Fairview Fellowship Home For Senior Citizens, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairview, Oklahoma.
- Location
- 605 East State Road, Fairview, Oklahoma 73737
- CMS Provider Number
- 375427
- Inspections on file
- 16
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Fairview Fellowship Home For Senior Citizens, Inc during CMS and state inspections, most recent first.
Staff failed to use required gowns during wound and catheter care for two residents needing enhanced barrier precautions. An LPN did not wear a gown and used soiled gloves to apply cream to open wounds after incontinent care, while two CNAs also omitted gowns during catheter care, despite stating they understood EBP protocols.
A resident with dementia and anxiety received unnecessary doses of hydroxyzine after an LPN changed a physician-ordered dose reduction from TID to BID back to TID without proper authorization, resulting in four extra doses being administered before the error was identified and corrected.
A resident with dementia and anxiety received four extra doses of hydroxyzine after an agency LPN entered an order for three times daily dosing, despite the physician's directive to reduce the dose to twice daily. The LPN made this change without proper verification, resulting in the resident receiving unnecessary medication until the error was identified by an RN.
A resident with severe cognitive impairment and anxiety received four extra doses of hydroxyzine after an agency LPN incorrectly entered a TID order, despite the physician's directive to reduce the dose to BID. The error was identified when another nurse reviewed the orders and confirmed the correct dosage with the physician.
Two residents with severe cognitive impairment and documented exit-seeking behaviors were not reassessed for wandering risk or provided with effective elopement prevention interventions. Despite repeated incidents of attempted elopement and ineffective redirection, only minimal interventions were used, and one resident was able to exit through an unsecured door, resulting in injury.
Two residents with cognitive impairment and a history of exit-seeking and wandering behaviors were not timely reassessed or had their care plans updated to include interventions for elopement prevention, despite multiple documented incidents and one resident sustaining an injury after elopement. Staff and leadership confirmed that interventions were not consistently implemented or documented in the care plans as required by facility policy.
The facility failed to maintain resident dignity during meal assistance, as staff were observed standing while assisting residents with eating, contrary to policy. Several residents with cognitive impairments and other conditions requiring meal assistance were affected. Staff admitted to leaving residents unattended and acknowledged the dignity issue of standing over residents during meals.
The facility failed to update care plans with fall interventions for two residents with dementia who experienced multiple falls. Despite implementing measures like increased supervision and fall mats, these interventions were not documented in the care plans. The facility's policy required new interventions to be added within 14 days, but this was not followed, leading to deficiencies in care planning.
A resident with dementia and a UTI was not consistently offered fluids, despite needing assistance with drinking. Observations showed staff frequently failed to offer drinks during care activities, and the resident's fluid intake was below the required amount. The MDS coordinator confirmed the expectation to offer fluids, but this was not consistently practiced.
The facility failed to assess risks and obtain informed consent before installing bed rails for two residents with severe cognitive impairment. The DON confirmed no entrapment assessments or consents were conducted for any residents using bed rails, affecting 23 residents.
The facility did not ensure RN coverage for eight consecutive hours a day, seven days a week, as required. The PBJ Staffing Data Report showed missing RN hours on specific dates, and HR confirmed the lack of RN coverage on one of those dates.
The facility failed to securely store controlled drugs, as a medication refrigerator at a nurse's station was not permanently affixed, and a lock box inside was unsecured. The refrigerator contained Lorazepam syringes and was located in an area with an open window to the hall. The nurse's station door was observed propped open, compromising the security of the controlled medications.
The facility's PBJ report failed to accurately reflect RN coverage for specific dates. The report for a period did not identify RN hours for certain days. Upon request, HR provided documentation confirming RN coverage for some of these dates, but the PBJ report still inaccurately reflected RN coverage on three of the four days in question.
The facility failed to maintain hand hygiene during meal assistance, implement enhanced barrier precautions for a resident with a catheter, and label oxygen equipment. Staff did not change gloves between assisting residents, a catheter bag was improperly handled, and oxygen tubing lacked required labeling. These actions were against the facility's policies, leading to deficiencies in infection control.
The facility failed to administer the pneumonia vaccine to two residents who had signed consents, despite the facility's policy requiring it. One resident had dementia, and the other had pneumonia and diabetes. The MDS Coordinator confirmed the absence of documentation for the vaccine administration in both the facility's records and the Oklahoma State Immunization Information System.
