North County Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Collinsville, Oklahoma.
- Location
- 2300 West Broadway, Collinsville, Oklahoma 74021
- CMS Provider Number
- 375504
- Inspections on file
- 23
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at North County Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A CMA was observed administering oral medications to multiple residents consecutively without performing hand hygiene between each resident, despite facility policy and prior training requiring handwashing before medication administration. This lapse was noted during the preparation and administration of various medications, including pain relievers, muscle relaxants, and gastric agents.
A resident was prescribed and administered Seroquel, an antipsychotic, for unspecified dementia with behavioral disturbances and anxiety, despite facility policy requiring antipsychotics only for specific, indicated conditions. Staff interviews confirmed the medication was used for dementia-related behaviors, and the DON acknowledged it was not approved for this diagnosis, resulting in a deficiency for unnecessary medication use.
A resident's MDS discharge assessment was completed but not transmitted to the CMS QIES ASAP system within the required 7-day period. The MDS coordinator acknowledged the oversight, and the DON reported not monitoring the export status of MDS records due to limited training. This resulted in a failure to comply with facility policy and federal regulations regarding timely MDS data transmission.
A resident with severe cognitive impairment and multiple diagnoses was denied re-entry to the facility after an overnight stay with family, despite only being provided 24 hours of medication and not intending a permanent discharge. The administrator refused to allow the resident to return, there was no discharge documentation, and the resident was left without appropriate notice or placement, resulting in a deficiency for improper discharge procedures.
A facility failed to manage controlled medications properly, resulting in the misappropriation of narcotics for three residents. Despite policies requiring reconciliation, numerous lapses in procedure were found, including missing counts and improper staff signatures. The DON acknowledged the issues but failed to monitor compliance effectively, allowing the deficiencies to persist.
The facility failed to complete baseline care plans within 48 hours of admission for three residents, citing reasons such as staff absence and weekend admissions. This resulted in delays and, in one case, a complete lack of a baseline care plan.
The facility failed to develop comprehensive care plans for the use of bed rails for four residents, despite physician orders allowing therapeutic devices. The care plans were not completed in a timely manner, and one resident's comprehensive care plan was entirely missing due to staff shortages.
The facility failed to attempt alternative interventions and assess the risk of entrapment before using bed rails for three residents. The DON confirmed that staff did not follow the policy requiring these steps.
The facility failed to complete the required yearly performance reviews for two CNAs. The last documented skills performance for both CNAs was completed in 2022. The DON confirmed that no skills performance checks had been completed for the year 2023 and was unaware of the requirement.
The facility failed to maintain an infection prevention and control program, including proper catheter and incontinent care, and did not implement a water treatment program to prevent Legionella. Staff did not follow hand hygiene protocols, and the water management program was not instituted.
The facility failed to ensure two residents were offered the choice to formulate advanced directives. One resident had chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy, and chronic respiratory failure with hypoxia, while the other had embolism and thrombosis of an unspecified vein, edema, hypokalemia, and cerebral fluid drainage. The clinical records for both residents did not document that they or their representatives were offered the choice to formulate an advanced directive.
The facility failed to complete an admission assessment for a resident with multiple diagnoses, including congestive heart failure and dementia, within the required timeframe. The MDS coordinator cited a backlog due to a staff nurse's family emergency.
The facility failed to complete quarterly assessments within the required time frame for two residents. One resident with respiratory failure, congestive heart failure, and cerebrovascular disease had an incomplete assessment, and another resident with dementia, schizoaffective disorder, and auditory hallucinations also had an overdue assessment.
The facility failed to submit a resident's assessment data to CMS within the required seven days. A resident with urinary tract infection and cellulitis had their quarterly assessment completed but not submitted until over a month later. The MDS coordinator was unaware of the delay's cause.
The facility failed to develop a discharge summary for a resident, including a recapitulation of the stay, medication reconciliation, and a post-discharge plan. The resident had multiple diagnoses and was discharged to another facility, but the necessary documentation was missing.
The facility failed to notify the physician and implement interventions for a resident with significant weight loss. Despite a dietary order for daily supplements, the resident experienced weight loss and was observed eating without being offered the prescribed supplements. The MDS Coordinator confirmed the physician was not informed of the weight loss.
The facility failed to ensure a resident's nutritional issues were supervised by a physician, resulting in significant weight loss. Despite a dietary order for supplements, the resident was observed eating without being offered the prescribed supplement, and the physician was not notified of the weight loss.
