Tuscany Village Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 2333 Tuscany Blvd, Oklahoma City, Oklahoma 73120
- CMS Provider Number
- 375536
- Inspections on file
- 39
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Tuscany Village Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and diagnoses including obstructive uropathy and non-Alzheimer dementia had physician orders for weekly weights, a milk/soy protein supplement, and sodium bicarbonate. Over multiple occasions, the resident refused the ordered protein supplement, a scheduled weight, and sodium bicarbonate, with these refusals documented in nurses' notes. However, there was no documentation that the resident's family or physician were notified of these refusals, despite facility policy and staff statements indicating that such refusals should be communicated and recorded. The DON confirmed that the record lacked evidence of required notifications.
Two residents with urinary catheters did not receive appropriate assessment, orders, and monitoring. One resident with a suprapubic catheter had no admission documentation of the catheter, no physician order specifying catheter type or diagnosis, and no catheter-related focus or interventions in the care plan, even though staff and a representative confirmed the catheter was present on admission and throughout the stay. Another resident with an indwelling catheter was observed with thick off-white material filling the catheter tubing into the drainage bag; staff described this as sometimes normal, and the DON noted the tubing was very cloudy with sediment and not secured to the leg, despite acknowledging it should be secured.
A resident with a tracheostomy, severe cognitive impairment, COPD, and documented need for suctioning received regular tracheostomy suctioning without a corresponding physician order, contrary to facility policy requiring care in accordance with standard practice guidelines. The baseline care plan and admission assessment both indicated the need for suctioning and tracheostomy care, but a review of physician orders showed no order for tracheostomy suctioning. The DON confirmed that an order should have been in place, and an LPN reported suctioning the resident’s tracheostomy after the family requested suctioning and stated that the resident was suctioned regularly.
A resident with obstructive uropathy and severe cognitive impairment was admitted with an indwelling catheter and received a regular diet, but the physician orders and treatment records documented suprapubic catheter care and enteral tube feeding. An LPN and the DON confirmed there was no physician order for the actual catheter type in use and that the enteral feeding order was erroneous, resulting in medical records and orders that did not accurately reflect the resident’s catheter type or nutritional status.
A resident with severe cognitive impairment, obstructive uropathy, and a suprapubic catheter was admitted with physician orders for catheter changes as needed, output monitoring each shift, and catheter care every shift, and treatment records showed catheter care was being provided. However, the comprehensive care plan created after admission addressed only activities and did not include any focus, goals, or interventions for catheter care or ADLs, despite the resident’s dependence for transfers and need for assistance with self-care. A resident representative confirmed the catheter was present throughout the stay, a CNA reported there was no documentation directing catheter care, and both the DON and MDS coordinator later acknowledged that the comprehensive care plan was incomplete and had been missed.
Two residents who required assistance with ADLs did not consistently receive scheduled baths, and refusals or completed baths were not properly documented. One cognitively impaired resident, scheduled for twice‑weekly showers, only received showers on two occasions during a two‑week period, with no refusals recorded and family reporting showers occurred only after complaints. Another resident with intact cognition but significant physical impairments and physician‑ordered twice‑weekly baths did not receive a bath on a scheduled day, despite an LPN initialing the MAR as if the bath occurred, while the TAR and nurses’ notes showed no bath or refusal. Staff interviews revealed that showers were not completed for all residents, that aides cited insufficient staffing, and that required documentation and notification procedures for bath refusals were not followed.
A resident with severe cognitive impairment, septicemia, renal failure, and IV access had a physician order for weekly IV midline dressing changes on day shift, or sooner if the dressing became compromised. Review of the MAR showed a scheduled dressing change was missed without a documented reason, and a family grievance later reported the IV dressing had not been changed since admission and was dated nearly two weeks earlier. Nursing staff told the family the dressing change was missed because the resident was at dialysis when it was scheduled, and documentation and interviews with the DON and regional nurse consultant confirmed there was no record of the ordered IV dressing change being completed as required.
A resident with multiple medical conditions experienced a significant change in condition and received a new medication order. In both cases, documentation showed that the spouse and hospice company were notified, but there was no evidence that the designated HealthCare contact, the resident's daughter, was informed as required by policy. Staff interviews confirmed the omission.
