Brentwood Extended Care & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskogee, Oklahoma.
- Location
- 841 North 38th Street, Muskogee, Oklahoma 74401
- CMS Provider Number
- 375174
- Inspections on file
- 28
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Brentwood Extended Care & Rehab during CMS and state inspections, most recent first.
The facility did not submit required PBJ staffing data to CMS for a full quarter when 55 residents were present, due to the departure of the employee responsible for the submission and the lack of another staff member able to complete the task.
A facility administrator, who was new and untrained in abuse investigation procedures, failed to properly investigate an allegation of physical abuse involving a resident with intact cognition. The administrator did not conduct required interviews, failed to restrict the accused staff member's contact with the resident, and did not notify authorities within mandated timeframes, resulting in a deficient investigation.
A resident with intact cognition reported being slapped by a staff member, but the facility did not notify OSDH within the required timeframe and failed to contact law enforcement. The administrator stated these actions were not taken due to lack of training and awareness of reporting requirements.
A resident with intact cognition reported being slapped by a staff member, but the facility did not conduct timely interviews with staff or other residents as part of its abuse investigation. The administrator, who was new and untrained in the process at the time, acknowledged the investigation was incomplete.
A resident who was severely cognitively impaired and dependent on staff for bathing did not receive scheduled baths as required by facility policy. Over a three-month period, only six baths were documented, with multiple scheduled bath days lacking any record of completion or refusal. Staff interviews confirmed that all baths and refusals should be documented, but no additional records could be found to verify care was provided.
A facility failed to notify the legal representatives of three residents about inappropriate sexual behavior involving a resident with PVD and hypertension. Incident reports documented the behavior, but clinical records lacked family notification. The facility's policy required family notification, but an LPN did not find it necessary.
A resident with a history of CVA and PVD, dependent on staff for transfers, reported being handled roughly by staff, resulting in a red area and pain in the right upper arm. The resident also reported verbal abuse. An investigation revealed improper use of a mechanical lift by a CNA, leading to significant bruising. The CNA was terminated, and another was suspended.
A facility failed to submit the results of an abuse investigation to the SSA within the required timeframe. A resident with PVD and Diabetes Mellitus type two was reported for inappropriate behavior, and while an initial report was made, the final results were not submitted. The administrator admitted the oversight, believing the DON had completed the task.
The facility failed to assess two residents after an allegation of inappropriate sexual behavior by a resident. Despite the facility's policy requiring assessments, there was no documentation in the clinical records of the affected residents, who had conditions such as anxiety, depression, and dementia. Staff interviews confirmed the lack of assessments.
An IJ situation was identified due to the facility's failure to protect residents from falls resulting in major injuries. One resident fell twice, resulting in a broken neck, and another resident fell twice, resulting in a broken back. The facility did not document or implement required fall prevention interventions.
The facility failed to maintain a safe and clean environment, with issues including missing and cracked tiles, unrepaired damage in a resident's room, and leaking washing machines in the laundry room. Maintenance staff were unaware of these issues due to a lack of logged maintenance requests.
The facility failed to ensure that quarterly resident assessments were completed within 14 days of the assessment reference date for two residents. One resident's assessment was delayed by nearly a month, and another's by over a month. The administrator confirmed the assessments should have been timely but could not explain the delays.
The facility failed to document mental health diagnoses in the PASARR for two residents with major depressive disorder, anxiety, and delusional disorders. The administrator confirmed that these diagnoses should have been documented and OHCA notified.
The facility failed to ensure that baths were given as scheduled for two residents and that assistance with eating was provided for one resident. One resident did not receive documented showers for nearly a month, and another resident went one to two weeks without a shower. Additionally, a resident with hemiplegia and hemiparesis was observed eating with their hands in a dark dining room without staff assistance or supervision.
A resident with COPD and chronic pain did not receive prescribed pain medication and nebulizer treatments due to a mix-up in medication delivery and lack of coordination with hospice. Staff confirmed the absence of necessary medications, and the resident reported missing treatments since admission.
A resident with chronic pain and opioid dependence did not receive their prescribed pain medication for five doses due to a delay in receiving the medication from the pharmacy. The resident experienced severe pain and was unable to perform usual activities. The facility's policy to reorder medication in advance was not followed.
The facility failed to administer insulin and blood pressure medication per physician's orders for two residents, leading to significant medication errors. One resident received insulin despite low blood sugar levels, and another was prepared to receive Metoprolol despite a low diastolic blood pressure reading. Staff admitted to not following prescribed guidelines.
The facility failed to ensure proper infection control measures, including disinfecting a blood pressure machine between residents, preventing soiled linens from being placed on the floor, and correctly storing a nebulizer mouthpiece. Additionally, the facility lacked an infection surveillance system and a water Legionella prevention program.
The facility failed to implement a system to assess residents for infections using standardized tools before initiating antibiotics. Despite having a policy and new assessment forms, the facility had not tracked antibiotic use since December 2023, and it was unclear if the tools were used for residents administered antibiotics in early 2024.
The facility failed to provide a SNF ABN to a resident who was discharged from skilled services but remained in the facility. The MDS Coordinator confirmed that the resident was not given the required ABN form.
The facility failed to complete a significant change resident assessment within the required 14-day timeframe. The assessment, dated October 19, 2023, was not signed until November 9, 2023. The administrator acknowledged the delay but could not provide an explanation.
The facility failed to ensure accurate resident assessments for two residents. One resident was incorrectly documented as being on an anti-coagulant instead of an anti-platelet medication. Another resident was inaccurately documented as requiring restraints despite assessments indicating otherwise.
The facility failed to refer a resident with new mental health diagnoses to OHCA for a PASRR level II evaluation. The resident had a history of traumatic brain injury and was later diagnosed with a mood disorder and major depressive disorder with psychotic symptoms. The facility did not notify OHCA as required.
A facility failed to document hospice services and pain management interventions in a baseline care plan for a resident with chronic pain. The resident did not receive pain medication due to a delivery error, and the administrator confirmed the oversight.
The facility failed to assist a resident with limited range of motion in wearing their splint. The resident, with left-sided hemiplegia and contractures, reported that staff did not help with exercises or applying the splint, which had not been worn for about two months. Observations and interviews confirmed the lack of assistance, despite the resident's desire to wear the splint to prevent further contracture.
The facility failed to have physician orders for maintaining an indwelling urinary catheter for a resident admitted with urinary retention and kidney calculus. The facility's policy required a physician's order for catheter and bag changes at 30-day intervals, but no such order was present, and the catheter had been in place for over 30 days. The administrator confirmed the oversight.
The facility failed to follow the physician's orders for oxygen therapy for a resident with acute respiratory failure and tracheostomy. The resident's oxygen was consistently set at 2.5 liters per minute instead of the prescribed 3.5 liters per minute, and an LPN was unaware of the correct setting.
The facility failed to document and retain the required staffing information. White boards at each nursing station displayed the facility name, date, census, and staff titles, but did not include staffing hours worked. The administrator was unaware of the requirements and identified 49 residents in the facility.
A resident with ESRD was prescribed Eliquis with an incorrect diagnosis of hypertension. Despite a pharmacy review and physician concurrence, the diagnosis was not updated. The administrator confirmed the medication was for preventative use due to a dialysis fistula.
The facility failed to maintain a functional microwave for heating resident food after hours. A resident reported the issue, and dietary staff confirmed the lack of a working microwave. An attempt to replace it with a dirty, unusable microwave was made, which the administrator acknowledged should not be used.
