Parkhill North Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Salina, Oklahoma.
- Location
- 319 North Owen Walters Blvd, Salina, Oklahoma 74365
- CMS Provider Number
- 375322
- Inspections on file
- 18
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Parkhill North Nursing Home during CMS and state inspections, most recent first.
The facility failed to obtain and monitor physician-ordered laboratory tests for two residents with severe cognitive impairment and medical conditions requiring lab monitoring. One resident had orders for CBC and CMP every six months and was care planned for lab monitoring related to pressure ulcer risk, but required labs were not completed as ordered. Another resident with hypertension and on Valproic Acid had orders for CBC, CMP, LFT, and Valproic Acid levels every six months, yet these labs were not completed as scheduled. The DON acknowledged that the labs had not been done and that monthly monitoring of lab reports, as expected, was not occurring, without being able to explain the cause.
Surveyors found that the facility lacked a full‑time dietary manager and that kitchen staff were inadequately trained in basic food safety, sanitation, and diet-specific meal preparation for residents. Over several observations, no dietary manager was present, staff allowed an aide without a hair cover to scoop ice, a dietary aide stepped on a box of potatoes to tie a shoe, and a cook handled food-contact surfaces and plated food with bare hands without handwashing. A broken blender lid was operated using a butter knife, personal drinks were stored in the kitchen, and an open can of pears was improperly stored in the refrigerator. Pureed and regular diet trays were not served according to the RD‑approved menu, with pureed residents receiving incomplete meals and regular diet residents receiving reduced portions. Multiple staff, including cooks and dietary aides, reported they did not know what an extended menu was, did not know food temperature danger zones or proper hot/cold holding temperatures, and had minimal training, while leadership acknowledged there was no dietary manager and that oversight was informal and limited.
Surveyors found that meals were not prepared or served according to the dietician-approved extended menus for both regular and pureed diets. During observed meal services, pureed trays were missing required items such as pureed bread and specified components of pureed chicken noodle soup, and regular diet trays were served with reduced portions and substitutions not reflected on the menu. Kitchen staff used an unsafe method to operate the blender and reported they did not follow or were unaware of the extended menu, instead relying on what was written on a board by another cook. Staff, including the DON, acknowledged a lack of a dietary manager, limited training, and poor oversight of dietary practices.
Surveyors found extensive food safety and sanitation deficiencies, including unsealed holes and gaps in the kitchen ceiling, a visibly soiled ice machine, and staff and non-kitchen personnel entering the kitchen without hair restraints. Dietary staff were observed stepping on an open box of potatoes, touching counters and food-contact surfaces with bare hands, improperly storing an open can of pears in the refrigerator, handling plates and grilled cheese sandwiches with bare hands, and keeping an open personal drink in the kitchen. An unsealed bag of bread was stored on top of a toaster. Interviews showed that cooks and a dietary aide lacked knowledge of leftover storage requirements, proper cooling, temperature danger zones, hot/cold holding temperatures, extended menus, and pureed diet requirements. The DON and staff reported there was no dietary manager, food handler permits were not required, and oversight of kitchen operations was handled informally by the activities director and a long-term cook, while the DON was unaware of structural issues in the recently renovated kitchen.
A commercial blender used to prepare puree meals for six residents was operated with a broken cover and an improvised safety override. A cook placed canned carrots and lasagna into the blender, used a cracked and damaged cover, and bypassed the blender’s safety mechanism with a butter knife to start and run the equipment. The cover was visibly cracked, and the locking plastic component was missing, yet the blender continued to be used to prepare puree meals served to residents.
The facility failed to conduct and document routine safety inspections of bed frames and side rails used by a resident with intact cognition who was repeatedly observed in bed with bilateral quarter side rails in the up position around the shoulders and head. The maintenance supervisor reported that beds and rails were only checked and repaired when issues were reported, and there was no established program for routine inspections. The DON believed beds and rails were inspected before use but confirmed there was no documentation of such inspections and no policy or procedure governing bed frame and bed rail use and inspection.
A resident received quetiapine for vascular dementia with agitation despite a facility policy that did not permit antipsychotic use for any form of dementia. Physician orders directed scheduled morning and bedtime doses, and the MAR showed the medication was administered on multiple consecutive days. The DON confirmed antipsychotics were not approved under the policy for dementia, while an LPN reported giving quetiapine for the resident’s aggression but did not know whether it was an approved treatment indication. The DON also noted that multiple residents in the facility were receiving antipsychotic medications.
