Baptist Village Of Oklahoma City
Inspection history, citations, penalties and survey trends for this long-term care facility in Oklahoma City, Oklahoma.
- Location
- 9700 Mashburn Blvd, Oklahoma City, Oklahoma 73162
- CMS Provider Number
- 375381
- Inspections on file
- 21
- Latest survey
- October 1, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Baptist Village Of Oklahoma City during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral challenges was physically abused by a CNA during care, resulting in visible injuries and fear. The abuse was witnessed by another CNA, who delayed reporting the incident. Documentation and staff interviews confirmed the resident was not protected from abuse, as required by facility policy.
A resident who was unable to bear weight and required total assistance was transferred by three CNAs using an unsafe method, with a loose gait belt and lifting under the arms, resulting in pain and distress. Staff had reported the resident's decline and the need for a mechanical lift, but the care plan and transfer procedures were not updated, and interdisciplinary team meetings did not address the change in transfer needs.
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices, leading to a deficiency in infection prevention and control. Staff were unaware of the need for these precautions, and residents reported incomplete use of PPE during care.
A CNA in a memory care unit was found to have physically restrained a resident with Alzheimer's and cognitive impairments by grabbing them to force them into a seated position. The resident, who was independent in ambulation, showed no physical harm upon assessment. The CNA was terminated following an investigation that confirmed the abuse allegation.
An Immediate Jeopardy situation was identified in a memory care unit due to unsafe conditions in the shower room. The door failed to close and lock automatically, allowing residents unsupervised access. The room had a wet floor, a plugged-in hair dryer, numerous bottles of personal care products, and an unlocked cabinet with razors. Emergency call lights were looped around grab bars, making them unusable. An LPN confirmed these conditions were against protocol, and 28 residents were potentially affected.
A resident with parkinsonism and pain experienced a fall resulting in a fractured finger. Despite orders for buddy taping and a recommendation for a splint, the facility failed to document the application of the buddy tape and did not provide range of motion exercises or physical therapy. The resident reported not receiving therapy or seeing an orthopedic surgeon for two months, leading to a decline in hand functionality.
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for residents on psychotropic medications, as required by their policy. Four residents were not reviewed for GDR, despite being on multiple psychotropic medications. For instance, a resident with dementia and depression was on escitalopram and trazodone without any documented recommendation for a GDR. Another resident with emotional lability and anxiety was prescribed multiple medications, and although the pharmacist suggested a GDR, no changes were made. Additionally, a resident with Alzheimer's disease and dementia was on several medications, and despite experiencing a fall, there was no documentation of a GDR review.
The facility did not post the breakfast menu as required by their policy, which states that menus should be posted at least one week in advance and in a readable font size. This was observed on two occasions, and the Registered Dietician was unsure if the menu was posted. The facility houses 101 residents.
The facility did not inform residents of their right to hold resident council meetings without staff presence, as required by their policy. During interviews, nine residents expressed unawareness of this right, and a social service staff member admitted to not knowing the policy, indicating a need for review.
The facility did not ensure the ombudsman's contact information was accessible to residents, interfering with their rights to communicate with the state's ombudsman office. Residents were unaware of the ombudsman's role or contact details. The information was posted in small print and out of view for wheelchair users, with no information board on the skilled halls.
The facility failed to distribute mail to residents on weekends. Nine members of the resident council reported that mail was not distributed on weekends, and social services staff confirmed that mail delivered on Saturdays was not passed out until Monday. This affected the 101 residents residing in the facility.
The facility did not ensure survey results were easily accessible to residents and visitors. Resident council members were unaware of the location of the state inspection book, and while a sign on the LTC halls indicated survey results were at the front desk, there was no such information in the skilled halls.
The facility did not ensure residents and their representatives could file grievances anonymously or were informed about the grievance official. Despite a policy stating the provision of a grievance mechanism without fear of retaliation, residents were unaware of how to file grievances, and social services staff were unsure of the grievance official's identity.
A resident with parkinsonism and pain experienced a fall resulting in a fractured finger. Despite a physician's order for ice packs and an orthopedic referral, the resident did not receive timely care. The resident was not seen by a provider for nearly a month, and the orthopedic consultation was delayed for over two months. An LPN acknowledged the failure to set up the appointment, and the DON confirmed the delay, noting that only ice packs and Tylenol were provided during the interim.
