Gracewood Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 6201 East 36th Street, Tulsa, Oklahoma 74135
- CMS Provider Number
- 375438
- Inspections on file
- 26
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Gracewood Health & Rehab during CMS and state inspections, most recent first.
A resident sustained a leg fracture after being pushed to the ground by another resident in the smoking area following an altercation in which water was poured on one resident. Staff found the injured resident on the ground, yelling in pain and unable to get up, and hospital x‑rays confirmed a leg fracture. The resident who pushed had bipolar disorder, PTSD, depression, anxiety, and moderate cognitive impairment, yet their care plan did not identify behaviors or include a behavior care plan, despite facility policy requiring assessment and care plan interventions for residents at risk of abusing others. An LPN acknowledged that a behavior care plan should have been in place, while the administrator reported that the injured resident was considered the aggressor and that the other resident was generally not a problem unless unable to smoke.
Surveyors found that the facility failed to maintain a safe and sanitary environment in both the kitchen and a resident restroom. In the kitchen, the floor between two sinks had been torn up and filled with gravel for about a year following a flood, and staff reported they could only clean it as best as possible. Meals were being served on paper plates with plastic utensils because the dishwasher was not in use during ongoing construction. In a resident restroom, hot water was not available, the sink was pulled away from the wall with chipped and torn paint behind it, and the toilet lid was removed and placed under the sink. The resident reported wanting hot water to wash their face, and the ADON acknowledged the hot water problem and described it as a financial issue affecting what maintenance could do.
A resident with Alzheimer’s disease, dementia, and severely impaired cognition was initially assessed as not being an elopement risk, but later eloped after a lapse in supervision at an exit door. Observations showed the resident generally resting in bed without elopement behaviors and being easily redirected when seen in the hallway. Staff reported they kept close tabs on the resident, but the administrator acknowledged staff should have ensured no resident followed them out an exit, resulting in a deficiency for failure to provide adequate supervision to prevent elopement.
The facility failed to provide privacy curtains in certain rooms, affecting residents' privacy during personal activities. Observations showed rooms without curtains, and a resident reported a lack of privacy. The DON confirmed the issue, noting maintenance had removed curtains after work was done. Maintenance staff acknowledged the absence of curtain tracks, leaving residents without privacy.
The facility failed to provide adequate activities for four residents with unique needs, including one with mobility issues due to a damaged wheelchair and others with dementia requiring structured programs. Staff were unaware of specific needs, and documentation did not reflect care plans, indicating a lack of oversight and personalized care.
The facility failed to conduct monthly medication regimen reviews for several residents, as required by its policy. Residents with various diagnoses, including schizoaffective disorder, dementia, and anxiety, had missing reviews for multiple months. Interviews revealed issues with medical records and the accuracy of medication orders, with the pharmacist facing challenges in accessing lab results and relying on unreliable records.
The facility failed to secure and properly manage medications across several carts. Medication carts were left unlocked and unattended, and medications were not dated when opened or discarded after 28 days. Expired medications were also found on a cart. The DON acknowledged these oversights.
The facility failed to maintain complete and accessible records for several residents, including those with dementia and schizoaffective disorder. Records were missing current physician's orders, medication regimen reviews, and lab results. The DON and MDS coordinator were responsible for record completeness but lacked a monitoring system. The pharmacist faced challenges accessing accurate orders and lab results, indicating systemic issues in record-keeping practices.
The facility failed to ensure operational call lights for residents, as multiple rooms were observed without call light cords and some had exposed wires. Despite a policy requiring call systems, maintenance logs and staff interviews revealed ongoing issues, with residents reportedly removing call lights and replacements delayed. The administrator did not provide a solution for residents needing assistance without call lights.
The facility failed to implement enhanced barrier precautions for a resident with a PEG tube during medication administration and site care. The policy requires gowns and gloves for high-contact activities, but RN #1 only used gloves. There was no signage indicating precautions near the resident's room, and the DON was unaware of the policy.