A resident with multiple diagnoses, including hemiplegia and muscle weakness, was admitted to hospice care as documented by certification and physician's order. However, the significant change MDS assessment did not indicate the resident's hospice status, and the MDS coordinator confirmed the assessment was not accurately coded to reflect this change.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident with multiple medical conditions, including hemiplegia and muscle weakness, did not have required documentation of intake, output, or meal percentages for a week prior to a hospital stay. Facility policy required documentation of meal consumption in the EHR, but records for this period were missing, and the regional nurse consultant confirmed the absence of both the documentation and a specific policy for eating or intake and output.
An LPN in a facility used disinfectant wipes, not intended for skin use, to clean two residents' skin before blood sugar testing and insulin administration, contrary to the facility's policy requiring alcohol swabs. The LPN acknowledged the correct procedure, highlighting a deviation from established protocols.
The facility failed to ensure staff competency with the new EMR system, affecting three staff members. A medication was not administered to a resident because the CMA was unaware of how to verify orders using the new system. Both the CMA and an LPN reported not receiving training on the EMR. The corporate nurse confirmed that in-service sheets did not show attendance for these staff members, and the AD also demonstrated a lack of knowledge about the system.
The facility failed to administer medications as ordered for five residents. Observations showed that a CMA and an LPN did not administer medications according to physician orders, with issues such as missing medications, incorrect dosages, and unauthorized administration. Staff interviews revealed problems with medication availability and adherence to procedures, contributing to these deficiencies.
The facility experienced a medication error rate of 23.68%, significantly above the acceptable threshold. Errors included missed doses of hydrocodone/acetaminophen, lisinopril, amlodipine, and clindamycin, as well as incorrect administration of Vitamin B12 and gabapentin. Staff interviews revealed issues with medication availability and adherence to the MAR.
The facility failed to maintain infection control practices during the handling of soiled linen and hand hygiene. An LPN transported a soiled incontinent pad without bagging it, and a CNA did not change gloves or perform hand hygiene during incontinent care, placing soiled items on the floor instead of in a bag.
The facility failed to provide adequate treatment and services for a resident with a stage 3 pressure ulcer, resulting in the worsening of the wound. Despite physician orders for bi-weekly treatments and a care plan requiring frequent repositioning, the resident received only one wound care treatment over a two-week period, and staff did not document turning or repositioning efforts.
The facility failed to ensure that two residents experiencing pain received appropriate treatment. One resident, who had a hip fracture, was not properly assessed for pain during care, and another resident experienced delays in receiving prescribed pain medication. The staff did not follow the facility's pain management policy, resulting in prolonged pain and discomfort for the residents.
The facility failed to hold a care plan meeting and include a resident's representative for a resident with chronic kidney disease and chronic pain. The meeting was missed due to the responsible LPN not working and no one covering for them.
The facility failed to ensure accurate resident records, as one resident's clinical record contained hospital records belonging to four other residents. The Records Management policy requires consistent and logical maintenance of records, but the process failed, leading to incorrect documents being included in the resident's record.
The facility failed to ensure dishware was clean, as 32 blue-handled coffee cups were found with white residue and contaminants. Both a cook and the Corporate Dietary Manager confirmed the presence of debris inside the cups. The Administrator identified that 114 residents received nutrition from the kitchen.
The facility failed to maintain proper infection control during incontinent care for two residents and did not ensure staff wore required PPE before entering a COVID-19 positive room. CNAs did not change gloves as required, and a CMA entered a COVID-19 positive room without appropriate PPE.
A CNA failed to provide thorough incontinent care for a resident with hemiplegia and hemiparesis by not cleaning the labia, contrary to the facility's perineal care policy. The CNA acknowledged the omission, stating they did not wipe the labia because the resident had just voided.
Failure to Notify Family and Physician of Resident's Repeated Refusals of Care
Penalty
Summary
The facility failed to notify a resident's family and physician of repeated refusals of ordered care and treatment. Facility policy on Refusal of Care and Treatment, dated 02/16/23, required staff to notify the physician when a resident refused ordered treatment or procedures and to notify the resident's responsible party unless the resident chose otherwise. Resident #8 had physician orders dated 10/08/25 for weekly weights for four weeks, a milk/soy protein supplement of 60 milliliters twice daily, and sodium bicarbonate 650 milligrams twice daily. An admission assessment dated 10/14/25 documented that the resident had severely impaired cognition with a BIMS score of 3 and diagnoses of obstructive uropathy and non-Alzheimer dementia, and that the resident did not reject care during the seven-day look-back period. Subsequent nurses' notes from 10/2025 through 11/2025 showed multiple refusals of ordered care by Resident #8, including repeated refusals of the protein supplement health shake on several dates, refusal to be weighed on one date, and refusals of both the protein supplement and sodium bicarbonate on multiple dates. The resident representative stated they were not notified of these refusals. CNA #4 and LPN #6 each stated that when a resident refused care, the nurse should document the refusal and notify both the family and the physician. When shown the nurses' notes, the DON acknowledged there was no documentation that the family or physician had been notified of Resident #8's refusals of care and confirmed that such notification should have occurred and been documented in the nurses' notes.