The facility failed to notify the OHCA after two residents experienced significant changes in their mental health diagnoses. One resident was diagnosed with unspecified psychosis and prescribed Seroquel, while another was diagnosed with delusional and anxiety disorders and prescribed Abilify and buspirone. The DON confirmed that no PASARR assessments were completed following these new diagnoses, and the facility lacked a PASARR policy.
A facility failed to document the use of bed rails in a resident's care plan, despite observations confirming their use for independence and repositioning. The facility's policy requires accurate care plans, but the Director of Nursing acknowledged the omission.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were properly implemented during wound and catheter care for two residents who required these precautions. Observations revealed that an LPN performed wound care on a resident's left lower leg and subsequent incontinent care without wearing a gown, as required by the facility's EBP policy. The LPN also used soiled gloves to apply cream to open wounds on the resident's buttocks after providing incontinent care, further deviating from proper infection control practices. The resident had chronic venous hypertension with ulcers on both lower legs and stage 2 pressure ulcers on the buttocks, with care plans and physician orders indicating the need for EBP. Additionally, two CNAs provided catheter care to another resident with an indwelling catheter for comfort measures, also without wearing gowns as mandated by the EBP policy. Both CNAs stated they understood and followed EBP protocols, despite not adhering to the required use of gowns during high-contact care activities. The ADON reported that staff had been educated on EBP practices, but the observed actions did not align with facility policy or training.
Incorrect Medication Order Leads to Unnecessary Psychotropic Drug Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of unspecified dementia and generalized anxiety disorder received unnecessary doses of a psychotropic medication due to incorrect medication orders. The resident's medication regimen was under review, and the consulting pharmacist recommended a gradual dose reduction (GDR) of hydroxyzine 25 mg, which was initially prescribed three times daily (TID) for anxiety. The physician agreed with the recommendation and ordered the dose to be reduced to twice daily (BID). The Director of Nursing (DON) entered the new BID order into the resident's chart as directed by the physician. However, an agency LPN subsequently changed the order back to TID without proper verification, despite the physician's confirmation of the BID order. The LPN stated that they believed the physician intended for the medication to remain at TID and entered the order accordingly, even though the DON and the physician had already confirmed the reduction to BID. This unauthorized change resulted in the resident receiving four additional doses of hydroxyzine between the dates the error occurred and when it was discovered. The error was identified when another nurse reviewed the resident's orders and noticed the discrepancy. The nurse confirmed with the physician that the correct order was for BID dosing, not TID. The facility's records and interviews confirmed that the LPN had altered the medication order without a physician's directive, leading to the administration of unnecessary medication doses to the resident.
Incorrect Medication Order Entry Led to Unnecessary Administration of Anti-Anxiety Medication
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and diagnoses of unspecified dementia and generalized anxiety disorder received an anti-anxiety medication, hydroxyzine, in a manner inconsistent with physician orders. The resident's medication regimen was reviewed by a consultant pharmacist, who recommended a gradual dose reduction (GDR) of hydroxyzine from three times daily (TID) to twice daily (BID). The primary care physician agreed and ordered the reduction, which was entered into the resident's chart by the Director of Nursing (DON). Despite the physician's order to reduce the hydroxyzine dose to BID, an agency LPN subsequently entered a new order for hydroxyzine 25 mg TID, contrary to the physician's instructions. This change was made after the LPN claimed to have clarified with the physician, but in reality, the physician had confirmed the BID order. The LPN admitted to changing the order to TID without proper verification, influenced by requests from medication aides, and not based on a new physician directive. As a result of the incorrect order entry, the resident received four additional doses of hydroxyzine 25 mg between the dates the error occurred and when it was identified. The error was discovered by an RN, who noticed the discrepancy and confirmed with the physician that the correct order was for BID dosing. The facility's records and interviews confirmed that the LPN's unauthorized change led to the administration of unnecessary medication doses.
