New Hope Retirement & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcalester, Oklahoma.
- Location
- 1220 East Electric Blvd, Mcalester, Oklahoma 74501
- CMS Provider Number
- 375384
- Inspections on file
- 24
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at New Hope Retirement & Care Center during CMS and state inspections, most recent first.
A resident who had a physician's order for BIPAP with oxygen at 3 LPM during sleep and naps was repeatedly observed resting in bed without the BIPAP machine in use, and the mask was left on the bedside table. An RN confirmed the resident should have been using the BIPAP during naps, but the order was not followed.
The facility did not ensure that all dietary staff received required training in safe food handling practices for the prevention of foodborne illness. When surveyors requested verification of food handler training, the administrator could only provide certificates for five of seven dietary employees and acknowledged that one cook and one dietary aide had not completed the required training. Meals prepared and served by the dietary department were provided to dozens of residents, but two staff members involved in food service lacked documented safe food handling education.
Surveyors found that during a noon meal service, the kitchen served a different entrée and side dishes than those listed on the posted weekly menu, while still serving the same dessert and bread item. The administrator reported that 37 residents received nutrition from the kitchen for this meal. Although facility policy required that any menu substitutions be recorded on a substitution form along with the reason for the change, the dietary manager stated that items were substituted because the planned foods were not available and acknowledged that substitutions and reasons were not documented and that they were unaware of any substitution form.
Surveyors found that the facility failed to follow food safety and sanitation standards, including storing expired coleslaw and cottage cheese, keeping unlabeled juice in the refrigerator, and not consistently documenting refrigerator and freezer temperatures. Freezers lacked visible thermometers, and the food preparation and dry storage floors were damaged, rough, and had debris and dark buildup, with boxes of apple juice stored directly on the floor. A cook prepared lunch without checking or recording final food temperatures and reported not knowing this was required, while the dietary manager confirmed there was no process or log for cooked food temperatures despite policies requiring labeling, dating, and use of a thermometer for internal temperatures.
An allegation of abuse involving a resident with dementia and behavioral disturbances was not reported to the state agency within the required timeframe. The administrator conducted an internal investigation but decided not to submit an incident report, resulting in a failure to comply with mandatory reporting policies.
A resident’s quarterly assessment was inaccurately coded to show that the resident was receiving anticoagulant therapy, while the corresponding medication administration record for the same period showed no anticoagulant medications ordered or administered. During interview, the MDS coordinator confirmed the resident was not on anticoagulation and that the assessment coding was erroneous.
Surveyors observed that the medication storage room contained multiple expired items, including syringes with needles, lubricating jelly packets and tubes, and bisacodyl suppositories. An RN present during the observation acknowledged that these expired medications and supplies should have been removed. The facility had 37 residents at the time, and the deficiency centered on the failure to ensure timely removal of expired drugs and related supplies from the medication room.
Surveyors found that the facility did not fully implement its Legionella water management program as part of its infection prevention and control efforts. The written policy required a water management team that included the infection preventionist, administrator, medical director or designee, director of maintenance, and director of environmental services, along with a detailed water system diagram and identification of areas prone to waterborne bacteria. Record review showed a 2025 shower head cleaning schedule with quarterly entries for three quarters but no documentation for the fourth quarter. In interviews, the infection preventionist reported not knowing they were part of the water management team, and the administrator acknowledged the absence of a required water system diagram and missing October documentation, while noting that 37 residents were residing in the facility.
Surveyors observed multiple ceiling tiles with brown water stains and sagging in the dining room and several resident rooms, caused by persistent roof leaks that occurred during rain. The maintenance supervisor and administrator confirmed the roof had not been permanently repaired, despite management's awareness of the issue, resulting in a failure to maintain a safe, clean, and homelike environment as required by facility policy.
A resident with urinary retention and a congenital bladder neck obstruction, who had an indwelling urinary catheter and physician orders for regular catheter care, did not have a comprehensive care plan developed for catheter care and maintenance. The absence of this care plan was confirmed by the MDS coordinator.