The facility failed to maintain an ice machine in a sanitary condition. An observation revealed a black substance inside the ice machine used by all 44 residents. The machine was cleaned only every six months, and there was no regular monitoring or documentation of its cleanliness.
The facility failed to conduct regular inspections of beds and bed rails for three residents, contrary to their policy. One resident with severe cognitive impairment had an assist bar attached, while two residents with intact cognition had bed rails but were unaware of any safety assessments. The Maintenance Supervisor confirmed no routine inspections were conducted.
The facility failed to follow physician orders for wound care for a resident with a sacral pressure ulcer. The wound vac was observed not in use, and the resident reported it had been off since Saturday due to a nurse's unfamiliarity with its operation. Staff confirmed the wound vac frequently came off and was not always reapplied promptly.
A resident with impulse disorder and dementia exhibited multiple instances of verbally abusive behavior towards other residents. Despite these documented behaviors, the DON and the administrator did not classify these incidents as verbal abuse and failed to implement the facility's abuse policy, leading to a failure in protecting other residents.
The facility failed to report allegations of verbal abuse involving a resident with impulse disorder and dementia to the administrator and OSDH as required by their abuse policy. Multiple incidents of the resident's verbally abusive behavior were documented, but notifications to the administrator or DON were not consistently recorded, and reports were not submitted to OSDH within the mandated timeframe.
The facility failed to provide abuse training upon hire for four employees, including three CNAs and one housekeeper, as required by their abuse policy. The DON and administrator confirmed that no abuse training had been provided since the facility changed ownership.
Failure to Perform Hand Hygiene Between Residents During Medication Administration
Penalty
Summary
Facility staff failed to follow infection control practices during medication administration for three of eight sampled residents. On multiple occasions, a Certified Medication Aide (CMA) was observed preparing and administering oral medications to residents without sanitizing or washing hands between residents. The CMA prepared medications for one resident, assisted with administration, and then proceeded to prepare and administer medications to subsequent residents without performing hand hygiene. This sequence was observed with three different residents, each receiving various prescribed oral medications, including pain medication, muscle relaxants, anticonvulsants, expectorants, and gastric protective agents. Facility policy required staff to wash their hands prior to administering medications and after handling items potentially contaminated with blood, body fluids, or secretions. Despite this, the CMA did not adhere to these protocols, as confirmed by direct observation. The Director of Nursing (DON) stated that all CMAs had completed training on medication administration and infection control, including the requirement for hand hygiene between residents.
Unnecessary Antipsychotic Medication Prescribed for Dementia
Penalty
Summary
A deficiency was identified when a resident was prescribed and administered Seroquel, an antipsychotic medication, for the diagnosis of unspecified dementia with behavioral disturbances and anxiety. Facility policy states that antipsychotic medications should only be used when necessary to treat specific, indicated conditions. However, the medication administration record showed the resident received Seroquel twice daily over several days for dementia, a diagnosis for which the medication is not approved. Staff interviews revealed that the primary behaviors observed were attempts by the resident to leave the facility and statements about needing to go to work. Further interviews with a certified medication aide, an LPN, and the DON confirmed that the medication was being used for dementia-related behaviors and anxiety. The DON acknowledged awareness that CMS does not approve Seroquel for the treatment of dementia and that the resident had been on the medication since admission for these behaviors. The documentation and staff responses did not indicate a specific, approved psychiatric diagnosis justifying the use of the antipsychotic, resulting in the finding of unnecessary medication use.
Failure to Transmit MDS Discharge Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) discharge assessment record was transmitted within the required 7-day timeframe for one of the sampled residents. According to facility policy, all MDS assessments, including discharge records, are to be completed, encoded, and transmitted to the CMS QIES ASAP system in accordance with OBRA regulations. Record review showed that a resident was discharged on 03/01/25, and while the MDS discharge record was completed, it was not transmitted as required. The MDS coordinator acknowledged that the record had been completed but not exported, attributing the failure to an error on their part. Further interviews revealed that the DON reviewed and signed MDS assessments as they became due but did not monitor whether records had been exported or were incomplete, citing minimal training in the MDS process. The corporate nurse consultant, new to their role, had planned to audit two medical records weekly but indicated a need to reconsider this approach after learning of the missed transmission. The deficiency was identified through record review and staff interviews, confirming the lapse in timely MDS data transmission.