A resident with dementia, dependent on staff for ADL care, did not receive adequate nail care as per facility policy. Despite the requirement for daily cleaning and regular trimming, the resident's records showed minimal documentation of nail care being offered or provided. Observations revealed long, debris-filled nails, and staff interviews confirmed the resident's dependency on staff for nail care. The DON acknowledged the lack of documentation and monitoring, indicating a failure in policy adherence.
A resident with dementia and delusions had a bruise on their neck that was not documented or monitored by the facility. Despite staff awareness and previous reports, the bruise was not addressed according to protocol, and no documentation was found to support any intervention by the medical director. The facility failed to follow its protocol for reporting and assessing the resident's condition.
A facility failed to properly assess and document the use of bed rails for a resident with dementia and hemiparesis. The resident was observed with bed rails, but the assessment was incomplete, and there was no documentation of medical necessity, alternative interventions, or informed consent. Staff were unaware of the necessity for the rails, and the care plan did not reflect their use.
The facility did not post nurse staffing information for public view as required. Although staffing numbers were generally adequate, the administrator admitted that the total number of nursing hours was not posted. The DON stated that the daily schedule book, which was supposed to be at the nurses' desk, was in their office and lacked the total nursing hours.
A facility failed to ensure proper monitoring and documentation for a resident receiving psychotropic medications, including Risperdal, without evidence of side effect monitoring or a medication regimen review. The care plan was not updated to include Risperdal, and the DON cited issues with medical records as the reason for the lack of documentation. The pharmacist had no record of a recent order for Risperdal, indicating a communication and documentation failure.
The facility failed to complete physician-ordered lab tests for two residents. A resident with schizoaffective disorder did not have a valproic acid level obtained as ordered, and another resident with vascular dementia did not have a CMP completed as scheduled. The DON acknowledged responsibility but did not provide additional lab reports.
A facility failed to document regular safety inspections of a resident's bed, who had unspecified dementia and hemiparesis, and was using bed rails. The facility's policy required regular inspections to identify risks, but no documentation was found. Observations confirmed the use of bedrails, and interviews revealed that maintenance staff did not document safety checks, addressing issues only when noticed or during rounds.
The facility failed to ensure an RN was licensed in accordance with state laws. An RN was observed working as a charge nurse with a valid Texas license but an expired Oklahoma license. The DON was unaware of the expired license, and the RN had been working full-time since a specified date.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate Behavior Care Planning
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when a resident sustained a leg fracture after being pushed. According to an Oklahoma State Department of Health final report, a staff member witnessed one resident pour water on another resident, who then pushed the first resident, causing them to fall. A nursing note documented that around 5:30 p.m. the pushed resident was found on the ground in the smoking area, yelling and reporting that the other resident had pushed them down. Staff attempted to assist the resident up, but the resident reported being in great pain and unable to get up. Hospital x‑ray records from the same day showed the resident sustained a leg fracture. The deficiency was further supported by record review showing that the resident who pushed the other had multiple psychiatric diagnoses, including bipolar disorder, PTSD, depression, and anxiety, and a BIMS score of 12 indicating moderate cognitive impairment. Despite these conditions and the incident in which the resident pushed another resident, the resident’s care plan, reviewed later, did not show any behaviors, and an LPN stated there was no behavior care plan initiated for this resident and that there should have been. The administrator reported that the facility’s investigation concluded the injured resident was the aggressor and stated that the resident who pushed was not a problem unless they did not get to smoke, but the facility’s Resident to Resident Incidents policy required assessment for risk of abusing others and care plan interventions to prevent such occurrences.