A resident with non-Alzheimer's dementia and intact cognition engaged in abusive behavior toward another resident, including physical contact and attempting to tie a neck pillow around the other resident's neck. Although the incident was reported and immediate supervision was provided, the resident's care plan was not updated to reflect the new behaviors or interventions, contrary to facility policy.
A resident with an indwelling urinary catheter exhibited odorous brown drainage at the catheter entry site over several days, as documented by nursing staff. Despite physician orders to monitor and report signs of infection, there was no documentation that the physician was notified. The resident was later hospitalized for a complicated UTI and hypotension.
The facility did not post complete staffing information as required. Observations revealed that the whiteboard at the nursing station lacked the facility name, projected staffing hours, and actual staffing hours, only showing the date, census, and staff/title. The DON was unaware of the specific requirements for staffing documentation.
The facility failed to date and cover urinary catheter bags for two residents, leading to a deficiency. One resident with overactive bladder, paraplegia, and a stage 4 sacral pressure ulcer was observed with an undated and uncovered catheter bag. Another resident with urine retention and congenital bladder neck obstruction was repeatedly observed with an undated and uncovered catheter bag. The DON confirmed the deficiency.
The facility failed to document physician's orders for DNR status for three residents, despite having DNR care plans and signed consent forms. The MDS coordinator was unaware of the requirement for a physician's order, resulting in the oversight.
The facility failed to notify the physician of out-of-parameter blood sugar levels for two residents with diabetes. One resident had a blood sugar of 458, and another had multiple instances of blood sugar levels exceeding 400, yet there was no documentation of physician notification. Staff interviews confirmed that the physician should have been notified, and the lack of documentation indicated this did not occur.
The facility failed to ensure accurate assessments for two residents. One resident was incorrectly documented as taking an anticoagulant instead of an antiplatelet medication, due to an error in the auto-populated medication section. Another resident's admission assessment failed to document their hospice services admission, despite a physician's order. The MDS coordinator acknowledged both errors.
A resident with muscle spasm, pain, and anxiety disorders was prescribed Tramadol for pain relief. Despite a care plan and physician order requiring daily pain monitoring, the facility failed to document the resident's pain status as required. The resident reported persistent pain, with some relief from medication, but the DON confirmed that monitoring was not completed as ordered.
A facility failed to ensure a resident receiving Risperidone, an antipsychotic medication, had an appropriate diagnosis. The resident, diagnosed with dementia without behavioral disturbances, anxiety disorders, and unspecified mood affective disorder, was cognitively intact and prescribed 0.5 mg of Risperidone twice daily. The care plan required monitoring for behaviors related to the medication, but the DON and pharmacist confirmed the absence of a proper diagnosis for the antipsychotic use.
A facility failed to document the coordination of care between hospice services and the facility for a resident with chronic obstructive pulmonary disease. Despite a physician's order for hospice admission, the resident's admission assessment did not reflect hospice services, and the administrator could not provide hospice documentation, including the plan of care.
A resident with a history of peripheral vascular disease and osteoporosis developed multiple pressure ulcers that were not adequately documented or treated in a timely manner. The facility failed to notify the physician promptly and did not implement sufficient preventative measures, as required by their policy. The administrator acknowledged the lack of action and documentation, and the resident had limited access to wound care specialists.
A facility failed to include critical medical needs in a baseline care plan for a resident with a right hip fracture, osteoarthritis, hypertension, anxiety, and impulse disorder. The resident returned from the hospital with an infected hip incision, requiring a JP drain, urinary catheter, wound vac, PICC line with IV antibiotics, and had wounds to the coccyx and buttocks. The baseline care plan did not address these needs, as confirmed by the DON.
Failure to Follow Physician's Order for BIPAP Use During Sleep and Naps
Penalty
Summary
The facility failed to follow a physician's order for respiratory care for one resident who required the use of a BIPAP machine with oxygen at 3 LPM during sleep and naps. On three separate occasions, the resident was observed resting in bed during nap times without the BIPAP machine turned on, and the mask was found on the bedside table rather than in use. The physician's order, dated 07/14/25, specifically required the BIPAP to be used at bedtime and while napping. An RN confirmed that the resident should have had the BIPAP on during naps, indicating the order was not followed as required.