A resident with severe cognitive impairment was receiving lorazepam PRN for anxiety and divalproex daily, as documented on the MAR, yet the quarterly and annual MDS assessments indicated the resident had not received antianxiety or anticonvulsant medications during the applicable 7-day look-back periods. The MDS coordinator reported reviewing MARs when completing assessments but could not explain the omission of lorazepam and stated that, because the resident did not have a seizure diagnosis, divalproex was not coded as an anticonvulsant on the assessments.
A resident was admitted with a BIMS score indicating intact cognition, but no baseline care plan was developed within 48 hours of admission. Review of the electronic and paper records confirmed the absence of a baseline care plan. The MDS coordinator reported that either they or the ADON typically complete baseline care plans, and the ADON acknowledged that the plan was not completed because they were off work during the relevant period.
A resident with dementia, delusions, and documented wandering behavior was assessed multiple times as having impaired cognition and risk factors for wandering and elopement, including resistance to placement, confusion, and a history of wandering. A quarterly wandering/elopement assessment completed by an LPN indicated that any single "yes" response required wandering/elopement precautions, yet the resident’s care plan, created under the responsibility of the ADON, contained no problem, goals, or interventions addressing wandering or elopement risk. During interview, the ADON confirmed the absence of such care plan entries and acknowledged they should have been included.
A resident with severely impaired cognition, delusions, and documented wandering behavior was assessed as an elopement risk and met criteria for wandering/elopement precautions, yet was able to access the front exit and had previously gone outside into the parking lot without staff initially realizing it. Multiple CNAs and LPNs later acknowledged that the resident had been found outside on at least one prior occasion but did not report the incident to administration, and the DON learned of it only through the surveyor. Staff accounts conflicted with the DON’s belief that a CNA had never lost sight of the resident during the prior event.
A resident with obstructive uropathy and an indwelling urinary catheter had a physician order and care plan directing monthly catheter changes, with the due date documented on the MAR but not completed. The resident reported receiving routine catheter care but no catheter change for the month, while an LPN believed a hospice nurse had performed the change. The DON later confirmed the hospice nurse had not changed the catheter, clarified that the charge nurse was responsible for catheter changes, and acknowledged there was no monitoring system in place to ensure indwelling urinary catheters were changed per physician orders.
A resident with orders for thrice-weekly dialysis was assessed by an LPN prior to transport, but the facility failed to maintain ongoing communication with the contracted dialysis provider. The facility’s dialysis policy did not address continued communication with the dialysis center, and the LPN reported never using the facility’s dialysis communication form or sending pre- or post-dialysis assessment information during two years of employment. The DON confirmed that the communication form had not been used or sent to the dialysis center in years and that the facility did not receive routine information about the resident’s dialysis sessions, aside from nutrition documentation from the dialysis center’s nutritionist.
The facility did not maintain RN coverage for eight consecutive hours on several days in April 2024, as required. The DON confirmed the lack of coverage during an interview, affecting the care of 36 residents.
Failure to Obtain and Monitor Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory tests were obtained as ordered by physicians for two residents. Facility policy titled "Lab and Diagnostic Test Results-Clinical Protocol" dated November 2018 stated that physicians would order diagnostic and lab testing based on residents' needs and staff would process test requisitions and arrange for tests. For one resident, a physician order dated 04/11/25 required a CBC and CMP every six months in April and October. The resident’s quarterly assessment dated 10/31/25 documented a BIMS score of 2, indicating severe cognitive impairment for daily decision making, and no current pressure ulcers. The care plan, revised 10/31/25, identified the resident as at risk for pressure ulcers and directed staff to monitor labs as ordered by the physician. Record review showed that the ordered labs were not completed in April or October 2025, and the DON confirmed the labs had not been completed and could not explain why. For a second resident, a physician order dated 03/12/24 required a CBC, CMP, LFT, and Valproic Acid level every six months in April and October. An annual assessment dated 10/09/25 showed the resident was severely impaired in cognition for daily decision making and had hypertension. The care plan, revised 10/09/25, documented hypertension and directed staff to monitor labs as ordered. Clinical record review did not show that the ordered labs were completed in October 2025. The DON stated that these labs had not been completed and reported they were supposed to monitor lab reports monthly but did not know why that monitoring was not being done.