Failure to Maintain Appropriate Catheter Orders, Assessment, and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate assessment, orders, and care for residents with urinary catheters. For one resident with a suprapubic catheter, the admission assessment did not document the presence of a catheter, and physician orders lacked a specific order for the catheter type and supporting diagnosis, despite orders for suprapubic catheter care, catheter changes as needed, and monitoring of output each shift. The treatment administration record showed ongoing suprapubic catheter care, but the comprehensive care plan contained no focus or interventions for catheter care, and the catheter was not included on the baseline or comprehensive care plan. The resident had severe cognitive impairment, obstructive uropathy, and non-Alzheimer dementia, and was known by staff and the resident representative to have a catheter upon admission and throughout the stay. Staff, including an LPN and the DON, acknowledged that there was no physician order specifying the catheter type, even though they stated such an order was required to guide care. For another resident with an indwelling catheter, surveyors observed the catheter tubing filled with a thick off-white substance extending from the resident’s body into the drainage bag. The physician order directed that the catheter be changed as needed or when clinically indicated. The resident had severe cognitive impairment with a BIMS score of 0, diagnoses of cerebral palsy and traumatic brain injury, and was dependent on staff for all needs. An LPN stated that catheters should be changed if there were signs of infection, but noted the resident did not have a fever and described the thick off-white substance as sometimes normal. The DON described the catheter tubing as stained and very cloudy with sediment and was unsure if this appearance was normal for the resident, and also noted the catheter tubing was not secured to the resident’s leg, despite acknowledging it was advised to secure the catheter to prevent pulling against the bladder wall.
Failure to Obtain Physician Order for Tracheostomy Suctioning
Penalty
Summary
The facility failed to obtain a physician’s order for tracheostomy suctioning for one resident who required this care. The facility’s Tracheostomy Care policy dated 03/02/23 stated that staff would provide care and suctioning for residents with a tracheostomy in accordance with standard practice guidelines. A baseline care plan for Resident #1 dated 01/14/26 documented that the resident had a tracheostomy and required suctioning, and an admission assessment dated 01/21/26 showed the resident had severely impaired cognition with a BIMS score of 07, required suctioning and tracheostomy care, and had a diagnosis of chronic obstructive pulmonary disease. However, a review of physician orders from 01/14/26 through 01/27/26 showed no order for tracheostomy suctioning. The DON confirmed that Resident #1 should have had a physician order for tracheostomy suctioning and that no such order was present. An LPN reported that on 01/26/26 the resident’s family stated the resident needed to be suctioned; the resident was not in distress and was suctioned via the tracheostomy after eating and after the family left, and the LPN stated the resident’s tracheostomy was suctioned regularly despite the absence of a physician order. This deficiency centers on the provision of tracheostomy suctioning without a corresponding physician order, despite documented care needs and facility policy requiring care in accordance with standard practice guidelines.
Inaccurate Physician Orders for Catheter Type and Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate physician orders and medical records for a resident with an indwelling catheter and no enteral feeding. Facility policy on care and removal of indwelling catheters required staff to evaluate the need for catheter removal by validating the record and physician’s order. For this resident, physician orders dated 10/08/25 included directions to change a suprapubic catheter as needed, monitor output every shift, provide suprapubic catheter care every shift, and administer enteral tube feeding twice a day. The treatment administration record for the same period showed the resident received care for a suprapubic catheter. However, the resident’s annual assessment dated 10/14/25 documented that the resident had a catheter in place, not a suprapubic catheter, and that the resident did not have a tube feeding device and instead ate with supervision or touching assistance. The resident had diagnoses of obstructive uropathy and non-Alzheimer dementia, with severely impaired cognition (BIMS score of 3), and was later discharged for a short-term hospital stay. During interviews, the resident’s representative stated the resident had a catheter upon admission and throughout the stay and was not receiving enteral tube feeding. An LPN confirmed that residents admitted with catheters should have orders specifying the catheter type and size, acknowledged that this resident had a catheter upon admission, and identified that there was no physician order for a catheter, only for suprapubic catheter care, and that the resident was on a regular diet rather than enteral tube feeding. The DON similarly confirmed the resident had a catheter upon admission, that the orders incorrectly specified suprapubic catheter care and lacked an order for the actual catheter, and that the resident was on a regular diet and not nothing by mouth, identifying the enteral tube feeding order as an error. These findings show the resident’s physician orders were inaccurate and inconsistent with the resident’s actual catheter type and nutritional status.
