Community Health Care Of Gore
Inspection history, citations, penalties and survey trends for this long-term care facility in Gore, Oklahoma.
- Location
- 503 South Main Street, Gore, Oklahoma 74435
- CMS Provider Number
- 375295
- Inspections on file
- 23
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Community Health Care Of Gore during CMS and state inspections, most recent first.
A resident with major depressive disorder experienced trauma when another resident with cognitive impairment entered their room and engaged in inappropriate behavior. The facility failed to notify physicians, address interventions, or consult psychiatric services, leaving the affected resident without necessary support and care plan adjustments.
A facility failed to update a high fall risk resident's care plan with new interventions after multiple falls, including one resulting in a nasal bone fracture. Additionally, the facility did not assess a resident who smoked for safety, allowing them to smoke unsupervised without proper evaluation. These oversights highlight the facility's failure to adhere to safety protocols.
A resident experienced psychosocial harm after another resident entered their room and engaged in inappropriate behavior. Despite the resident's distress, the facility failed to notify their physician, address interventions, or consult psychiatric services. The other resident had a history of disturbed behaviors, but the facility did not adequately monitor or refer them to mental health services, contributing to the incident. The facility's policy on resident-resident altercations was not followed, leading to a deficiency in protecting residents from abuse.
A facility failed to update care plans for a resident who experienced multiple falls, resulting in harm, and did not ensure interdisciplinary team participation in care plan revisions for another resident. Despite several falls, including one causing a nasal bone fracture, the care plan for a resident was not updated with new interventions. Additionally, another resident's care plan lacked documentation of interdisciplinary team involvement, and the resident reported not participating in a care plan meeting.
A resident experienced a traumatic incident when another resident entered their room naked and engaged in inappropriate behavior. Despite the incident, the facility failed to notify the resident's physician, assess for psychosocial injury, or consult psychiatric services. The facility's policies on abuse and resident altercations were not followed, and no interventions or care plan changes were documented. The resident reported ongoing distress and fear, and the family confirmed no psychological counseling was arranged.
A facility failed to report an allegation of neglect involving a CMA who allegedly did not administer medications to residents as ordered. Despite residents' complaints and discrepancies in medication records, the DON did not report the incident to the state agency within the required timeframe, believing it was a patient education issue. The administrator later instructed the DON to report the incident, but it was unclear if this was done promptly.
The facility did not provide two residents with the required bed-hold policy upon their transfer to a hospital, despite the facility's policy mandating this. Both residents, diagnosed with urinary tract infections, were hospitalized without receiving the necessary documentation. The administrator was unaware of this requirement, and the ADON confirmed the omission.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their care plans. One resident's fall history was inaccurately reported, while another resident's dental condition was not properly assessed, resulting in missed care areas. The MDS coordinator acknowledged the inaccuracies and the lack of proper assessment.
The facility failed to develop comprehensive care plans for two residents, one with an anxiety disorder and another with a psychotic disturbance. Both residents were receiving medications for their conditions, but their care plans did not address these diagnoses or the use of the medications, as confirmed by the MDS coordinator.
A resident with severe cognitive impairment was administered medications without documented informed consent. The resident's POA reported insufficient communication from the facility regarding care plans and medication risks. The MDS coordinator confirmed the absence of documentation in the resident's record, indicating a failure to complete the informed consent process.
A facility failed to assess a resident for the use of a geriatric chair as a restraint, leading to a deficiency. The resident, with significant cognitive impairment and mobility limitations, was observed with facial bruising while in the chair. The facility's policy required a pre-restraining assessment, which was not conducted before the chair's use. An LPN confirmed the lack of assessment, and the administrator acknowledged the oversight.
A resident was discharged from hospice services, but the facility failed to conduct a significant change assessment within the required timeframe. The MDS coordinator was unaware of the discharge until weeks later, resulting in a deficiency due to non-compliance with the facility's policy.
A facility failed to complete a Level I PASARR for a resident after a new diagnosis of bipolar disorder. The resident was initially admitted with cerebral infarction and dementia. The MDS coordinator acknowledged that a PASARR should have been conducted following the new diagnosis but was not.