Environmental and Sanitation Failures in Kitchen and Resident Restroom
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in the kitchen and in at least one resident restroom. Surveyors observed on 03/31/26 that the tile floor between two sinks in the kitchen had been ripped up and filled in with gravel, and staff reported this condition had existed for about a year following a flood caused by a busted pipe. Staff stated they could only wipe down and sanitize as much as possible and did the best they could to keep the gravel-filled floor clean. During the same kitchen observation, food was seen being plated onto paper plates with plastic silverware, and the administrator later stated the dishwasher was not being used due to ongoing construction in the kitchen and that residents had been using paper products since the previous Friday. The deficiency also includes the facility’s failure to ensure hot water and proper maintenance in a resident restroom. On 03/31/26, the hot water in Resident #21’s restroom was observed to be nonfunctional. The sink was pulled away from the wall, with paint chips on the back of the sink and on the wall where it had previously been touching, and the wall paint around the sink was torn away. The toilet lid was observed sitting below the sink instead of on the back of the toilet. On 04/03/26, Resident #21 stated they did not want to change rooms and only wanted hot water available to wash their face. The ADON acknowledged awareness that the hot water issue in this resident’s room needed to be addressed, describing it as a financial issue and stating that maintenance could only do what they were approved to do, and indicated they would have to ask maintenance about the toilet and sink in the restroom.
Failure to Provide Adequate Supervision to Prevent Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident in the memory care unit. The resident had diagnoses including Alzheimer’s disease, dementia, protein-calorie malnutrition, and hypertension, and an admission assessment documented severely impaired cognition without wandering behaviors. An elopement risk assessment completed in January indicated the resident was not an elopement risk. Despite this, the resident was later involved in an elopement event that prompted the facility to reassess elopement risk and implement increased monitoring. Surveyor observations on multiple days showed the resident resting in bed without elopement behaviors and later walking in the hallway in pajamas, where the resident was pleasant and easily redirected by staff. Certified nursing staff reported that they kept close tabs on the resident’s whereabouts at all times. The administrator later acknowledged that staff should have ensured no resident followed them out of an exit door, indicating that a lapse in supervision at an exit allowed the resident to elope, leading to the cited deficiency for not ensuring the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to ensure residents were provided with privacy curtains, compromising their privacy. Observations revealed that certain rooms lacked privacy curtains, affecting the residents' ability to maintain privacy during personal activities. In one instance, a resident expressed that all activities, except using the restroom, were conducted in full view of their roommate due to the absence of a privacy curtain. The Director of Nursing (DON) acknowledged that privacy was not effectively provided in a room where maintenance had removed the curtain following work completed a month prior. Maintenance staff confirmed the absence of curtain tracks in the room and were unsure why they had not been installed, resulting in a lack of privacy for the residents.
Inadequate Activity Provision for Residents
Penalty
Summary
The facility failed to provide adequate activities for four residents, each with unique needs and conditions. Resident #18, who had chronic pain, obesity, and limited mobility, was unable to participate in activities due to an uncomfortable and damaged wheelchair. Despite expressing the need for a better wheelchair, staff were unaware of the issue until it was brought to the attention of the Director of Nursing (DON), who then took action to replace it. The lack of communication and awareness among staff about the resident's needs contributed to the deficiency. Resident #22, diagnosed with dementia and anxiety, was observed to have little engagement in activities despite a care plan that emphasized the need for sensory stimulation and structured programs. The resident was often found in bed, and there was no evidence of activities occurring on the memory unit. The activities director admitted to not monitoring activity documentation and was unaware of the specific goals for Resident #22, indicating a lack of oversight and personalized care. Resident #26, with Alzheimer's disease and dementia, and Resident #42, with vascular dementia, also experienced inadequate activity provision. Both residents had care plans that outlined specific activities and goals, but the documentation did not reflect these interventions. The activities director acknowledged the lack of formal training in dementia care and the absence of proper documentation, which contributed to the failure in meeting the residents' needs. The administrator confirmed that the activities director was responsible for documenting and completing activities, but there was a lack of daily monitoring and tracking by the social services director.