A facility failed to provide a call light in the room of a resident with mobility issues, despite the facility's policy requiring every resident to have a functioning bedside call light. The resident confirmed the absence of the call light since moving into the room, and the administrator acknowledged the oversight.
Failure to Submit PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required Payroll-Based Journal (PBJ) staffing data to CMS for the second quarter of fiscal year 2025. Record review showed that no staffing data was provided for the period from January 1, 2025, through March 31, 2025, despite 55 residents residing in the facility during that time. During an interview, the office manager explained that the employee responsible for submitting the PBJ data was no longer employed at the facility, and at the time, there was no one available who could complete the submission.
Administrator Lacked Training, Leading to Inadequate Abuse Investigation
Penalty
Summary
The facility failed to ensure that the administrator was knowledgeable about and followed the facility's abuse policy, resulting in a substandard investigation of an abuse allegation involving one resident. The facility's policy required staff to be informed about abuse prevention, intervention, detection, and reporting requirements. A quarterly MDS assessment indicated that the resident involved had intact cognition at the time of the incident. An incident form documented an allegation of physical abuse, but the investigation records provided by the administrator did not include interviews with staff or other residents regarding the alleged abuse. During interviews, the administrator confirmed that they were responsible for conducting abuse investigations but admitted to being unaware of all investigation requirements at the time, as they were new to the organization and had not received training. The administrator did not conduct interviews with staff or residents, did not suspend or otherwise restrict the accused staff member from contact with the resident during the investigation, and failed to notify the state health department and local law enforcement within the required timeframes. These omissions resulted in a deficient response to the abuse allegation.
Failure to Timely Report Alleged Abuse and Notify Law Enforcement
Penalty
Summary
The facility failed to report an allegation of physical abuse by a staff member against a resident to the Oklahoma State Department of Health (OSDH) within the mandated timeframe and did not notify local law enforcement as required. According to the facility's policy, any suspected abuse, neglect, or exploitation must be reported to OSDH and other relevant agencies. Documentation showed that the incident involving the resident was reported to OSDH the day after the allegation was made, as evidenced by the fax receipt. The incident form also lacked documentation indicating that law enforcement had been contacted regarding the allegation. The resident involved had an intact cognitive status, as indicated by a recent BIMS score of 15. During an interview, the administrator acknowledged that the abuse allegation was not reported to OSDH within the required two-hour window and that law enforcement was not contacted. The administrator attributed these failures to a lack of training and awareness of the reporting requirements at the time of the incident.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of physical abuse involving one resident. According to the facility's policy, all allegations of abuse, neglect, and mistreatment are to be investigated in a timely and objective manner. Documentation showed that a resident with intact cognition reported to the activities director that a staff member had slapped them. The incident was reported to the state health department, but the facility's investigation records did not include interviews with staff or other residents regarding the alleged abuse at the time it was reported. Further review revealed that the investigation materials provided by the administrator only included interviews conducted much later, and not around the time of the incident. The administrator acknowledged that, at the time of the investigation, they were new to the organization and had not received training on the abuse investigation process. As a result, the investigation did not include essential steps such as interviewing relevant staff and residents or addressing concerns about the alleged perpetrator.
Failure to Provide Scheduled Bathing and Documentation for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for bathing received baths as scheduled. According to facility policy, residents are to be bathed three times weekly and as needed, with refusals documented in the electronic medical record and on a refusal form signed by the resident, CNA, and charge nurse. Review of the resident's records over a three-month period showed that the resident received only six documented baths, with multiple scheduled bath days lacking any documentation of completion or refusal. The resident, who was severely cognitively impaired with a BIMS score of 99 and dependent on staff for bathing, reported not having received a bath in a while and was unsure of the scheduled days. Interviews with the DON and CNA confirmed that all completed baths should be documented and refusals recorded with appropriate forms. However, no additional bath sheets or refusal forms could be located for the resident, and the DON acknowledged there was no way to prove the resident was bathed more than six times in the last three months. The lack of documentation and missed scheduled baths constituted a failure to provide care and assistance with activities of daily living as required by facility policy.
Failure to Notify Families of Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to notify the legal representatives of three residents about inappropriate sexual behavior involving a resident with diagnoses of peripheral vascular disease (PVD) and essential hypertension. An incident report dated 12/01/24 documented that this resident was sexually inappropriate with two female residents, who had diagnoses including anxiety disorder, depression, dementia, and major depression disorder. The clinical health records for these residents did not contain documentation of family notification regarding the inappropriate behavior. The facility's policy required the charge nurse to complete an incident report and notify the physician and family, but this was not adhered to. The administrator acknowledged that the LPN did not feel it was necessary to notify the families.
Resident Abuse Due to Improper Handling by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a resident who reported being handled roughly by staff during assistance in bed. The resident, who had a history of cerebrovascular accident and peripheral vascular disease, was dependent on staff for transfers and had intact cognition. The resident reported that staff told them they were going to die in the facility, and a red area was noted on the resident's right upper arm, with the resident experiencing pain rated at 6 out of 10. This incident was documented in an Initial Incident Report, and staff were suspended pending investigation. Further investigation revealed that a CNA used a mechanical lift improperly, causing harm to the resident's right upper arm. The resident, who was alert and oriented, reported that the CNA purposefully put the straps on wrong, resulting in significant bruising. The CNA involved was terminated, and another CNA was suspended and educated on reporting suspected abuse. The administrator acknowledged the lack of formal Quality Assurance involvement in the incident, although steps were discussed to prevent further occurrences.
Failure to Submit Abuse Investigation Results Timely
Penalty
Summary
The facility failed to ensure the results of an abuse investigation were submitted to the State Survey Agency (SSA) within five business days for a resident involved in an abuse allegation. The incident involved a resident with diagnoses including Peripheral Vascular Disease (PVD) and Diabetes Mellitus type two, who was reported to have been sexually inappropriate with multiple female residents. An initial report was faxed to the state on December 1st, documenting the allegation and the immediate action of placing the resident under one-on-one supervision during the investigation. However, there was no documentation that the final results of the investigation were submitted to the SSA. The facility's administrator acknowledged the oversight, stating that they believed the Director of Nursing (DON) had completed the final report, but it was not done.
Failure to Assess Residents After Allegation of Sexual Misconduct
Penalty
Summary
The facility failed to assess two residents after an allegation of inappropriate sexual behavior. The facility's policy on managing suspected abuse/neglect requires a complete assessment of both residents involved, to be conducted by the charge nurse. An incident report documented an allegation of sexual misconduct by a resident towards multiple female residents. However, there was no documentation in the clinical records of the two affected residents, who had diagnoses including anxiety disorder, depression, dementia, and major depression disorder, being assessed following the allegation. Interviews with facility staff confirmed the absence of assessments in the clinical records, indicating that the assessments were not conducted.
Failure to Prevent Falls Resulting in Major Injuries
Penalty
Summary
An Immediate Jeopardy (IJ) situation was identified due to the facility's failure to protect residents from falls resulting in major injuries. One resident had a non-injury fall on 04/11/24, but hourly checks were not documented as completed. This resident subsequently fell again on 04/14/24, resulting in a broken neck. Additionally, on 05/17/24, the resident's call light was found unplugged and placed on top of a dresser, out of reach. Another resident experienced a fall with minor injury on 04/20/24, but no interventions were developed following the fall. This resident fell again on 04/23/24, resulting in a broken back. The intervention to move the resident closer to the nurse's station was not implemented due to room availability, and no new interventions were put in place. The facility's fall policy required nurses to complete an incident report and initiate fall interventions for fall prevention. However, the records showed that these steps were not followed. For the first resident, the hourly checks were not documented, and the call light was not kept within reach, as required by the care plan. For the second resident, there was no incident report or updated care plan following the initial fall, and the intervention to move the resident closer to the nurse's station was not documented or implemented. The deficiencies were confirmed through observations, record reviews, and interviews with staff. The Director of Nursing (DON) identified that 51 residents resided in the facility. The facility's failure to develop and implement appropriate fall prevention interventions led to significant injuries for the two residents involved. The Oklahoma State Department of Health was notified, and the IJ situation was verified and communicated to the facility's administrator.