The facility failed to assess and document the use of bed rails for two residents, one with a leg fracture and another with hemiplegia. Both residents used bed rails without documented assessments, physician's orders, or informed consent, as confirmed by facility staff.
The facility failed to comply with its policies on food storage, handling, and sanitization, resulting in several deficiencies. Food items were not labeled or stored properly, and hot food temperatures were not maintained or documented as required. Additionally, staff did not change gloves between tasks, and the dishwasher lacked sanitizer solution, compromising cleanliness. These lapses indicate a failure to adhere to established food safety protocols.
The facility failed to ensure call devices were accessible for two residents in the memory care unit. One resident with dementia and heart failure had a call light cord hanging over the head of the bed, while another with diastolic heart failure and Alzheimer's had cords over the foot of an empty bed. A CNA confirmed the inaccessibility, and the DON stated call devices should always be within reach.
A facility failed to promote resident dignity by not following its policy for meal assistance. A resident with Alzheimer's disease, requiring supervision with eating, was assisted by an LPN who stood while helping the resident, contrary to the policy that staff should be seated. Both the LPN and the DON acknowledged the policy violation.
A facility failed to ensure a resident had a physician order and assessment for self-administering a nasal spray. The resident was observed with the spray on their nightstand and confirmed self-administration. An LPN and the DON acknowledged the absence of required documentation for self-administration.
A facility failed to accurately complete a quarterly MDS assessment for a resident with parkinsonism and a psychotic disorder. Despite a physician's order for Nuplazid, an antipsychotic, and its documented administration, the admission assessment incorrectly noted that the resident had not received antipsychotic medications. This error was confirmed by the MDS Coordinator.
The facility failed to update care plans for two residents to include the use of bed rails, as required by their policies. A resident with a leg fracture and another with hemiplegia had bed rails in use, but their care plans did not document this. The MDS Coordinator confirmed the omission, and the DON acknowledged the presence of bed rails since admission.
A facility failed to follow physician's orders for a resident with chronic respiratory failure and COPD by not changing oxygen tubing and cleaning concentrator filters weekly. Observations revealed outdated tubing and dusty filters, which an LPN confirmed were not maintained as required.
The facility did not post complete nurse staffing information, including actual hours worked and resident census, in a prominent place. Observations on multiple dates revealed that assignment sheets lacked this information, and no RNs were listed. The AIT confirmed the omission of hours and census details.
A facility failed to maintain infection control when a CNA handled wet linens without wearing gloves and carried them down the hall without placing them in a bag, allowing them to touch their clothing. The DON confirmed that wet linens should be bagged and gloves worn when handling soiled linens, as per the facility's infection control policy.
The facility did not update its facility-wide assessment annually as required. The last update was in 2017, and the Administrator confirmed that the assessment had not been revised since then, despite having 101 residents. The process for updating information was acknowledged but not executed.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A resident with severe cognitive impairment, multiple chronic conditions, and a history of behavioral challenges was physically abused by a certified nurse aide (CNA) during care. The resident, who required substantial assistance with transfers and had a BIMS score indicating severe cognitive impairment, was observed to have two red marks on their right leg that were tender to touch. The abuse occurred when the resident became aggressive and resistant to care, leading the CNA to respond by grabbing the resident's face, twisting their head and fingers, pulling their hair, and punching the resident twice in the leg. The incident was witnessed by another CNA, who later reported the abuse to a nurse. The resident was able to recall being hit and having their hair pulled during an assessment, although they could not identify the perpetrator by name but indicated it was a male. Documentation from staff statements and progress notes confirmed the physical abuse, with the nurse and DON both assessing the resident for injuries and noting the presence of red marks and tenderness on the leg. The resident's family was notified of the incident and confirmed that the resident reported being struck by a male staff member. Staff interviews indicated that the resident had not previously complained about staff and that this was the only reported incident of abuse involving the CNA in question. The incident caused the resident to express fear of the CNA involved, and staff also reported feeling afraid of the CNA due to their actions. The facility's abuse policy defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The events leading to the deficiency included the CNA's reaction to the resident's aggressive behavior by inflicting physical harm, the delay in reporting the abuse by the witnessing CNA, and the subsequent identification of physical injuries consistent with the reported abuse. The facility's documentation and staff interviews confirmed that the resident was not protected from abuse as required by policy.