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly medication regimen reviews (MRRs) were conducted by a licensed pharmacist for five residents who were reviewed for unnecessary medications. The facility's policy required the consultant pharmacist to review each resident's medication regimen monthly and provide a written, signed, and dated report to the Director of Nursing Services and Medical Director. However, the clinical records for residents #24, #57, #62, #22, and #59 revealed missing MRRs for various months in 2024, indicating non-compliance with the facility's policy. Resident #24, diagnosed with schizoaffective disorder, bipolar type, did not have MRRs conducted in January, February, March, or July 2024. Resident #57, with unspecified dementia, lacked MRRs for December 2023 and March 2024. Resident #62, diagnosed with vascular dementia, was missing an MRR for January 2024. Resident #22, with Alzheimer's disease/dementia, anxiety, and depression, had missing MRRs for January, February, March, and August 2024. Additionally, the care plan for Resident #22 was not updated to include all current medications. Resident #59, with dementia and anxiety, had missing MRRs for several months in 2024, and the clinical record did not reveal lab results. Interviews with the Director of Nursing (DON) and the pharmacist highlighted issues with medical records and the accuracy of medication orders. The pharmacist reported difficulties accessing lab results and relied on the medication administration record rather than the clinical record due to its unreliability. The pharmacist also mentioned challenges in obtaining lab access and noted that they visited the facility monthly, with reports delivered shortly after. These deficiencies in conducting timely MRRs and maintaining accurate clinical records contributed to the facility's failure to comply with its medication management policies.
Medication Management Deficiencies in Facility
Penalty
Summary
The facility failed to ensure the security and proper management of medications across several medication carts. On multiple occasions, the 300 hall treatment cart was left unattended and unlocked by RN #2 and RN #1 during medication administration, contrary to the facility's policy that requires medication carts to be locked when not in use. Additionally, medication cups containing various medications were left unattended on top of the cart. The Director of Nursing (DON) confirmed that medication carts should be locked when unattended. The facility also failed to date medications when opened and did not discard insulin after 28 days as required. Observations revealed that several inhalers and insulin vials on the 200 and 300 hall treatment carts were opened but not dated. Furthermore, expired medications were found on the 100 hall medication cart, including Tussin DM and geri-lanta, which had passed their expiration dates. The DON acknowledged the oversight in monitoring for expired medications and the failure to date opened medications.
Incomplete and Inaccessible Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accessible for four of the 18 sampled residents. The Medication Orders policy required a current list of orders to be maintained in each resident's clinical record, and the Charting and Documentation policy required documentation of all services provided, progress toward care plan goals, and any changes in the resident's condition. However, the records for residents with diagnoses such as dementia, schizoaffective disorder, Alzheimer's disease, anxiety, and depression were found to be incomplete. For instance, Resident #57's records lacked recent dose reductions and lab reports, while Resident #24's records were missing current physician's orders. Resident #22's records were missing several months of medication regimen reviews, and Resident #59's records lacked multiple months of medication regimen reviews and lab results. The Director of Nursing (DON) and the MDS coordinator were identified as responsible for ensuring the completeness and accessibility of clinical records, but they admitted to not knowing how records were monitored. The pharmacist also expressed difficulties in accessing accurate orders and lab results, relying instead on the medication administration record and staff assistance to obtain necessary information. The pharmacist noted that they had not seen certain medication orders and had issues with lab access, indicating a systemic problem with the facility's record-keeping practices. These deficiencies in maintaining complete and accessible records hindered effective communication and care coordination for the residents involved.