Resident Denied Re-Entry After Overnight Absence Without Proper Discharge Notice
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, anoxic brain damage, PTSD, and bipolar disorder was not allowed to return to the facility after an overnight stay with family. The resident had signed out of the facility for an overnight visit, was provided with 24 hours of medication, and was expected to return the following day. Upon attempting to return, the resident was informed by the DON that they were no longer considered a resident, based on information from the administrator, despite the resident's statement that they had not intended to discharge themselves permanently. There was no documentation of a formal discharge for the resident, and the facility was unable to produce any discharge paperwork. The administrator refused to allow the resident to re-enter the facility, even after being informed by police that the resident had nowhere else to go. The administrator paid for a one-night hotel stay for the resident, but did not facilitate their return to the facility or provide the required discharge notice and documentation as outlined in the facility's policy and regulatory requirements. Interviews with staff confirmed that the resident had only planned an overnight stay and had not expressed intent to leave the facility permanently. The facility's failure to provide proper discharge notice, documentation, and to allow the resident to return after a temporary absence resulted in a deficiency related to improper discharge procedures.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure the proper management and reconciliation of controlled medications, leading to the misappropriation of narcotics for three residents. Resident #4, who had diagnoses including abnormal posture and weakness, was missing 60 tablets of Hydrocodone. The medication was delivered by the pharmacy, but discrepancies were found during a routine check. Similarly, Resident #8, diagnosed with chronic pain, was missing 30 tablets of Hydrocodone. The medication was delivered, but the facility could not account for the missing quantity. Resident #7, with cervical disc degeneration, was also affected, with 56 tablets of Hydrocodone unaccounted for, despite the medication being delivered months earlier. The facility's Controlled Substances policy required reconciliation of medications upon receipt, administration, and at the end of each shift. However, the review of Controlled Substance Card Count Sheets revealed numerous instances where medications were not counted, and staff signatures were missing or improperly recorded. The same employee often signed as both the on-coming and off-going staff member, indicating a lack of proper oversight and accountability. These lapses in procedure contributed to the misappropriation of medications. The Director of Nursing (DON) acknowledged the issues, stating that they were first made aware of the misappropriation when staff reported missing medications. Despite initial investigations and reconciliation efforts by a consultant pharmacist, further discrepancies were discovered. The DON admitted to not monitoring staff compliance with medication reconciliation procedures, which allowed the deficiencies to persist. The administrator confirmed that the DON was responsible for ensuring residents were free from medication misappropriation by reviewing count sheets, but this oversight was not effectively implemented.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for three residents. Resident #31, who had multiple diagnoses including osteomyelitis, stage four pressure ulcer, diabetes, and hypertension, was admitted on [DATE], but the baseline care plan was completed six days later. The care plan coordinator acknowledged the delay, attributing it to their absence from work. Similarly, Resident #45, admitted with diagnoses such as non-traumatic intracranial hemorrhage and dementia, had their baseline care plan initiated four days after admission. The MDS coordinator explained that the delay was due to the admission occurring over a weekend, and the baseline care plan was not initiated until the care plan staff member returned to work. They also mentioned that any nurse could initiate a baseline care plan, but it was typically completed by the MDS/Care plan staff nurse. Resident #246, who had diagnoses including congestive heart failure, dementia, and anxiety, was admitted on [DATE], but there was no documentation of a baseline care plan in the EHR. The MDS coordinator stated that they had been helping with the baseline care plans but had fallen behind, resulting in the failure to complete a baseline care plan for this resident. These findings indicate a systemic issue in the timely completion of baseline care plans, particularly when admissions occur over weekends or when key staff members are absent.
Failure to Develop Comprehensive Care Plans for Bed Rails
Penalty
Summary
The facility failed to develop a comprehensive care plan to include the use of bed rails for four residents reviewed for accident hazards. Resident #16, diagnosed with primary osteoarthritis, had an assist bar attached to their bed that was not care planned until 04/02/24, despite a physician's order dated 11/21/23 allowing the use of therapeutic devices. Resident #23, diagnosed with multiple sclerosis and generalized muscle weakness, had half-size bed rails on each side of their bed since admission, but these were not care planned until 04/02/24, even though a physician's order dated 07/25/23 permitted the use of therapeutic devices. Resident #146, diagnosed with a broken internal joint prosthesis, had side rails attached to their bed since admission, but these were not care planned until 04/03/24, despite a physician's order dated 01/30/24 allowing the use of therapeutic devices. Resident #246, diagnosed with congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome, was admitted to the facility, but there was no documentation of a comprehensive care plan available. The MDS stated that the other person helping with assessments and care plans had been out, causing delays in completing the care plans. The DON confirmed that the bed side rails had not been care planned for residents #16, 23, and #146 in a timely manner or in accordance with facility policy.