Medication Order Error Leads to Unnecessary Doses Administered
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and diagnoses of unspecified dementia and generalized anxiety disorder received four additional doses of hydroxyzine 25 mg that were not ordered by the treating physician. The resident's medication regimen was reviewed by the consultant pharmacist, who recommended a gradual dose reduction (GDR) of hydroxyzine from three times daily (TID) to twice daily (BID). The primary care physician agreed and ordered the reduction, which was entered into the resident's chart by the Director of Nursing (DON). Despite the physician's order to reduce the hydroxyzine dose, an agency LPN entered a new order for hydroxyzine 25 mg TID, contrary to the physician's instructions. The LPN stated they believed the physician intended the resident to continue on the TID dose, despite confirmation from the physician for the BID order. This incorrect order resulted in the resident receiving four extra doses of hydroxyzine over several days. The error was discovered when another nurse reviewed the resident's orders and found the discrepancy. The nurse confirmed with the physician that the correct order was for hydroxyzine 25 mg BID, not TID. The DON and administrator confirmed that the LPN had changed the order without proper authorization, leading to the administration of unnecessary medication doses to the resident.
Failure to Prevent Elopement and Inadequate Supervision for Residents with Exit-Seeking Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent elopement for residents with known exit-seeking behaviors. One resident, admitted with dementia and a history of a femur fracture, was initially assessed as low risk for elopement. However, over several months, this resident exhibited repeated exit-seeking behaviors, including multiple documented attempts to leave the facility, both alone and with another resident. Despite these behaviors, the only intervention documented prior to the incident was redirection, which was repeatedly noted as ineffective. No additional interventions were added to the care plan, and the resident was not reassessed for wandering risk as required by facility policy. Another resident, also with severe cognitive impairment and a diagnosis of Alzheimer's disease, was assessed as a moderate risk for wandering upon admission. This resident also demonstrated exit-seeking and wandering behaviors on multiple occasions, but there was no documentation of reassessment for wandering risk or the addition of elopement prevention interventions to the care plan prior to the incident. Staff interviews confirmed that hourly location checks and redirection were the only interventions used, and these were discontinued after a short period without further action. Staff also reported a lack of knowledge regarding identification of residents at risk for elopement and appropriate interventions. The deficiency culminated in an incident where the first resident was able to exit the facility through a laundry room door that was supposed to be locked, resulting in a fall and injury outside the building. The facility's own policy required regular reassessment for wandering risk and the implementation of additional interventions for residents exhibiting exit-seeking behaviors, but these steps were not taken. The DON and administrator acknowledged that the residents were not reassessed or care planned appropriately, and that the door used for elopement was not secured as required.
Failure to Timely Review and Revise Care Plans for Residents with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for two of three sampled residents who exhibited exit-seeking and wandering behaviors. Both residents had cognitive impairments, including dementia and Alzheimer's disease, and were admitted with risk factors for wandering. Despite documented incidents of exit-seeking, attempts to leave, and actual elopement, the care plans for these residents were not updated in a timely manner to reflect necessary interventions for elopement prevention. For one resident, multiple nursing notes documented exit-seeking behaviors, including searching for keys, attempting to leave, and being found outside the facility after elopement, which resulted in a fall and injury. Although hourly location checks were initiated for a short period, these interventions were not documented in the care plan, and no interventions to prevent elopement were added until after the resident had already eloped and sustained an injury. The resident's care plan was not updated to include a wander guard or other preventive measures until after the incident occurred. The second resident, who also had severe cognitive impairment and a moderate risk for wandering, exhibited similar exit-seeking behaviors on multiple occasions. However, this resident was not reassessed for wandering or elopement risk after these incidents, and the care plan did not include a focus on elopement prevention until much later. Staff interviews confirmed that interventions such as redirection and hourly checks were used inconsistently and were not reflected in the care plans. The DON and administrator acknowledged that the residents were not reassessed or care planned for elopement risk in accordance with facility policy, and that interventions were not implemented or documented in a timely manner.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents who required assistance with meals were treated with dignity during meal times. Observations revealed that staff members, including CNAs, were standing while assisting residents with eating, which is against the facility's policy. This behavior was observed with several residents who had varying degrees of cognitive impairment and required different levels of assistance with eating. For instance, a CNA was seen standing over a resident with dementia while providing meal assistance, which was acknowledged as a dignity issue by the CNA. The report highlights specific instances where staff members did not adhere to the facility's policy of remaining seated while assisting residents with meals. In one case, a CNA was observed standing and moving between residents, providing assistance without sitting down, which could compromise the residents' dignity. Another CNA admitted to leaving a resident unattended with food in front of them to assist another resident, which resulted in the resident not receiving the necessary assistance for a period of time. The residents involved in these observations had various medical conditions, including dementia, Alzheimer's disease, Parkinson's disease, and stroke-related impairments, which affected their ability to eat independently. The care plans and assessments for these residents documented their need for assistance with meals, yet the staff's actions did not align with these documented needs, leading to a deficiency in maintaining the residents' dignity during meal times.
