Betty Ann Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grove, Oklahoma.
- Location
- 1400 South Main Street, Grove, Oklahoma 74344
- CMS Provider Number
- 375457
- Inspections on file
- 23
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Betty Ann Nursing Center during CMS and state inspections, most recent first.
A resident with communication and mobility impairments reported sexual abuse by another resident. Although law enforcement was notified and the resident was relocated for safety, the facility did not notify the health department within the required two-hour window, as confirmed by staff interviews and documentation.
A resident with a history of mental health issues and moderate cognitive impairment physically assaulted eight other residents on multiple occasions. Despite repeated incidents, staff did not implement new interventions or increase monitoring, and the care plan was not updated to address the ongoing aggressive behaviors. Staff interviews confirmed a lack of special precautions or changes in care, resulting in continued resident-to-resident abuse.
A resident with behavioral health diagnoses repeatedly engaged in physical altercations with other residents, but the care plan was not updated with new interventions despite ongoing incidents and documentation. The DON confirmed the care plan remained unchanged and ineffective in addressing the resident's behaviors.
A facility failed to thoroughly investigate an abuse allegation involving a resident with schizophrenia and anxiety disorder. The investigation was limited to statements from the alleged abuser and the reporter, with no interviews conducted with other residents, staff, or visitors. The DON admitted that a more comprehensive investigation was necessary.
The facility did not ensure survey results were accessible to residents and visitors. Although policy stated results should be in the front lobby with signage, residents and staff were unaware of their location. The results were kept in a locked area, and the DON had them in their office for months, unaware they needed to be accessible. The administrator admitted the signage had been removed.
The facility failed to complete and communicate baseline care plans within 48 hours of admission for two residents. One resident with chronic conditions did not have a care plan meeting or receive a summary, and the clinical record lacked a completed care plan. Another resident with diabetes and anxiety did not receive a care plan summary, and the document was incomplete. The DON was unsure about the process and acknowledged the oversight.
The facility did not ensure holding temperatures were obtained for the noon meal service. The Food Temperatures policy required temperatures to be recorded for each meal, but the temperatures documented were taken when the food was removed from the oven, not at serving time. Cook #1 confirmed they did not obtain holding temperatures before serving, relying instead on steam from the steam table. The dietary manager was unaware of the discrepancy in the temperature log.
The facility failed to provide pureed foods at a smooth consistency for two residents on pureed diets during a noon meal. Observations revealed that the turkey, dressing, and mixed vegetables were not properly pureed, containing visible pieces and being too thin. The dietary manager confirmed the inconsistency, noting that pureed foods should resemble smooth mashed potatoes.
The facility failed to maintain proper food storage and infection control practices. Uncovered and undated food was found in a refrigerator, and kitchen staff did not follow hand hygiene protocols during meal service. A CNA delivering meals to residents' rooms also neglected hand sanitization. Additionally, the ice machine was observed in an unsanitary condition, with residues present. These deficiencies highlight lapses in adhering to established policies for food safety and infection control.
The facility failed to maintain infection control protocols during medication administration and wound care. An LPN was observed not changing gloves or sanitizing hands between tasks for residents on enhanced barrier precautions. Additionally, a CMA did not sanitize hands between residents while administering medications. The DON and infection preventionist confirmed these actions did not align with facility policies.
A resident with a history of cerebral vascular accident and hemiplegia was admitted with a weak left hand, but the facility failed to document this impairment in the admission assessment or develop a comprehensive care plan. Observations showed the resident's left hand was contracted, and staff were unaware of any limitations or interventions. The DON acknowledged the oversight in the assessment and care plan.
A resident with multiple health issues, including cerebral vascular accident and hemiplegia, did not have a comprehensive care plan addressing all their needs. The care plan only included DNR status and an indwelling catheter, despite an assessment identifying ten areas of concern. The DON admitted to not monitoring the care plan development.
A facility failed to update the care plan for a resident with a history of pressure ulcers and diabetes. Although a physician's order required wound care for the right heel, this was not reflected in the care plan. Additionally, a quarterly assessment did not document any pressure wounds, despite the presence of a closed wound on the left heel. The DON acknowledged the care plan should have been updated.
A facility failed to implement interventions for a resident with hemiplegia and hemiparesis following a cerebral infarction, leading to a deficiency in maintaining range of motion. The resident's admission assessment did not document any impairments, despite noted left hand weakness. A CNA and LPN were unaware of any interventions, and the DON confirmed the oversight in documentation.
A facility failed to consistently offer and document dietary supplements for a resident with protein calorie malnutrition, leading to a 6.76% weight loss in one month. Despite physician orders for supplements between meals, records showed they were provided only 36 out of 72 times. Staff interviews revealed inconsistencies in the process, with unclear documentation practices and occasional resident refusals.