Failure to Develop Comprehensive Care Plan for Resident With Suprapubic Catheter
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for one resident with a suprapubic catheter. Facility policy required a comprehensive care plan with measurable objectives and timeframes to be developed within seven days after completion of the comprehensive MDS, considering all triggered Care Area Assessments and other identified needs. For this resident, physician orders dated at admission directed suprapubic catheter changes as needed, monitoring of catheter output every shift, and catheter care every shift, and the treatment administration record showed ongoing suprapubic catheter care throughout the month. However, the comprehensive care plan initiated shortly after admission contained only an activities focus and did not include any focus, goals, or interventions related to catheter care or other ADLs. The resident’s admission assessment documented severe cognitive impairment with a BIMS score of 3, diagnoses of obstructive uropathy and non-Alzheimer dementia, and the presence of a catheter, with urinary continence not rated due to catheter use. The assessment also showed the resident required varying levels of assistance for eating, bathing, dressing, and was dependent for bed transfers, but these needs were not reflected in the comprehensive care plan. A resident representative confirmed the resident had a catheter upon admission and throughout the stay. A CNA reported there was no documentation directing catheter care, although they stated they checked and provided care for all catheters every two hours. The DON and the MDS coordinator both acknowledged on review that the comprehensive care plan for this resident was incomplete, containing only an activities focus and omitting catheter care and ADLs, and that the comprehensive care plan had been missed.
Failure to Provide and Accurately Document Scheduled Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing and to document refusals or completed baths for two residents who required assistance with activities of daily living. Facility policy required staff to provide bathing services per standard practice and to document refusals in the record. For one resident with severely impaired cognition, a BIMS score of 7, and no history of rejecting care, CNA flow sheets showed showers only on two Sundays within a two‑week period, despite the resident being scheduled for showers on Tuesdays and Fridays. Interdisciplinary progress notes contained no documentation of shower refusals, and the resident’s family member reported the resident only received showers after they complained to staff. For a second resident with intact cognition (BIMS 14), polyneuropathy, anxiety disorder, depression, and bilateral upper and lower extremity impairments, assessments showed the resident required substantial to maximum assistance with showers/baths and personal hygiene and was dependent for tub/shower transfers and non‑ambulatory. Physician orders specified bath days twice weekly on first shift. The TAR for a specific month showed the resident did not receive a bath on one scheduled bath day, while the MAR for the same date was initialed by an LPN as if a bath had been given. Nurses’ notes for that date contained no documentation of a bath being provided or refused. Multiple staff interviews confirmed that scheduled showers were not consistently completed for all residents and that there were no bath sheets for the second resident over several days at the end of the month. A CNA reported the second resident stated they had not had a shower for two weeks and that aides told the resident there was not enough staff to bathe all residents. Nursing staff, including CNAs, LPNs, the ADON, and the DON, described a process in which CNAs should notify nurses of refusals, and nurses should document refusals and notify family and physicians, but review of the electronic health record and bath documentation showed no evidence that this process was followed for the missed bath date. The second resident stated they did not receive a bath over several consecutive days and reported being told by aides that staffing shortages prevented all residents from being bathed.
