Lindsay Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lindsay, Oklahoma.
- Location
- 1103 West Cherokee, Lindsay, Oklahoma 73052
- CMS Provider Number
- 375206
- Inspections on file
- 25
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Lindsay Nursing & Rehab during CMS and state inspections, most recent first.
A resident with intact cognition, independent ADLs, COPD, respiratory failure, and PRN oxygen orders had multiple small portable oxygen cylinders stored unsecured on the floor of their closet, despite a facility policy requiring cylinders to be secured in a designated locked storage area and routinely checked. The care plan included use of a portable oxygen apparatus but lacked interventions addressing the resident’s practice of bringing in and storing portable cylinders from a family member’s home. Staff interviews revealed that a CNA knew cylinders should only be kept in a locked oxygen room, while a housekeeper had seen cylinders in the closet but did not know they were prohibited, and the DON acknowledged prior removals of cylinders from the room without established interventions to prevent recurrence.
A resident with COPD, intact cognition, and PRN oxygen orders was found to have numerous small portable oxygen cylinders stored in a closet, some standing and some tipped over on the floor, with at least two cylinders confirmed full. The resident reported bringing these cylinders from a family member’s home because the facility did not supply that type of portable oxygen. Although the resident’s care plan noted oxygen therapy and provision of a portable oxygen apparatus, it lacked interventions addressing the resident’s repeated unsafe storage of portable oxygen cylinders, despite the DON acknowledging the cylinders had been removed from the room several times for safety and that such interventions should have been included on the care plan.
A cognitively intact resident with paraplegia and an indwelling urinary catheter reported that when they approached an RN to discuss concerns about their catheter bag, the RN became angry, stated they did not care, and directed the resident to speak with someone else, causing the resident embarrassment and prompting them to return to their room. The facility’s abuse prevention policy required protection of residents from abuse by anyone, yet interviews and a grievance investigation confirmed that the RN had been verbally aggressive, including hollering and cursing, resulting in a substantiated finding of verbal abuse.
A cognitively intact resident with paraplegia and an indwelling catheter reported that an RN became angry when approached about a catheter bag and responded with profane, dismissive language, which was later substantiated as verbal abuse. The resident informed a CMA about the incident that evening, but the CMA did not immediately notify the administrator, honoring the resident’s request to self-report the next morning. The administrator was not informed until the following day and then had the resident complete a grievance form, after which the allegation was faxed to the state agency, resulting in the allegation not being reported within the required 2-hour timeframe.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised on two occasions, including being found walking on a highway, due to the facility's failure to identify elopement risk and implement appropriate supervision and interventions. Staff acknowledged that the resident's behaviors warranted earlier preventive measures, but these were not put in place until after the incidents occurred.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to three residents reviewed for beneficiary notification. The DON reported that no SNF ABN form was provided to these residents or their representatives. An RN stated that the SNF ABN form was previously included in the resident admission packet but had been removed at some point, and she was unaware of when this occurred.
A resident with Alzheimer's and a history of wandering eloped from the facility and was found by the local fire department. Despite being identified as at risk for elopement, the facility did not implement additional preventive measures after the incident. Staff were aware of the resident's wandering behavior, but no specific interventions were added to prevent future elopements.
A resident's grievance about a staff member's rudeness was not fully addressed by the facility, and the resident did not receive a requested written summary of the grievance. The facility's grievance policy required providing a written summary upon request, but the administrator and activity manager did not comply, believing it was an internal document. A corporate consultant confirmed residents are entitled to a copy of their grievances.
A resident with schizophrenia and other conditions was involved in an altercation with a staff member, leading to an abuse allegation. The facility failed to conduct a thorough investigation, as required by its policy, by not obtaining staff statements, notifying the DON, or reporting the incident to the police. The administrator relied on a single witness, and the ADON was unaware of the incident until days later.
A resident with a history of brain injury and dementia repeatedly eloped from the facility without supervision, despite being at risk. The facility lacked a comprehensive care plan and failed to report incidents, leading to multiple unsupervised departures and police involvement. Staff were unaware of the need for incident reporting, contributing to ongoing safety risks.
The facility allowed the DON to work as a charge nurse when the resident census exceeded 60, contrary to policy. Records and interviews confirmed the DON assumed charge nurse duties on several occasions with a census ranging from 61 to 72 residents. Staffing sheets and interviews with the DON and a corporate consultant corroborated these findings.