Unsafe Transfer Practices Result in Resident Distress
Penalty
Summary
The facility failed to provide safe transfer procedures for a resident who was unable to bear weight on their lower extremities and required total assistance. During an observed transfer from bed to wheelchair, three CNAs assisted the resident using a loose-fitting gait belt placed around the upper body, while two CNAs lifted the resident under the arms, causing the resident to moan and grimace in pain. The resident's care plan indicated a two-person assist for transfers, but the method used placed undue stress on the resident's arms and shoulders, and the resident was unable to communicate their pain level. Staff interviews revealed that CNAs had reported the resident's decline and the need for a mechanical lift to the charge nurse and hospice staff over the preceding months, expressing concerns for both resident and staff safety. Despite these reports, the care plan and transfer method were not updated to reflect the resident's increased needs. The interdisciplinary team meetings did not document discussion of transfer needs, and there was a lack of timely reassessment and adjustment of the transfer process, even as staff recognized the resident was no longer able to assist in transfers.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents with indwelling devices, leading to a deficiency in infection prevention and control. Resident #1, who had diabetes mellitus with peripheral angiopathy and gangrene, was dependent on staff for daily living activities and had a central line for antibiotic administration. Resident #3, diagnosed with cystitis and bacteremia, also relied on staff for daily activities and had an indwelling catheter. Observations revealed that their rooms lacked signage indicating the need for enhanced barrier precautions, and there were no PPE carts nearby. Interviews with staff highlighted a lack of understanding and implementation of enhanced barrier precautions. LPN #1 and LPN #2 were unaware of what enhanced barrier precautions entailed, although they were familiar with standard and isolation precautions. The Director of Nursing (DON) indicated that such precautions were only implemented with a confirmed communicable disease diagnosis. Residents reported that while staff washed hands and wore gloves during care, they did not wear gowns, which are part of enhanced barrier precautions. This oversight was only addressed after it was brought to the facility's attention.
CNA Physically Restrains Resident in Memory Care
Penalty
Summary
The facility failed to prevent a certified nursing assistant (CNA) from physically restraining a resident, which constitutes a deficiency in ensuring residents are free from physical restraints unless needed for medical treatment. The incident involved a resident with Alzheimer's, anxiety, depression, and cognitive communication deficit, who was severely cognitively impaired and had a history of wandering. The deficiency was identified when an incident report documented that, following an allegation of abuse, camera footage showed the CNA grabbing the resident by the arm and shirt to force them into a seated position. The resident, who resided in memory care and was independent with ambulation, did not exhibit any physical harm such as redness, bruising, or swelling upon assessment after the incident. The CNA involved was terminated following the investigation that substantiated the abuse allegation. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property defines abuse as the willful infliction of injury or unreasonable confinement, which was violated in this case.
Immediate Jeopardy Due to Unsafe Shower Room Conditions
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified in a memory care unit due to the facility's failure to ensure the shower room door closed and locked automatically, preventing residents from entering unsupervised. During an initial tour, the shower room was found with a wet and slippery floor, a plugged-in hair dryer placed in the grab bar area, and more than ten bottles of shampoos, conditioners, alcohol-based surface cleaner, and shaving cream covering over half of the shower bench. Additionally, the cabinet in the shower room was unlocked, with razors within reach, and two emergency call lights were looped around grab bars, rendering them unusable for alerting staff for assistance. The Director of Nursing (DON) identified that 28 residents resided on the memory care unit, all potentially affected by these hazards. An LPN confirmed that the shower room door was supposed to be shut and locked, the hair dryer should not have been plugged in, and chemicals should not have been present. The running water was acknowledged as a hazard, and the call lights should not have been wrapped around the grab bar. It was also stated that residents were not to be in the shower room without staff supervision.
Removal Plan
- The shower room door was trimmed to ensure self-closure.
- The hair dryer had been removed from the grab bar and locked in the shower room cabinet. The hair dryers were removed from the locked cabinet and completely removed from the shower room.
- The ten bottles of shampoos, conditioners, alcohol-based surface cleaner and shaving cream were removed from the shower room.
- The cabinet in the shower room was locked.
- All nursing team members in the building were educated, and all remaining team members were educated. Proof of education is attached.