Lack of Dietary Management and Inadequate Food Safety Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full‑time dietary manager and to ensure kitchen staff had the competencies and skills necessary to safely perform food and nutrition service duties for 39 residents receiving meals from the kitchen. On multiple observations across several days and times, no dietary manager was present in the kitchen. Staff interviews confirmed the facility did not have a dietary manager, and the DON stated that an activities director and a cook informally monitored dietary staff. A cook reported being told a dietary manager was unnecessary because a registered dietician visited monthly, and the DON acknowledged difficulty hiring dietary staff and that the facility did not require food handler permits. Surveyors observed repeated food safety and sanitation issues. A hospice aide entered the kitchen without a hair covering and scooped ice from a cooler in front of kitchen staff who did not intervene or offer a hair net. A dietary aide stepped onto an open box of russet potatoes stored under a prep table to tie their shoe, then returned their foot to the floor. A large Styrofoam drink cup belonging to a dietary aide was stored on a top shelf in the kitchen. A cook handled multiple kitchen surfaces and equipment with bare hands, pushed a metal can lid down into a gallon can of pears and stored it in the refrigerator, then handled a plate by covering the food-contact surface with their palm and fingers before placing a grilled cheese sandwich on it and delivering it to a resident’s room, returning to the kitchen and handling leftovers and trash without washing hands. A broken blender lid required staff to use a butter knife to engage the safety lock before pureeing foods. The facility also failed to ensure staff followed menus and diet orders and understood basic dietary procedures. Pureed meals were not prepared according to the menu: a cook chose not to puree bread sticks on the menu, stating residents on pureed diets would not eat pureed bread, and a pureed plate was served with pureed lasagna, carrots, and dessert but no bread. A pureed tray requested by a CNA was served as mashed potatoes, applesauce, and chicken broth without noodles or meat, while a regular diet tray consisted of half a grilled cheese sandwich, diced peaches, and chicken noodle soup despite bread being available. Staff, including cooks and dietary aides, stated they did not know what an extended (RD‑approved) menu was, did not know food temperature danger zones or proper hot/cold holding temperatures, and did not know proper leftover cooling and storage requirements. One dietary aide stated the biggest problem in the kitchen was lack of management and training, and the DON stated one cook was considered “untrainable.”
Failure to Follow Dietician-Approved Menus and Puree Diet Requirements
Penalty
Summary
The deficiency involves the facility’s failure to provide meals according to the registered dietician–approved menus, including required items and portions, for both regular and pureed diets during two observed meal services. Surveyors observed cook #1 pureeing canned carrots and lasagna using a blender that was started by sliding a butter knife between the housing and cover to engage the safety mechanism. During the noon meal, a pureed plate was served with pureed lasagna, carrots, and a whipped dessert, but without the required breadstick/bread component, despite the extended menu specifying pureed garlic bread and defined scoop sizes for each pureed item. Cook #1 stated they would not puree breadsticks and reported that residents would not eat pureed bread, and that substitutions were written on a paper on the wall for the registered dietician to review. During the evening meal observation, surveyors noted a partial loaf of white bread on top of the toaster and observed a dietary aide providing a pureed tray consisting only of mashed potatoes, applesauce, and chicken broth without noodles or meat, instead of the specified pureed chicken noodle soup, pureed pimento cheese sandwich, pureed vegetable blend, pureed bread, and pureed pears. A regular diet tray was served as half of a grilled cheese sandwich, diced peaches, and chicken noodle soup, rather than the full menu of chicken noodle soup, pimento cheese sandwich, cucumber onion salad, saltine crackers, and pears. Multiple dietary staff, including cook #2 and dietary aides, reported they were unaware of the extended menu, did not know dietary requirements for pureed diets, and followed what was written on the board by the daytime cook. The DON confirmed there was no dietary manager, that cook #1 functioned as an interim lead, and acknowledged issues with the evening cook’s training, while staff also cited lack of management and training in the kitchen.