A facility failed to perform or document a gradual dose reduction (GDR) for an antipsychotic medication prescribed to a resident with vascular dementia. Despite pharmacy recommendations and assessments showing severe cognitive impairment and no behaviors, the facility did not attempt a GDR or provide a rationale for its contraindication. The administrator acknowledged the lack of documentation but did not provide further information by the end of the survey.
A resident with broken and missing teeth was not offered dental services, despite facility policy and their expressed need for care. The resident's care plan lacked documentation of dental needs, and their annual assessment inaccurately reported their dental status. Interviews revealed that the facility did not actively offer dental services, relying instead on the dental provider to contact residents. The MDS coordinator admitted to not performing a visual assessment, leading to inaccuracies in the resident's care plan.
The facility failed to maintain the ice machine in a sanitary manner, affecting 44 residents who used ice from the kitchen. A slimy black and brown substance was observed in the crevices and around the pump of the water reservoir. The dietary manager was unaware of who cleaned the mechanical area, although the ice bin was cleaned weekly. The administrator confirmed that the ice machine should be on a regular cleaning schedule for maintenance.
The facility failed to ensure staff conducting COVID-19 testing received appropriate training. The social services director and activities assistant, who sometimes performed testing, did not recall receiving training on infection control or specimen collection. An LPN confirmed that unlicensed activities staff conducted outbreak testing. The DON acknowledged the use of social services and activities staff for testing and could not find documentation of their training.
A resident with a history of falling and dementia experienced a non-injury fall, but the LPN on duty failed to notify the resident's family or physician, contrary to facility policy. This was confirmed by the DON and the administrator, who acknowledged the lapse in communication.
A resident with a history of falling and dementia experienced a non-injury fall, but the LPN did not complete an assessment as required by facility policy. This failure was confirmed by the DON and the administrator, who acknowledged the oversight.
The facility failed to thoroughly investigate abuse allegations for two residents. One resident with severe cognitive impairment had an incomplete investigation after a family reported rough handling by staff. Another resident, cognitively intact, reported being slapped by a staff member, but no interviews with other residents were conducted. The DON and administrator acknowledged the investigations were not thorough.
The facility did not follow the dietary menus planned for residents, failing to provide the specified meal items. On a particular day, the dietary manager reported running out of coleslaw and coconut cake, leading to substitutions with salad and ice cream for four residents. Additionally, the evening menu was changed due to staff oversight in thawing meat, and the dietary manager admitted to frequent menu substitutions.
Failure to Implement Abuse Policy After Resident Incident
Penalty
Summary
The facility failed to implement its abuse policy and procedure following an incident involving two residents. Resident #20, who was admitted with acute and hypoxic respiratory failure and major depressive disorder, experienced an incident where Resident #44 entered their room, exposed themselves, and engaged in inappropriate behavior. Despite Resident #20's intact cognition, the facility did not notify their physician, address interventions, or consult psychiatric services after the incident. This lack of action left Resident #20 without necessary psychological support and care plan adjustments. Resident #44, admitted with acute kidney failure, morbid obesity, and cellulitis, exhibited behaviors indicating cognitive impairment and distress prior to the incident. Their admission assessment showed mild cognitive impairment and physical behaviors directed toward others. Despite these signs, the facility did not notify Resident #44's physician or refer them to mental health services before the incident. The facility's failure to address these behaviors and consult appropriate services contributed to the incident with Resident #20. The facility's policies required staff to notify physicians, review events with nursing supervisors, and document interventions and their effectiveness. However, these steps were not followed, resulting in a deficiency in implementing the abuse policy. The facility's inaction left Resident #20 without necessary support and failed to address Resident #44's behaviors, leading to the incident and subsequent trauma for Resident #20.