Removal Plan
- Placing all residents on checks relating to prevention of falls it will be documented on TAR's
- Call light for Res #1 has been secured so it cannot be unplugged.
- Resident #2 have relocated her room across from nurse station.
- All staff has been in-serviced on new policy and procedure for fall prevention and falls.
- All nurses have been in-serviced on development and implementation of fall interventions and updated fall procedure.
- Every resident will have a new Fall Risk Assessment completed.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents. Observations revealed multiple issues with the flooring, including missing and cracked tiles in the dining room, hall entrance, common area, and resident halls, creating uneven surfaces that posed a trip hazard. Maintenance staff acknowledged the problem, noting that the tiles had been in disrepair for two to three months, but no maintenance requests had been logged. Additionally, a resident's room was found to have missing sheetrock, broken window blinds, and torn wheelchair armrests, none of which had been reported for repair. Maintenance staff confirmed they were unaware of these issues, as no maintenance requests had been submitted by the staff responsible for logging such concerns. Further deficiencies were noted in the laundry room, where two washing machines were leaking, and the area behind the machines was not cleaned. The washers had been leaking for an extended period, with one reported to have been leaking for at least a year. The drywall behind the washers was damaged, and the area was dusty and cluttered with laundry detergents and other items stored directly on the floor. Missing tiles were also observed in front of and between the washers and dryers. These conditions indicate a failure to maintain the facility in good repair and free from hazards, as required by the facility's maintenance policies.
Failure to Complete Quarterly Resident Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly resident assessments were completed within 14 days of the assessment reference date for two residents. One resident's quarterly assessment, dated October 12, 2023, was not completed and signed until November 9, 2023. Another resident's quarterly assessment, dated October 22, 2023, was not completed and signed until November 28, 2023. The administrator confirmed that the assessments should have been completed and signed within 14 days and could not provide an explanation for the delay.
Failure to Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to ensure the PASARR for two residents with mental health diagnoses was filled out correctly and referred to the OHCA. Resident #18, admitted with major depressive disorder and anxiety, had a PASARR Level I dated 03/04/20 that did not document the mental health diagnosis. Similarly, Resident #41, admitted with delusional disorders and major depressive disorder, had a PASARR Level I dated 06/14/21 that also did not document the mental health diagnosis. The administrator confirmed that the mental health diagnoses should have been documented and OHCA should have been notified.
Failure to Provide Scheduled Baths and Assistance with Eating
Penalty
Summary
The facility failed to ensure that baths were given as scheduled for two residents and that assistance with eating was provided for one resident. Resident #15, who had diagnoses including chronic obstructive pulmonary disease, neuropathy, and rheumatoid arthritis, was supposed to receive showers on Mondays and Thursdays. However, there was no documentation that Resident #15 received a shower from March 1 to March 22, 2024. The resident complained about not receiving a shower for the entire month and reported going three to four weeks without a shower before. The MDS Coordinator and the administrator confirmed that Resident #15 frequently refused baths, but these refusals were not documented, and no alternative days or times were offered to make up for missed showers. Similarly, Resident #16, who had diagnoses including Parkinson's disease, neuralgia, and pain, was supposed to receive showers on Tuesdays and Fridays. There was no documentation that Resident #16 received a shower from March 1 to March 22, 2024. The resident reported not receiving showers on scheduled days and going one to two weeks without a shower. The administrator confirmed that refusals were not documented and no alternative days or times were offered for missed showers. Additionally, the facility failed to provide assistance with eating for Resident #18, who had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease. An assessment documented that Resident #18 had moderately impaired cognition, limited range of motion, and required supervision or touching assistance for eating. On March 20, 2024, Resident #18 was observed eating their meal with their hands in a dark dining room without any staff assistance or supervision. Staff members walked through the dining room but did not turn on the lights or encourage the resident to use utensils. The administrator eventually found a staff member to move the resident to a lighted area, but the resident continued to eat with their hands until a CNA arrived and assisted another resident. The administrator acknowledged that staff had not provided the necessary supervision during lunch on that day.
Failure to Coordinate Care with Hospice and Ensure Medication Availability
Penalty
Summary
The facility failed to ensure care was coordinated with hospice to ensure a resident's medications were available for administration. The resident, who had diagnoses including COPD and chronic pain, was admitted to the facility with orders for Albuterol Sulfate Inhalation Nebulization Solution and oxycodone-acetaminophen oral tablets. However, the resident did not receive their pain medication or nebulizer treatments as prescribed. The pain medication was delivered to the wrong facility, and the nebulizer medication was not available in the building. Staff members, including a CMA and LPN, confirmed the medication mix-up and the lack of administration of the prescribed treatments. The hospice nurse stated that they were notified about the missing medications after the resident had already missed several doses. The facility's policies required reordering medications in advance and coordinating care with hospice, but these protocols were not followed. The resident reported not receiving any nebulizer treatments since admission, and staff confirmed the absence of the necessary medications. This lack of coordination and failure to ensure medication availability led to the resident not receiving essential treatments for their conditions.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that pain medication was administered as ordered for a resident with chronic pain and opioid dependence. The resident was admitted with six oxycodone/acetaminophen tablets and had a physician's order to receive the medication every four hours. However, the resident's clinical record did not contain a pain assessment, and the baseline care plan did not document interventions for chronic pain. The resident missed five doses of their pain medication due to a delay in receiving the medication from the pharmacy, which was sent to the wrong nursing home. The resident reported severe pain and was unable to perform usual activities due to the lack of pain management. The Director of Nursing (DON) acknowledged the delay and stated that the pain medication was on the way. The hospice nurse confirmed that they were notified about the medication shortage the previous day. The resident finally received their pain medication after a significant delay, which caused them considerable discomfort. The facility's policy required reordering medication four days in advance, but this was not followed, leading to the deficiency in pain management for the resident.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure insulin and blood pressure medication were administered per physician's orders for two residents. Resident #31, who had diagnoses including hypertension and diabetes, received insulin Detemir on multiple occasions despite their blood sugar being below the threshold of 100, as specified in the physician's order. Additionally, Metoprolol ER was incorrectly held for this resident when their vital signs did not meet the criteria for withholding the medication. The errors were acknowledged by the staff involved, who admitted to not following the prescribed guidelines and making mistakes in medication administration. Resident #46, diagnosed with hypertension, was also subject to medication administration errors. The resident's blood pressure was recorded with a diastolic reading below the threshold specified in the physician's order for holding Metoprolol Tartrate. Despite this, the medication was prepared for administration. The CMA involved admitted to not reading the blood pressure parameters on the medication label due to nervousness and failing to see the hold directions in the computer. These actions led to significant medication errors, compromising the residents' safety and well-being.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by multiple deficiencies observed during the survey. A blood pressure machine was not disinfected between residents, leading to potential cross-contamination. Specifically, a CMA used the same wrist blood pressure monitoring device on three residents without disinfecting it before or after each use. The CMA admitted to only cleaning the device a couple of times a day and was unaware of the need to disinfect it between each resident. Additionally, soiled linens were found on the floor in a resident's room, and the CNA responsible acknowledged that they did not bring a big enough bag for the linens and were aware that placing soiled linens on the floor was against protocol. Furthermore, a nebulizer mouthpiece was improperly stored on top of the nebulizer machine instead of in a bag, as confirmed by an LPN who stated it should have been stored correctly to prevent cross-contamination. The facility also lacked a comprehensive infection surveillance system, as evidenced by the absence of infection tracking and trending since December 2023. The administrator confirmed that infections had not been tracked, and the IP admitted that although three residents had clostridium difficile infections in March, there was no documentation of monitoring staff for proper PPE use and handwashing. Additionally, the facility did not have a water Legionella prevention program in place, and the maintenance personnel were unaware of any such program. The administrator confirmed the lack of documentation related to the facility's water system management for Legionella prevention.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to have a system in place to assess residents for infections using standardized tools and criteria for the initiation of antibiotics. The facility's undated policy indicated that nurses should perform and document a comprehensive assessment using established protocols when an infection is suspected. However, the facility had not tracked antibiotic use since December 2023. An undated document titled 'Attention All Nurses' introduced new assessment forms for various infections, but it was unclear if these tools were utilized before initiating antibiotics. The Infection Preventionist (IP) confirmed that they could not determine if assessment tools were used prior to antibiotic administration for 13 residents in January 2024, 12 residents in February 2024, and 15 residents in March 2024.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to one of three sampled residents whose beneficiary notices were reviewed. Resident #23 was admitted to skilled services on January 18, 2024, and discharged from skilled services on February 21, 2024, but remained in the facility. A review documented that an ABN was not provided to the resident. On March 20, 2024, the MDS Coordinator confirmed that Resident #23 was not given an ABN form.