A resident with dementia and mood disorder did not receive a PSA test as ordered by the physician due to initial refusal and lack of follow-up by staff. Although the resident later complied with lab tests, the PSA was not conducted because it was missing from the electronic record. The DON admitted there was no monitoring to ensure labs were obtained or followed up on.
A facility failed to serve hot foods at palatable temperatures for a resident who ate meals in their room. The facility's policy required hot foods to stay above 140 degrees F, but a resident reported that meals were served cold. Observations showed that food was only slightly warm when delivered. The dietary manager noted that insulated lids and carts should be used to maintain temperatures, but the DON could not confirm if this was achieved for residents eating in their rooms.
Failure to Timely Report Alleged Abuse to Health Department
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident with aphasia and weakness to the health department within the required two-hour timeframe. Documentation showed that the resident reported being sexually abused by another resident, and the incident was recorded on an incident report form. The report indicated that local law enforcement was notified and the resident was moved to another room for safety. However, the health department did not receive notification of the allegation until several hours after the initial report, exceeding the mandated reporting window. Interviews with staff confirmed that the delay in reporting occurred and that the required timeframe was not met.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident physical assaults, resulting in nine incidents involving one resident physically assaulting eight other residents over a four-month period. The resident responsible for the assaults had a history of mental health diagnoses, including schizophrenia, anxiety disorder, depression, restlessness, and agitation, and was known to have moderate cognitive impairment. Despite repeated incidents of aggression, the facility did not implement new or effective interventions after the initial care plan was created, nor did they update the care plan to address the ongoing behaviors. Documentation shows that after each incident, staff separated the residents involved, assessed for injuries, and noted that they would monitor and intervene if further behaviors were observed. However, there was no evidence of increased monitoring, special precautions, or additional interventions being put in place for the resident exhibiting aggressive behaviors. Interviews with staff confirmed that the resident was not on any special monitoring or precautions, and staff were not aware of any specific changes to the resident's care plan to address the repeated assaults. The facility's policy required staff to monitor for aggressive behavior, make necessary changes to care plans, and transfer residents if care could not be provided safely. Despite this, the care plan for the resident in question was not updated after multiple incidents, and interventions remained unchanged and ineffective. The lack of timely and appropriate action to address the resident's escalating behaviors resulted in continued physical assaults on other residents.
Failure to Revise Care Plan After Repeated Resident-to-Resident Altercations
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple behavioral health diagnoses, including schizophrenia, anxiety disorder, depression, restlessness, and agitation. Despite repeated incidents where the resident physically assaulted other residents, the care plan, which was initiated shortly after admission, was not updated with new interventions. Documentation showed that the resident was involved in multiple altercations, including hitting, grabbing, and causing injury to other residents over several months. Each incident was documented, and staff responded by separating residents and monitoring for further behaviors, but no new interventions were added to the care plan. The facility's policy requires ongoing assessment and revision of care plans as residents' conditions change. However, the care plan for this resident remained unchanged despite ongoing aggressive behaviors and documented incidents. The Director of Nursing confirmed that the care plan had not been updated and that the existing interventions were not effective in addressing the resident's behaviors.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident diagnosed with schizophrenia and anxiety disorder, who was severely impaired in daily decision-making. The incident report documented an allegation of abuse involving the resident and an LPN in the resident's room. However, the investigation was limited to statements from the alleged abuser and the reporter of the alleged abuse, with no interviews conducted with other residents, staff members, or visitors. The Director of Nursing (DON) acknowledged that a more comprehensive investigation should have been completed, noting that other residents were not interviewed due to cognitive impairments and other staff members were not asked to provide statements as they were not in the area.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that survey results were posted and accessible for residents and visitors. The Survey Results policy indicated that survey results should be available in the front lobby, identified with a sign. However, during a resident council meeting, four residents stated they did not know where the survey results were located. Observations confirmed that neither the survey results nor signage indicating their location were present in the facility. The activities director was unaware of the location of the survey results, and the administrator stated that the results were in a locked lobby area, inaccessible to residents without staff assistance. The DON revealed that the survey results had been in their office for approximately four months and were unaware that they needed to be accessible. The administrator acknowledged that the signage indicating the location of the survey results had been removed.