Failure to Implement Fall Interventions and Smoking Safety Assessment
Penalty
Summary
The facility failed to implement necessary fall interventions for a resident with severe cognitive impairment who was identified as a high fall risk. Despite multiple falls, including some resulting in injury, the care plan was not updated with new interventions after each incident. The resident experienced several falls, including one that resulted in a nasal bone fracture and blunt head trauma, yet no additional interventions were added to their care plan to prevent further accidents. The resident's Morse Fall Scale assessments consistently indicated a high fall risk, yet the facility did not take appropriate action to mitigate this risk. The MDS coordinator admitted that no interventions were added to the care plan following several falls, and the facility's policy on fall prevention was not followed. The lack of communication and failure to update the care plan contributed to the ongoing risk of falls for the resident. Additionally, the facility failed to assess another resident who smoked for safety, as required by their policy. The resident was allowed to smoke unsupervised without a proper evaluation of their ability to do so safely. The care plan did not include the necessary components of a smoking evaluation, and the resident reported not receiving any instruction on smoking risks or the facility's smoking policy. This oversight further highlights the facility's failure to adhere to its own safety protocols.
Failure to Prevent Resident Abuse and Inadequate Response
Penalty
Summary
The facility failed to prevent abuse for one of the residents, resulting in psychosocial harm. Resident #20, who was cognitively intact and admitted with diagnoses including acute and hypoxic respiratory failure and major depressive disorder, experienced an incident on 02/23/25 where another resident, Resident #44, entered their room, exposed themselves, and engaged in inappropriate behavior. Despite Resident #20's distress and subsequent fear, the facility did not notify their physician, address interventions, or consult psychiatric services as required by their policies. Resident #44, who had a history of disturbed thought processes and behaviors such as wandering and making threats, was not adequately monitored or referred to mental health services despite documented behaviors starting on 02/11/25. The facility's failure to notify Resident #44's physician or make necessary referrals contributed to the incident on 02/23/25. The facility's policy on resident-resident altercations was not followed, as evidenced by the lack of documentation and intervention following the incident. The Director of Nursing (DON) acknowledged that the policy was not adhered to and that Resident #20 was not assessed for psychosocial injury or referred to psychiatric services after the incident. The report highlights the facility's failure to implement and document appropriate interventions and follow-up care for both residents involved, leading to a deficiency in protecting residents from abuse.
Failure to Update Care Plans and Ensure Interdisciplinary Participation
Penalty
Summary
The facility failed to ensure that care plans were updated and revised for a resident who experienced multiple falls, resulting in harm. Resident #3, who had a history of falls and was diagnosed with type 2 diabetes mellitus, syncope and collapse, and chronic kidney disease, experienced several falls without the care plan being updated with new specific interventions. Despite multiple incidents, including a fall that resulted in a nasal bone fracture, the care plan was not revised to include new interventions to prevent further falls. The facility's policy required that care plans be updated with new interventions after each fall, but this was not followed. The MDS coordinator admitted that no interventions were added to the care plan after several falls, citing being busy and not always being communicated about falls. The lack of updated interventions in the care plan contributed to Resident #3 experiencing significant harm, including a broken nose and facial bruises. Additionally, the facility failed to ensure the participation of the interdisciplinary team and the resident or their representative in the revision of care plans. Resident #12's care plan did not document the participation of the interdisciplinary team members, and the resident stated they had not participated in a care plan meeting. The MDS coordinator confirmed that there was no documentation of the participation of social services, activities, or dietary staff in the care plan meeting, highlighting a deficiency in the facility's care planning process.
