Tulsa Center For Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulsa, Oklahoma.
- Location
- 6202 East 61st Street, Tulsa, Oklahoma 74136
- CMS Provider Number
- 375568
- Inspections on file
- 43
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Tulsa Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with dementia, mood and conduct disorders, and a history of aggressive and verbally abusive behaviors, including racial slurs, was involved in an altercation with a CNA in a common area. After the resident threw a soda or drink toward the CNA, the CNA immediately retaliated by throwing the drink or can back into the resident’s face and then walked away using explicit language about the resident. Witness statements, the incident report, and the resident’s documented behavioral history showed that the staff member’s retaliatory action constituted abuse, demonstrating a failure to protect the resident from staff abuse as required by facility policy.
A resident with multiple cardiac and vascular conditions was not weighed daily as ordered after hospital discharge, despite protocols for monitoring fluid overload. The omission of daily weights and lack of care plan interventions led to unmonitored weight gain and worsening edema, resulting in the resident's rehospitalization for CHF exacerbation. Staff interviews confirmed that daily weights were expected but not performed due to documentation and communication lapses.
A green capsule in a medication cup was found left unattended on top of a medication cart in the Southeast Hallway. An LPN stated they had intended to administer the medication to a resident but forgot, leaving it unsecured and accessible, contrary to facility policy requiring medications to be secured and accessible only to authorized personnel.
A resident with diabetes mellitus was receiving ordered Lantus insulin and had a standing physician order for HbA1c testing every three months to monitor blood glucose control. Facility policy required that ordered labs be provided or obtained. Review of records showed that all ordered HbA1c tests were completed except for one scheduled in February, which was missing from the chart. The administrator and ADON acknowledged there was no HbA1c result for that month; the ADON reported they had assumed the contracted dialysis company would perform the test and therefore the facility did not collect the blood sample, resulting in the ordered HbA1c not being obtained until the next scheduled test in May.
A resident requiring enhanced barrier precautions for tracheostomy care received care from an LPN who did not follow the facility’s hand hygiene and PPE protocols. The LPN left the room to obtain missing supplies, returned and donned a gown and gloves without performing hand hygiene, and later changed to sterile gloves without sanitizing hands between glove changes. The LPN cleaned the tracheostomy site and inner cannula, removed and replaced the trach collar, handled a pen from a uniform pocket to label the new collar, and completed the procedure without changing gloves appropriately or performing required hand hygiene steps, contrary to the facility’s hand hygiene policy and the DON’s stated expectations.
A facility failed to report an abuse allegation involving a resident with quadriplegia and generalized anxiety disorder to the OSDH within the required two-hour timeframe. The incident, which involved a physical altercation with the resident's significant other, occurred around midnight, but was not reported until the afternoon, exceeding the mandated reporting period.
A resident with dementia and a left leg amputation suffered a right knee abrasion when staff assisted with a transfer without using a gait belt, contrary to facility standards.
The facility failed to provide alternative meals due to insufficient dietary staff. Multiple residents reported that their requests for alternative meals were often denied or limited to peanut butter and jelly sandwiches. The CDM and Administrator confirmed that staff shortages led to this issue.
The facility failed to provide alternative meals as listed on the menu, often offering only peanut butter and jelly sandwiches due to staffing issues. This affected the nutritional needs and meal satisfaction of the residents.
The facility failed to ensure a timely transmission of an assessment for a resident who had expired. The Death In Facility assessment remained 'In Progress' and was not submitted within the required timeframe due to an unresolved warning that was not caught during the double-check procedure.
A resident with epilepsy did not receive scheduled doses of phenobarbital and phenytoin sodium due to medication unavailability, leading to seizures and hospitalization. The facility's policy to reorder medications in advance was not followed, resulting in a gap in treatment.
The facility failed to ensure a shower stall and curtain were clean in the southeast shower room. Observations revealed hard water stains, a black substance in the grout, and stained shower curtains. Despite daily cleaning claims, the issues persisted, and the housekeeping supervisor was unaware of the process for cleaning shower curtains.
Staff-to-Resident Abuse Following Behavioral Outburst
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by staff. Facility policy on abuse and neglect required staff to identify, assess, care-plan, and monitor residents with behaviors that might lead to conflict, including those with aggressive behaviors, self-injurious behaviors, communication disorders, or total dependence on staff, and to monitor for early warning signs or changes that could trigger abusive behavior. The resident involved had diagnoses including violent behavior, dementia, depression, mood disorder, anxiety, and conduct disorder. A care plan and quarterly assessment documented that the resident was moderately impaired for daily decision-making and had the potential to demonstrate behaviors such as yelling out, swinging at staff and residents, cussing, and making racial slurs toward staff. An incident report documented that the resident threw soda on a CNA, who then threw a drink back into the resident’s face. A receptionist who witnessed the event stated the resident, seated near the CNA in a common room, suddenly threw a can of soda at the CNA, and the CNA immediately jumped up and threw the soda can back into the resident’s face, then walked down the hall saying staff should “get” the resident and using explicit language. The incident was reported to the administrator. In a later phone interview, the CNA stated the resident had called them racial names and thrown a drink that hit a bowl in the CNA’s hand, spilling drinks on the table and splashing on the resident, which led the resident to yell that the CNA had thrown a drink at them. The resident later stated they had not had a staff member throw a drink at them or abuse them. Despite these differing accounts, the documented staff action of throwing a drink back at the resident constituted abuse and demonstrated the facility’s failure to ensure the resident was free from abuse.