Failure to Complete Timely Significant Change Assessment
Penalty
Summary
The facility failed to ensure a significant change resident assessment was completed within 14 days of the assessment reference date for one of four sampled residents whose assessments were reviewed. The facility's Resident Assessment Instrument policy, revised in October 2010, mandates timely resident assessments when there is a significant change in the resident's condition. However, the significant change assessment for a resident, dated October 19, 2023, was not completed and signed until November 9, 2023. The administrator acknowledged that the assessment should have been signed within 14 days but could not explain the delay.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents. One resident with congestive heart failure was incorrectly documented as being on an anti-coagulant instead of an anti-platelet medication in two quarterly assessments. The administrator and MDS Coordinator were unaware of the correct classification of aspirin. Another resident with type 2 diabetes mellitus, recurrent depressive disorders, and chronic viral hepatitis C was inaccurately documented as requiring restraints in an MDS re-admission assessment, despite a side rail assessment indicating no need for bedrails and the administrator confirming the resident never required restraints.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with a new mental health diagnosis to the Oklahoma Health Care Authority (OHCA) for a Pre-Admission Screening and Resident Review (PASRR) level II evaluation. The resident, who was admitted with a diagnosis of diffuse traumatic brain injury with loss of consciousness of unspecified duration, was later diagnosed with a mood disorder due to a known physiological condition and major depressive disorder, recurrent, severe with psychotic symptoms. Despite these new diagnoses, the facility did not notify OHCA as required. This deficiency was identified during a record review and interview, with the administrator acknowledging the oversight.
Failure to Document Hospice Services and Pain Management in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan included hospice services and interventions for pain management for a resident who was on hospice. The resident was admitted with diagnoses including chronic pain and was on hospice prior to admission. The baseline care plan did not document the resident's hospice status or interventions for pain management. The resident reported not receiving pain medication since the previous day due to a delivery error. The administrator confirmed that pain interventions and hospice services should have been documented in the baseline care plan.
Failure to Assist Resident with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion was offered assistance with splints. The resident, who had cerebrovascular disease with left-sided hemiplegia and contractures, reported that staff did not assist them with exercises for their arms or hands. Observations confirmed that the resident's left hand was closed, and they were unable to open it without a splint. The resident stated that they had not worn the splint for about two months and that staff had not offered to help them apply it recently. Further interviews revealed that the restorative aide was unsure when they last performed range of motion exercises for the resident, as they were working as a CNA. The occupational therapist (OT) mentioned that the range of motion exercises might have been turned over to the nurse aides and confirmed that the resident's hand was very tight. The OT was observed applying the splint, which was found in the resident's drawer. Despite the resident expressing a desire to wear the splint to prevent further contracture, staff did not offer assistance with the splint on the morning of the observation.
Lack of Physician Orders for Indwelling Urinary Catheter Maintenance
Penalty
Summary
The facility failed to have physician orders for maintaining an indwelling urinary catheter for one resident who was admitted with an indwelling urinary catheter and diagnoses including urinary retention and calculus of kidney and ureter. The facility's policy required a physician's order for the catheter and bag to be changed at 30-day intervals, but no such order was present. The resident's nursing notes did not document any catheter and drainage bag changes, and the indwelling urinary catheter had been in place for over 30 days. The administrator confirmed that the catheter and bag should have been changed and that there should have been a physician's order for the change at least monthly and as needed.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow the physician's orders for oxygen therapy for a resident diagnosed with acute respiratory failure and tracheostomy. The physician's order, dated 04/15/23, specified that the resident should receive oxygen at 3.5 liters per minute via nasal cannula or trach mask, with pulse oximetry checks every shift and adjustments to maintain oxygen saturation above 92%. However, observations on multiple dates revealed that the resident's oxygen was set at 2.5 liters per minute, contrary to the prescribed 3.5 liters per minute. Additionally, an LPN was unaware of the correct oxygen setting and had to refer to the orders to verify it.
Failure to Document and Retain Required Staffing Information
Penalty
Summary
The facility failed to document and retain the required staffing information. During the survey, it was observed that the facility had two white boards at each nursing station with the facility name, date, census, and staff titles documented. However, the staffing hours worked were not documented. The administrator, who was unaware of the requirements regarding posted staffing information and the need to keep staffing information for at least 18 months, identified 49 residents residing in the facility.
Failure to Ensure Drug Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, a resident with a diagnosis of end-stage renal disease (ESRD) was prescribed Eliquis, a blood thinner, with an incorrect diagnosis of hypertension secondary to other renal disorder. A pharmacy review suggested clarification of the Eliquis diagnosis, noting that it is not used for hypertension. The physician concurred with the pharmacy's recommendation but did not change the diagnosis. The administrator confirmed that the Eliquis was not prescribed for hypertension and should have been updated to reflect its use as a preventative medication due to the resident having a fistula for dialysis.
Failure to Maintain Functional Microwave for Resident Food Heating
Penalty
Summary
The facility failed to ensure the microwave used to heat up resident food after hours was in good repair. A resident reported that they were not allowed to have a microwave in their room and that the staff microwave was broken, resulting in their food not being heated the previous night. Dietary staff confirmed the lack of a working microwave and the inability to heat resident food after hours. An attempt to replace the microwave with one from the maintenance building revealed that the replacement was discolored, stained, and could not be cleaned properly. The administrator acknowledged that the replacement microwave should not be used for heating resident food.
Failure to Provide Call Light in Resident's Room
Penalty
Summary
The facility failed to provide a call activation button in the room of a resident who was admitted with diagnoses of acquired absence of the right leg above the knee and unspecified abnormalities of gait and mobility. During an observation, it was noted that the resident's room did not have a call light, and the resident confirmed that they had not had one since moving into the room. The facility's policy requires that every resident should have a functioning bedside call light, which was not adhered to in this case. The administrator acknowledged that every resident should have a call light regardless of room changes.