Failure to Complete and Communicate Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were completed and communicated to residents or their representatives within 48 hours of admission, as required by their policy. Resident #150, who had diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and a pressure ulcer, reported not having a care plan meeting or receiving a summary of their baseline care plan after admission. A review of the clinical record confirmed that a baseline care plan had not been completed for this resident. The Director of Nursing (DON) acknowledged the oversight but could not explain why the care plan was not completed. Similarly, Resident #29, with diagnoses of diabetes, anxiety, and chronic pain, did not receive a summary of their baseline care plan. The baseline care plan document for this resident was incomplete, lacking signatures from the resident or their representative. The DON admitted uncertainty about who should receive the care plan summary and noted that resident representatives were typically contacted 10-14 days post-admission for care plan meetings. However, there was no documentation indicating that a summary of the baseline care plan had been provided to Resident #29 or their representative, and the resident confirmed that staff had not discussed the care plan with them upon admission.
Failure to Obtain Holding Temperatures for Noon Meal
Penalty
Summary
The facility failed to ensure that holding temperatures were obtained for the noon meal service, as observed on 10/01/24. The undated Food Temperatures policy required that temperatures of food items be taken and properly recorded for each meal. During the observation of the noon meal service, it was noted that the temperatures documented on the Daily Food Temperature Log were obtained when the food was removed from the oven, not at the time of serving. Cook #1 confirmed that they did not obtain holding temperatures before serving the food and relied on the steam from the steam table to assess the food's heat. The dietary manager was unaware of why the holding temperatures were not obtained or why the log indicated temperatures were taken at 11:30 a.m., despite the surveyor's presence in the kitchen at that time.
Failure to Ensure Smooth Consistency of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared to a smooth consistency for residents on pureed diets during the noon meal observation. Cook #1 was observed preparing the meal, which included turkey with gravy, dressing, mixed vegetables, bread, and lemon pudding. The turkey and gravy, as well as the dressing, contained visible pieces of food and were not smooth. The mixed vegetables were processed into a thin, runny consistency with remaining pieces of vegetables. Despite these inconsistencies, the meals were plated and prepared for delivery to residents. The dietary manager confirmed that pureed foods should be the consistency of smooth mashed potatoes and acknowledged that the turkey, dressing, and mixed vegetables were not prepared correctly, being clumpy and too thin. Cook #1 stated that they processed foods until they resembled baby food and visually checked for remaining pieces, but this method failed to achieve the required consistency. The deficiency was identified during the observation of the meal preparation process, highlighting a lapse in ensuring the dietary needs of residents on pureed diets were met.
Deficiencies in Food Storage and Infection Control Practices
Penalty
Summary
The facility failed to adhere to proper food storage and infection control practices, as observed in several instances. In one of the facility's refrigerators, eleven dessert dishes with sliced peaches were found uncovered and undated, contrary to the facility's policy that requires all refrigerated foods to be covered, labeled, and dated. The dietary manager acknowledged that the staff had not followed the policy, which is essential for maintaining food safety standards. During meal service, infection control practices were not consistently followed by the kitchen staff. Cook #1 and Cook #2 were observed handling various items, including meal tickets, countertops, and food, without changing gloves or washing hands as required. Both cooks admitted to not following proper procedures, such as using gloves when touching food and handling dessert bowls by the sides. The dietary manager confirmed that staff should use gloves and utensils like tongs to maintain hygiene during food preparation and service. Additionally, a CNA delivering meal trays to residents in their rooms did not sanitize their hands after handling personal items and assisting residents, which is against the facility's policy. The CNA admitted to forgetting to sanitize their hands, and the DON confirmed that hand sanitization is required between each resident. Furthermore, the ice machine was found to be in an unsanitary condition, with a slimy pink substance and other residues observed. The dietary manager and maintenance supervisor acknowledged that the ice machine was not cleaned as frequently as necessary to prevent contamination.
Infection Control Protocol Breach During Medication Administration
Penalty
Summary
The facility failed to maintain infection control protocols during medication administration and wound care for residents on enhanced barrier precautions. On October 1st, an LPN was observed administering insulin and checking blood sugar for two residents without changing gloves or sanitizing hands between tasks. The LPN handed used supplies to another LPN, who also failed to follow proper hand hygiene protocols. This breach in protocol occurred despite the residents being on enhanced barrier precautions, which require strict adherence to infection control measures. On October 2nd, a CMA was observed preparing and administering medications without sanitizing hands between residents. The CMA acknowledged the requirement to sanitize hands between residents but did not comply. The DON and infection preventionist confirmed that staff were expected to wash or sanitize hands between resident interactions and that the observed actions did not align with the facility's infection control policies.