Failure to Ensure Safe Food Handling Training for All Dietary Staff
Penalty
Summary
The facility failed to ensure all dietary staff received training in safe food handling practices for the prevention of foodborne illness. During a record review and interview, surveyors requested verification of food handler training for all dietary staff, and the administrator later provided training certificates for only five of seven dietary employees. It was identified that one cook and one dietary aide had not received the required food handler training, despite the administrator identifying that 37 residents received meals from the dietary department. This deficiency centers on the lack of documented and completed safe food handling training for these two dietary staff members.
Failure to Follow Posted Menu and Document Menu Substitutions
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned menu and document menu substitutions during a noon meal service. Surveyors observed that at 12:30 p.m. on 12/22/25, the kitchen served chicken fried steak, mashed potatoes and gravy, cream corn, a dinner roll, and pineapple crisp, while the posted week five menu specified crumb crusted chicken, savory rice, Brussels sprouts, a dinner roll, and pineapple crisp. The administrator identified that 37 residents received nutrition from the kitchen for this meal. The facility had an undated policy titled “Menu Substitution” stating that menu substitutions would be recorded on a substitution record form and that the reason for the change would be noted. During the same observation, the dietary manager stated they were working off the week five menu and had to substitute items because the planned menu items were not available, but also acknowledged they did not document substitutions or specific reasons for them and were not aware of any substitution form. No additional resident-specific medical histories or conditions were documented in the report beyond the number of residents receiving nutrition from the kitchen.
Food Service Sanitation, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility’s food service operations affecting 37 residents who received nutrition from the kitchen. In the kitchen refrigerator, they observed a container of prepared coleslaw and a container of cottage cheese that remained in storage past the manufacturer’s use-by dates, as well as two unlabeled plastic pitchers containing juice-like liquids without any preparation or use-by dates. Review of the Daily Refrigerator and Freezer Temperature Log for December showed missing temperature documentation for two consecutive days. Six chest freezers containing frozen food items were observed without visible thermometers inside. The dietary manager acknowledged that thermometers had been ordered and that staff had not been checking freezer temperatures because there were no thermometers present. Surveyors also observed environmental and procedural deficiencies in food preparation and storage. The food preparation area between the stove, steam table, and counters had missing floor tiles, and the dry food storage area floor had rough surfaces with debris and a buildup of dark matter. Two cardboard boxes of apple juice drink blend were stored directly on the floor under shelving in the dry storage room. During a lunch meal preparation observation, a cook prepared food without checking or documenting final cooking temperatures, and later stated they did not know they were supposed to check temperatures when food was finished cooking. The dietary manager stated there was no process or log in place for cooked and served food temperatures, while existing facility policies required refrigerated food to be covered, dated, and labeled, and required use of a meat thermometer to check internal temperatures.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with dementia, behavioral disturbances, hyperlipidemia, anxiety disorder, and migraines to the state agency within the required 2-hour timeframe. According to facility policy, all alleged violations and substantial incidents must be reported to the state agency. On the date in question, a staff member was observed being rough and speaking loudly to the resident while assisting them to a chair. The incident was reported to the facility administrator, who immediately initiated an internal investigation, including a camera review by the corporate office. However, the administrator determined the incident was not reportable and did not submit an incident report to the state agency, resulting in noncompliance with reporting requirements.
Inaccurate MDS Coding for Anticoagulation Therapy
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident receiving anticoagulation therapy. A quarterly assessment dated 11/05/25 documented that Resident #25 was receiving anticoagulant therapy. However, review of the resident’s November 2025 medication administration record showed no anticoagulant medication was ordered or administered for this resident. During an interview on 12/31/25 at 12:42 p.m., the MDS coordinator confirmed that Resident #25 did not take an anticoagulant medication and acknowledged that the assessment had been coded in error.