Failure to Attempt Alternatives and Assess Risks Before Using Bed Rails
Penalty
Summary
The facility failed to attempt alternative interventions before using bed rails for three residents and did not assess the risk of entrapment for two of these residents. Resident #16, who had severe cognitive impairment and chronic pain, was observed with an assist bar attached to their bed without documentation of alternative interventions or a risk assessment. Similarly, Resident #23, who had multiple sclerosis and intact cognition, was found with half-size bed rails on each side of their bed without any documented attempts at alternative interventions. Resident #23 confirmed that no alternatives were tried before the bed rails were used. Resident #146, who had a broken internal joint prosthesis and intact cognition, also had bed rails attached to their bed without documentation of alternative interventions or a risk assessment. The DON confirmed that alternative interventions were not attempted and risk assessments were not performed for residents #16 and #146 before the use of bed rails. The facility staff did not follow the policy related to the use of bed rails, which requires attempts at alternative interventions and risk assessments before installation.
Failure to Complete Yearly Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete the required yearly performance reviews for two certified nurse aides (CNAs), specifically CNA #2 and CNA #4. The last documented skills performance for both CNAs was completed on 09/22/22. During an interview on 04/04/24, the Director of Nursing (DON) reviewed the skills performance checklists and confirmed that no skills performance checks had been completed for the year 2023 for any current CNAs. The DON admitted to being unaware of the requirement for yearly performance reviews.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of infections. For one resident with a catheter and multiple pressure ulcers, a CNA did not follow the enhanced barrier precautions posted on the resident's door. The CNA did not wear a gown and failed to wash their hands between glove changes while providing catheter care and repositioning the resident. The Director of Nursing confirmed that the CNA should have used the appropriate PPE and followed proper hand hygiene protocols. Another resident, who was incontinent of bowel and bladder, did not receive proper infection control measures during incontinent care. The CNA assisting the resident did not change gloves or wash hands between removing the soiled undergarment and placing a clean one on the resident. The CNA later acknowledged that they should have changed gloves and washed hands during the care process. Additionally, the facility did not implement a water treatment program to prevent Legionella. The administrator admitted that the new water management program provided by the corporation had not been instituted. There was no documentation of preventive measures such as flushing toilets in unoccupied rooms, and no risk assessment or water management team had been established. The maintenance supervisor confirmed that no assessment of the facility's piping had been conducted to identify potential areas of standing water.
Failure to Offer Advanced Directives
Penalty
Summary
The facility failed to ensure residents were offered the choice to formulate advanced directives for two residents. Resident #4, who had diagnoses including chronic kidney disease - stage 3, type 2 diabetes mellitus with diabetic neuropathy, and chronic respiratory failure with hypoxia, did not have documentation in their clinical records indicating that they or their representative were offered the choice to formulate an advanced directive. Similarly, Resident #7, with diagnoses including embolism and thrombosis of unspecified vein, edema, hypokalemia, and cerebral fluid drainage, also lacked documentation in their clinical records showing that they or their representative were offered the choice to formulate an advanced directive. The Director of Nursing identified that 41 residents resided in the facility at the time of the survey.
Failure to Complete Timely Admission Assessment
Penalty
Summary
The facility failed to ensure an admission assessment for a resident was completed within the required timeframe. The resident, who had diagnoses including congestive heart failure, dementia, psychotic disturbance, mood disturbance, anxiety, hypertension, and pain syndrome, was admitted to the facility, but the Electronic Health Record (EHR) did not document an admission assessment. The MDS coordinator stated that the staff nurse responsible for completing the MDS assessments had been out for a family emergency, causing a backlog in assessments.
Failure to Complete Quarterly Assessments on Time
Penalty
Summary
The facility failed to complete quarterly assessments within the required time frame for two residents out of 13 whose assessments were reviewed. Resident #32, who had diagnoses including respiratory failure, congestive heart failure, and cerebrovascular disease, had a quarterly assessment dated 12/15/23 completed, but the subsequent assessment dated 03/15/24 was still in progress as of 04/03/24. The MDS coordinator confirmed that the assessment was not completed on time. Similarly, Resident #14, with diagnoses including dementia, schizoaffective disorder, and auditory hallucinations, had a quarterly MDS assessment with an ARD date of 03/12/24 that was still in progress as of 04/02/24. The MDS coordinator acknowledged that this assessment was also not completed and submitted on time.