Failure to Prevent Decrease in Range of Motion for Resident's Fractured Finger
Penalty
Summary
The facility failed to prevent a decrease in range of motion for a resident with a fractured finger. The resident, who had diagnoses including parkinsonism and pain, experienced a fall resulting in a fracture of the right ring finger. Despite a physician's order to buddy tape the fingers and a subsequent recommendation for a finger splint and surgical evaluation, there was no documentation that the buddy tape was applied as ordered. The resident reported not receiving therapy for the finger and not seeing an orthopedic surgeon for two months following the injury. Observations confirmed the resident's inability to straighten the ring finger, and the facility did not provide range of motion exercises or physical therapy to address the fracture. The LPN and DON acknowledged the lack of implementation of the buddy tape order and the absence of range of motion or physical therapy interventions. This inaction contributed to the resident's decline in hand functionality, as noted by the LPN, who was unaware of the resident's ability to straighten the finger prior to the fracture.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for residents on psychotropic medications, as required by their policy. The report highlights that four residents were not reviewed for GDR, despite being on multiple psychotropic medications. For instance, Resident #40, diagnosed with dementia and depression, was on escitalopram and trazodone without any documented recommendation for a GDR. The pharmacist stated they were following the resident's wishes, indicating a lack of adherence to the facility's policy. Resident #14, with emotional lability and anxiety, was prescribed multiple medications, including Effexor, Xanax, Seroquel, and lamotrigine. Although the pharmacist suggested a GDR, the resident did not want their medications changed, and the APRN confirmed that no GDR recommendation was made. Similarly, Resident #33, with Alzheimer's disease and dementia, was on several medications, including melatonin, bupropion, Zoloft, risperidone, and Seroquel. Despite experiencing a fall resulting in a fracture, there was no documentation of a GDR review, and subsequent medication reviews did not address the need for GDR. Resident #41, admitted with dementia and behavioral disturbances, was prescribed quetiapine, despite FDA warnings against its use in dementia-related psychosis. The pharmacist deemed it appropriate, but the report notes the increased risk of death associated with such treatment. Overall, the facility's failure to adhere to its policy on GDR and non-pharmacological interventions for psychotropic medications resulted in deficiencies in medication management for these residents.
Failure to Post Breakfast Menu
Penalty
Summary
The facility failed to ensure that the breakfast menu was posted, as required by their policy. The policy, dated January 24, mandates that menus be posted at least one week in advance and in a font size that is easily readable by all residents. On July 12, at 8:31 a.m., it was observed that no breakfast menu was posted. Additionally, on July 16, at 2:08 p.m., the Registered Dietician reported uncertainty about whether the menu was posted. This deficiency affected the facility, which houses 101 residents, as reported by the Director of Nursing (DON).
Failure to Inform Residents of Right to Private Meetings
Penalty
Summary
The facility failed to notify residents of their right to hold resident council meetings without staff presence, which interfered with their ability to organize and participate in such meetings privately. The deficiency was identified through record review and interviews, revealing that the residents were unaware of this right. The facility's policy on Resident Rights: Resident and Family Groups, dated 02/20/24, stated that team members, visitors, and other guests may only attend the meeting upon invitation. However, during an interview on 07/17/24, nine residents in attendance expressed their lack of awareness regarding their right to conduct meetings without staff. Additionally, a social service staff member acknowledged their unawareness of this policy and indicated a need to review it.
Ombudsman Contact Information Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the ombudsman's contact information was accessible and visible to residents, which interfered with their rights to communicate and access the state's ombudsman office. During an interview with nine resident council members, it was revealed that they were unaware of who the ombudsman was, their purpose, or where to find that information. An observation showed that the ombudsman's contact information was posted on an information board by the long-term care halls, but it was written in small print and displayed out of view for residents utilizing a wheelchair. Additionally, there was no information board located on the skilled halls, further limiting access to this important information for residents.
Failure to Distribute Mail on Weekends
Penalty
Summary
The facility failed to provide mail delivery to residents on Saturdays, resulting in a deficiency. On July 17, 2024, at 11:22 a.m., nine members of the resident council reported that mail was not distributed on weekends. At 11:24 a.m., the social services staff confirmed that while mail was delivered on Saturdays, it was not distributed to residents until Monday. This affected the 101 residents residing in the facility, as identified by the Director of Nursing (DON).
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey results were readily accessible and available to residents and visitors. During an observation and interview on July 17, 2024, at 11:28 a.m., nine resident council members stated they did not know where the state inspection book was located. Additionally, at 11:43 a.m., a sign was observed on the information board in the long-term care halls indicating that survey results could be found at the front desk. However, there was no sign or mention of the survey results in the skilled halls.