Failure to Accurately Assess and Plan for Resident Mobility Impairment
Penalty
Summary
The facility failed to ensure that a resident's mobility impairment was accurately assessed and included in the care plan. Resident #29, who had a history of cerebral vascular accident, osteoarthritis, and hemiplegia/hemiparesis, was admitted with a noted weak left hand and no grasp due to a CVA. However, the admission assessment did not document this impairment, and the comprehensive care plan was not developed. A subsequent Functional Abilities and Goals Assessment initially failed to note any impairment, but a later assessment did document impairment to the upper and lower left side. Observations and interviews revealed that the resident's left hand appeared contracted, and no devices or restorative therapy were in place. Staff members, including a CNA and an LPN, were unaware of any limitations or interventions for the resident's left hand. The DON acknowledged that the impairment should have been included in the assessment and care plan but was not captured, and they could not explain why the assessment was not done.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including cerebral vascular accident, osteoarthritis, and hemiplegia/hemiparesis. The care plan, initiated on 08/02/24, only documented focus areas for DNR status and an indwelling catheter, neglecting other significant concerns. An admission assessment dated 08/15/24 identified ten areas of concern for care planning, such as cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence, behavioral symptoms, falls, nutritional status, dehydration fluid maintenance, dental care, pressure ulcer, and psychotropic drug use. However, only one of these concerns was included in the comprehensive care plan. The Director of Nursing acknowledged the oversight and admitted to not monitoring the care plan development.
Failure to Update Care Plan for Resident with Wound Care Needs
Penalty
Summary
The facility failed to ensure the care plan was revised and updated for a resident with a history of pressure ulcers and diabetes type II. The resident's care plan initially documented a wound to the left heel, which was noted as resolved. However, a physician's order later indicated the need for wound care on the right heel, which was not reflected in the care plan. A quarterly assessment also failed to document any deep tissue injuries or pressure wounds, despite the presence of a closed wound on the left heel observed during wound care. The Director of Nursing acknowledged that the care plan should have been updated to reflect the current wound care needs.
Failure to Implement ROM Interventions for Resident with Hemiplegia
Penalty
Summary
The facility failed to implement necessary interventions to prevent a reduction in range of motion and mobility for a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident was admitted with left hand weakness and no grasp due to a cerebrovascular accident, yet the admission assessment did not document any impairments to the upper or lower body. A CNA noted that the resident did not allow any interaction with their left hand and observed no supportive devices in the room. An LPN, unfamiliar with the resident, reported no limitations in range of motion and no interventions in place. The DON acknowledged that the resident's left hand was not fully functional and should have been documented in the assessment and care plan, but it was not captured.
Inconsistent Provision and Documentation of Dietary Supplements
Penalty
Summary
The facility failed to ensure that dietary supplements were consistently offered and documented for a resident diagnosed with moderate protein calorie malnutrition. The resident was 26% below their ideal body weight and had a physician's order for dietary supplements to be provided between meals. Despite this, the facility's records showed that supplements were documented as provided or offered only 36 times out of 72 opportunities. This inconsistency in documentation and provision of supplements contributed to a significant weight loss of 6.76% over one month for the resident. Interviews with facility staff revealed a lack of clarity and consistency in the process of providing and documenting supplements. The dietary department was responsible for providing supplements, while the nursing department was tasked with documenting the amount consumed. However, there were discrepancies in the documentation process, with some entries marked as 'response not required' without clear justification. The resident confirmed being offered snacks and shakes multiple times a day but admitted to occasionally refusing them. This situation highlights a breakdown in communication and procedure adherence among the facility's staff, leading to inadequate nutritional support for the resident.
Failure to Obtain Physician-Ordered Labs
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered by the physician for a resident reviewed for unnecessary medications. The resident, who had diagnoses including dementia, mood disorder, and unspecified psychosis, had a physician's order dated April 23, 2024, for a lipid panel and PSA for annual labs. However, the PSA was not obtained as ordered. The resident initially refused the lab tests for three days, but later complied in June and July 2024 after staff explained the tests to them. Despite this compliance, the PSA was not conducted because it was no longer in the electronic clinical record. The Director of Nursing (DON) acknowledged that there was no documentation of staff explaining the lab to the resident in April 2024 and admitted that there was no monitoring to ensure the labs ordered by the physician were obtained or followed up on if the resident initially refused.
Failure to Serve Hot Foods at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that hot foods were served at palatable temperatures for a resident who was reviewed for food. The facility's undated Food Temperatures policy required that hot foods stay above 140 degrees F and cold foods stay below 40 degrees F during the portioning, transporting, and serving process. However, a resident reported that hot foods were consistently served cold, particularly when meals were eaten in their room. During an observation, meal trays were prepared and placed on a metal cart with a plastic zippered cover. A test tray was used to assess the temperature of the food, which included penne pasta with chicken and alfredo sauce, green beans, bread, and spiced apples. When the test tray was checked after delivery, the penne pasta and green beans were only slightly warm. The dietary manager stated that food holding temperatures should be obtained before serving, and insulated lids and food carts should be used to maintain palatable temperatures. The DON was unable to confirm if hot foods were served hot to residents eating in their rooms.
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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