Expired Medications and Supplies Found in Medication Storage Room
Penalty
Summary
Surveyors identified a failure to ensure removal of expired medications and supplies from the facility’s medication storage room, contrary to requirements that drugs and biologicals be properly labeled and stored. During an observation of the medication room with a registered nurse, surveyors found multiple expired items, including a box of 25-gauge needles with 3 ml syringes, a box of 21-gauge needles with 3 ml syringes, several packets and tubes of lubricating jelly, and multiple bisacodyl suppositories, all past their labeled expiration dates. The administrator reported that 37 residents resided in the facility at the time of the survey. During the same observation, the RN accompanying the surveyor acknowledged that the expired medications and supplies should already have been removed from the medication room. No additional information was provided about specific residents’ medical histories or conditions in relation to these expired items.
Failure to Implement Legionella Water Management Program and Involve Infection Preventionist
Penalty
Summary
The facility failed to ensure its Legionella water management program, which is part of the infection prevention and control program, was implemented as written and included the participation of the infection preventionist. The written policy dated 1/2022 specified that the water management team must include the infection preventionist, the administrator, the medical director or designee, the director of maintenance, and the director of environmental services, and referenced a detailed description and diagram of the facility’s water system and identification of areas that could promote growth and spread of waterborne bacteria. Record review showed a 2025 cleaning schedule for shower heads with quarterly entries completed for January, April, and July, but no documentation for October. During interview, the infection preventionist stated they did not know they were on the water management team, and the administrator stated there was no diagram for a water management program and confirmed there was no documentation for October 2025 in the logbook. The administrator identified that 37 residents resided in the facility at the time of the survey.
Failure to Maintain Safe and Homelike Environment Due to Ongoing Roof Leaks
Penalty
Summary
The facility failed to maintain the physical environment in good repair, as evidenced by multiple observations of ceiling tiles with large brown watermark stains and sagging tiles in the dining room and several resident rooms. The stained and sagging ceiling tiles were noted around and near air vents, and the maintenance supervisor confirmed these issues were due to ongoing water leaks from the roof, which occurred every time it rained. The maintenance supervisor reported that while stained and sagging tiles were replaced frequently, the underlying issue of the leaking roof had not been permanently addressed. The administrator acknowledged that the roof had been leaking since their employment began and that management was aware of the problem but had not taken permanent action to resolve it. The facility's policy required a safe, clean, comfortable, and homelike environment, which was not upheld due to these ongoing environmental deficiencies.
Lack of Comprehensive Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing indwelling urinary catheter care and maintenance for one resident with a documented need for such care. Record review showed that the resident had medical diagnoses including urinary retention and congenital bladder neck obstruction, and a physician's order was in place to change the catheter every 30 days and perform catheter care every shift and as needed. The resident was assessed as cognitively intact and was known to have an indwelling urinary catheter. However, review of the resident's care plan revealed no documentation or plan for catheter care and maintenance. The MDS coordinator confirmed that a comprehensive care plan for urinary catheter care had not been developed for this resident, despite it being required.
Failure to Update Care Plan After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to update a resident's care plan following an incident of abusive behavior involving two residents. According to the facility's policy, care plans are to be revised as new information about a resident's condition becomes available, and interventions should address the underlying sources of problem areas. Despite this, after an incident where a resident with non-Alzheimer's dementia and intact cognition was observed pushing another resident and attempting to tie a neck pillow around their neck, no updates or new interventions were added to the resident's care plan. The incident was reported to the appropriate authorities, and immediate actions were taken to separate the residents and provide one-on-one supervision for the resident involved in the abusive behavior. A review of the resident's care plan, last revised after the incident, showed no documentation of the behaviors or any new interventions related to the event. The MDS coordinator confirmed that the care plan was not updated following the incident, despite facility policy requiring updates after significant changes in a resident's health or behavior. The lack of care plan revision occurred even though the resident's assessment indicated ongoing cognitive and behavioral concerns.
