Grace Skilled Nursing And Therapy Jenks
Inspection history, citations, penalties and survey trends for this long-term care facility in Jenks, Oklahoma.
- Location
- 711 North 5th Street, Jenks, Oklahoma 74037
- CMS Provider Number
- 375358
- Inspections on file
- 31
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Grace Skilled Nursing And Therapy Jenks during CMS and state inspections, most recent first.
The facility did not ensure that wound care was properly documented for two residents with severe cognitive impairment and pressure ulcers. Despite physician orders specifying wound care regimens, treatment administration records showed missing documentation for several scheduled wound care dates. Nursing staff confirmed that wound care was performed but not consistently recorded, resulting in incomplete medical records.
A resident's room was found to have broken mini blinds and multiple areas of missing paint, with the resident stating these issues had persisted for three years. Staff interviews revealed uncertainty about responsibility and whether maintenance had been notified, despite maintenance being designated for such repairs.
A resident with severe cognitive impairment and a feeding tube did not receive a prescribed nutritional supplement because the order was not entered into the medication/treatment administration record. Staff interviews confirmed the supplement was not administered, and the omission was not detected during daily audits by nursing leadership.
A resident with intact cognition and a history of stroke reported that their television stopped working after a power outage, displaying only sound and no picture. The facility provided a loaner television but did not replace the damaged one, with the administrator stating that replacement of personal property was not the facility's responsibility according to the admission agreement. No grievance was filed regarding the incident.
Two residents identified as high fall risk did not consistently receive fall prevention interventions as outlined in their care plans. One resident, with a history of falls and fractures, repeatedly did not have a fall mat at the bedside as required. Another resident, with severely impaired cognition and a recent fall resulting in injury, had a fall mat placed under the bed rather than at the bedside. Staff interviews and observations confirmed inconsistent implementation of these safety measures.
A resident with severe cognitive impairment was left calling out for help to use the bathroom without timely assistance, as staff were not available to respond promptly. Multiple CNAs and an LPN confirmed that staffing levels were inadequate to answer call lights within the expected five-minute timeframe.
A resident with intact cognition and a history of stroke was placed on a soft diet with thickened liquids without clear justification, despite expressing a preference for a regular diet and no history of choking. Facility staff could not trace the origin of the diet order, did not provide a swallow evaluation, and did not honor the resident's dietary choices, citing physician orders and lack of waivers outside of hospice care.
The facility failed to secure chemicals in three of its eight halls, with unlocked closets containing various cleaning agents and chemicals labeled to be kept out of reach of children. Observations revealed that the 800 hall linen closet, 700 hall housekeeping closet, and 100/200 hall central supply closet were all unsecured, contrary to the facility's policy. Interviews with the DON and administrator confirmed lapses in securing these areas, posing potential safety hazards.
The facility failed to label and date food items in refrigerator #1, including sliced cheese, diced onion, diced tomatoes, diced honeydew melon, and tuna salad. The dietary manager was unaware of why the items were not labeled or dated, despite acknowledging that they should be. The Director of Nursing noted that 122 residents received nourishment from the kitchen.
A resident with dementia had a significant change assessment completed but not transmitted within the required timeframe. The assessment was completed but transmitted late due to the absence of an MDS coordinator, despite monitoring by the corporate office.
A resident with intact cognition reported neglect by a nurse aide, who failed to provide care after turning off the call light. The complaint was reported to the ADON and administrator, but no thorough investigation or documentation was completed, and the issue was not addressed.
A resident with a history of constipation went five days without a bowel movement, leading to hospitalization for stercoral colitis. The facility failed to follow its policy of assessing and notifying the physician after three days without a bowel movement. The electronic health record system did not alert staff, and the resident's condition was not addressed until they were in significant pain. Staff interviews revealed a lack of awareness and adherence to procedures, resulting in the resident's hospitalization.
A resident with seizures experienced a significant medication error when an ACMA incorrectly measured Dilantin using medication cups instead of a syringe, leading to a potential overdose. The DON confirmed that the medication should have been measured with a syringe, and a discrepancy in the Dilantin count was not reported, highlighting lapses in communication and monitoring.
The facility failed to date medications when opened across four medication and treatment carts. Observations revealed that various medications, including inhalers, insulin, eye drops, and test strips, were opened but not dated. The DON confirmed that staff were expected to date these items, and a consultant pharmacist audited the carts monthly.
