Corn Heritage Village And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Corn, Oklahoma.
- Location
- 106 West Adams, Corn, Oklahoma 73024
- CMS Provider Number
- 375409
- Inspections on file
- 21
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 4 (2 serious)
Citation history
Health deficiencies cited at Corn Heritage Village And Rehab during CMS and state inspections, most recent first.
A resident on long-term anticoagulant therapy experienced an unwitnessed fall with head injury, but staff failed to notify the physician of the resident's medication status and subsequent changes in condition. Despite developing significant bruising, low blood pressure, and mental status changes, the resident was not promptly assessed or sent to the hospital, resulting in delayed intervention. Staff interviews confirmed that established protocols for monitoring and physician notification were not followed.
Nursing staff did not effectively assess, monitor, or intervene for a resident on a blood thinner who sustained a head injury after a fall. Staff failed to notify the physician of the resident’s anticoagulant use and abnormal vital signs, resulting in delayed hospital transfer and diagnosis of an acute subdural hematoma. Interviews indicated staff were unaware of the need to report such changes, and annual competency checks had not been completed.
A resident on anticoagulation therapy experienced a fall with head injury, but the LPN did not inform the physician of the resident's blood thinner use or subsequent changes in condition, including abnormal vital signs and new injuries. The physician was only notified after the resident's neurological status declined significantly, resulting in hospital transfer and diagnosis of a subdural hematoma.
The facility did not report an allegation of resident-to-resident sexual abuse to OSDH within the required 24-hour period. Two residents with cognitive impairments were involved in the incident, and the DON later confirmed the reporting delay, which was not in accordance with facility policy.
A resident with anxiety disorder did not receive medications as per physician's orders due to a discrepancy between the drug label and the physician's order list. The order specified administration every four hours, but the medication was given four times a day. The inconsistency was noted, but no clarification was sought from the physician.
The facility failed to implement an antibiotic stewardship program for three residents who were prescribed antibiotics without completing the Mcgreer criteria checklist. The DON and infection preventionist acknowledged the oversight, citing staff changes as the reason for the lapse.
A facility failed to report new mental illness diagnoses for a resident to the OHCA as required by PASARR policy. The resident had new diagnoses of anxiety disorder, recurrent depressive disorder, hallucinations, and psychosis, but these were not reported for a level II review. The DON was unaware of the reporting requirement until recently, and a level II screen was not conducted until later, when it was deemed unnecessary.
A resident with congestive heart failure and chronic obstructive pulmonary disease was admitted to hospice care, but the facility failed to include hospice services in the resident's care plan. Despite a comprehensive assessment noting the resident's intact cognition and receipt of hospice services, the care plan did not reflect these services, contrary to the facility's policy requiring updates within seven days of changes in condition.
The facility failed to provide incontinent care every two hours to three dependent residents with impaired range of motion and incontinence. Observations revealed that these residents were left without care for several hours, resulting in grossly saturated briefs. A CNA and RN confirmed the facility's policy was not followed.
The facility failed to provide food handling training to eight out of nineteen dietary staff members, including cooks and dietary aides, which is crucial for preventing foodborne illness. The deficiency was identified during a review, with the Administrator unable to verify training for these staff members, affecting meal preparation for 61 residents.
Failure to Monitor and Intervene After Fall in Resident on Anticoagulant
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper monitoring and intervention for a resident on long-term anticoagulant therapy following an unwitnessed fall. The resident, who had diagnoses including rheumatoid arthritis, atrial fibrillation, hypertension, and a history of transient ischemic attack, experienced a fall from a recliner, hitting their head and developing significant bruising. Despite the facility's policy requiring neurologic assessments and immediate physician notification for head injuries, there was no documentation that the physician was notified of the resident's change in condition after the fall. Subsequent nursing notes indicated the resident had increased bruising, low blood pressure, decreased oxygen saturation, and required more assistance, but these changes were not communicated to the physician. The LPN who reported the fall to the physician's nurse failed to mention that the resident was on a blood thinner, leading to a lack of appropriate medical response. The resident's condition further deteriorated, with pinpoint pupils and a mental status change observed two days after the fall, at which point the physician was finally notified and the resident was sent to the hospital. Interviews with staff confirmed that the resident should have been sent to the hospital immediately after the fall due to their anticoagulant use and head injury. The LPN acknowledged overlooking the resident's anticoagulant therapy and not reporting abnormal blood pressure readings or the development of two black eyes to the physician. The failure to follow established protocols for monitoring and physician notification after a significant change in condition resulted in a delay in appropriate medical intervention.