Failure to Ensure Anonymous Grievance Filing and Identification of Grievance Official
Penalty
Summary
The facility failed to ensure that residents and their representatives could file grievances anonymously and were informed about the grievance official. The grievance policy, dated February 2024, stated that the health center would provide a mechanism for filing grievances without fear of retaliation and would inform residents and their representatives about the grievance process and the designated grievance official. However, during an interview on July 17, 2024, resident council members expressed that they were unaware of how to file a grievance, relying instead on staff to address their issues. Additionally, social services staff were uncertain about the identity of the grievance official, indicating a lack of communication and implementation of the grievance policy.
Delay in Care for Fractured Finger
Penalty
Summary
The facility failed to provide timely care to a resident with a fractured finger. The resident, who had diagnoses including parkinsonism and pain, experienced a fall and complained of pain in their right hand. An x-ray confirmed an acute fracture in the right proximal phalanx of the fourth finger. A physician's order was given for ice pack application four times daily and an orthopedic hand specialist referral was made. However, the resident was not seen by any provider until nearly a month later, and the orthopedic consultation did not occur until over two months after the fall. The delay in care was acknowledged by an LPN, who stated that the appointment was not set up and should have been followed up to prevent the delay. The DON confirmed the delay in care and stated that the interventions during the period included ice packs and Tylenol as needed for pain.
Failure to Document Bed Rail Assessment and Consent
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails for two residents. Resident #4, who had a fracture of the right lower leg and required extensive assistance with transfers, was observed with bed rails in use without any documented assessment, physician's order, or informed consent. Despite the resident using the rails for positioning since January, the necessary documentation was not found, as confirmed by the LPN and the Director of Quality. Similarly, Resident #19, admitted with hemiplegia and hemiparesis and severe cognitive impairment, had been using bed rails since admission without any documented assessment, physician's order, or informed consent. The DON confirmed the absence of these critical documents, indicating a failure in the facility's adherence to its own bed rail policy and procedure.
Deficiencies in Food Storage, Handling, and Sanitization Practices
Penalty
Summary
The facility failed to adhere to its policies regarding food storage, handling, and sanitation, leading to multiple deficiencies. Observations revealed that food items such as tater tots, chicken tenders, and bread were not labeled, dated, or stored according to the facility's policy. Additionally, a bowl of sausages was found uncovered on the counter. The facility's policy required that all food items be covered, labeled, and dated, which was not followed. Furthermore, the temperature of bacon was recorded at 125 degrees Fahrenheit, below the required 135 degrees Fahrenheit for hot food service, indicating improper food handling practices. The facility also failed to ensure proper glove use and sanitization practices. Dietary Aide #2 did not change gloves between tasks, such as cracking eggs and handling silverware, contrary to the facility's policy. Additionally, the dishwasher was found without sanitizer solution, preventing the measurement of parts per million (ppm) and compromising dish cleanliness. The facility's policy required a sanitizer solution concentration of 50-100 ppm sodium hypochlorite. Moreover, there was a failure to document hot food temperatures as required by the facility's guidelines, further indicating lapses in adherence to food safety protocols.
Inaccessible Call Devices in Memory Care Unit
Penalty
Summary
The facility failed to ensure that call devices were accessible to residents in the memory care unit, affecting two residents. One resident, diagnosed with dementia and heart failure, was observed with the call light cord hanging over the head of the bed, making it inaccessible. Another resident, with diastolic heart failure and Alzheimer's disease, was found with call light cords hanging over the foot of an empty bed, also out of reach. A CNA confirmed that the call light cords were not within reach for both residents. The Director of Nursing acknowledged that call devices should be within reach at all times.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote resident dignity by not adhering to its policy regarding meal assistance. A resident with Alzheimer's disease, who was severely cognitively impaired and required supervision or touching assistance with eating, was observed being assisted by an LPN while the LPN was standing. This occurred on two separate occasions during the same meal period. The facility's policy mandates that staff should be seated when assisting residents with meals. The LPN acknowledged standing while assisting the resident and confirmed that this was against the facility's policy. The Director of Nursing also stated that staff should be seated when assisting residents with meals.