Failure to Provide Trauma-Informed Care After Incident
Penalty
Summary
The facility failed to provide trauma-informed care following an incident of sexual abuse involving a resident. Resident #20, who had a fully intact cognition with a BIMS score of 15, experienced a traumatic event when another resident, Resident #44, entered their room naked and engaged in inappropriate behavior. Despite the incident, the facility did not notify Resident #20's physician, assess the resident for psychosocial injury, or consult psychiatric services for further evaluation and support. The facility's policies on abuse and resident altercations were not followed. The policies required notifying the resident's representative and attending physician, reviewing the incident with nursing supervisors, and making necessary changes to the care plan. However, there was no documentation of these actions being taken. Additionally, the facility did not document any interventions or their effectiveness, nor did they consult with psychiatric services to assist in assessing the resident and developing a care plan. Interviews with Resident #20 and their family representative revealed ongoing distress and fear following the incident. Resident #20 reported difficulty sleeping, fear of the opposite sex, and reluctance to be alone. The family representative confirmed that the facility did not arrange for psychological counseling, and the DON acknowledged that the policy was not followed. The lack of appropriate response and support for Resident #20 highlights the facility's failure to provide trauma-informed care after the incident.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe after becoming aware of the allegation. This involved three residents who reported not receiving their medications as ordered. The facility's policy mandates that all allegations of abuse and neglect be reported immediately, defined as within two hours for abuse-related allegations. However, the incident involving a Certified Medication Aide (CMA) who allegedly did not administer medications was not reported until over a month later. The incident began when residents complained about not receiving their medications, which was corroborated by discrepancies in the medication administration records. The Director of Nursing (DON) and other staff members noticed that medications were charted as given, but the physical count of medications did not match. Despite these findings, the DON did not initially report the incident to the state agency, believing it was a patient education issue rather than neglect. The DON removed the CMA from their duties but did not file a report with the state agency as required. The administrator was informed of the situation and instructed the DON to report the incident, but it was unclear if this was done promptly. The failure to report the incident in a timely manner was a violation of the facility's policy and state regulations, which require immediate reporting of such allegations to ensure resident safety and compliance with legal obligations.
Failure to Provide Bed-Hold Policy to Residents
Penalty
Summary
The facility failed to provide a copy of its bed-hold policy to two residents who were transferred out with the intention of returning. The facility's policy, revised in October 2022, mandates that all residents or their representatives receive written information about the bed-hold policy during periods of absence, such as hospitalization or therapeutic leave. Resident #9, diagnosed with a urinary tract infection, was hospitalized in February 2025, and Resident #147, also diagnosed with a urinary tract infection, was hospitalized in March 2025. In both cases, there was no documentation that the residents received the bed-hold policy. The administrator was unaware of the requirement to provide the policy upon a resident's departure, and the ADON confirmed that the policy was not included in the documents sent with residents to the hospital.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their care plans. Resident #3, who was admitted with conditions including type 2 diabetes mellitus and chronic kidney disease, had multiple falls documented in their care plan. However, their annual MDS assessment inaccurately reported no falls since admission. The MDS coordinator confirmed the inaccuracy, acknowledging that the assessment did not reflect the resident's actual fall history, which included several incidents after the quarterly assessment. Resident #13, admitted with dysphagia following a cerebral infarction, was observed with broken and missing teeth, contrary to their annual MDS assessment, which indicated they had all their natural teeth. The MDS coordinator admitted to not performing a visual assessment of the resident's oral condition, as required by the Resident Assessment Tool manual. This oversight resulted in missed care areas in the resident's care plan, as the coordinator did not verify the resident's dental status, which was inaccurately documented.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident, diagnosed with an anxiety disorder, was receiving Buspar, an anti-anxiety medication, as noted in the physician's monthly summary. However, the resident's care plan did not address the anxiety disorder or the use of the medication, as confirmed by the MDS coordinator. Another resident, diagnosed with a psychotic disturbance and receiving Zyprexa, an antipsychotic medication, also had a care plan that failed to address their diagnosis or the use of the medication. This oversight was similarly acknowledged by the MDS coordinator. These deficiencies were identified through record reviews and interviews, highlighting the facility's failure to ensure that care plans were comprehensive and reflective of the residents' current medical treatments and diagnoses.
Failure to Obtain Informed Consent for Medications
Penalty
Summary
The facility failed to provide informed consent for medications for a resident diagnosed with aphasia following a cerebral infarction and vascular dementia. The resident was receiving Depakote for anxiety, Sertraline as an antidepressant, and Zyprexa as an antipsychotic. However, there was no documentation in the resident's clinical record indicating that informed consent for these medications was obtained. The resident's cognition was severely impaired, as indicated by a BIMS score of 03 on the quarterly MDS assessment. The resident's Power of Attorney (POA) reported a lack of communication from the facility regarding care plan meetings, medication risks versus benefits, and possible alternatives to the medication treatment. The POA mentioned that the facility staff occasionally contacted them about the resident falling but provided no further details during visits. The MDS coordinator confirmed that there was no documentation of communication with the family regarding the risks and benefits of the medications in the resident's electronic medical record, indicating that the necessary informed consent process was not completed.