Removal Plan
- Staff will identify residents on anticoagulants at shift change by notifying oncoming staff at shift change of all residents on anticoagulants.
- Administration will post a roster in the medication room of all residents on anticoagulants.
- Administration will post a roster in the medication room of all anticoagulant medications.
- Will adjust EHR resident dashboard to indicate the use of anticoagulant medication.
- Immediate In-Service Education of medication management with a focus on high-risk drugs like anticoagulants for nursing staff and CMAs.
- Competency assessments will be completed by nursing administration including demonstrations of skills, med-administration, side effects and monitoring requirements.
- All residents were reassessed for changes in condition and care plans were updated for discrepancies.
- Nursing staff were educated on monitoring residents through routine assessments, ongoing observation, and documentation. This includes checking vital signs, evaluating physical and mental status, and noting any changes in behavior, appearance, or function.
- Staff are now trained to recognize both subtle and obvious changes in residents' health, such as increased confusion, changes in mobility, altered appetite, new or worsening pain, or unusual sleep patterns.
- Nursing Staff were educated on promptly notifying the physician whenever there is a significant change in the condition of a nursing home resident on anti-coagulants. This includes any acute medical events, substantial changes in physical or mental status, or any situation that may require a change in treatment or intervention. Notification should occur as soon as reasonably possible after the change has been identified by nursing staff, in accordance with regulatory guidelines and the facility's policies.
- Nursing home nursing staff will receive dedicated training focused on the indications for commonly used medications, with special emphasis on blood thinners. The training will cover: Overview of blood thinners: indications, expected outcomes, and common side effects. Recognizing signs and symptoms of adverse reactions or complications (e.g., bleeding, bruising, changes in mental status, or unexplained pain). Monitoring protocols for residents on blood thinners, including vital signs, laboratory values, and physical assessments. Documentation requirements and communication procedures for reporting changes in resident conditions. Emergency response procedures for suspected medication-related complications.
- The training will be delivered by the facility's Director of Nursing, in collaboration with the facility pharmacist consultant and CHV nurse consultant.
Failure to Ensure Nursing Staff Competency in Change of Condition for Resident on Anticoagulant
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in assessing, monitoring, and intervening for a resident who was on a routine blood thinner and sustained a fall with a head injury. The resident, who had a history of atrial fibrillation and heart failure and was prescribed Xarelto, experienced a fall resulting in a head injury and subsequent acute subdural hemorrhage. Despite facility policy requiring neurological assessments and immediate physician notification for head trauma, staff did not communicate the resident’s anticoagulant use to the physician and did not send the resident to the hospital immediately after the fall. Documentation showed that after the fall, the resident developed a large hematoma, bruising, and later two black eyes and additional bruising, with abnormal blood pressure readings noted. Staff continued to monitor the resident in the facility, performing neuro checks and documenting changes, but failed to recognize or report significant changes in condition, including abnormal vital signs and new injuries, to the physician in a timely manner. The resident’s condition deteriorated over the following days, culminating in confusion, pinpoint pupils, and slow responsiveness, at which point the resident was finally transferred to the hospital and diagnosed with an acute subdural hematoma. Interviews with staff revealed a lack of awareness regarding the importance of reporting anticoagulant use and abnormal vital signs after a fall. The LPN involved admitted to overlooking the resident’s blood thinner status and not communicating critical information to the physician. The DON and ADON acknowledged that the facility’s process for physician notification after a fall was not consistently followed, and that annual competency check-offs for nursing staff had not been completed.