Failure to Perform Ordered IV Midline Dressing Change
Penalty
Summary
The facility failed to provide a physician-ordered IV midline dressing change for one resident receiving IV therapy. A physician’s order dated 07/09/25 directed that the resident’s IV midline dressing be changed on the day shift weekly on Friday, or sooner if the dressing became damp, loose, soiled, or if problems at the site required further inspection. The MAR for 07/11/25 showed the IV midline dressing change was missed, with no documented reason. The resident’s admission assessment dated 07/12/25 documented severe cognitive impairment with a BIMS score of 07, dependence in ADLs, and active IV access, with diagnoses including septicemia and renal failure. The resident’s care plan dated 07/28/25 indicated the resident was on IV therapy for infection and that medications and treatments were to be administered as ordered. A grievance form dated 07/16/25 documented that the resident’s family reported the IV dressing had not been changed since admission, and that the dressing present at that time was dated 07/03/25. Family reported being told by nursing staff that the dressing change had been missed because the resident was at dialysis when it was scheduled, and that it would be changed that day. A nurse progress note dated 07/18/25 stated the IV dressing change was not performed because it had been changed on 07/16/25. During interviews, the DON stated the resident had been out of the facility for an appointment and that the dressing change should have been done upon return, and the regional nurse consultant confirmed there was no documentation that the IV dressing change was performed before 07/16/25.
Failure to Notify Responsible Party of Change in Condition and New Medication Order
Penalty
Summary
The facility failed to ensure that responsible parties were notified in two separate instances for one resident. In the first instance, a resident with a history of hemiplegia, hemiparesis, cerebral infarction, muscle weakness, and bipolar disorder experienced a significant change in condition, including vomiting, inability to keep food, water, and medication down, increased confusion, and hallucinations. The physician ordered the resident to be sent to the emergency room, and documentation showed that the resident's spouse, who was also the roommate, was notified. However, there was no documentation that the designated HealthCare contact, the resident's daughter, was notified as required by facility policy. In the second instance, a new physician's order for alprazolam was issued for the same resident to address anxiety. Documentation indicated that the resident and the hospice company were notified of the new medication order, but again, there was no documentation that the HealthCare contact was informed. Interviews with staff confirmed that the daughter was listed as the HealthCare contact and should have been notified in both cases, but there were no notes indicating that this notification occurred.
Inaccurate Coding of Significant Change MDS Assessment
Penalty
Summary
The facility failed to accurately code a significant change Minimum Data Set (MDS) assessment for one resident. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and bipolar disorder. Documentation showed the resident was admitted to hospice care, with a hospice certification and physician's order confirming the start of hospice services. However, the significant change MDS assessment did not reflect the resident's hospice status, as the section for hospice care was not marked. The MDS coordinator confirmed that the assessment was related to the resident's transition to hospice but acknowledged that hospice was not coded on the MDS, resulting in an inaccurate assessment.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency were not provided in the report.
Failure to Document ADL Intake and Output for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure that activities of daily living (ADL) documentation was completed for one of three sampled residents reviewed for ADLs. Specifically, for a resident with diagnoses including hemiplegia, hemiparesis, muscle weakness, cerebral infarction, and bipolar disorder, there was no documentation of intake and output or meal percentages for a seven-day period leading up to a hospital stay. The resident was assessed as cognitively intact with a BIMS score of 15. Review of facility policy indicated that staff were required to document percentage consumed in the electronic health record (EHR), but no such documentation was found for the specified period. The regional nurse consultant confirmed that all available ADL documentation had been provided and acknowledged the absence of a generalized ADL policy, as well as the lack of a specific policy for documenting eating or intake and output.
Improper Use of Disinfectant Wipes for Blood Sugar Testing and Insulin Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed during blood sugar testing and insulin administration for two residents. On April 1, 2025, an LPN was observed using disinfectant wipes, which were not intended for use on skin, to clean the fingers of two residents before obtaining blood sugar levels. Additionally, the LPN used the same type of disinfectant wipe to clean the skin on a resident's abdomen before administering insulin. The disinfectant wipes' container and Safety Data Sheet explicitly stated they were not safe for skin contact. The facility's policy required the use of alcohol swabs for these procedures. The LPN acknowledged the correct procedure involved using alcohol swabs, indicating a deviation from established protocols.