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Surveyors found that staff failed to follow Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. Facility policy required targeted gown and glove use for high-contact care under EBP, and the resident had physician orders for catheter care every shift and placement on EBP. During an observation, two CNAs provided catheter care without wearing gowns. Both CNAs later acknowledged that gowns should have been used, and the DON confirmed that gowns are required for catheter care for residents on EBP. The resident, who was cognitively intact, reported that staff usually did not wear gowns during catheter care.
The facility did not update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed licensed nursing staff. The written assessment specified one RN for one day shift per week and projected a need for 10 LPNs across 24 hours, with detailed LPN coverage by shift, and stated it should be reviewed and updated as needed to guide staffing decisions. At the time of survey, the DON reported 36 residents in the facility, acknowledged that resident acuity was higher than when the assessment was completed, and stated that the actual pattern was two LPNs on the floor for the day shift and two LPNs for the night shift, with the DON, ADON, and MDS coordinator available only during weekday business hours. The DON identified a total of seven licensed staff available and stated that more staff were needed to work directly with residents, confirming that the facility assessment no longer reflected current resident needs or staffing resources.
A resident with a pressure ulcer received wound care during which an LPN and CNAs failed to follow basic infection control practices. The overbed table was not sanitized before wound supplies were placed, gloves were not changed after contact with feces, and the resident was repositioned onto a clean bed pad while still soiled. The LPN used the same contaminated gloves to handle personal items, suction equipment, wound care supplies, and to cleanse the resident’s skin and pressure ulcer, including applying collagen paste and calcium alginate with gloved fingers. Hand hygiene was not performed between glove changes, and the resident’s open wound came into contact with a cloth bed pad or pillow after cleansing and medication application but before the final dressing was applied.
A deficiency was cited for failure to prevent elopement and recurrent falls due to inadequate supervision, unsecured exits, and incomplete care planning. A newly admitted resident assessed as at risk for elopement and wandering had no related interventions on the baseline care plan, despite moderately impaired cognition and psychiatric and seizure diagnoses. This resident later left the building, was found several blocks away after falling and sustaining abrasions, and was subsequently observed at times without the one-on-one supervision that had been ordered, while a dining room exit door and perimeter gate remained unlocked and accessible. Another resident with vascular dementia, muscle weakness, and a history of multiple falls experienced several unwitnessed falls over months, culminating in two right hip fractures requiring surgical repair, yet fall-prevention interventions were not added to the care plan, and staff relied on verbal instructions and vague "close observation" rather than documented, individualized fall-prevention measures.
A resident with atrial fibrillation on Eliquis, with documented orders and a care plan to monitor and report signs of bleeding, experienced multiple episodes of active rectal bleeding while on the toilet, accompanied by anxiety, complaints of not being able to breathe, pain, pallor, and shivering. An ACMA and an LPN observed and documented that the toilet was full of blood and that the resident repeatedly refused transfer to the ER, but the LPN did not contact the physician or the family and instructed staff to continue monitoring. ACMA staff later attempted to follow instructions to contact family but reported no family contact information in the medical record, did not notify the physician, and ultimately called EMS only when the resident became pale and shivering; EMS found the resident unconscious amid evidence of a significant hemorrhagic event. Progress notes contained no documentation of physician or family notification during the change in condition, and the family, listed as POA and emergency contact in admission paperwork, reported they were not informed of the change in condition and learned of the resident’s death hours later.
A resident with recent abdominal aortic aneurysm repair and a history of circulatory surgery was on multiple anticoagulant and antiplatelet agents (Eliquis, aspirin, Plavix) and had care plans directing staff to monitor for and report abnormal labs and signs of bleeding, including black or bloody stools. A critical hemoglobin of 6.3 g/dL was reported by the lab, which documented unsuccessful attempts to reach nursing staff; the result was later signed by facility staff, but the DON confirmed the physician was never notified and no intervention was documented. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding with screaming, shortness of breath, and anxiety while on the toilet; an ACMA notified an LPN, who did not promptly assess the resident and instead instructed continued monitoring and attempts to convince the resident to go to the hospital. Nursing notes and EMS documentation showed a significant hemorrhagic event with extensive blood in the room and on the resident, yet there was no evidence of ongoing assessment, monitoring, or timely physician notification for the change in condition or the critical lab, leading surveyors to cite a deficiency under F684 for failure to provide appropriate treatment and care according to orders and the resident’s condition.
A resident with a history of circulatory surgery, an aortocoronary bypass graft, and on anticoagulant therapy experienced an acute onset of profuse rectal bleeding and shortness of breath during a night shift. An ACMA was functioning as charge on one hall while an LPN covered the other hall; the ACMA reported the resident’s bleeding and distress, and the LPN came once to the room but did not provide ongoing assessment or monitoring, later stating they were behind on work and relying on the ACMA to monitor. EMS later found the room with evidence of a significant hemorrhagic event and the resident unconscious on the toilet. Progress notes lacked documentation of significant change in condition, assessments, or interventions for the bleeding and respiratory distress, and the facility failed to notify the medical provider of a critical Hgb of 6.3 or of the acute bleeding. The facility also could not produce annual competency records for the LPN or ACMA, and the resident’s family was not notified of the change in condition or death until later.
A resident with a history of abdominal aortic aneurysm repair and on anticoagulant therapy had a critically low Hgb on lab testing, but the lab’s critical results were not successfully communicated to a nurse and the physician was not notified. Later, the resident developed anxiety, SOB, screaming, and profuse rectal bleeding while on the toilet. An LPN was notified of these symptoms and received a photo showing a large amount of blood but did not perform an assessment or ongoing monitoring, relying instead on an ACMA despite acknowledging this was not standard procedure. There was no documentation of a significant change in condition or interventions in the progress notes. EMS was eventually called and found evidence of a major hemorrhagic event in the room before transporting the resident, and the incident was identified by the regional nurse consultant as neglect.
Surveyors found multiple food safety deficiencies involving approximately 80 residents, including unlabeled and undated stored food items, and an ice machine with visible pink and brown residue on the chute above the ice. The dietary manager acknowledged that food should be labeled and noted visible dirt when wiping the ice machine. A cook was observed preparing pureed food with one gloved and one ungloved hand, using the same gloved hand to handle both ready-to-eat food and kitchen surfaces without changing gloves or performing hand hygiene until after taking equipment to the dishwasher. The DON reported there was no policy for food storage or ice machine maintenance, and only prior-year invoices were available to show servicing of the ice machine, with no recent documentation provided.
A resident with moderately impaired cognition who required partial to moderate assistance with ADLs expired in an ambulance, but staff documentation did not accurately reflect the resident’s status. A nursing progress note describing severe anxiety, complaints of inability to breathe, and blood in the toilet was entered without being identified as a late entry. Task logs showed ADL assistance documented as completed after the resident’s death, instead of being marked as not available or not applicable. Staff interviews confirmed that tasks should not be documented as completed when a resident is no longer in the facility or has died, indicating a failure to follow the facility’s nursing documentation policy.
Failure to Use Gowns During Catheter Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during catheter care. The facility’s Infection Control policy dated 04/01/24 required targeted gown and glove use during high-contact resident care activities under EBP. Physician orders showed that Resident #7 had an indwelling catheter with catheter care ordered every shift as of 01/07/26 and was placed on EBP as of 01/16/26. A quarterly assessment dated 03/27/26 documented that Resident #7 had intact cognition, with a Brief Interview for Mental Status score of 15, and an indwelling catheter. On 04/29/26 at 11:03 a.m., CNA #1 and CNA #2 were observed providing catheter care to Resident #7 without wearing gowns, despite the resident being on EBP and the facility’s policy requiring gown use for such care. CNA #1 acknowledged that gowns should have been worn under EBP, and CNA #2 stated they had forgotten to put on a gown. Resident #7 reported that staff usually did not wear gowns during catheter care, and on 04/30/26 the DON confirmed that gowns should be worn when providing catheter care to residents on EBP.