A resident with a history of constipation went five days without a bowel movement, yet the attending physician was not notified as required by facility policy. The resident's condition was only addressed when they were sent to the hospital. Both the DON and an RN acknowledged the oversight, with the DON realizing the issue upon returning from vacation.
A resident with intact cognition reported neglect when a nurse aide failed to provide care after turning off the call light. The resident filed a complaint with the ADON, who reported it to the administrator. However, the facility did not report the incident to the OSDH, as required by their policy, because the administrator did not believe it constituted abuse.
A facility failed to maintain accurate medication records and reconcile controlled drugs for a resident prescribed oxycodone for pain management. Discrepancies were found between the Medication Administration Records and narcotics sheets, with missing documentation contributing to the inconsistency. An investigation revealed that CMAs and LPNs often documented only on narcotic sheets, neglecting electronic records, but found no evidence of medication diversion.
A resident with dementia and COPD, requiring supervision while smoking, was left unsupervised and attempted to smoke with oxygen on, resulting in a fire. The resident sustained severe burns and was transported to a hospital burn center, where they later passed away. Staff confirmed the lack of supervision during the incident.
The facility failed to ensure that dependent residents were offered or provided showers as required. One resident with a left femur fracture received only one shower over a two-week period, and another resident with right and left humerus fractures received only one shower since admission. Despite monitoring and staffing efforts, the facility did not consistently offer or provide showers, as evidenced by the lack of documentation and staff statements.
The facility failed to monitor weights as ordered for two residents, leading to undocumented weight values and significant weight loss. One resident with osteoporosis and another with humerus fractures experienced unmonitored weight changes, with the latter losing 13 pounds in 14 days.
The facility failed to ensure snacks were provided to residents as required, particularly affecting four residents with specific medical conditions. Interviews with staff revealed inconsistencies in the process of offering snacks, and there was confusion about where to document snack distribution. The lack of a consistent and documented process for offering snacks, especially to diabetic residents with specific orders for bedtime snacks, led to the identified deficiencies.
A facility failed to notify a physician of a resident's low blood pressure readings as required by a physician's order. The resident, with diagnoses including congestive heart failure and chronic kidney disease, had blood pressure readings outside the specified range on two occasions. An LPN confirmed they did not call the physician, and the nurse practitioner identified the issue during a clinical record review, leading to the resident being sent to the hospital.
The facility failed to ensure wound care was provided as ordered for a resident with a sacral pressure ulcer. Wound care was not documented as completed multiple times in March and April 2024, and the wound nurse and DON could not explain the lapses.
The facility failed to ensure proper pain management for a resident with a sacral pressure wound and cervical spine fractures. Despite a physician's order for pain medication, staff did not monitor or document its effectiveness, as confirmed by interviews with a CMA, an LPN, and the DON.
Failure to Document Wound Care for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper documentation of wound care for two of three sampled residents with pressure ulcers. For one resident with severe cognitive impairment and multiple pressure ulcers, physician orders specified wound care regimens for different wounds, including cleansing and dressing changes on specific days and shifts. However, review of the treatment administration records revealed missing documentation for several scheduled wound care dates and shifts. Interviews with wound care nurses confirmed that while the wound care was reportedly performed, it was not consistently documented in the treatment administration records as required. Another resident, also with severe cognitive impairment and a stage 3 pressure ulcer, had physician orders for wound care on designated days. The treatment administration record for this resident similarly lacked documentation for several scheduled wound care dates. Nursing staff acknowledged that the wound care was completed but not recorded. The Director of Nursing stated that daily audits and weekly monitoring of treatment records were in place, but the documentation failures persisted during the review period.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident's room was observed to have two broken and missing slats on the mini blinds, as well as a one foot by one foot area of missing paint on the North wall and several smaller areas of missing paint along the North and East walls. The resident reported that both the broken blinds and missing paint had been present for the three years they had resided in the facility. When interviewed, a CNA was unsure who was responsible for addressing these issues, while an LPN stated that maintenance was responsible but was unaware if maintenance had been informed of the room's condition. The maintenance supervisor confirmed responsibility for repairs, and the administrator stated that such issues should be reported to maintenance for resolution.