Deficiency in Call Light System Availability
Penalty
Summary
The facility failed to ensure that call lights were operational and available for residents, as observed during a survey. The facility's policy, reviewed in May 2024, mandates that all resident rooms be equipped with a call system for staff assistance. However, multiple observations revealed deficiencies in this area. On several occasions, rooms were found without call light cords, and some had exposed wires where the call lights should have been. Specifically, on January 6, 2025, several rooms were noted to lack call light cords, and exposed wires were observed in some rooms. Additionally, on January 8, 2025, a room was found with wires protruding from the wall where the call light should be. The maintenance log indicated that a call light was ripped from the wall in one room on December 28, 2024, with repairs documented on December 30, 2024. Despite this, issues persisted into January 2025. Maintenance staff reported that residents removed call lights and did not replace them, and it had been about a month since new call lights were ordered by the administrator. When questioned about how residents could notify staff without call lights, the administrator did not provide an answer, highlighting a significant gap in ensuring resident safety and communication with staff.
Failure to Implement Enhanced Barrier Precautions for Resident with PEG Tube
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with a PEG tube during medication administration and site care. The Enhanced Barrier Precautions policy, dated August 2022, requires the use of gowns and gloves during high-contact resident care activities, such as device care or use, including feeding tubes. However, during observations, RN #1 was seen administering medications and performing PEG tube site care for Resident #279 without utilizing the required personal protective equipment (PPE) except for gloves. Additionally, there was no signage indicating enhanced barrier precautions or PPE requirements near the resident's room. The nurse manager identified two residents with PEG tubes, and the Director of Nursing (DON) admitted to not understanding what enhanced barrier precautions were, indicating a lack of awareness and implementation of the facility's policy.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident diagnosed with unspecified dementia, who was dependent on staff for activities of daily living (ADL) care. The facility's policy required daily cleaning and regular trimming of nails, with documentation of any refusals and notification to the supervisor. However, the resident's Activity of Daily Living Record showed that nail care was offered or provided only five times out of 93 opportunities in December 2024, and not at all during the first week of January 2025. Observations on January 6 and January 9 revealed the resident's fingernails were approximately a quarter inch long with dark debris underneath, despite the resident's preference for shorter nails. Interviews with facility staff, including a CNA and an LPN, confirmed that the resident was dependent on staff for nail care and that refusals were sometimes documented. The Director of Nursing (DON) acknowledged the lack of documentation and stated that nail care should have been provided on scheduled shower days and as needed. Upon reviewing the records and observing the resident's nails, the DON admitted that the facility had failed to adequately monitor and document nail care, indicating a lapse in the facility's adherence to its own care policies.
Failure to Monitor and Document Resident's Bruising
Penalty
Summary
The facility failed to monitor and evaluate a resident's response to an intervention, specifically regarding the presence of bruising on the neck of a resident diagnosed with vascular dementia, Alzheimer's disease, and delusions. The care plan for the resident included monitoring for skin alterations due to incontinence and notifying the physician of changes such as bruising. However, there was no documentation of concern regarding bruising in the care plan, and no records of the bruise on the resident's neck were found in the priority charting or physician progress notes. Staff members, including LPNs and CNAs, were unaware of the bruise or had previously reported it without follow-up. The DON acknowledged that the bruising had been addressed over a year ago but had not been re-evaluated since it resolved without intervention. Despite the DON's claim that the medical director had addressed the issue by discontinuing aspirin, no documentation was found to support this. The facility's protocol for reporting and assessing such incidents was not followed, as evidenced by the lack of documentation and communication with the physician regarding the resident's condition.
