheduled times. Residents expressed dissatisfaction, noting the lack of activities and the absence of an activity director. One resident mentioned that activities like Bingo were offered infrequently, and another resident confirmed that the posted activities did not occur. The Social Services director and the administrator acknowledged the lack of daily activities, with discussions about splitting activity responsibilities between staff members but no implementation at the time of the survey.
Deficiencies in Smoking Area Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety of residents in the smoking area, leading to deficiencies in accident prevention. Specifically, a smoking assessment was not completed for a resident with schizophrenia, who was observed smoking without a smoking apron despite having shaky hands. This oversight was acknowledged by the MDS coordinator, who confirmed that a smoking assessment had not been conducted for this resident. The lack of assessment and supervision contributed to the resident's exposure to potential hazards while smoking. Another resident, diagnosed with depression, experienced a burn hole in their jacket due to overcrowding in the smoking area. The resident reported that the area was too crowded, which led to another resident accidentally burning their jacket. Staff members, including the laundry supervisor and a CMA, confirmed the crowded conditions and the incident. The administrator acknowledged the overcrowding issue and the resulting burn incident, indicating a failure to provide adequate space and supervision in the smoking area to prevent such accidents.
Failure to Develop Comprehensive Care Plan for Smoking
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident with schizophrenia, specifically regarding their smoking habits. The facility's policy requires a comprehensive care plan to be developed within seven working days of completing a resident's comprehensive assessment. However, for this resident, whose assessment documented tobacco use, no care plan was completed by the required date. On a specific day, the resident was observed smoking outside with the assistance of a staff member, yet there was no care plan addressing this behavior in the resident's clinical record. The MDS coordinator admitted to being behind on care plans, resulting in the omission for this resident.
Failure to Document Adverse Behaviors in Resident Records
Penalty
Summary
The facility failed to accurately document adverse behaviors for a resident diagnosed with hallucinations and other psychotic disorders. The resident exhibited several adverse behaviors, including urinating in inappropriate places, aggression towards staff and other residents, and entering other residents' rooms without permission. These behaviors were recorded in the nursing progress notes but were not reflected in the Treatment Administration Records (TAR) for September and October 2024. The discrepancy was confirmed when an LPN acknowledged that the behaviors documented in the progress notes should have been recorded in the TAR. The failure to document these behaviors accurately on the TAR represents a deficiency in maintaining medical records in accordance with accepted professional standards, as required by the facility's policies and procedures.
Failure to Notify Mental Health Physicians of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to notify the mental health physicians following incidents of resident-to-resident abuse involving two residents who were receiving routine mental health services. The facility's abuse policy, updated in July 2021, mandates that a physician be notified to implement actions to prevent a recurrence when a person is suspected of abusing another. However, this protocol was not followed for two residents with mental health diagnoses, including hallucinations and psychotic disorders, who were involved in multiple incidents of aggression towards other residents. Resident #5 was involved in three separate incidents of aggression, including hitting another resident with a cane, taking away a walker, and slapping another resident. Despite these incidents, there was no documentation that the mental health physician was notified, and a progress note later indicated no combative behaviors. Similarly, Resident #6 was involved in an incident of choking another resident, but again, there was no documentation of physician notification. Interviews with the mental health physicians confirmed they were not informed of these incidents, and the MDS Coordinator acknowledged the oversight.
Inaccurate Assessment of Resident's Adverse Behaviors
Penalty
Summary
The facility failed to accurately assess adverse behaviors in a resident with diagnoses of hallucinations and other psychotic disorders. The nursing progress notes documented multiple instances of aggressive and inappropriate behavior by the resident, including urinating in inappropriate places, physical aggression towards staff and other residents, and taking items from other residents. Despite these documented behaviors, the Significant Change MDS assessment for the resident did not reflect any physical, verbal, or other behavioral symptoms, and several sections related to the impact of behaviors on others and wandering were either not completed or inaccurately documented. The MDS Coordinator acknowledged that the assessment was not completed accurately after reviewing the resident's clinical records and progress notes. The coordinator stated that the assessment process should involve talking to various staff, reviewing clinical records, and interviewing the resident if possible. However, the failure to accurately document the resident's behaviors in the MDS assessment indicates a lapse in this process, leading to an incomplete and inaccurate assessment of the resident's condition.