A facility failed to provide a resident with written notification of the bed hold policy upon transfer to a hospital. The resident, with conditions including hypertension and diabetes, was transferred for further evaluation and later admitted to another LTC facility. The facility's staff, including the BOM and ADON, were unaware of the bed hold policy, and the Administrator admitted that written notification should have been provided.
Unsecured Portable Oxygen Cylinders Stored in Resident Closet
Penalty
Summary
The facility failed to ensure safe storage of portable oxygen cylinders in accordance with its Oxygen Storage and Safety policy. The policy required full cylinders to be stored in a designated, well-ventilated area, empty cylinders to be stored separately and labeled as empty, and oxygen in resident rooms to be secured to prevent tipping, with routine checks to ensure proper storage and safety. For one resident with intact cognition, independent in activities of daily living, and receiving oxygen therapy for COPD and respiratory failure, the care plan included provision of a portable oxygen apparatus but did not include any interventions addressing unsafe storage of portable oxygen cylinders brought into the facility. The resident’s medical record contained no documentation that the facility checked the resident’s room for safe oxygen storage. During observation, surveyors found approximately 25 small portable oxygen cylinders for an over-the-shoulder carrier bag stored in the resident’s closet, standing upright and tipped over on the floor, and unsecured. Subsequent checking by the DON of three of these cylinders revealed that two were full. The resident reported that the facility would not supply the small portable cylinders, that they brought the cylinders from a family member’s home, and that only empty cylinders were stored in the closet. A CNA stated that oxygen cylinders were supposed to be stored in a locked room designated for oxygen and not in residents’ rooms. A housekeeper reported having seen oxygen cylinders in the resident’s closet while hanging clothes but was unaware they were not allowed there. The DON stated that oxygen cylinders were to be stored secured in a rack in a locked closet, acknowledged prior removal of cylinders from this resident’s room several times for safety, and was not aware of what interventions had been implemented to prevent the resident from continuing to store cylinders in the closet.
Failure to Update Care Plan for Safe Storage of Portable Oxygen Cylinders
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to update and individualize a resident’s care plan with interventions addressing unsafe storage of portable oxygen cylinders. Observation of the resident’s room showed 25 small oxygen cylinders stored in the closet, some standing and some tipped over on the floor, with subsequent checking by the DON revealing at least two cylinders were full. The resident had an annual assessment indicating intact cognition (BIMS 15), independence with ADLs, a diagnosis of COPD, and receipt of oxygen therapy. A physician’s order directed oxygen at 2 L/min via nasal cannula as needed for a history of respiratory failure. The existing care plan documented that the resident had oxygen therapy and was to be provided with a portable oxygen apparatus, but it did not include any interventions related to the resident’s practice of storing portable oxygen cylinders in the closet. The facility’s policy on comprehensive person-centered care plans stated that assessments are ongoing and care plans are to be revised as residents’ conditions or information about them change. The resident reported that the facility would not supply the small portable oxygen cylinders used in an over-the-shoulder carrier bag and that these cylinders were brought in from a family member’s home. CNA staff stated that no residents stored portable oxygen cylinders unsecured in their rooms or closets. The DON acknowledged that portable oxygen cylinders had been removed from this resident’s room several times for safety and that they were not aware of what interventions had been implemented to prevent the resident from storing cylinders in the closet. The DON further stated that interventions to ensure the resident was not storing oxygen cylinders unsecured should have been included on the care plan, and the administrator stated they had been unaware of the cylinders stored in the closet.
Failure to Protect a Resident From Verbal Abuse by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member. A cognitively intact resident with paraplegia, who was largely independent with ADLs and had an indwelling urinary catheter, approached an RN to discuss concerns about their catheter bag. According to a grievance form, when the resident attempted to discuss the catheter issue, the RN appeared angry and responded, "I don't want any part of that. I don't give a damn. Go talk to [name removed] about it." The resident reported feeling embarrassed by this interaction and returned to their room. The facility’s Abuse Prevention Program policy stated that administration would protect residents from abuse by anyone, including facility staff. Despite this policy, the resident’s grievance and subsequent investigation documented that the RN was verbally aggressive toward the resident. Staff interviews corroborated the resident’s account, including a CMA who reported that the resident told them later that day about the RN hollering and cursing at them. The investigation concluded that verbal abuse had occurred between the RN and the resident.
Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the state survey agency within the required 2-hour timeframe. The facility’s Abuse Prevention Program policy required allegations of abuse to be investigated and reported within federal timeframes. A cognitively intact resident with paraplegia, an indwelling catheter, and independence with most ADLs reported that a registered nurse became angry when approached about the resident’s catheter bag and stated, “I don't want any part of that. I don't give a damn. Go talk to [name removed] about it.” This allegation of verbal abuse occurred on 02/25/26 sometime around 2:00 p.m. On the evening of 02/25/26 at around 8:45 p.m., the resident informed a CMA that the RN had hollered and cursed at them earlier in the day. The CMA acknowledged being told of the incident but did not immediately report it to the administrator, stating the resident wanted to self-report the next morning. The administrator reported being notified of the allegation on 02/26/26 and then had the resident complete a grievance form, after which the allegation was faxed to the state agency on 02/26/26 at 11:16 a.m. The grievance investigation substantiated verbal abuse. The administrator confirmed that staff had been educated to report suspected abuse immediately, even if unsure it was abuse, and acknowledged the incident should have been reported within 2 hours of the resident notifying the CMA.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for one resident identified as at risk for wandering and elopement. The resident, who had diagnoses including hypertension, hyperlipidemia, and severe cognitive impairment, was admitted with a history of decreased awareness and required frequent redirection. Despite multiple nursing notes documenting wandering behavior, confusion, and attempts to leave the facility, the initial elopement risk assessment did not identify the resident as at risk. The resident was observed leaving the facility on two separate occasions, once through the front door and another time walking down the highway, both times without appropriate staff intervention or supervision. Staff interviews confirmed that the resident had demonstrated confusion and exit-seeking behaviors since admission, and that interventions to prevent elopement were not implemented in a timely manner. The DON and LPN both acknowledged that the resident should have been considered an elopement risk upon admission and that supervision and preventive measures were lacking prior to the incidents. Video surveillance further revealed that the resident was able to exit the facility by following others without being stopped, indicating a failure to ensure a safe and secure environment as outlined in the facility's own policy.
Failure to Provide SNF ABN Forms to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to three residents who were reviewed for beneficiary notification. Resident #56 was admitted to Part A skilled services on May 7, 2024, and discharged on July 26, 2024. Resident #53 was admitted on September 19, 2024, and discharged on September 11, 2024. Resident #13 was admitted on November 18, 2024, and discharged on December 11, 2024. During a review on December 17, 2024, the Director of Nursing (DON) reported that no SNF ABN form was provided to these residents or their representatives. Additionally, RN #1 stated that the SNF ABN form was previously included in the resident admission packet but had been removed at some point, and she was unaware of when this occurred.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident who was at risk for wandering and elopement. The resident, diagnosed with Alzheimer's disease and other conditions, was known to ambulate independently and had a history of attempting to leave the facility without informing staff. Despite being identified as severely cognitively impaired and at risk for elopement, the facility did not implement additional interventions after the resident previously left the facility without staff. The resident was found by the local fire department at a neighboring church, and upon return, was placed on 1:1 observation, but no further preventive measures were documented. Staff interviews revealed that the resident was known to wander the halls and approach exit doors, but there was no awareness of the resident ever leaving the premises prior to the incident. The facility's Elopement Risk Evaluation and care plan acknowledged the resident's risk, yet failed to include specific interventions to prevent future elopements. The administrator confirmed that while staff were familiar with the resident's wandering behavior, no additional interventions were added following the elopement incident.
Failure to Provide Written Grievance Decision and Address Complaint
Penalty
Summary
The facility failed to issue a written grievance decision upon request and did not address the grievance in its entirety for a resident. The grievance policy and procedure, which was not dated, stated that the facility would provide a prompt and equitable resolution of complaints and grievances, including providing a written summary of the report to the resident if requested. However, in the case of a grievance filed by a resident regarding a staff member's rudeness, the facility did not provide a written summary to the resident, despite the resident's request. The grievance form documented that the staff member was enforcing smoking regulations, but it did not address the complaint about the staff member's rudeness, nor did it include the date the grievance was discussed with the resident. Interviews with the facility's administrator and activity manager revealed that the grievance was not fully addressed, and the resident did not receive a copy of the grievance report as requested. The administrator believed the grievance was an internal document and did not provide a copy to the resident. The activity manager confirmed that the grievance about the staff member's rudeness was not addressed and that the resident's request for a copy was denied based on the administrator's instructions. A corporate consultant later confirmed that residents are allowed to have a copy of grievances they file.