Removal Plan
- All nursing staff complete Skills Competency proficiency of change of condition with a focus on high-risk drugs like anticoagulants.
- DON and ADON are in-serviced on training and completing nursing skills competency education for nursing staff.
- All residents are reassessed for changes in condition and care plans are updated for discrepancies.
- DON and ADON are educated on auditing nursing staff annual skills competency education.
- DON and ADON are educated on auditing nursing staff new hire skills competency education.
- Nursing staff complete testing regarding changes in condition, medication drug class identification, and recognizing vital signs.
- Nursing staff are educated on what constitutes a significant change in condition that requires reporting, including sudden onset of symptoms, significant changes in vital signs, new or worsening pain, changes in mobility, altered level of consciousness, signs of infection, unexplained weight loss or gain, and changes in skin integrity.
Failure to Notify Physician of Change in Condition After Fall with Head Trauma
Penalty
Summary
The facility failed to ensure timely and appropriate physician notification following a significant change in condition for a resident who experienced a fall with head trauma. The resident, who had a medical history including atrial fibrillation and was prescribed Xarelto (a blood thinner), sustained a head injury after an unwitnessed fall. Facility policy required immediate physician notification and neurological assessment for any head trauma, especially for residents on anticoagulants. However, documentation and interviews revealed that the physician was not informed that the resident was on a blood thinner at the time of the initial notification, and critical details such as abnormal blood pressure readings and the development of new injuries (including two black eyes and additional bruising) were not promptly communicated. Nursing notes indicated that the resident developed worsening symptoms over the following days, including increased bruising, new injuries, and abnormal vital signs. Despite these changes, there was no evidence that the physician was updated about the resident's deteriorating condition or the significance of the blood thinner therapy. The resident continued to receive Xarelto, and neuro checks were performed, but the escalation of symptoms and abnormal findings were not reported as required by facility policy. It was only after a significant decline in neurological status, including confusion and pinpoint pupils, that the physician was notified and the resident was transferred to the hospital, where a diagnosis of acute subdural hematoma was made. Interviews with facility staff, including the LPN and ADON, confirmed that the physician should have been notified immediately after the fall due to the resident's anticoagulant use and that subsequent changes in condition warranted further communication, which did not occur.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to the Oklahoma State Department of Health (OSDH) within 24 hours as required by policy and state law. Specifically, an incident involving two residents, where one resident was observed placing another resident's hands in their groin area over clothing, was not reported to OSDH within the mandated timeframe. The facility's policy requires immediate reporting of any alleged abuse to the administrator and DON, who are then responsible for notifying authorities. However, the initial report to OSDH was made after the 24-hour window had passed. Resident records indicated that one resident involved had moderate cognitive impairment and a history of sexually inappropriate behavior, while the other had severe cognitive impairment and required significant assistance with activities of daily living. During interviews, one resident denied being approached by another resident, and the DON confirmed that the incident should have been reported within 24 hours. The failure to report the allegation in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Medication Administration Discrepancy for Resident with Anxiety Disorder
Penalty
Summary
The facility failed to administer physician-ordered medications correctly for a resident diagnosed with senile degeneration of the brain, anxiety disorder, and polyarthritis. The physician's order, dated November 6, 2024, instructed the administration of 0.5 mg PLO gel every four hours. However, the drug label and the physician's order list documented conflicting instructions, with the label indicating application every four hours and the order list specifying four times a day. This discrepancy was not clarified with the physician, leading to a medication error. The Controlled Narcotic Administration Record showed an accurate count of 53 pre-filled syringes of 0.5 ml medication, but it documented administration four times a day instead of every four hours as ordered. A Medication Error Report noted the inconsistency between the prescription label and the chart order, yet no clarification was sought. The Director of Nursing acknowledged the discrepancy and the need to contact the physician for clarification, but this action was not taken at the time of the report.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for three residents who were sampled for medication review. Resident #17, diagnosed with chronic systolic congestive heart failure, permanent A-Fib, and recurrent depressive disorders, was prescribed Macrobid for a urinary tract infection without the completion of the Mcgreer criteria checklist. Similarly, Resident #39, with chronic obstructive pulmonary disease and acute kidney disease, was prescribed Cephalexin for a urinary tract infection, but the Mcgreer criteria checklist was not completed. Resident #44, who had congestive heart failure and atrial fibrillation, was given Piperacillin-Tazobactam for a severe liver infection, yet again, the Mcgreer criteria checklist was not utilized. The Director of Nursing (DON) and the infection preventionist acknowledged the oversight, citing a change in staff as the reason for the lapse in completing the Mcgreer criteria for residents prescribed antibiotics. The infection preventionist was unaware that the Mcgreer criteria checklist should have been completed for residents receiving antibiotics. This lack of adherence to the antibiotic stewardship program was identified during interviews with the DON and the Assistant Director of Nursing (ADON), highlighting a significant gap in the facility's infection control program.