Failure to Update Care Plans with Fall Interventions
Penalty
Summary
The facility failed to ensure that the care plans for two residents were updated with fall interventions after multiple falls. Resident #32, who had dementia and severe cognitive impairment, experienced numerous falls from June 2023 to May 2024, some resulting in injuries such as skin tears and hematomas. Despite these incidents, the care plan for Resident #32 had not been updated with new interventions since December 2022. The MDS Coordinator acknowledged that while some interventions were implemented, such as increased supervision, they were not documented in the care plan. Resident #36, also diagnosed with dementia, experienced falls on several occasions between March and May 2024. Although interventions like a low bed and fall mat were used, these were not documented in the care plan. The comprehensive care plan for Resident #36 had not been updated with new interventions since November 2020. Staff members, including a CMA and LPN, confirmed that the interventions in place were not reflected in the care plan. The Director of Nursing (DON) confirmed that the facility's policy required new interventions to be added to the care plan after a fall, ideally within 14 days. However, this was not done for either resident, indicating a failure to adhere to the facility's policy and ensure accurate and up-to-date care plans for residents at risk of falls.
Failure to Ensure Adequate Hydration for Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a resident diagnosed with dementia, urinary incontinence, and a UTI, who required assistance with eating and drinking. The resident's fluid intake was consistently below the estimated need of 1802 milliliters, with records showing significantly lower amounts consumed over several days. Despite a physician's note indicating the need to push fluids due to a UTI, the resident was not consistently offered drinks by the staff. Observations revealed that the resident's water was often placed out of reach, and staff did not offer fluids during routine care activities. On multiple occasions, staff members entered and exited the resident's room without offering a drink, even when providing personal care or transferring the resident. A family member reported not seeing staff offer drinks, and the resident was observed to have a significant decline, receiving hospice care. The MDS coordinator acknowledged the expectation for staff to offer fluids whenever in the resident's room, but this was not consistently practiced. The deficiency was highlighted by the lack of staff action to ensure the resident's hydration needs were met, despite clear indications and instructions to do so.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper assessment and informed consent procedures were followed before the installation of bed rails for two residents. Resident #43, who had severe cognitive impairment and required extensive assistance with activities of daily living (ADLs), was observed with a half bed rail in place. Despite the presence of the bed rail, there was no documented assessment for entrapment risks or informed consent in the resident's records. Similarly, Resident #168, who had severe cognitive impairment and required assistance with bed mobility and transfers, was also observed with bed rails in the upright position. The facility did not document the risks and benefits of the bed rails or obtain informed consent for their use. The Director of Nursing (DON) confirmed that no entrapment assessments or informed consents were conducted for any residents using bed rails, including Residents #43 and #168. The DON acknowledged that alternatives to bed rails were not considered prior to their installation. This oversight affected 23 residents identified as utilizing bed rails, indicating a systemic issue in the facility's approach to bed rail use and resident safety.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. The Payroll-Based Journal (PBJ) Staffing Data Report for the period from October 1, 2023, to December 31, 2023, indicated that the facility did not document RN hours for October 1, 2023, December 22, 2023, December 25, 2023, and December 30, 2023. On May 21, 2024, at 9:15 a.m., the facility's Human Resources (HR) department was asked to provide documentation proving that an RN had worked the required hours on the specified dates. Later that day, at 1:40 p.m., HR confirmed that there was no RN coverage in the building on October 1, 2023.
Improper Storage of Controlled Drugs
Penalty
Summary
The facility failed to provide a separately locked, permanently affixed compartment for the storage of controlled drugs in one of the two refrigerators used for drug storage. During an observation on May 21, 2024, a medication mini refrigerator was found at the nurse's station on hall five, sitting on the counter and not permanently affixed. Inside the refrigerator, a small metal lock box was also not affixed and contained controlled medications, specifically Lorazepam 0.5mg syringes. The nurse's station had an open window area to the hall, and on May 22, 2024, the door to the nurse's station was observed propped open, with the refrigerator still unsecured. An RN stated that the door was closed and locked most of the time. The Director of Nursing was informed of these observations on May 23, 2024.