Failure to Update Facility Assessment to Reflect Increased Resident Acuity and Staffing Needs
Penalty
Summary
The facility failed to update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed nursing resources. The written facility assessment dated 10/15/25 stated that one RN was needed for one day shift per week, including weekends, and projected a total of 10 LPNs needed to provide care in a 24-hour period. The assessment further specified that seven LPNs were needed for the day shift, five for the evening shift, and four for the night shift. The assessment document itself stated that it was to be reviewed annually and updated as needed, and that it was to be used to evaluate the resident population and determine the resources necessary to care for residents competently during day-to-day operations and emergencies, and to drive staffing decisions. At the time of the survey, the DON identified that 36 residents resided in the facility and reported that the acuity level of the residents was higher than it had been in October 2025 when the facility assessment was completed. The DON stated that the projected need for ten LPNs in a 24-hour period was not correct and described the actual staffing pattern as two LPNs working on the floor from 7 a.m. to 7 p.m. and two LPNs working on the floor from 7 p.m. to 7 a.m., with the DON (RN), assistant DON (RN), and MDS coordinator (LPN) available to assist with resident needs during business hours, five days a week. The DON counted a total of seven licensed staff members available and acknowledged that more staff were needed to work directly with residents given the current higher acuity, demonstrating that the facility assessment had not been updated to reflect the current resident population and resource needs.
Improper Infection Control During Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care in a manner that prevented contamination and potential infection for one resident with a pressure ulcer. During an observed dressing change, an LPN entered the resident’s room, pushed personal items aside, and placed plastic trash bags and wound care supplies on the overbed table without sanitizing the surface. The LPN and CNAs provided incontinent care during which feces remained on the resident’s legs and buttocks, and at least one CNA did not change gloves after wiping feces and before placing a clean cloth bed pad under the resident. The resident was repositioned onto the new pad while still soiled with feces. Wearing the same gloves used during incontinent care, the LPN handled the resident’s personal items, oral suction yankauer, and suction machine, and prepared wound care supplies, including soaking gauze in a cleansing solution. The LPN then used the same contaminated gloves to obtain wet gauze from the cleansing solution and clean feces from the resident’s legs and buttocks before proceeding to remove the old dressing and packing from the pressure ulcer. Some packing fell onto the cloth bed pad, and the resident’s back and buttocks, including the open pressure ulcer area after cleansing and medication application but before placement of the absorbent dressing, came into contact with the cloth bed pad or pillow. The LPN applied a collagen paste to the wound bed by inserting gloved fingers into a cup of white paste and then applied calcium alginate with the same gloved fingers, without using an applicator. The LPN discarded the gloves but did not perform hand hygiene before donning a new pair of gloves stored on the overbed table. During a post-observation interview, the LPN acknowledged feeling nervous, recognized that their gloves and multiple items and surfaces may have been contaminated by contact with feces, and stated that the resident’s bed pad and wound bed were likely contaminated during the dressing change.
Failure to Prevent Elopement and Recurrent Falls Due to Inadequate Supervision and Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to elopement risk and fall prevention. One resident identified as a new admission was evaluated on 02/28/26 as being at risk for elopement and wandering, with documentation that the resident wandered around the facility and into rooms. Despite this evaluation, the baseline care plan dated the same day did not include any interventions for wandering or elopement risk. An admission assessment dated 03/06/26 documented moderately impaired cognition with a BIMS score of 09 and diagnoses including schizophrenia and seizure disorder. On 03/07/26, the resident was reported missing from their room around 11:20 a.m., and an incident report and progress note showed the resident was found a couple of blocks from the facility, having tripped and fallen outside and sustaining abrasions to the hand and knee that required first aid. Following the elopement, documentation showed the resident was placed on one-on-one staff supervision and the care plan was updated; however, subsequent observations revealed lapses in supervision. On 03/11/26, the resident was observed in bed with a staff member seated outside the door, and the resident stated they were not allowed to leave the facility alone. On 03/12/26, the resident was observed in bed with no staff supervision, then walking out of the room toward the dining room without staff present, until an unidentified staff member later noticed the resident in the hall and alerted the charge nurse. Interviews indicated that prior to the elopement the resident had not been on frequent checks because staff did not consider them an elopement risk, despite the earlier evaluation. The ADON later stated the baseline care plan lacked elopement/wandering interventions because they had failed to communicate with the weekend RN who completed the elopement evaluation and were unaware the resident was at risk. Environmental observations on 03/13/26 showed the dining room exit door and the outside perimeter gate in the smoking area were unlocked and accessible to residents, and the DON and administrator acknowledged the dining room exit door was not secured and that the resident likely exited through the unlocked door and perimeter gate. The deficiency also includes the facility’s failure to provide adequate supervision, reassess fall risk, investigate root causes, and implement fall-prevention interventions for a resident with a history of multiple falls. Facility records identified this resident as having several falls without injury on 06/04/25, 06/05/25, 06/18/25, 06/30/25, and 07/31/25, with no fall-prevention interventions documented for any of these events. A fall on 09/25/25 resulted in severe right leg pain and an emergency room visit, with a subsequent nurse’s note documenting a right hip fracture requiring surgical repair. Review of the care plan dated 07/31/25 showed no fall-prevention interventions in place for the 09/25/25 fall, and a later care plan dated 10/06/25 documented the resident’s diagnoses, including vascular dementia and muscle weakness, and the prior falls, but still showed no interventions for those falls. A nurse’s note dated 10/20/25 documented another fall on 10/19/25 that resulted in a second right hip fracture, again with no documentation of interventions in place to prevent that fall. Observations and interviews further demonstrated the lack of systematic fall-prevention planning for this resident. On 03/12/26, the resident was observed sitting in a geriatric chair near the nurse’s station with a fall mat at bedside and was later assisted to stand and ambulate with a walker. The resident reported falling frequently and not knowing why, and stated that staff followed them everywhere to prevent falls but were unsure what specific interventions were in place. An LPN stated the resident had frequent falls and that interventions included a fall mat at bedside and keeping the resident under close observation, but could not clarify what “close observation” entailed and acknowledged that interventions were communicated verbally rather than being reflected in the care plan. Another LPN stated they relied on the care plan to know fall-prevention interventions and, if not listed, had to depend on other staff for guidance. The MDS coordinator stated all falls, regardless of injury, should result in care plan interventions to prevent recurrence and did not know why this resident’s falls lacked interventions, and the DON confirmed there were no interventions on the care plan for the resident’s falls despite the expectation that such interventions should have been in place. Facility policies reviewed by surveyors underscored the deficiencies. An undated wandering policy stated that the facility would ensure the safety of residents who wander and that the MDS nurse would complete a wandering assessment on admission and work with the care plan team to develop, maintain, and update a care plan for each resident who wanders. A Falls – Clinical Protocol dated 03/2018 stated that staff and the physician would identify pertinent interventions to prevent subsequent falls and address the risks of clinically significant consequences of falling. A Care Plan Completion policy stated the facility would develop a comprehensive person-centered care plan for each resident that includes measurable objectives, timeframes, and services to meet medical, nursing, mental, and psychosocial needs. Despite these policies, the facility did not ensure that the elopement risk assessment for the first resident was communicated and incorporated into the baseline care plan, did not secure exit doors and perimeter fencing to prevent elopement, and did not consistently implement or document individualized fall-prevention interventions for the second resident after multiple falls and two hip fractures.