Failure to Update Care Plans for Abuse Prevention
Penalty
Summary
The facility failed to update care plans with necessary interventions to protect vulnerable residents from abuse and prevent further potential abuse. Specifically, two residents with diagnoses including dementia, legal blindness, ESRD, and hypertensive heart disease were involved in incidents where they were assaulted by other residents. Despite these incidents, there was no documentation on their care plans of interventions designed to prevent occurrences of abuse perpetrated by other residents. Additionally, a resident with diagnoses of hallucinations and other psychotic disorders exhibited abusive behavior towards other residents on multiple occasions. This resident's care plan, however, did not include preventative interventions for their abusive behavior. The MDS Coordinator acknowledged that the interventions on the care plans for these residents should have been updated, indicating a lapse in the facility's adherence to its abuse policy, which mandates reassessment for preventative interventions at least quarterly.
Failure to Maintain Full-Time DON and RN Coverage
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) and did not ensure registered nurse (RN) coverage for eight consecutive hours, seven days per week. The administrator acknowledged that the facility had been without a full-time DON for several months, with a corporate RN occasionally filling in as the interim DON. A review of timecard reports for August and September 2024 revealed that there was no RN coverage for eight consecutive hours on 20 days each month. The interim DON confirmed that the facility had been without a full-time DON since May 15, 2024, and regular RN attendance had not been maintained since they assumed the interim role on August 1, 2024.
Inconsistent COVID-19 Isolation Procedures
Penalty
Summary
The facility failed to adhere to its COVID-19 isolation procedures, as outlined in their policy, for four residents who tested positive for COVID-19. The policy required residents who tested positive to be isolated for at least 10 days from the onset of symptoms or the first positive test. However, observations and interviews revealed inconsistencies in the implementation of these procedures. For instance, one resident was observed ambulating in the lobby and reported that isolation procedures were inconsistently applied, with isolation lasting only a few days. Additionally, staff members, including a CMA and LPNs, were uncertain about which residents were in isolation and for how long, indicating a lack of communication and adherence to the established protocol. The report highlights that the facility was in outbreak status for several weeks, yet there was no signage indicating the presence of positive COVID-19 cases upon entry. Staff interviews revealed confusion regarding the duration of isolation, with some residents being removed from isolation after only five days if asymptomatic, contrary to the 10-day policy. The corporate interim DON confirmed that residents who tested positive were not kept in isolation for the required duration, and the ADON acknowledged that isolation procedures were not consistently followed during the outbreak period. This lack of consistent implementation of isolation protocols contributed to the deficiency identified by the surveyors.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. The administrator identified the Assistant Director of Nursing (ADON) as the infection preventionist, but there was no documentation of the required certification for the ADON. The interim Director of Nursing (DON) stated they had the certification but had been on vacation, and the ADON had been handling the infection preventionist duties for several months. However, the ADON confirmed they had the certification but had not been asked to perform the infection preventionist duties, which were previously managed by the former full-time DON. The ADON attempted to manage COVID outbreak procedures but did not complete all required duties of the infection preventionist role.
Failure to Facilitate Resident's Court Hearing Attendance
Penalty
Summary
The facility failed to ensure a resident attended a scheduled court hearing regarding guardianship, which was a violation of the resident's right to self-determination and choice. The resident, who had diagnoses including chronic pain and generalized anxiety disorder, was admitted to the facility with intact cognition. Upon admission, the resident informed the facility's social services and administrator about the upcoming court hearing. However, the facility did not take the necessary steps to ensure the resident's attendance at the hearing. The Business Office Manager (BOM) was only made aware of the hearing the day before it was scheduled and attempted to arrange a virtual appearance, but it was too late. The admitting nurse failed to communicate the court hearing information to social services, which was confirmed by the social services director and the interim Director of Nursing (DON). This lack of communication among the facility staff resulted in the resident missing the court hearing and having to wait for the next scheduled date.