Failure to Report New Mental Illness Diagnoses
Penalty
Summary
The facility failed to report new mental illness diagnoses for a resident to the Oklahoma Health Care Authority (OHCA) as required by the Preadmission Screening and Annual Resident Review (PASARR) policy. The policy mandates that all residents with newly evident or possible serious mental disorders be referred for a level II review upon a significant change in status assessment. Resident #6, who was admitted with primary diagnoses of chronic obstructive pulmonary disease and acute on chronic systolic heart failure, had new diagnoses of anxiety disorder, recurrent depressive disorder, hallucinations, and psychosis documented on various dates. Despite these new mental health diagnoses, the Director of Nursing (DON) reported that they were not aware of the requirement to report these to the OHCA until recently, and a level II screen was not conducted until 11/18/24, when it was determined not to be required.
Failure to Include Hospice Services in Care Plan
Penalty
Summary
The facility failed to include hospice services in the care plan for a resident who was receiving hospice care. The resident had diagnoses of congestive heart failure and chronic obstructive pulmonary disease and was admitted to hospice with a diagnosis of hypertensive heart disease with heart failure. Despite a comprehensive assessment documenting the resident's intact cognition and receipt of hospice services, the care plan did not address or document these hospice services. The facility's policy required comprehensive care plans to be revised and updated within seven days of any new changes in a resident's condition, but this was not adhered to in this case.
Failure to Provide Timely Incontinent Care to Dependent Residents
Penalty
Summary
The facility failed to provide incontinent care to dependent residents at least every two hours, as required by their policy. Three residents, all of whom had impaired range of motion in both upper and lower extremities and were incontinent of bowel and bladder, were observed sitting in the common area and later escorted to the dining room and activity area without receiving incontinent care. These residents were dependent on staff for all activities of daily living (ADLs). During the observation period, the residents were not provided with incontinent care for several hours. When care was finally administered, the residents' briefs and padding were found to be grossly saturated, indicating a significant delay in care. A Certified Nursing Assistant (CNA) confirmed that the facility's policy was to check dependent residents every two hours, acknowledging that this policy was not followed for the observed residents. The Registered Nurse (RN) also confirmed the policy and acknowledged the failure to adhere to it.
Lack of Food Handling Training for Dietary Staff
Penalty
Summary
The facility failed to ensure that all dietary staff received training in safe food handling practices, which is essential for the prevention of foodborne illness. This deficiency was identified during a record review and interview process, revealing that eight out of nineteen dietary staff members, including four cooks and four dietary aides, had not received the required food handlers training. The Director of Nursing (DON) confirmed that 61 residents resided in the facility, all of whom received meals prepared by the dietary department. The deficiency was noted when the Administrator was unable to provide verification of food handlers training for these eight staff members, acknowledging the lapse in training compliance.
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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