Widespread Food Safety, Sanitation, and Training Deficiencies in Dietary Services
Penalty
Summary
Surveyors identified multiple failures in the facility’s food service operations affecting 39 residents who ate meals prepared in the kitchen. The physical kitchen environment had several unsealed holes and gaps in the ceiling, including around an electrical conduit pipe, loose bell fixture with exposed wiring and screw holes, separated crown molding, and an unsealed hole near a ceiling rack over a food preparation table. The ice machine contained a black and brown mucous-like substance along the drip pan edges and dark buildup inside and outside the water tubing. A hospice aide entered the kitchen without a hair restraint and scooped ice from a cooler in the center of the kitchen without being corrected or offered a hair cover by kitchen staff who were present. Surveyors observed multiple breaches of food handling and infection control practices by dietary staff. A dietary aide stepped onto the top of an open box of russet potatoes stored on the bottom shelf of a food preparation table to tie their shoe. Cook staff were seen touching multiple kitchen counter surfaces and the food preparation table with bare hands. One cook pushed the metal lid of a gallon can of pears down into the can and stored it open in the refrigerator, then handled a plate by covering the food-contact surface with their palm and fingers, placed a grilled cheese sandwich on the plate with bare hands, delivered it to a resident’s room, and returned to the kitchen without washing their hands before resuming leftover storage and trash disposal. An open personal Styrofoam drink cup with lid and straw was present on a kitchen shelf, and an unsealed plastic bag of white bread was stored on top of the toaster. Staff interviews revealed significant gaps in dietary training, oversight, and knowledge of food safety standards. One cook stated they did not know the requirements for storing leftover foods, had not been taught how to properly cool leftovers, did not know the temperature danger zone for foods, and were unaware of proper hot and cold holding temperatures, extended menus, or specific dietary requirements for residents on pureed diets. A dietary aide similarly reported not knowing about extended menus, temperature danger zones, or holding temperatures, though they acknowledged that touching plate surfaces and food with bare hands, having personal drinks in the kitchen, and stepping on a box of potatoes were unsanitary. The DON and kitchen staff reported there was no dietary manager, that the activities director and a long-term cook informally monitored kitchen duties and ordered food, that food handler permits were not required, and that some kitchen staff were considered “not trainable.” The DON also stated they were unaware of the holes in the recently renovated kitchen.
Improper Use of Broken Blender to Prepare Puree Meals
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe working order when a commercial blender used to prepare puree meals was operated with a broken cover and an improvised safety override. During observation, a cook poured canned carrots into the blender bowl, placed a broken cover onto the bowl, and used a butter knife to engage the safety mechanism and start the blender. The cook then blended canned carrots and lasagna using this same bowl with the broken cover and the butter knife to bypass the safety feature. The blender cover was observed to be cracked in several places, and the plastic portion that locked the blender bowl in place was missing and appeared to have broken off. The cook stated that the top of the blender used to puree foods was broken and that they had to work the safety with a butter knife to get the blender to operate. Six residents were identified as receiving puree meals prepared in the kitchen using this blender. No additional resident medical history or clinical conditions were documented in the report beyond the fact that six residents consumed puree meals prepared with this equipment.
Failure to Conduct and Document Routine Bed and Side Rail Safety Inspections
Penalty
Summary
The deficiency involves the facility’s failure to ensure routine inspection of a resident’s bed and side rails, as required for safety. One resident was repeatedly observed in bed with bilateral quarter side rails in the up position around the shoulders and head on multiple dates, with the rails attached to the bed frame. An annual MDS assessment showed this resident had a BIMS score of 13, indicating intact cognition and normal memory and thinking abilities. Despite the ongoing use of these bed rails, there was no evidence that the bed frame or side rails had been routinely inspected for safety. During interviews, the maintenance supervisor, who had been in the role for 1.5 years, stated that their practice was to repair beds or rails only when an issue was reported and to assemble new beds when they arrived, but confirmed there was no program for routine inspection of bed frames and bed rails. The DON stated they believed beds and bed rails were inspected before resident use but acknowledged there was no documentation of such inspections. The DON also confirmed there was no policy or procedure in place regarding the use and inspection of bed frames and bed rails. These actions and inactions resulted in the failure to conduct and document routine safety inspections for beds and side rails used by residents.