Failure to Submit Assessment Data Timely
Penalty
Summary
The facility failed to ensure assessments were encoded and submitted to CMS within seven days of completion for one of the 13 residents whose assessments were reviewed. Resident #16, who had diagnoses including urinary tract infection and cellulitis, had a quarterly assessment completed on 02/27/24, but it was not submitted until 04/03/24. During the survey, the resident was observed in a manual wheelchair and mentioned they had been receiving an antibiotic for cellulitis but were unsure if they were still taking it. The MDS coordinator stated that someone at the corporate offices submitted the assessment on 04/03/24 and did not know why it had not been submitted within the required timeframe.
Failure to Develop Discharge Summary
Penalty
Summary
The facility failed to develop a discharge summary for a resident, including a recapitulation of the resident's stay, a reconciliation of the resident's medications, and a post-discharge plan of care. The resident had diagnoses including a fracture of the right fibula, osteoarthritis, chronic stage four kidney disease, and diabetes. An admission assessment documented the resident was cognitively intact. A discharge assessment indicated the resident was discharged to another facility in a different state. However, the MDS coordinator confirmed that the discharge summary was not documented in the nursing notes, and there was no summary of the resident's stay, interventions, or medication reconciliation.
Failure to Notify Physician and Implement Interventions for Weight Loss
Penalty
Summary
The facility failed to ensure the physician was notified of significant weight loss and did not implement interventions to maintain or prevent further weight loss for a resident diagnosed with tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis. The resident's care plan indicated that supplements or alternates should be offered if the resident ate less than 50% of meals or refused meals. Despite a dietary order for a house supplement every day shift for weight loss, the resident experienced a weight loss from 145.2 lbs to 137.4 lbs. Observations on multiple occasions showed the resident eating without being offered the prescribed supplements. Additionally, the MDS Coordinator confirmed that the physician was not notified of the significant weight loss.
Failure to Supervise Nutritional Issues by Physician
Penalty
Summary
The facility failed to ensure that a resident's nutritional issues were supervised by a physician, leading to a significant weight loss. The resident, who had diagnoses including tremors, anxiety disorder, weakness, abnormality of gait and mobility, and multiple sclerosis, was admitted with a care plan that included offering supplements if the resident ate less than 50% of meals or refused meals. Despite a dietary order for a house supplement every day shift for weight loss, the resident's weight dropped from 145.2 lbs to 137.4 lbs over a month. Observations on multiple occasions showed the resident eating without being offered the prescribed supplement. Additionally, the MDS Coordinator confirmed that the physician was not notified of the significant weight loss, indicating a lapse in communication and adherence to the care plan.
Facility Failed to Maintain Ice Machine Sanitation
Penalty
Summary
The facility failed to maintain an ice machine in a sanitary condition. During an observation, a staff member wiped the inside of an ice machine located in an employee-only hallway next to the kitchen, and the cloth came back with a black substance. The Director of Nursing (DON) confirmed that all 44 residents received ice from this machine. The facility's Sanitation policy, dated November 2022, required the food service area to be maintained in a clean and sanitary manner. The Dietary Manager (DM) stated that the ice machine was cleaned once every six months. The administrator provided documentation of cleanings for two ice machines, dated December 29, 2023, and January 31, 2024, but no other documentation was available. The DM later stated that the dirty ice machine had been turned off and the second machine had not been working for several weeks and was due for repair. The facility did not monitor the ice machines for cleanliness on a schedule and did not document inspections of the ice machines.