Failure to Assess Geriatric Chair Use as Restraint
Penalty
Summary
The facility failed to properly assess the use of a geriatric chair for a resident, leading to a deficiency in ensuring the resident was free from physical restraints unless medically necessary. Resident #3, who had significant cognitive impairment and required assistance with mobility, was observed in a geriatric chair with facial bruising. The facility's policy required a pre-restraining assessment to determine the necessity of restraints and explore less restrictive interventions. However, there was no documentation of such an assessment for Resident #3 before the use of the geriatric chair. The resident's physician had ordered the use of a geriatric chair for poor balance and trunk control, but the assessment was only conducted after the resident had already been placed in the chair. An LPN confirmed that the resident was not properly assessed for the use of the chair as a restraint, resulting in the resident being removed from the chair until an assessment was completed. The facility administrator acknowledged that the required pre-restraining assessment was not conducted prior to the resident's placement in the geriatric chair.
Failure to Conduct Timely Significant Change Assessment Post-Hospice Discharge
Penalty
Summary
The facility failed to conduct a significant change assessment for a resident who was discharged from hospice services. The facility's policy requires a comprehensive assessment to be completed when a resident experiences a significant change in status, such as being discharged from hospice. Resident #2, who had diagnoses including chronic kidney disease and end-stage renal disease, was admitted to hospice services on April 23, 2024. However, the resident was discharged from hospice on February 27, 2025, as they were deemed no longer appropriate for hospice care. Despite this significant change, the required assessment was not completed within the two-week timeframe stipulated by the facility's policy. The MDS coordinator was unaware of the resident's discharge from hospice services until March 17, 2025, when they were provided with the physician's order indicating the discharge date. The coordinator acknowledged that the significant change assessment was overdue. The lack of awareness and failure to complete the assessment in a timely manner highlights a breakdown in communication and adherence to the facility's policy, resulting in a deficiency in the care provided to the resident.
Failure to Complete PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a Level I Pre-Admission Screening and Resident Review (PASARR) for a resident after a new mental health diagnosis was made. The resident was admitted with diagnoses including cerebral infarction and dementia. On a later date, the resident was diagnosed with bipolar disorder. However, the facility did not conduct a Level I PASARR following this new diagnosis. During an interview, the MDS coordinator confirmed that a PASARR should have been completed after the new diagnosis but was not.
Failure to Document Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to perform a gradual dose reduction (GDR) or document the rationale for not performing a GDR of an antipsychotic medication for a resident with vascular dementia and other mental health diagnoses. The resident was prescribed Zyprexa 5mg at bedtime, and despite pharmacy recommendations to consider a GDR to 2.5mg, the facility did not attempt a dose reduction or provide documentation explaining why it was contraindicated. The resident's assessments consistently showed severe cognitive impairment and no behaviors, yet the facility did not document any attempts or contraindications for a GDR. During the survey, the administrator and MDS coordinator were unable to provide documentation of a prior GDR or a clinical rationale for not performing one. Despite being informed of a possible deficiency related to unnecessary medications, the facility did not provide further documentation by the end of the survey. The administrator acknowledged the lack of documentation and contacted the resident's physician for a rationale, but no additional information was provided before the survey concluded.