Antipsychotic Medication Used for Dementia Contrary to Facility Policy
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident did not receive an antipsychotic medication for a diagnosis of dementia, contrary to the facility’s own policy. The 2025 policy titled "Monitoring of Anti-Psychotics" specified that residents were only to be prescribed antipsychotic medications if they had one of the listed diagnoses, and no form of dementia was included on that list. Despite this, physician orders dated 11/19/25 directed that Resident #10 receive quetiapine 25 mg every morning and 50 mg at bedtime for a diagnosis of vascular dementia, unspecified severity, with agitation. The December 2025 medication administration record showed the resident received both the morning and bedtime doses of quetiapine on multiple consecutive days from 12/01/25 through 12/11/25. During interviews, the DON confirmed that antipsychotic medications were not approved under facility policy for the treatment of dementia, and an LPN reported administering quetiapine for the resident’s aggression toward other residents but stated they did not know whether the medication was approved for treating dementia with aggression. The DON also identified that a total of 11 residents in the facility were receiving antipsychotic medications, indicating that the reviewed resident was among a broader group of residents on such therapy. The documentation and interviews together showed that the antipsychotic was ordered and administered for a dementia-related diagnosis that was not permitted under the facility’s antipsychotic monitoring policy, and that nursing staff lacked knowledge about whether the use of quetiapine for dementia with aggression was in accordance with approved indications.
Inaccurate MDS Coding of Antianxiety and Anticonvulsant Medication Use
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for a resident in relation to antianxiety and anticonvulsant medication use. Record review showed that the resident had an order for lorazepam 1 mg every four hours as needed for anxiety from 07/02/25 through 07/16/25 and received a dose on 07/15/25 at 9:26 p.m. The resident was also ordered and received divalproex 125 mg daily from 07/01/25 through 07/16/25. However, the quarterly assessment dated 07/15/25 documented that the resident, who was assessed as severely impaired in cognition for daily decision making, had not received an antianxiety or anticonvulsant medication during the seven-day look-back period, despite the documented administration of both medications. An annual assessment dated 10/09/25 again showed the resident as severely impaired in cognition for daily decision making and indicated that the resident had not received an anticonvulsant during the seven-day look-back period. This conflicted with the October 2025 medication administration record, which showed the resident was ordered and received divalproex 125 mg daily and had doses administered on 10/03/25, 10/04/25, 10/05/25, 10/07/25, and 10/08/25. During interview, the MDS coordinator stated they reviewed the medication administration records when completing assessments and did not know why the lorazepam use was not accurately coded. The MDS coordinator further explained that because the resident did not have a diagnosis of seizures, they did not code divalproex as an anticonvulsant received during the seven-day look-back periods for either the quarterly or annual assessments.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop a baseline care plan within 48 hours of admission for one resident. Record review showed that the resident was admitted on 06/20/25 and had a BIMS score of 13, indicating the resident was cognitively intact for daily decision making. Review of the clinical record did not show that a baseline care plan had been completed for this resident. During interviews, MDS coordinator #1 stated that they or the ADON were responsible for completing baseline care plans and, after reviewing both the electronic clinical record and the paper chart, could not locate a baseline care plan for the resident. The ADON confirmed that they were responsible for completing baseline care plans and acknowledged that a baseline care plan had not been completed within 48 hours of admission for this resident because the ADON had been off work on those days. The DON identified that 39 residents resided in the facility at the time of the survey, and the deficiency was identified for 1 of 14 sampled residents whose care plans were reviewed.
Failure to Care Plan for Resident at Risk for Wandering and Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan addressing wandering and elopement risk for a resident who had been assessed as at risk. An MDS admission assessment dated 12/01/24 documented that the resident’s cognition was moderately impaired, and that the resident experienced delusions and wandered one to three days in the previous seven days. A quarterly wandering/elopement assessment completed by an LPN on 09/02/25 showed "yes" responses to questions about resistance to being placed in the facility, a history of wandering, confusion and disorientation, and indications of dementia. The assessment form’s instructions stated that a single "yes" answer required the resident to be placed on wandering/elopement precautions. A subsequent MDS admission assessment dated 12/04/25 showed the resident’s cognition had declined to severely impaired, with continued delusions and wandering one to three days in the previous seven days. Despite these findings, the resident’s care plan revised on 12/06/25 contained no problem, goals, or interventions related to wandering or elopement risk. During an interview on 12/18/25, the ADON, who stated they were responsible for creating resident care plans, reviewed the care plan and confirmed there were no entries addressing wandering or elopement. The ADON acknowledged that, given the resident’s dementia and wandering behavior, problems related to wandering and elopement should have been included in the care plan.