Failure to Obtain Daily Weights as Ordered for Resident with Fluid Overload Risk
Penalty
Summary
The facility failed to obtain daily weights for a resident as ordered by the physician following a hospital discharge. The resident, who had a history of coronary artery disease, hypertension, peripheral vascular disease, respiratory failure, ischemic cardiomyopathy, and a prior coronary artery bypass graft, was readmitted from the hospital with instructions to be weighed daily and to notify the physician if there was a weight gain of three pounds or more in 48 hours. Despite these orders, daily weights were not recorded in the electronic health record for the remainder of September or throughout October. The care plan did not include interventions for daily weights or fluid restriction, and the October active orders did not reflect the need for daily weights. The resident experienced significant weight gain and worsening edema, ultimately requiring hospitalization for congestive heart failure exacerbation. Interviews with facility staff revealed that the protocol for monitoring fluid overload included daily weights, especially for residents with CHF or noted edema. However, the DON stated that daily weights were not obtained because the resident was not identified as having CHF in the facility records, and the APRN acknowledged that weights should have been obtained but were not. The lack of adherence to physician orders and facility protocols contributed to the failure to monitor the resident's fluid status appropriately.
Unattended Medication Left on Cart
Penalty
Summary
A medication security deficiency occurred when a green capsule in a plastic medication cup was observed left unattended on top of a medication cart in the Southeast Hallway. The medication cart was not attended by staff at the time of observation. According to facility policy, medications are to be accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. An LPN later confirmed they had left the medication on top of the cart with the intention to administer it to a resident but forgot, acknowledging that the medication should have been secured inside the cart and not left unattended.
Failure to Obtain Ordered A1C Monitoring for Diabetic Resident
Penalty
Summary
A resident with a diagnosis of diabetes mellitus had a physician’s order for Lantus Solostar insulin, 5 units in the morning and 27 units in the afternoon, and a standing laboratory order for hemoglobin A1C testing every February, May, August, and November to monitor average blood glucose levels. Facility policy required that laboratory services be provided or obtained when ordered by a physician or other authorized practitioner. During record review, surveyors requested the resident’s A1C results and the administrator reported that, after searching the record, there were no A1C results for February 2025. The ADON confirmed that A1C results were present for all ordered months except February 2025. The ADON stated they had spoken with the contracted dialysis company that month and believed the dialysis staff would perform the A1C test, and therefore the facility did not collect the blood sample for testing. As a result, the ordered A1C test for February 2025 was not obtained, and the resident’s A1C was not tested again until May 2025, contrary to the physician’s lab order and the facility’s laboratory services policy.
Failure to Follow Hand Hygiene and PPE Protocols During Tracheostomy Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control protocols during tracheostomy care for one resident who had a physician order for enhanced barrier precautions related to tracheostomy care. During an observation of tracheostomy care, an LPN began the procedure and then discovered that needed supplies were not available in the resident’s room. The LPN removed their gloves and gown and left the room to obtain supplies. When the LPN returned with the supplies, they donned a gown and gloves in the room but were not observed to perform hand hygiene before putting on the new PPE. During the continuation of the tracheostomy care, the LPN opened a pair of sterile gloves, removed the existing gloves, and donned the sterile gloves without performing hand hygiene between glove changes. The LPN then opened supplies, used an alcohol wipe to clean the inner cannula, cleaned the area around the tracheostomy site, and placed the inner cannula without changing gloves between cleaning the site and inserting the cannula. While still wearing the same gloves, the LPN removed the old collar, cleaned the area around the site, opened a new collar, took a pen from a uniform pocket to label the collar, placed the new collar, gathered trash, and left the room. The facility’s hand hygiene policy required hand sanitizing before applying and after removing PPE, before and after handling clean or soiled dressings, and after handling items potentially contaminated with blood or bodily fluids. The DON stated that hand washing or sanitizing should occur before starting a procedure, between glove changes, and when the procedure was over.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe for one of the four sampled residents reviewed for abuse. The facility's policy on Abuse, Neglect, and Exploitation, revised in October 2023, mandates that alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. Resident #4, who had diagnoses including quadriplegia and generalized anxiety disorder, was involved in a physical altercation with their significant other in their room around midnight on August 10, 2024, prompting a police call. However, the incident was not reported to the OSDH until 4:13 p.m. on the same day, exceeding the two-hour reporting requirement. The facility administrator confirmed that allegations of abuse should be reported to the OSDH within two hours.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to use a gait belt during a transfer for one of the residents sampled for assistance with transfers. The resident involved had diagnoses including dementia and an amputation of the left lower leg. An incident occurred on 09/24/24, where staff assisted the resident with a transfer without using a gait belt, resulting in the resident suffering a right knee abrasion.