Inadequate Abuse Investigation Following Resident-Staff Altercation
Penalty
Summary
The facility failed to conduct a thorough abuse investigation for a resident who was involved in an incident with a staff member. The incident occurred when the staff member attempted to read a letter with the resident, leading to a physical altercation where the resident allegedly struck the staff member. The resident claimed that the staff member had pushed them first. The facility's policy requires immediate reporting and a comprehensive investigation, including interviews with all potential witnesses and assessments of the resident's condition. However, the investigation was insufficient as the administrator did not obtain statements from the nursing staff or notify the Director of Nursing (DON) about the abuse allegation. Additionally, the incident was not reported to the local police department as required by the facility's policy. The resident involved in the incident had a medical history that included schizophrenia, COPD, essential hypertension, and recurrent depressive disorders. Despite the resident's request to report the incident to the police, the facility did not follow through with this action. The DON was informed of the incident by the resident but did not update the resident's clinical record or care plan. The administrator relied on a single witness's account and did not conduct a comprehensive investigation, as required by the facility's abuse policy. The Assistant Director of Nursing (ADON) was also unaware of the allegation until two days after the incident, indicating a lack of communication and proper procedure adherence within the facility.
Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a resident at risk for elopement, leading to multiple incidents where the resident left the facility unsupervised. The resident, who had a history of traumatic brain injury, depression, schizoaffective disorder, and dementia, was found on several occasions outside the facility without signing out or informing staff. Despite these incidents, the facility did not have a comprehensive care plan addressing the resident's elopement risk or illicit drug use. The facility's elopement policy required staff to investigate and report all cases of missing residents, but this was not consistently followed. The resident was found in various locations outside the facility, including passed out by a dumpster and in someone's yard, requiring police intervention. The facility's assessments and documentation failed to accurately reflect the resident's risk for elopement, and interventions were not officially implemented in the care plan. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's elopement risk and the need for incident reporting. The Director of Nursing and other staff members were not aware that incident reports were necessary for elopements or drug use until informed by an RN consultant. This lack of proper documentation and intervention contributed to the ongoing risk and incidents of elopement for the resident.
DON Worked as Charge Nurse with Census Over 60
Penalty
Summary
The facility failed to comply with regulations by allowing the Director of Nursing (DON) to work as a charge nurse when the resident census exceeded 60. The facility's policy explicitly states that the DON should not assume charge nurse duties when the census is above 60 residents. However, records indicate that the DON worked as a charge nurse on multiple occasions when the census ranged from 61 to 72 residents. Specifically, the DON worked as a charge nurse on June 24th, July 25th, July 31st, August 1st, 5th, and 6th, 2024, despite the facility having a census over 60 residents on these dates. Interviews with the DON and a corporate consultant confirmed these occurrences, and staffing sheets reviewed by an LPN corroborated the findings. The DON was also noted to be covering night shifts during the survey, further indicating their involvement in charge nurse duties during periods of high census.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to a resident or their representative upon transfer to a hospital, resulting in a deficiency. The facility's Readmission to the Facility policy, dated March 1, 2022, states that a Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident meets the admission criteria. However, the clinical record for a resident with diagnoses including hypertension and diabetes mellitus did not contain documentation that the resident or representative had been provided written documentation of the bed hold policy at the time of discharge. The resident was transferred to a hospital for further evaluation of urinary retention and trouble breathing, and the discharge summary indicated that the resident was admitted to the hospital. Despite the discharge status indicating a return was anticipated, the resident was not allowed to return to the facility after being admitted to another long-term care facility following discharge from the hospital. Interviews with the Business Office Manager (BOM) and Assistant Director of Nursing (ADON) revealed a lack of awareness and communication regarding the bed hold policy, and the Administrator acknowledged that written notification should have been provided to meet regulatory requirements.
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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