Failure to Prevent and Report Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent a cognitively impaired resident, assessed as an elopement risk, from exiting the building and entering the parking lot without staff awareness. The resident had an MDS admission assessment showing moderately impaired cognition with delusions and wandering behaviors, and a subsequent MDS showing severely impaired cognition with continued delusions and wandering. A quarterly wandering/elopement assessment documented multiple “yes” responses to risk questions, which per the tool’s instructions required placement on wandering/elopement precautions. Despite this, the resident was observed by surveyors attempting to open the front door, repeatedly pushing on the door latch until a staff member intervened. Staff interviews revealed that the resident had previously exited the facility without staff initially knowing, and was later found outside near the front parking lot. Multiple CNAs and LPNs acknowledged awareness of at least one prior incident in which the resident was outside the building, but none could recall the exact date, and the involved LPNs and CNA stated they did not report the incident to administration. The DON stated they only became aware of the prior exit when informed by the surveyor and indicated that staff were supposed to report such incidents, but this had not occurred. There were conflicting accounts between the DON and CNAs regarding whether a particular CNA had maintained visual contact with the resident during the incident, with several CNAs stating that CNA was not present when the resident was found outside.
Failure to Change Indwelling Urinary Catheter as Ordered
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter was changed as ordered by the physician for one resident. Observation on 12/17/25 showed Resident #19 in bed with an indwelling urinary catheter. A physician order dated 06/10/25 directed that the catheter be changed monthly on the 9th and as needed, and a quarterly assessment dated 12/04/25 documented that the resident, who had a BIMS score of 15 indicating cognitive intactness, had an indwelling urinary catheter and obstructive uropathy. The care plan revised on 12/04/25 also specified that the catheter was to be changed every month and as needed. The medication administration record for 12/01/25 through 12/17/25 showed the catheter was scheduled to be changed on 12/09/25, but there was no documentation that this was completed. On 12/17/25, the resident reported receiving catheter care but stated the catheter had not been changed in December. LPN #3 stated they believed the hospice nurse had changed the catheter on 12/09/25, while on 12/18/25 the DON confirmed the hospice nurse had not changed it and stated that the charge nurse was responsible for catheter changes and that there was no monitoring in place to ensure catheters were changed as ordered. This deficiency centers on the missed monthly catheter change for Resident #19 despite clear physician orders, care plan directives, and MAR entries, combined with staff misunderstanding about who performed the change and the absence of a monitoring system to verify that indwelling urinary catheters were changed as ordered.
Failure to Maintain Ongoing Communication With Dialysis Provider
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of dialysis-related care and services for a resident who required routine dialysis. The resident had a physician’s order, dated 01/30/25, to be sent to a contracted dialysis provider every Monday, Wednesday, and Friday. On 12/17/25 at 10:08 a.m., an LPN was observed conducting a pre-dialysis assessment of this resident. Review of the facility’s policy titled “Dialysis-General Guidelines and Management,” dated 01/2008, showed the policy did not address ongoing or continued communication between the dialysis center and the facility. During interviews, the LPN stated they had never used the facility’s dialysis communication form to document pre- and post-dialysis assessments or to send pre-dialysis assessment information to the dialysis center, despite having worked at the facility for two years. The LPN reported they believed this was because the dialysis center would not complete their portion of the form or return it. The DON confirmed that the dialysis communication form existed but had not been completed or sent to the dialysis center in years. The DON further stated that the facility had not received routine communication back from the dialysis center regarding the resident’s dialysis sessions, with the only regular documentation coming from the dialysis center’s nutritionist about nutrition.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. The deficiency was identified through a review of the nursing schedule for April 2024, which documented the absence of RN coverage for eight consecutive hours on specific dates: April 5, April 8, April 9, and April 10, 2024. During an interview on June 5, 2024, the Director of Nursing (DON) confirmed that there was no RN coverage on these dates. The facility had 36 residents at the time of the report, but no specific details about the residents' conditions or medical history were provided in relation to the deficiency.
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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