Failure to Provide Scheduled Baths
Penalty
Summary
The facility failed to ensure that a resident received scheduled baths, resulting in a deficiency. The resident, who had diagnoses including edema and morbid obesity, was cognitively intact and dependent on staff for bathing. According to the facility's shower schedule, the resident was supposed to receive a bath or shower three times a week on Tuesdays, Thursdays, and Saturdays. However, there was no documentation in the medical record of any completed baths. During an observation, the resident was found shirtless in bed with breadcrumbs on and around their upper body, and they reported having received only three baths since admission. A CNA confirmed that completed baths should be documented in the electronic health record (EHR), and any refusals should be noted and reported to the charge nurse. The Assistant Director of Nursing (ADON) acknowledged the lack of documentation for the resident's baths.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents. One resident, with a cognitive communication deficit, was reported to have forced another resident, who had aphasia and dementia with behavioral disturbances, into their room and started to undress them. A witness, another resident, reported the incident to a CNA, who was on transport at the time. The CNA stated that the previous social services director also heard the allegation and reported it to the DON. However, the administrator did not complete an incident report, as they believed the residents were only holding hands and fully clothed. The incident occurred when several staff members were at a convention. Further interviews revealed discrepancies in the accounts of the incident. A witness stated they saw the resident's genitals and that the resident locked themselves in the bathroom afterward. LPN #1, who was in charge at the time, stated they were informed that the resident had pulled their pants down but there was no physical contact. LPN #1 moved the resident to a private room and was instructed to gather statements from staff. The police were also involved. Despite these actions, there was no documentation of the incident in the residents' medical records, no assessments were performed, and the incident was not reported to the Oklahoma State Department of Health.
Failure to Prevent Physical Abuse of a Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent physical abuse for a resident who was severely cognitively impaired and dependent on staff for most activities of daily living (ADLs). An email correspondence to the Assistant Director of Nursing (ADON) documented that a Certified Nursing Assistant (CNA) witnessed another CNA grab the resident's groin with force and yell at the resident during care, being rough during incontinent care. The facility's investigation substantiated the allegation of abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Oklahoma State Department of Health (OSDH) for one of the four sampled residents reviewed for allegations of abuse. The facility's undated Abuse Policy and Procedure mandates that any allegation involving abuse or resulting in serious bodily injury must be reported within two hours of notification. An email from a CNA to the Assistant Director of Nursing (ADON) documented that the CNA witnessed potential abuse by another CNA towards a resident. The incident occurred at approximately 8:00 p.m., but the report was not filed with OSDH until the following morning at 9:48 a.m., exceeding the two-hour reporting requirement.
Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a manner that promotes food safety and sanitation, affecting 74 residents who received services from the kitchen. During a tour of the kitchen, several deficiencies were observed, including an accumulation of grease, black residue, and food debris on and around the griddle, as well as black grease on the back panel and floor behind the griddle. Four 5-pound rolls of hamburger meat were found sitting in dirty dishwater in the sink, and the meat packages were warm to the touch. Additionally, there was an accumulation of food debris, grease, and dead cockroaches on the floor in the cook and preparation areas. Open garbage cans without lids were observed, filled with refuse and food waste, with live cockroaches crawling around them. Numerous cockroaches, both dead and alive, were found in the dry storage area and around the refrigerators and freezers. Further observations included an open uncovered cardboard box of hamburger patties in the freezer, undated open packages of sliced cheeses, shredded cheese, and coleslaw mix in the refrigerator, and a smashed unsealed plastic jug of peanut butter and salsa leaking in the refrigerator. There was also an accumulation of food debris and liquid in the bottom of the refrigerator. The facility's Freezer and Refrigerator Temperature Chart lacked documentation of daily temperatures for a week. Staff interviews revealed that the kitchen was not cleaned due to staff shortages, and there was an ongoing cockroach problem. The Dietary Manager (DM) was unaware of the kitchen's condition due to being on sick leave and expressed embarrassment over the situation, acknowledging that the facility had not promoted food safety and proper sanitation in the kitchen.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous cockroaches in the kitchen and dry storage areas. During a tour of the kitchen, both dead and live cockroaches were observed underneath wire racks, food bins, and around refrigerators and freezers. Live cockroaches were also seen crawling around open trash cans in the meal preparation area. A staff member acknowledged the ongoing cockroach problem, noting that while it had improved somewhat, it remained an issue. Additionally, a resident reported finding a cockroach in their breakfast eggs a few months prior, and another resident observed cockroaches in the dining area on multiple occasions. The Dietary Manager was informed of the cockroach presence and confirmed it as a major concern, despite a decrease in numbers over the past few months.