Inaccurate RN Coverage in PBJ Report
Penalty
Summary
The facility failed to ensure that the Payroll Based Journal (PBJ) accurately reflected Registered Nurse (RN) coverage for specific dates. The PBJ Staffing Data Report for the period from October 1, 2023, to December 31, 2023, did not identify RN hours for October 1, December 22, December 25, and December 30, 2023. On May 21, 2024, at 9:15 a.m., the facility's Human Resources (HR) department was requested to provide documentation confirming RN coverage on these dates. Later that day, at 1:40 p.m., HR provided documentation showing RN coverage for December 22, December 25, and December 30, 2023. However, the PBJ report did not accurately reflect the RN coverage on three of the four days in question, indicating a discrepancy in the facility's staffing records.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain proper hand hygiene during meal assistance for several residents in the secure unit. Observations revealed that staff members, including CNAs and a CMA, did not change gloves or sanitize their hands when moving between residents, handling food, or after touching dirty dishes. This lack of hand hygiene was observed during the noon meal assistance, where staff used the same gloves to assist multiple residents, handle food items, and manage utensils without washing their hands or changing gloves. The facility also failed to implement enhanced barrier precautions for a resident with an indwelling catheter. During perineal care, the catheter bag was placed on the bed and subsequently fell to the floor, where it remained while care was provided. The catheter bag was then dragged across the floor before being hooked to the bed frame. The facility's policy stated that catheter bags should not touch the floor, and enhanced barrier precautions were not implemented for residents with indwelling catheters unless they were colonized with a multidrug-resistant organism. Additionally, the facility did not label or date oxygen tubing and humidification bottles for a resident using oxygen equipment. The resident had been hospitalized for pneumonia and a UTI and was on oxygen therapy. Observations showed that the oxygen concentrator in the resident's room had no labels on the tubing or humidification bottle, and the nasal cannula was not covered or protected. Staff acknowledged the lack of labeling, which was against the facility's policy requiring all oxygen equipment to be labeled and dated.
Failure to Administer Pneumonia Vaccination
Penalty
Summary
The facility failed to ensure that residents were administered the pneumonia vaccination as required. Specifically, two residents, one with dementia and another with pneumonia and diabetes, had signed consents for the pneumococcal vaccine, but there was no documentation in their records indicating that the vaccine had been administered. The facility's policy stated that pneumococcal vaccines should be offered between October and March each year and every five years unless specified otherwise by the primary physician. However, the MDS Coordinator confirmed that there was no record of the vaccines being administered, nor was there any record in the Oklahoma State Immunization Information System of the vaccine being previously administered.
Failure to Notify OHCA of Significant Mental Health Changes
Penalty
Summary
The facility failed to notify the Oklahoma Health Care Authority (OHCA) after two residents experienced significant changes in their mental health diagnoses, which is a requirement for residents receiving mental health or intellectual disability services. Resident #12 was admitted with vascular dementia and anxiety, and later received a new diagnosis of unspecified psychosis, for which Seroquel was prescribed. Despite this significant change, the Director of Nursing (DON) confirmed that a PASARR II was not completed following the new diagnosis. Similarly, Resident #30 was admitted with type 2 diabetes and unspecified intellectual disabilities, and later diagnosed with depression and anxiety disorder. The resident was prescribed Abilify for delusional disorder and buspirone for anxiety disorder. However, the facility did not have a PASARR policy in place, and the DON acknowledged that no PASARR was completed after the new diagnoses of delusional and anxiety disorders. This oversight indicates a failure to comply with the necessary notification and assessment procedures for residents with significant mental health changes.
Failure to Document Bed Rail Use in Care Plan
Penalty
Summary
The facility failed to develop a care plan for the use of bed rails for a resident who had bed rails. The facility's policy on the MDS and Care Plan Process, revised in July 2023, emphasizes the importance of having an accurate care plan that identifies individualized approaches for each resident. However, upon review, it was found that the care plan for the resident did not document the use of bed rails. Observations on May 22, 2024, confirmed that the resident was using half bed rails in the upright position while in bed. The Director of Nursing (DON) acknowledged that the resident used bed rails for independence and repositioning but admitted that this was not documented in the care plan.
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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