Failure to Administer Ordered Nutritional Supplement via Feeding Tube
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a nutritional supplement ordered for a resident with severe cognitive impairment and a feeding tube was provided as prescribed. The resident, who had a diagnosis of dementia and was at risk for nutritional problems and weight fluctuations, was recommended by the dietician to receive a 2.0 cal nutritional supplement, 30cc twice daily via feeding tube. This order was confirmed by both a nurse note and a physician order. However, review of the medication/treatment administration records for the relevant period showed that the order for the nutritional supplement was not entered, and thus was not administered to the resident. Interviews with staff, including an LPN, an ACMA, the ADON, and the DON, confirmed that the supplement order was not present on the medication/treatment record and had not been given. The ADON stated that when the order was entered into the electronic clinical record, it did not carry over to the administration record. The DON acknowledged that despite daily audits of new orders, the omission of the nutritional supplement from the administration record was not identified by the charge nurse or ACMA, resulting in the resident not receiving the ordered supplement.
Failure to Replace Damaged Resident Property After Power Outage
Penalty
Summary
The facility failed to ensure the replacement of a resident's damaged personal property, specifically a television, after a power outage rendered it unusable. The resident, who had intact cognition and a history of stroke, reported that following the outage, their television would only produce sound with no picture. The facility took the resident's television and provided a loaner but did not replace the damaged item. The administrator stated they were unaware of the issue and indicated that, according to the admission agreement, the facility does not replace personal property damaged under such circumstances. There was no record of a grievance filed by the resident regarding the television.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents identified as being at risk for falls. For one resident, repeated observations over two days revealed that a fall mat, which was an intervention specified in the care plan following a previous unwitnessed fall resulting in fractures, was not present at the bedside. Staff interviews indicated that the resident was on hospice and unable to move independently, but the care plan still included the use of a fall mat as a preventive measure. The care plan also listed other interventions such as keeping the call light within reach, using positioning bars, and frequent checks, but the absence of the fall mat was consistently noted during multiple observations. For another resident, who was assessed as a high fall risk with severely impaired cognition, the fall mat was observed to be under the bed rather than positioned at the bedside as intended. This resident had a recent history of a fall resulting in a head laceration and abrasions, despite the fall mat being in place at the time. Staff interviews revealed some uncertainty about the exact placement of the fall mat and the circumstances of the fall, with one CNA stating they did not know why the fall mat was not present at the bedside during one observation. The care plan for this resident included multiple interventions such as a concave mattress, fall mat at bedside, and keeping the bed in the lowest position, but the implementation of these interventions was inconsistent. The deficiencies were identified through direct observation, record review, and staff interviews, which demonstrated that the facility did not consistently ensure that fall prevention interventions were in place as specified in the residents' care plans. Both residents had documented histories of falls and were assessed as high risk, yet the required safety measures were not reliably implemented, leading to a failure to provide adequate supervision and prevent accident hazards.
Insufficient Staffing Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of a resident with severe cognitive impairment. On the observed date, the resident was repeatedly calling out for help to use the bathroom, but a CNA who was present in the hallway did not check on the resident and instead retrieved a dirty linen cart. The resident continued to call for assistance until an LPN was informed and responded. The resident's assessment indicated a BIMS score of 06, signifying severe cognitive impairment, and required supervision for transfers and partial to moderate assistance with toilet hygiene. Multiple CNAs interviewed stated that call lights should be answered within five minutes, but they did not feel there was enough staff to meet this expectation, confirming delays in responding to residents' needs due to insufficient staffing.
Failure to Honor Resident's Right to Dietary Choice
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding their diet. A resident with a history of stroke and aphasia, but with intact cognition, was observed consuming soda in their room and reported dissatisfaction with being placed on a soft diet with thickened liquids. The resident stated they had not experienced choking and had not undergone a swallow evaluation at the facility, being told by staff that insurance would not cover it. The resident also reported consuming regular food brought by friends and had previously eaten a regular diet at home and upon initial admission. Facility staff, including the ADON, social services director, and administrator, were unable to clearly identify the origin of the soft diet order, with some suggesting it may have been a transcription error or related to a previous hospice waiver. The medical director believed the order was due to a stroke and possible dysphagia, but there was no documented diagnosis of dysphagia or incidents of choking. The facility did not offer waivers for diet preferences outside of hospice care, and staff indicated they would not question the physician's order or seek justification, resulting in the resident's dietary preferences not being honored.