Failure to Properly Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the use of bed rails, as required by their policy. The policy mandates that side rails should only be used to treat a resident's medical symptoms or assist with mobility and transfer, and requires a comprehensive assessment including the resident's bed mobility, risk of entrapment, and appropriateness of bed dimensions. Additionally, documentation should indicate if less restrictive approaches were unsuccessful, and informed consent should be obtained after discussing the risks and benefits with the resident or their representative. However, for the resident in question, the assessment was incomplete, and there was no documentation indicating that the side rails treated a medical condition, that alternative interventions had been attempted, or that informed consent had been obtained. The resident, who had unspecified dementia and hemiparesis of the left side, was observed with half bed rails in the up position, yet they stated they did not use them and assumed they were for safety. The LPN and DON were unaware of the necessity for bilateral side rails, given the resident's inability to utilize their left side. The DON admitted that the resident preferred the rails but did not require them, and acknowledged that the assessment was not completed. Furthermore, the care plan did not document the use of bed rails, and the care plan coordinator was unaware of their presence, indicating a lack of communication and documentation within the facility regarding the resident's care needs and the use of bed rails.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted for public view, which is a requirement. During a review of the Quality of Care (QOC) reports for October, November, and December 2024, it was noted that staffing numbers were generally adequate, except for one day shift in December. On January 14, 2025, the administrator acknowledged that while they had the staff names and positions for each shift on each hall, they did not have the total number of nursing hours posted. Additionally, the Director of Nursing (DON) mentioned that there was a book containing the daily schedule at the nurses' desk, but during the survey, the book was in their office, and it did not include the total nursing hours.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident did not receive unnecessary medications, specifically psychotropic drugs, without proper monitoring and documentation. The resident, who had diagnoses including Alzheimer's/dementia, anxiety, and depression, was receiving multiple psychotropic medications such as Nuedexta, trazodone, Ativan, and Risperdal. However, the clinical record lacked documentation of side effect monitoring or evidence that the physician was provided with a medication regimen review (MRR) or a gradual dose reduction (GDR) for Risperdal. Additionally, the care plan for the resident was not updated to include Risperdal, despite documenting concerns for psychotropic drug use and approaches to evaluate the effectiveness and side effects of medications. The Director of Nursing (DON) was unable to provide a clear policy regarding gradual dose reductions and cited issues with medical records as the reason for the lack of documentation. Furthermore, the pharmacist reported not having seen an order for Risperdal since they started in April 2023 and had no notes about the resident being on Risperdal recently. This indicates a failure in communication and documentation within the facility, leading to the resident potentially receiving unnecessary medication without proper oversight.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as ordered by the physician for two residents. One resident, diagnosed with schizoaffective disorder, bipolar type, had a physician's order to obtain a valproic acid level every three months in July, October, January, and April. However, the clinical record and labs provided did not show that the valproic acid level was obtained in July or October 2024. Another resident, diagnosed with vascular dementia, had a physician's order to obtain a comprehensive metabolic panel (CMP) every six months. The last CMP was obtained in May 2024, but there was no record of a CMP for November 2024. The Director of Nursing (DON) acknowledged responsibility for ensuring labs were obtained as ordered and mentioned issues with medical records obtaining and filing lab reports. Despite this, no additional lab reports were provided by the end of the survey.
Failure to Document Regular Bed Safety Inspections
Penalty
Summary
The facility failed to ensure regular safety inspections of resident beds, specifically for a resident with unspecified dementia and hemiparesis of the left side, who was using bed rails. The facility's Bed Safety policy, dated June 2024, mandates regular inspections by maintenance staff to identify risks, including potential entrapment risks, and to ensure proper installation of bedrails. However, a review of the clinical record and maintenance logs revealed no documentation of regular safety inspections for the resident's bed. Observations confirmed the resident was using half bedrails in the up position. Interviews with the DON and a maintenance worker indicated that while maintenance staff were responsible for bed safety inspections, they did not document these checks, relying instead on addressing issues as they were brought to their attention or during routine rounds. The administrator confirmed the lack of documentation for these inspections.
Failure to Ensure RN Licensing Compliance
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was licensed in accordance with applicable state laws. An RN was observed working as the charge nurse at the nurse station, and their employee record showed a valid RN license for the state of Texas but not for Oklahoma. Upon review, the administrator found that the RN's Oklahoma license had expired, as confirmed by documentation from the Oklahoma Board of Nursing. The Director of Nursing (DON) stated that the RN had been working full-time at the facility since a specified date, with only one break in full-time status, and was unaware of the expired Oklahoma license.
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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