Failure to Conduct Regular Bed and Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of resident beds and did not inspect beds for safety prior to the attachment and use of bedrails for three residents. The facility's policy, dated August 2022, required bed frames, mattresses, and bed rails to be checked for compatibility and size before use, and for maintenance staff to routinely inspect all beds and related equipment. However, observations and interviews revealed that these inspections were not being performed. Resident #16, with severe cognitive impairment, was observed with an assist bar attached to their bed. Resident #23, with intact cognition, had half-size bed rails on each side of their bed and was unaware of any safety assessments or inspections. Resident #146, also with intact cognition, had side rails attached to their bed and did not recall any assessments or inspections prior to their use of the bed. The Maintenance Supervisor confirmed that they had not been informed about the need for routine inspections or pre-use inspections of bed rails and had not conducted any such inspections. The Director of Nursing (DON) acknowledged that the facility had not been following the policy regarding bed and bed rail inspections. The report documented that 17 residents at the facility used bed rails, and the facility had a total of 44 residents. The lack of adherence to the policy and the absence of routine inspections posed potential safety risks for the residents using bed rails. The DON stated that they would ensure compliance with the policy in the future, but no corrective actions were documented in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure physician orders were followed for wound care for Resident #7, who had a pressure ulcer of the sacral region and diabetes mellitus. The physician's order dated 02/20/24 required the sacral wound to be cleaned with normal saline and a wound vac to be applied. However, on 03/26/24, the wound vac was observed at the resident's bedside but not in use. The resident reported that the wound vac had been off since Saturday because the nurse on duty was unfamiliar with its operation and did not return to reapply it. LPN #1 confirmed that the wound vac sometimes comes off or gets soiled and that the nurse on duty might not be able to reapply it. Additionally, LPN #1 was unsure if the wound vac was supposed to have been discontinued on 03/14/24 and stated they would contact the wound physician for clarification. The DON stated that the nurse accompanying the wound physician was responsible for entering orders into the resident's medical record, and the charge nurses were responsible for ensuring the wound vac was in place and functioning properly. It was later confirmed that the wound vac had not been discontinued until 03/26/24. CNA #1, who provided care for Resident #7 on 03/26/24, also confirmed that the wound vac had not been in place all day and mentioned that it frequently came off. The DON reiterated that the charge nurses were responsible for ensuring the wound vac was in place and functioning properly. This failure to follow physician orders and ensure proper wound care led to a deficiency in the care provided to Resident #7.
Failure to Implement Abuse Policy for Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse policy for verbal abuse in the case of a resident with impulse disorder and dementia. The resident exhibited multiple instances of verbally abusive behavior towards other residents, including cursing, yelling, making derogatory comments, and threatening physical harm. Despite these documented behaviors, the Director of Nursing (DON) and the administrator did not classify these incidents as verbal abuse and therefore did not implement the facility's abuse policy. The DON and the administrator reviewed the incidents as behavioral issues rather than abuse, leading to a failure in policy implementation. The resident's care plan noted their tendency to become moody and verbally abusive, with interventions suggested to manage these behaviors. However, the facility's staff, including the DON and the administrator, did not follow the abuse policy despite multiple documented incidents of verbal abuse. The DON admitted to lacking experience with verbal abuse and misclassifying the incidents, while the administrator acknowledged the oversight and failure to implement the abuse policy. This resulted in a failure to protect other residents from verbal abuse by the resident in question.
Failure to Report Verbal Abuse Incidents
Penalty
Summary
The facility failed to ensure allegations of verbal abuse were reported to the administrator and the Oklahoma State Department of Health (OSDH) for one resident who was reviewed for abuse. The facility's abuse policy required employees to report all incidents of possible abuse immediately to their supervisor, who would then report to the administrator or person on call. The policy also mandated that the nursing facility must report allegations to OSDH immediately, but not later than two hours after the allegation is made. Despite this policy, multiple behavior notes documented incidents where Resident #6 exhibited verbally abusive behavior towards other residents, but there was no documentation that the administrator or Director of Nursing (DON) had been notified in some instances, and reports were not submitted to OSDH as required. Resident #6, who had diagnoses including impulse disorder and dementia, displayed a pattern of verbally abusive behavior towards other residents. Incidents included cursing, name-calling, and making derogatory comments. On several occasions, the behavior notes indicated that the administrator or DON were notified, but there were also instances where this notification was not documented. Interviews with staff revealed that while some reported incidents to the administrator or DON, they failed to document these notifications. The DON admitted that they had not reported the incidents to OSDH, acknowledging that they should have done so. The administrator also confirmed that they had not submitted reports to OSDH for the verbal abuse incidents involving Resident #6, indicating a failure to follow the facility's abuse reporting policy.
Failure to Provide Abuse Training Upon Hire
Penalty
Summary
The facility failed to ensure that staff received abuse training upon hire for four employees (three CNAs and one housekeeper) out of five employee files reviewed. The facility's abuse policy, dated 02/17/22, mandates that all new employees receive in-service training on abuse prohibition before working a shift. However, a review of the employee files for CNA #1, CNA #2, CNA #3, and housekeeper #1, who were hired between 11/11/23 and 01/04/24, revealed that they had not received the required abuse training. The Director of Nursing (DON) confirmed that the facility had not provided abuse training upon hire since the ownership change several months ago. The administrator also acknowledged that no employee abuse training had been provided since the new company took over in September 2023.
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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