Failure to Offer Dental Services to Resident
Penalty
Summary
The facility failed to offer dental services to a resident, identified as Resident #13, who was observed with broken and missing teeth. Despite the facility's policy indicating that dental services should be offered through a program with Medicaid, Resident #13 reported experiencing tooth pain and stated that they had not been offered dental services since their admission. The resident's care plan did not document the need for dental services, and their annual assessment inaccurately indicated that they had all their natural teeth, which was not the case. Interviews with facility staff revealed a lack of proper assessment and follow-up regarding the resident's dental needs. The Social Services Director (SSD) admitted that the facility did not actively offer dental services, leaving it to the dental service provider to contact residents or their responsible parties. The Minimum Data Set (MDS) coordinator acknowledged that they did not perform a visual assessment of the resident's oral health, which led to inaccuracies in the resident's assessment and care plan. This oversight resulted in the resident's dental needs being overlooked, affecting their overall care plan.
Unsanitary Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain the ice machine in a sanitary manner, affecting 44 residents who utilized ice from the kitchen. During an observation with the dietary manager, a slimy black and brown substance was found in the crevices, along the edges, and around the pump of the water reservoir of the ice machine. The dietary manager acknowledged the presence of the substance and stated that while the ice bin was cleaned weekly, they were unaware of who was responsible for cleaning the mechanical area of the ice machine. The administrator later confirmed that the ice machine should be on a regular cleaning schedule for the maintenance department to perform.
Inadequate Training for COVID-19 Testing Staff
Penalty
Summary
The facility failed to ensure that staff conducting COVID-19 testing received appropriate training. The social services director and activities assistant, who sometimes performed COVID-19 testing on residents, stated they did not remember receiving training on proper infection control techniques or specimen collection. An LPN confirmed that various employees, including unlicensed activities staff, conducted outbreak testing. The Director of Nursing (DON) acknowledged that social services and activities staff were sometimes used for outbreak testing and could not locate any documentation proving that these staff members had received the necessary training related to infection control or test specimen collection.
Failure to Notify Family and Physician of Resident Fall
Penalty
Summary
The facility failed to notify a resident's representative and physician of a fall incident involving a resident with a history of falling and dementia. The facility's policy required the assessment of the resident and notification of the medical director, DON, ADON, administrator, and emergency family contact in such situations. However, when the resident experienced a non-injury fall, the LPN on duty did not contact the physician or the family at the time of the incident. This lapse was confirmed by the DON and the administrator, who acknowledged that the nurse on duty did not notify anyone following the fall.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to assess a resident after a fall, which was identified during a review of records and interviews. The facility's policy requires neuro checks for falls with head injury and unwitnessed falls with possible head injury, including assessing the resident, contacting the medical director, DON, ADON, administrator, and emergency family contact, and obtaining vital signs and assessing the resident's orientation, level of consciousness, pupil size, and reaction to light. A resident with a history of falling and dementia experienced a non-injury fall, but the LPN did not complete an assessment after the incident. This was confirmed by the DON and the administrator, who acknowledged that the LPN failed to assess the resident after the fall.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse for two residents. Resident #1, who had severe cognitive impairment and was dependent on assistance for most activities of daily living, was involved in an incident where the family reported that an agency staff member was rough with the resident. The Director of Nursing (DON) acknowledged that the investigation was incomplete, as only one resident statement was obtained, and the documentation was unsigned and undated. Additionally, a staff member's statement identifying another agency staff member as the accused was provided four days after the allegation, but the investigation was not comprehensive. Resident #3, who was cognitively intact and required moderate assistance with activities of daily living, reported being slapped by a staff member a month prior to the incident report. The DON admitted that no interviews were conducted with other residents who had received care from the accused staff member. Both the DON and the administrator confirmed that a thorough investigation had not been completed for this allegation as well.
Failure to Follow Dietary Menus
Penalty
Summary
The facility failed to adhere to the dietary menus planned for the residents, which is a requirement to meet their nutritional needs. During an observation on June 26, 2024, it was noted that the meal service did not follow the documented menu. The menu specified a meal consisting of a philly steak sandwich, potato wedges, coleslaw, and cheesecake for dessert. However, the dietary manager (DM) reported that they ran out of coleslaw and coconut cake, and as a result, four residents were served a salad and ice cream instead. Additionally, the DM admitted that cheesecake had never been served, and the evening menu was altered because the staff forgot to thaw the meat. The DM also acknowledged that menu substitutions had been frequent recently.
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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