Staff Competency with New EMR System Lacking
Penalty
Summary
The facility failed to ensure that staff were competent with the new Electronic Medical Records (EMR) system, affecting three staff members observed for competency. During a medication pass observation, a medication for a resident was not administered because the Certified Medication Aide (CMA) was unaware of how to verify if the medication had been ordered using the new EMR system. The CMA stated they had not received training on the new EMR and were unaware of how to check medication orders. Similarly, an LPN also reported not knowing how to order medication on the new EMR system. The corporate nurse indicated that a two-day training was conducted with key staff and nursing administration, who were then responsible for training the rest of the staff. However, in-service sheets did not show that the CMA, LPN, or the Activities Director (AD) attended the training sessions. During an interview, the AD asked the corporate nurse how to access care plans in the new system, further indicating a lack of training. The corporate nurse was unable to find additional in-service sheets to confirm that all staff had been trained, highlighting a gap in ensuring staff competency with the new EMR system.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered for five residents. Observations revealed that a CMA did not administer hydrocodone/acetaminophen to one resident and incorrectly administered Vitamin B12 without an order to another resident, while failing to administer thiamine and ferrous sulfate as prescribed. Another resident did not receive their prescribed lisinopril, and yet another resident did not receive their prescribed amlodipine and clindamycin. Additionally, an LPN administered only one capsule of gabapentin instead of two and failed to administer a potassium tablet due to an empty medication card. Interviews with staff revealed issues with medication availability and administration. A CMA stated that clindamycin was not in the facility and was unsure of the pharmacy's delivery timeline. An LPN acknowledged administering an incorrect dosage of gabapentin and not administering potassium due to an empty medication card. The corporate nurse explained the process for ensuring medications are administered per physician orders, including interfacing with the pharmacy through the EMR and faxing orders if necessary. However, the observations indicated lapses in following these procedures, leading to the deficiencies noted.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 23.68 percent. This deficiency was observed in the administration of medications to five residents. For instance, a Certified Medication Aide (CMA) did not administer hydrocodone/acetaminophen to one resident as ordered. Another resident was given Vitamin B12 without an order, while their prescribed thiamine and ferrous sulfate were not administered. Additionally, a resident did not receive their prescribed lisinopril, and another resident did not receive their ordered amlodipine and clindamycin. Further observations revealed that a Licensed Practical Nurse (LPN) administered only one capsule of gabapentin instead of the prescribed two and failed to administer a potassium tablet to a resident. The facility's Medication Administration policy requires medications to be administered according to prescriber orders, but this was not adhered to in these cases. Interviews with staff indicated issues such as medication unavailability and failure to follow the Medication Administration Record (MAR), contributing to the high error rate.
Infection Control Deficiency in Handling Soiled Linen and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices during the handling of soiled linen and hand hygiene during incontinent care for one of the sampled residents. On two separate occasions, staff members were observed not following the facility's infection control policies. An LPN was seen exiting a resident's room with a soiled incontinent pad without placing it in a bag before transporting it to the soiled utility room. This action was contrary to the facility's policy, which requires contaminated laundry to be bagged or contained at the point of collection. Additionally, a CNA was observed providing incontinent care to a resident without changing gloves after cleaning the resident. The CNA used the same soiled gloves to handle clean items, including a clean brief, incontinent pad, and draw sheet. Furthermore, the CNA placed soiled linen and wipes on the floor instead of in a plastic bag, and did not perform hand hygiene during the process. These actions were in violation of the facility's hand hygiene policy, which mandates handwashing after contact with soiled or contaminated articles.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate treatment and services to promote the healing of a pressure ulcer for a resident with multiple diagnoses, including Parkinson's disease and cognitive impairment. The resident's care plan required frequent turning and repositioning, as well as weekly skin inspections. Despite these requirements, the resident developed a stage 3 pressure ulcer on the sacrum, which worsened over time. Documentation revealed that the resident received only one wound care treatment between late April and early May, despite physician orders for bi-weekly treatments. Additionally, the facility staff did not document turning or repositioning efforts, relying instead on an informal understanding to make rounds every two hours. The DON confirmed that wound measurements were performed by hospice services, not facility staff. The deficiency was identified through observation, record review, and interviews. The resident's wound care was observed, and it was noted that the wound had increased in size. The DON acknowledged the lack of documentation for turning and repositioning and the missed wound care treatments. The facility's failure to adhere to the care plan and physician orders, as well as the lack of proper documentation and consistent wound care, contributed to the worsening of the resident's pressure ulcer.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to ensure that two residents experiencing pain received appropriate treatment. Resident #15, who had diagnoses including Parkinson's disease and cognitive communication deficit, fell and sustained a hip fracture. Despite the resident's cries of pain during incontinent care, CNA #1 did not notify the nurse and continued with the care. The DON later confirmed that CNA #1 was aware of the fall but did not stop to get the nurse when the resident expressed pain. Video surveillance showed the resident screaming in pain multiple times during care, but CNA #1 did not take appropriate action to address the pain. Resident #1, who had diagnoses including metabolic encephalopathy and anxiety disorder, experienced delays in receiving prescribed pain medication. The resident reported that it took 1.5 weeks to get their pain pills at the facility, and during this period, they were only offered Tylenol despite having a prescription for oxycodone. The DON confirmed that the resident's pain levels were documented as high as five on multiple occasions, but the resident only received Tylenol and not the prescribed oxycodone until the order was received on 02/29/24. The facility's failure to provide timely and appropriate pain management for both residents resulted in prolonged pain and discomfort. The staff did not follow the facility's Pain Management and Basic Comfort Measures policy, which required evaluating pain and providing appropriate interventions. The lack of communication and proper assessment by the staff contributed to the deficiencies in pain management for these residents.