Failure to Notify Physician of Catheter Site Infection Signs
Penalty
Summary
The facility failed to notify the physician of signs and/or symptoms of a potential infection at the urinary catheter entry site for a resident with an indwelling urinary catheter. According to the facility's policy, nursing staff are required to document a comprehensive assessment and notify the physician when infection is suspected, including providing details of the assessment, observed symptoms, and the time symptoms were first noted. The resident in question had a history of urinary retention, congenital bladder neck obstruction, and recurrent urinary tract infections, and was cognitively moderately impaired. Physician orders were in place to monitor the catheter site for infection and report any signs to the physician. Despite multiple nurse notes documenting odorous brownish and tannish brown drainage from the catheter site over several days, there was no documentation that the physician was notified of these symptoms. Interviews with nursing staff confirmed that the physician should have been notified, but there was no record of such communication. The resident was later admitted to the hospital for a complicated urinary tract infection and hypotension, and the planned suprapubic catheter placement was not performed at that time.
Failure to Post Complete Staffing Information
Penalty
Summary
The facility failed to post the required staffing information as mandated. During observations on two separate occasions, it was noted that the staffing information was documented on a whiteboard at the nursing station. However, the facility name, projected staffing hours, and actual staffing hours were not included in the documentation. The observations took place on 11/05/24 and 11/07/24, where only the date, census, and staff/title were documented. Furthermore, during an interview, the Director of Nursing (DON) admitted to being unaware of the specific staffing information required to be documented on the staffing board.
Failure to Date and Cover Urinary Catheter Bags
Penalty
Summary
The facility failed to adhere to proper urinary catheter care protocols for two residents, leading to a deficiency. Resident #11, who had diagnoses including overactive bladder, paraplegia, and a stage 4 sacral pressure ulcer, was observed with a urinary catheter bag that was neither dated nor covered, despite a physician's order for catheter care per facility guidelines. This was confirmed by the Director of Nursing (DON) on a subsequent date. Similarly, Resident #35, diagnosed with retention of urine and congenital bladder neck obstruction, was observed multiple times with a urinary catheter bag that was not dated or covered. The observations were made while the resident was sitting in a recliner in their room, and the deficiency was acknowledged by the DON. Both residents were among the four identified by the DON as having urinary catheters, yet the facility failed to ensure their catheter bags were dated and covered as required.
Failure to Document DNR Orders for Residents
Penalty
Summary
The facility failed to ensure that Do Not Resuscitate (DNR) orders were properly documented for three residents, despite their advance directives indicating a preference for DNR status. Resident #4, diagnosed with type 2 diabetes mellitus and cerebral infarction, had a DNR care plan and signed consent form but lacked a physician's order for DNR. Similarly, Resident #7, with Parkinson's, dementia, behavioral disturbance, and anxiety, had a DNR care plan and a consent form signed by their Power of Attorney (POA), yet no physician's order was present. Resident #10, suffering from chronic kidney disease stage 3, type 2 diabetes mellitus, and congestive heart failure, also had a DNR care plan and signed consent form without a corresponding physician's order. The MDS coordinator was unaware that a physician's order was necessary for DNR residents, leading to this oversight.
Failure to Notify Physician of Out-of-Parameter Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician of out-of-parameter blood sugar levels for two residents with diabetes. Resident #21, diagnosed with type 2 diabetes with autonomic polyneuropathy, had a physician's order to notify the physician if blood sugar levels were below 70 or above 400. On October 2, 2024, the resident's blood sugar was recorded at 458, but there was no documentation indicating that the physician was notified. Similarly, Resident #31, with type 2 diabetes mellitus, had a physician's order to notify the physician if blood sugar levels were below 60 or above 400. There was no documentation of physician notification for several instances where the resident's blood sugar exceeded 400, specifically on September 20, 24, 27, 30, and October 14, 2024. Interviews with RN #1 and the Director of Nursing confirmed that the physician should have been notified, and the lack of documentation indicated that this did not occur.
Inaccurate Resident Assessments for Medications and Hospice Services
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents. One resident, with diagnoses including heart failure and cerebral infarction, was documented as taking an anticoagulant in their assessment, despite a physician's order indicating they were taking an antiplatelet medication, aspirin. The MDS coordinator acknowledged the error, noting that the medication section of the assessment was auto-populated and the mistake was not caught. Another resident, diagnosed with atrial fibrillation and chronic obstructive pulmonary disease, was admitted to hospice services, but their admission assessment did not reflect this. The MDS coordinator confirmed the omission upon review of the assessment.