Failure to Notify Physician and Family of Significant Bleeding Episode in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and family of a significant change in condition. The resident had a history of atrial fibrillation and was on Eliquis, with physician orders and a care plan directing staff to monitor and report signs of bleeding such as blood in urine or stool, black tarry stools, and other symptoms. The resident’s cognition was moderately impaired, with a BIMS score of 11, and they required supervision with ambulation and transfers and partial to moderate assistance with toileting hygiene. The admission contract identified a family member as the emergency contact and POA, with contact information provided. On the night of the incident, staff observed multiple episodes of active bleeding while the resident was on the toilet. Around 1:15 a.m., the resident was on the toilet and bleeding, with the toilet full of blood, and was reported to be screaming that they could not breathe. ACMA staff notified the LPN, left the blood in the toilet for the LPN to observe, and reported that the resident refused to go to the ER. The LPN assessed the resident at approximately 1:32 a.m., documented increased anxiety, complaints of not being able to breathe, and that most of the toilet contents were blood, and noted that the resident refused transfer to the emergency department. The LPN instructed ACMA staff to continue monitoring the resident and did not contact the physician or the family at that time. The resident continued to have episodes of bleeding while on the toilet around 2:00 a.m. and again around 2:50 a.m., with reports of pain, pallor, and shivering, and continued refusals to go to the hospital and to take pain medication. ACMA staff reported they were instructed by text to contact the family to encourage the resident to go to the ER but stated no family contact was listed in the medical record and did not call the physician. EMS was eventually called by ACMA staff when the resident became pale and shivering; EMS arrived to find the resident unconscious on the toilet with evidence of a significant hemorrhagic event in the room, including saturated towels and blood on the floor and on the resident. Progress notes did not show any contact with the physician or family during the change in condition, and the family member later stated they were not notified of the change in condition and did not learn of the resident’s death until several hours later. The facility’s failure to notify the physician and family of the resident’s serious change in condition was cited as an Immediate Jeopardy deficiency.
Failure to Respond to Critical Lab and Acute Bleeding in Anticoagulated Post-Surgical Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess, identify, and intervene when a resident with a recent abdominal aortic aneurysm repair experienced an acute change in condition, including profuse bleeding from an unknown source and a critically low hemoglobin level. The resident had diagnoses including encounter for surgical aftercare following circulatory system surgery and presence of an aortocoronary bypass graft, and was receiving multiple anticoagulant and antiplatelet medications (Eliquis twice daily, aspirin daily, and Plavix daily), along with psyllium and Imodium for diarrhea. Facility policies required nurses to assess acute condition changes, obtain and report pertinent information to the physician, and promptly notify the physician in emergencies, as well as to review and act on lab and diagnostic test results based on the seriousness of abnormalities. The resident’s care plan directed staff to monitor for and report abnormal lab results and signs of bleeding, including black or bloody stools and significant changes in vital signs, and to avoid aspirin use with anticoagulant therapy. A laboratory report for the resident showed a critically low hemoglobin of 6.3 g/dL, with a normal reference range of 13.7–17.5 g/dL. The lab documented attempts to call the facility at 3:35 p.m. and again, with no answer and inability to reach a nurse, and the report was released later that afternoon. The report bore a staff signature dated several days later and a stamped physician signature without a date. The DON confirmed that the physician was not notified of this critical result and stated that the physician should have been notified immediately per facility procedure. Despite the resident’s anticoagulant therapy and care plan instructions to report abnormal labs, there was no evidence that the critical hemoglobin value was communicated to the physician or that any clinical intervention occurred in response to this lab finding. Subsequently, during a night shift, the resident developed acute profuse rectal bleeding while on the toilet, accompanied by screaming, shortness of breath, increased anxiety, and refusal to go to the hospital. An ACMA reported to an LPN around 1:15–1:32 a.m. that the resident was having bloody stool and distress, but the LPN did not immediately assess the resident and instead instructed the ACMA to monitor and convince the resident to go to the hospital. The nursing progress note later documented that the resident’s toilet contents were mostly blood and that the resident was educated about the need to go to the ED but refused. EMS records indicated that when they arrived, the resident’s room showed signs of a significant hemorrhagic event, with towels saturated with blood and blood on the floor, legs, socks, and in the toilet. The nursing documentation showed no ongoing assessment, monitoring, or intervention for the resident’s shortness of breath, screaming, blood in the toilet, or refusal of transfer during the period before EMS was called. The facility’s failure to identify, monitor, and provide continuing assessments for the resident’s change in condition, to notify the medical provider of the critical hemoglobin result, and to promptly notify the provider and intervene for the acute onset of profuse bleeding constituted the cited deficiency. The report also notes that staff interviews revealed gaps in practice and understanding related to change in condition and bleeding. The LPN acknowledged being concerned the resident was “bleeding out” and stated they were traumatized by the amount of blood, yet did not perform an immediate assessment when first notified of bloody stool and pain, relying instead on the ACMA to monitor and attempt to persuade the resident to accept transfer. The LPN further stated they typically remained on one side of the building and did not routinely go to the other side unless needed, and that they did not visually see the resident in distress until later. A CNA reported having seen dark, clumped stool earlier in the week and indicated they had only minimal education on signs and symptoms of bleeding. These documented actions and inactions, in the context of the resident’s high-risk status and existing policies and care plans, led surveyors to determine that the facility failed to provide appropriate treatment and care according to orders, the resident’s condition, and established protocols for change in condition and critical lab results. The resident’s family reported that the resident had ongoing diarrhea with horrendous odor and black color since before admission, and that staff were aware of the stool characteristics. Another CNA described the resident’s stool as dark black and mixed solid/liquid, resembling stool from someone taking iron, though they only observed it once and did not report red blood. The care plan specifically directed staff to monitor for black tarry stools and other signs of bleeding in the context of anticoagulant therapy, and to report such findings to the physician. Despite these documented risk factors, symptoms, and care plan directives, the record lacked evidence that staff recognized and escalated these signs as potential bleeding or that they communicated them to the physician prior to the acute hemorrhagic event. This pattern of missed recognition, lack of timely assessment, and failure to notify the physician of both critical lab results and acute bleeding formed the basis of the deficiency under F684 (Quality of Care).