Insufficient Dietary Staff for Alternative Meals
Penalty
Summary
The facility failed to ensure sufficient dietary staff to provide alternative meals to residents. The facility had an alternative menu that included various options such as loaded baked potatoes, chef salad, and different types of sandwiches. However, observations and interviews revealed that residents were often told that only peanut butter and jelly sandwiches were available as alternatives due to staff shortages. This was confirmed by multiple residents who reported that their requests for alternative meals were frequently denied or limited to peanut butter and jelly sandwiches. The Certified Dietary Manager (CDM) and the Administrator both acknowledged that the lack of sufficient dietary staff led to the limited availability of alternative meals. The dietary schedules from late February to mid-March showed a reduction in the number of scheduled employees, with as few as three employees on some days. The CDM stated that seven people were needed daily to be adequately staffed. The Administrator and CDM both confirmed that the facility had been short-staffed recently due to personal reasons affecting dietary staff members. This staffing issue directly impacted the facility's ability to provide the alternative meals listed on the menu, leading to the deficiency noted in the report.
Failure to Provide Alternative Meals
Penalty
Summary
The facility failed to ensure alternative meals were provided for three residents reviewed for meal service. The facility's alternative menu listed various options such as loaded baked potatoes, chef salad, and different types of sandwiches. However, residents reported that dietary staff often stated they could not cook any alternatives or only offered peanut butter and jelly sandwiches. This was corroborated by multiple residents who confirmed the limited availability of alternative meals. On one occasion, a resident asked the Certified Dietary Manager (CDM) why alternative meals were not provided as ordered, and the CDM admitted that when there weren't enough staff, the alternative meals were limited. The Administrator confirmed that the facility did not have a policy regarding meal alternatives and acknowledged that only peanut butter and jelly sandwiches had been offered recently. This deficiency affected the nutritional needs and meal satisfaction of the residents involved.
Failure to Timely Transmit Resident Assessment
Penalty
Summary
The facility failed to ensure a timely transmission of an assessment for a resident who had expired. The resident's Death In Facility assessment was documented as 'In Progress' and had not been submitted within the required timeframe. The MDS Coordinator acknowledged that assessments are usually double-checked at the end of each month and typically completed within 48 hours. However, the assessment for this resident remained incomplete due to an unresolved warning, which was not caught during the double-check procedure. This resulted in the assessment not being submitted timely.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident diagnosed with epilepsy. The resident was supposed to receive phenobarbital 64.8 mg and phenytoin sodium 200 mg as part of their treatment plan. However, the medication administration record indicated that the resident did not receive the scheduled doses of phenobarbital on one occasion because the medication was not available. Additionally, the resident missed both the AM and PM doses of phenytoin sodium on another day due to the same issue of unavailability. This lapse in medication administration led to the resident experiencing two seizures and being sent to the hospital, where they were diagnosed with seizure-like activity and given a new order for phenytoin sodium 200 mg twice a day, which was their current dose at the time of the incident. The facility's policy on medication ordering and receiving from the pharmacy stated that medications should be reordered four days in advance to ensure an adequate supply. Despite this policy, the resident ran out of phenobarbital, and the medication was not reordered in time, resulting in a gap in treatment. Interviews with the Certified Medication Aide (CMA) and the Assistant Director of Nursing (ADON) confirmed that the medications were not administered as ordered, leading to the resident's hospitalization and subsequent return to the facility with a new medication order.
Failure to Maintain Clean Shower Facilities
Penalty
Summary
The facility failed to ensure a shower stall and curtain were clean in the southeast shower room. During an observation, the middle shower stall, which was the only one with a shower curtain, had hard water stains on the walls and a black substance in the grout on the floor next to the wall. The shower curtain had brown and orange stains scattered from top to bottom. The black substance was able to be scratched off, indicating it was not a permanent stain. Housekeeper #1 confirmed that shower rooms were cleaned every day, but the same issues were observed three days later. The housekeeping supervisor stated that shower rooms should be cleaned daily and monitored two to three times a day but was unaware of the process for ensuring shower curtains were cleaned. She acknowledged that the room had not been adequately cleaned despite the observations made on two separate occasions.
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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