Missed Care Plan Meeting for Resident
Penalty
Summary
The facility failed to ensure a care plan meeting was held and a resident's representative was included for one of three sampled residents reviewed for representative inclusion in the plan of care. Resident #4, who had diagnoses including chronic kidney disease and chronic pain, had a Care Plan Conference on 07/31/23 and an Annual Resident Assessment completed on 10/10/23. A Nurse's Note dated 10/17/24 documented an email was sent to Resident #4's representative regarding setting up a care plan meeting. However, the next documented Care Plan Conference for Resident #4 was on 02/09/24, indicating a missed care plan meeting. LPN #1, responsible for care plan meetings, stated that the meetings were supposed to be every three months and acknowledged that a meeting was missed because it was scheduled when they were not working, and no one covered for them.
Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure resident records were accurate for one of three sampled residents reviewed for accurate records. The Records Management policy, revised on 06/01/17, mandates that records be maintained in a consistent and logical manner, meeting legal standards for protection, storage, and retrieval, and protecting the privacy of healthcare facility residents and patients. However, Resident #3's clinical record contained hospital records belonging to four other residents. Specifically, hospital records for Residents #14, #13, #11, and #12 were found in Resident #3's clinical record. Medical Records staff stated that they received resident information in a basket by the scanner, which the ADON reviewed to ensure orders were correctly entered before scanning. Despite this process, incorrect documents were included in Resident #3's record, indicating a failure in the record management system.
Unclean Dishware in Kitchen
Penalty
Summary
The facility failed to ensure dishware was clean during a kitchen observation. The Cleaning Dishes in Dish Machine policy, dated 08/01/18, required dishes to be inspected and put away if clean and dry, and to repeat the cleaning steps if dishes were not clean. On 01/26/24 at 2:54 p.m., 32 blue-handled coffee cups were observed in the clean dish area with white residue, small particles, and visible contaminants inside. Cook #1 acknowledged the presence of the white substance and stated it did not look clean. The Corporate Dietary Manager also confirmed the debris and residue inside the cups when shown the cups at 3:05 p.m. The Administrator identified that 114 residents received nutrition from the kitchen.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control during the provision of incontinent care for two residents and did not ensure staff donned appropriate PPE before entering a COVID-19 positive room. For Resident #8, a CNA did not change gloves during the entire process of providing incontinent care, including when handling clean and dirty items. The CNA also placed a dirty pad on the floor instead of disposing of it immediately. Similarly, for Resident #10, another CNA did not change gloves during the provision of incontinent care, resulting in the resident being left with a smear of fecal matter on their anal area. The CNA also failed to take the trash out of the room promptly. Both CNAs acknowledged their failure to change gloves as required by the facility's policy during their respective tasks. Additionally, the facility did not ensure that staff wore the required PPE when entering a COVID-19 positive room. A CMA entered Resident #11's room without wearing an N95 mask, gown, face shield, and gloves, despite the posted precautions indicating these were necessary. The CMA stated they believed the precautions only applied to direct care involving body contact. The DON confirmed that staff were required to wear full PPE in COVID-19 isolation rooms, indicating a lapse in adherence to the facility's infection control policies.
Failure to Provide Thorough Incontinent Care
Penalty
Summary
The facility failed to ensure thorough incontinent care for a resident diagnosed with hemiplegia and hemiparesis. The resident's care plan required perineal care with incontinent changes. During an observation, a CNA performed incontinent care but did not clean the resident's labia, only wiping the groin and buttocks. The CNA acknowledged the omission, stating they did not wipe the labia because the resident had just voided. This action was contrary to the facility's perineal care policy, which mandates cleaning the labia majora and washing downward from the pubic area toward the rectum in one smooth stroke.
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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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