Failure to Ensure Medical Appointment Completion
Penalty
Summary
The facility failed to ensure a medical appointment was completed for a resident who was scheduled for a urology surgery. The resident, who was admitted with diagnoses including cerebral infarction, urinary catheter, hemiplegia, and stage II pressure ulcers, was cognitively intact and dependent on most ADLs and mobility. The resident had a supra-pubic catheter causing chronic pain and irritation and was scheduled for a surgical procedure to evaluate the possible permanent removal of the catheter. However, the appointment was canceled by the facility due to a lack of transportation and necessary paperwork, and it was not rescheduled promptly. The facility's social services policy required assistance with appointment scheduling and arranging transportation, but due to staff turnover, there was no consistent social services staff member to manage these responsibilities. The interim DON acknowledged the failure to transport the resident and the lack of planning to ensure both residents attended their appointments. The resident expressed frustration over the missed appointment and the continued need for a urinary catheter. The facility did not reschedule the appointment until nearly a month later, after a new SSD was employed.
Failure to Maintain Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food was palatable, attractive, and served at appetizing temperatures during two observed meal services. The Food and Nutrition Services policy, revised in October 2017, required staff to inspect food trays to ensure food was palatable and served at safe temperatures. However, the Food Temperature Chart lacked documentation of steam holding temperatures for several meals, indicating a failure to monitor and record food temperatures as required. During an observation on May 20, 2024, the lunch service revealed that food items were not at the correct holding temperatures, with the meat loaf, mixed vegetables, and potatoes all below the required 135 degrees F. Staff acknowledged that the lids had been left off the food too long, causing it to cool. Residents expressed dissatisfaction with the meals, stating that the food was often cold and unappetizing. One resident mentioned that the salad was frequently wilted and rotten, while another resorted to eating cereal for most meals due to the poor quality of the food. A test tray on May 22, 2024, further confirmed the issue, with food items such as pork rib, baked beans, fried okra, and a biscuit all served at temperatures significantly below the required 135 degrees F. The Dietary Manager acknowledged the oversight and confirmed that staff should have been documenting food temperatures for each meal, as per the facility's policy.
Improper Garbage Disposal in Kitchen
Penalty
Summary
The facility failed to ensure that garbage containers in the food preparation area were covered with lids, as required by their Food-Related Garbage and Refuse Disposal policy. During a kitchen tour, surveyors observed a large plastic garbage can without a lid next to the metal food preparation table, filled with refuse including food waste from the breakfast meal. Another large plastic garbage can without a lid was found next to the refrigerator and freezer area, also filled with food waste. Three live cockroaches were seen crawling around these open garbage cans. The Dietary Manager (DM) confirmed that the garbage cans should always be covered to reduce the risk of contamination and pest infestation.
Failure to Follow Menu and Serve Planned Meal
Penalty
Summary
The facility failed to ensure that the lunch menu was followed as planned for one meal service observed. The menu for 05/20/24 was supposed to include turkey pot pie with biscuit top, oven roasted potatoes, tossed side salad with dressing, frosted cinnamon roll, and a beverage of choice. However, due to the absence of the Dietary Manager (DM) who was on sick leave, the Food Services staff decided to serve meat loaf, au gratin potatoes, mixed vegetables, cherry cheesecake, and a bread roll instead. The Food Services Manager was not informed of this substitution, and the DM later confirmed that the ingredients for the turkey pot pie were available and that no menu change had been approved. Additionally, there was a delay in serving meals as the au gratin potatoes ran out before all residents were served, necessitating the preparation of mashed potatoes for the remaining residents.
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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