Failure to Monitor Resident's Pain as Ordered
Penalty
Summary
The facility failed to ensure proper monitoring of a resident experiencing pain. The resident, who was cognitively intact, had diagnoses including muscle spasm, pain, and anxiety disorders, and was prescribed Tramadol 50 mg as needed for pain. An admission assessment noted the resident experienced occasional pain rated six on a scale from 0 to 10. The care plan indicated the resident's pain should be relieved or controlled, and a physician order required staff to monitor the resident's pain daily across all shifts, documenting whether the resident experienced pain. However, the Director of Nursing (DON) confirmed that the monitoring was not completed as ordered, despite the resident reporting persistent pain in their left arm and leg, with some relief from the medication provided.
Lack of Appropriate Diagnosis for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication had an appropriate diagnosis or indication for the use of an antipsychotic medication. The resident, who had diagnoses including dementia without behavioral or psychotic disturbances, anxiety disorders, and unspecified mood affective disorder, was prescribed Risperidone, an antipsychotic medication, at a dose of 0.5 mg twice daily. The admission assessment indicated that the resident was cognitively intact and was receiving both an antipsychotic and an antianxiety medication. The care plan required staff to monitor the resident for behaviors, both verbal and non-verbal, for which the medication was being administered. However, upon review of the resident's clinical record, the Director of Nursing (DON) was uncertain if there was an appropriate diagnosis for the antipsychotic medication. Additionally, the facility pharmacist confirmed that the resident was receiving an antipsychotic medication without a corresponding diagnosis.
Lack of Hospice Care Documentation for Resident
Penalty
Summary
The facility failed to ensure proper documentation of the coordination of care between hospice services and the facility for a resident receiving hospice care. The resident, who had diagnoses including atrial fibrillation and chronic obstructive pulmonary disease, was admitted to hospice services with a physician's order dated 08/21/24. However, the admission assessment dated 08/27/24 did not document that the resident was receiving hospice services. Furthermore, on 11/06/24, the facility administrator was unable to provide any hospice documentation regarding the resident's hospice services, including the plan of care. This deficiency was identified during a review of records and interviews, affecting one resident out of the three identified by the Director of Nursing as receiving hospice services.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate treatment and services to prevent the worsening of pressure ulcers for a resident with a history of peripheral vascular disease, osteoporosis, and a fracture of the neck of the right femur. Upon admission, the resident did not have open pressure areas, but a small pressure area was noted on the buttocks shortly after. Despite this, there was a lack of consistent documentation and follow-up on the wound's condition until a week later when multiple open areas were identified on the resident's buttocks and sacrum. The wounds were not staged, and the physician was not notified until the day after the wounds were documented by the nursing staff. The facility's pressure ulcer policy requires aggressive and appropriate preventative measures, but the only documented intervention prior to the discovery of the wounds was repositioning every two hours. The treatment record showed that medication orders for the wounds were initiated only after the physician was notified, and a cushion for the wheelchair was ordered the following day. The facility's administrator acknowledged the lack of action and documentation, and the resident had only seen a wound care specialist once since the wounds were identified.
Failure to Include Critical Medical Needs in Baseline Care Plan
Penalty
Summary
The facility failed to ensure an accurate baseline care plan for a resident who was admitted with multiple complex medical needs. The resident had a history of a right hip fracture, osteoarthritis, hypertension, anxiety, and impulse disorder. Upon returning from the hospital, the resident had an infected right hip incision and required a JP drain, an indwelling urinary catheter, a wound vac to the right hip incision, a PICC line with IV antibiotics, and had wounds to the coccyx and buttocks. The baseline care plan initiated on 05/09/24 and updated on 05/21/24 did not address the resident's JP drain, indwelling urinary catheter, wound vac, PICC line, or wounds. The Director of Nursing acknowledged that the baseline care plan should have included these elements, indicating a lapse in the facility's care planning process for the resident's immediate needs.
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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