Failure to Obtain Physician Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident had a physician order and an assessment to self-administer medications. This deficiency was identified during an observation where a bottle of saline nasal spray was found on the nightstand of a resident, who stated they self-administered the spray at night. Upon review, there was no documentation of a physician's order or an assessment for the resident to self-administer the nasal spray. An LPN confirmed that the resident did not have the necessary physician order or assessment. The Director of Nursing acknowledged that a self-administration evaluation and physician order were required for medications kept at the bedside.
Inaccurate MDS Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately complete a quarterly assessment for a resident, leading to a deficiency in the accurate completion of Minimum Data Set (MDS) assessments. The resident, who was admitted with diagnoses including parkinsonism and a psychotic disorder with hallucinations, had a physician's order to receive 34 mg of Nuplazid, an antipsychotic medication, at bedtime. However, the admission assessment incorrectly documented that the resident had not received antipsychotic medications, despite the February Medication Administration Record (MAR) showing that Nuplazid had been administered daily during the look-back period. This discrepancy was confirmed by the MDS Coordinator, who acknowledged that the admission assessment was not coded correctly.
Care Plan Deficiency: Bed Rail Use Not Documented
Penalty
Summary
The facility failed to ensure that the care plans for two residents were revised to include the use of bed rails, as required by their policies. Resident #4, who had a diagnosis of a fracture of the right lower leg and required assistance with personal care, was observed with two bed rails up on each side of the head of the bed. However, the care plan for Resident #4 did not document the use of these bed rails. MDS Coordinator #2 confirmed that the use of positioning rails was not documented in the care plan, although it should have been. Similarly, Resident #19, who was admitted with diagnoses of hemiplegia and hemiparesis, had bed rails in use since admission. Despite this, the care plan for Resident #19 also failed to document the use of bed rails. The DON acknowledged the presence of bed rails since admission, and MDS Coordinator #2 confirmed the omission in the care plan documentation.
Failure to Maintain Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to adhere to physician's orders regarding the maintenance of oxygen equipment for a resident with chronic respiratory failure and chronic obstructive pulmonary disease. The physician's order, dated April 10, 2024, specified that the nasal cannula should be changed, and the concentrator filters should be cleaned and dried once a week. However, on July 15, 2024, it was observed that the oxygen tubing on the concentrator was last changed on June 24, 2024, and the tubing on the portable tank was last changed on June 3, 2024. Additionally, the concentrator filters had visible dust buildup. An LPN confirmed that the tubing and filters were not changed or cleaned as ordered, despite the facility's policy requiring weekly changes.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information, including the facility name, date, actual hours worked for RNs, LPNs, CMAs, and CNAs, and the resident census, was posted in a prominent place readily accessible to residents and visitors. During a tour of the memory care unit on 07/15/24, it was observed that a plastic note holder outside the nurses' station contained a daily assignment sheet listing staff members for the 7:00 a.m. to 3:00 p.m. shift, but it lacked the resident census and actual hours worked. Additionally, no RNs were listed on the page. Similar observations were made on 07/17/24, where assignment sheets on each unit also lacked the required information. On 07/19/24, the AIT confirmed that the hours worked were not included on the sheets and that the census was not documented, although RNs were present in the building.
Infection Control Breach in Handling Wet Linens
Penalty
Summary
The facility failed to maintain proper infection control procedures while handling wet linens. During an observation, a wet cloth bed pad, a wet blanket, a wet gown, and a clear trash bag were found on the floor in a resident's room. A CNA entered the room and picked up the dirty linens without wearing appropriate personal protective equipment (PPE), specifically gloves, and carried the wet linens down the hall without placing them in a bag, allowing them to touch their clothing. The CNA acknowledged that gloves should have been worn when handling soiled linens. The Director of Nursing (DON) confirmed that wet linens should be placed in a bag and not on the floor, and that gloves are required when picking up soiled linens. The facility's infection control policy and PPE use policy emphasize the importance of using PPE to prevent the spread of infections, particularly when there is potential exposure to blood, bodily fluids, or pathogens.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to ensure that a facility-wide assessment was updated annually, as required. The last documented update of the Facility Assessment Tool was on November 21, 2017, and the review with the Quality Assurance and Performance Improvement (QAA/QAPI) committee was on December 13, 2017. During an interview on July 19, 2024, the Administrator acknowledged that the facility assessment should be updated annually and stated that their process involved changing any information that required updating. However, upon review, it was confirmed that the facility assessment had not been updated since 2017, despite the presence of 101 residents in the facility.
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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