Failure to Assess, Monitor, and Notify Provider for Resident With Profuse Bleeding and Critical Lab Value
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and competent nursing staff to assess, monitor, and intervene for a resident with a known high-risk medical history who experienced an acute onset of profuse bleeding. The resident had a history of surgical aftercare following surgery on the circulatory system, including the presence of an aortocoronary bypass graft, and was receiving anticoagulant therapy (Eliquis) for atrial fibrillation. The resident’s care plan and physician orders directed staff to monitor for specific signs of bleeding and adverse reactions to anticoagulant therapy, such as blood in the stool or urine, changes in mental status, shortness of breath, and other symptoms. The facility also had an Acute Condition Changes – Clinical Protocol policy requiring baseline assessments, monitoring, and timely physician notification for acute changes in condition. On the night of the incident, assignment sheets showed that an ACMA was the charge nurse on one hall (South hall) for the 7:00 p.m. – 7:00 a.m. shift, while an LPN was the charge nurse on the other hall (North hall). EMS records documented that they were dispatched in the early morning hours after facility staff reported that the resident had blood in the stool starting about three hours earlier and was recovering from abdominal aortic aneurysm surgery. When EMS arrived, they observed the resident’s room with signs of a significant hemorrhagic event, including towels saturated with blood and blood on the floor, and found the resident unconscious on the toilet with blood on their socks, legs, and in the toilet. Progress notes for that date did not show documentation of a significant change in condition, nor did they show assessments, monitoring, or interventions for the resident’s shortness of breath, screaming, blood in the toilet, or refusal to be transported to the hospital. Interviews revealed that the LPN was the only licensed nurse in the building on the weekend and did not obtain a full report on the South hall because the ACMA was functioning as the charge for that hall. The LPN stated that the ACMA reported the resident was screaming, hurting, having a bowel movement, and there was blood, and that the resident had a history of abdominal aortic aneurysm surgery, raising concern about bleeding. The LPN instructed the ACMA to send the resident to the hospital, but the resident refused, and the LPN did not perform ongoing assessments or monitoring, citing being behind on work and relying on the ACMA to monitor and report. The ACMA reported that the resident was on the toilet and bleeding around 1:15 a.m., with vital signs within normal limits, and refused to go to the ER; the ACMA contacted the LPN, who came once at about 1:32 a.m. to check on the resident while the resident was back in bed, with blood left in the toilet for the LPN to see. The ACMA stated that later, as the resident continued to pass blood, became pale and shivering, and remained in pain while refusing pain medication and hospital transfer, they eventually called 911 when the resident’s condition worsened. The facility was unable to produce annual skills competencies for either the LPN or the ACMA, and a family member reported they were not notified of the resident’s change in condition or of the resident’s death until later, despite the resident’s room being on the South hall where the events occurred. The report also notes that the facility failed to notify the medical provider of a critical hemoglobin lab value of 6.3 (normal reference range 13.7–17.5) and failed to notify the medical provider of the acute onset of profuse bleeding. There is no documentation that the physician was contacted regarding the critical lab result or the resident’s active bleeding, despite facility policy requiring timely physician notification for acute changes in condition and the resident’s known risk factors and anticoagulant therapy. Additionally, the facility’s own policy required that direct care staff, including nursing assistants, be trained to recognize and report significant changes, and that phone calls to physicians be made by adequately prepared nurses with organized, pertinent information; however, the documented events and interviews show that the ACMA was functioning as charge on one hall and that the LPN did not consistently assess or directly manage the resident’s rapidly changing condition. These combined failures to assess, monitor, intervene, and notify the medical provider for a resident with profuse bleeding and a critical hemoglobin value constituted the cited deficiency.
Failure to Assess and Respond to Resident’s Significant Bleeding and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident experiencing a significant change in condition and profuse bleeding was assessed and monitored by a licensed nurse. The facility had an Acute Condition Changes - Clinical Protocol requiring nurses to assess and document vital signs, neurological status, pain, level of consciousness, cognitive and emotional status, onset and severity of symptoms, and other clinical information, and to promptly contact the physician for emergencies. The resident had a history of abdominal aortic aneurysm repair and was on anticoagulant therapy for atrial fibrillation, with care plans directing staff to monitor and report signs and symptoms of cardiovascular issues and adverse reactions to anticoagulants, including blood in stool and shortness of breath. A physician’s order required weekly CBC and CMP labs while on skilled services. A lab report for the resident showed a critically low hemoglobin level of 6.3 g/dl, but the lab’s attempts to call the facility at 3:35 p.m. and again later were unsuccessful, and the physician was not notified of the results. Subsequently, during the night, the resident experienced increased anxiety, was screaming that they could not breathe, was on the toilet with most of the contents being blood, and refused to go to the emergency department. LPN #1 was notified at 1:32 a.m. of the resident’s condition, including shortness of breath, screaming, and blood in the toilet, but did not perform an assessment or ongoing monitoring, and there was no documentation of a significant change in condition or interventions for these symptoms in the progress notes. LPN #1 reported typically being the only licensed nurse in the building on weekends and stated they did not go to the resident’s hall for a full report, relying instead on an ACMA to monitor residents and report concerns. LPN #1 acknowledged being told that the resident was screaming, hurting, having bloody stool, and had a recent abdominal aortic aneurysm, and expressed concern about the resident bleeding out. LPN #1 received a texted picture of the blood at 2:25 a.m. and described being traumatized by the amount of blood, but still did not assess or monitor the resident, citing being behind on work and relying on the ACMA, despite stating that it was not standard procedure for an ACMA to assess, monitor, and send a resident to the hospital. EMS was finally contacted at 3:12 a.m., arrived to find evidence of a significant hemorrhagic event with blood-saturated towels and blood on the floor, and transported the resident, who expired in the ambulance shortly thereafter. The regional nurse consultant stated the incident was considered neglect.
Improper Food Storage, Ice Machine Sanitation, and Glove Use in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food storage and ice handling practices during kitchen observations. In one kitchen tour, they observed a white paper bowl containing orange ice cream wrapped in plastic wrap that was unlabeled and undated, as well as an opened bag of hamburger buns that was also unlabeled and undated. The ice machine had a pink substance on the white plastic chute directly above the ice, which, when wiped with a clean paper towel, resulted in a pink and brown speckled residue. The dietary manager acknowledged that the food items should have been labeled and stated they saw dirt on the towel used to wipe the ice machine chute. The DON reported there was no policy for food storage or the ice machine, and stated that ice machine maintenance was based on the machine’s indicator and then calling an outside company, with invoices available only for servicing dates in the prior year and no documentation provided for recent cleaning or maintenance. Additional deficiencies were observed in food handling and glove use by kitchen staff. One cook was seen working with one hand gloved and one hand ungloved, using the gloved hand to place cornbread into a blender, then touching the blender, a utensil, and returning to touch the cornbread without changing gloves or performing hand hygiene between contact with food and other surfaces. The cook later took the blender to the dishwasher and only then removed the glove and washed their hands. When interviewed, the cook stated their process for changing gloves was when changing the type of food and after touching utensils, and acknowledged they did not change gloves after touching the cornbread. The dietary manager stated the process for changing gloves was to change when staff touched something or something was dirty. The administrator identified that 80 residents resided in the facility at the time of the survey.
Inaccurate Post-Death Documentation and Failure to Follow Nursing Charting Policy
Penalty
Summary
The facility failed to ensure accurate and timely documentation in the medical record for a resident who died. Facility policy on nursing documentation required staff to chart as soon as possible after care, to enter the actual date and time of charting, and to clearly label any late entries with the date and time being documented. The admission assessment for the resident showed moderately impaired cognition with a BIMS score of 12 and a need for partial to moderate staff assistance with most ADLs. An EMS report documented that the resident expired in the ambulance at 3:40 a.m. on a specified date. A progress note for that same date, timed at 1:32 a.m., described the nurse being notified that the resident was on the toilet, screaming that he could not breathe, with oxygen saturation at 98% and most of the toilet contents being blood; this note was not identified as a late entry despite the timing and circumstances. Task logs for the resident showed that staff documented completion of ADL assistance after the resident’s death. Specifically, the task log reflected that the resident received ADL assistance at 10:08 a.m. on the date of death, and additional ADL assistance entries at 6:54 a.m., 8:32 a.m., and 11:59 p.m. on another date, even though the resident had already expired. During interviews, a CNA stated that if a resident was not in the facility, the scheduled ADL task should be documented as the resident not being available. The RNC confirmed that if a resident had passed away, staff should not document task completion for that resident and that any remaining scheduled tasks should be documented as not applicable. These findings showed that staff documentation did not accurately reflect the resident’s status or comply with the facility’s documentation policy.
Trusted data from CMS and state health departments
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