Failure to Secure Chemicals in Facility
Penalty
Summary
The facility failed to ensure that chemicals were secured in three of the eight halls observed, specifically the 100/200 hall, 700 hall, and 800 hall. The facility's housekeeping policy mandates that all harmful chemicals must be stored in a locked storage at all times. However, during observations, it was found that the 800 hall linen closet was unlocked and contained chemicals such as periwash and shaving cream, both labeled to be kept out of reach of children. Similarly, the 700 hall housekeeping closet was unlocked and contained various cleaning chemicals, including floor finish, spot cleaner, and stain remover, all labeled with warnings to keep out of reach of children. Additionally, the 100/200 hall central supply closet was found unlocked with the latch taped open, containing iodine swab sticks labeled to be kept out of reach of children. Interviews with the Director of Nursing (DON) and the administrator revealed that the floor technician had not locked the 700 hall housekeeping closet after use, and the 800 hall linen closet did not have a functioning lock. The DON also noted that the tape on the latch of the 100/200 hall central supply closet was inappropriate and should not have been used to prevent the door from locking. The administrator confirmed that the green liquid found in a bottle labeled as purified drinking water in the 700 hall housekeeping closet was not water, and the door should have been locked. These observations and interviews indicate a failure to adhere to the facility's policy on securing chemicals, posing potential safety hazards.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were labeled and dated, as observed during a survey. Specifically, on September 16, 2024, at 8:50 a.m., several food items in refrigerator #1 were found without labels or dates. These items included two plastic containers with sliced cheese, one plastic container with diced onion, one plastic container with diced tomatoes, one plastic container with diced honeydew melon, a paper plate with sliced cheese, and an opened container of tuna salad. The Director of Nursing identified that 122 residents received nourishment from the kitchen. When questioned, the dietary manager stated they did not know why the containers were not labeled or dated, but acknowledged that they should be.
Failure to Transmit Resident Assessment Timely
Penalty
Summary
The facility failed to ensure timely transmission of assessments for a resident diagnosed with dementia. The significant change assessment for this resident had an Assessment Reference Date (ARD) of June 20, 2024, and was completed on July 4, 2024. However, the assessment was not transmitted until September 16, 2024, which was well beyond the required 7-day transmission period. During this time, the facility lacked an MDS coordinator, and the corporate MDS coordinator was assisting with MDS completion and transmission. Despite monitoring occurring twice a week by both the facility's MDS coordinator and the corporate office, the significant change assessment was transmitted late.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident with intact cognition and no cognitive impairments. The resident had complained about a nurse aide not providing adequate care, specifically mentioning an incident where the aide turned off the call light without providing care and promised to return but did not. The resident reported this issue to the Assistant Director of Nursing (ADON) approximately two weeks prior to the survey, but no action was taken to address the complaint. The ADON confirmed the complaint was reported to them and that they had informed the administrator, but no documentation or investigation was completed. The administrator acknowledged receiving the grievance form and speaking to one aide but did not conduct a comprehensive investigation, such as interviewing the roommate or other residents. The administrator also failed to document the interview with the aide, citing the resident's history of complaints as a reason for not taking further action.
Failure to Address Resident's Constipation Leads to Hospitalization
Penalty
Summary
The facility failed to notify the attending physician of a resident's prolonged constipation, which lasted five days without a bowel movement, leading to the resident's hospitalization for stercoral colitis. The facility's policy required assessment and physician notification after three days without a bowel movement, but this was not followed. The resident, who had a history of constipation and was moderately impaired cognitively, had an as-needed order for a laxative but did not receive it until the fifth day of constipation. The documentation showed that the resident had a bowel movement on one day and then went five days without another, during which time the facility did not assess the resident or notify the physician. The electronic health record system, which was supposed to flag such issues, did not alert the staff, and the resident's condition was not addressed until they were in significant pain and requested to go to the hospital. The resident was eventually sent to the hospital, where they were diagnosed with stercoral colitis due to longstanding constipation. Interviews with staff revealed that the facility's procedures for monitoring and addressing constipation were not followed. The CNA and CMA were unaware of the resident's constipation, and the RN admitted that the system did not flag the issue, leading to a lack of assessment and notification. The DON confirmed that the facility's policy was not adhered to, and there were no assessments or notifications documented until the resident was hospitalized.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during medication administration. The resident, who had a diagnosis of seizures, was prescribed Dilantin, an anti-epileptic medication, to be administered via a peg tube. The physician's order specified a dosage of 125 mg/5 ml, to be given as 8 ml three times a day. However, during an observation, a medication administration error was noted when an ACMA incorrectly measured the medication using two separate medication cups instead of a syringe, resulting in an incorrect dosage. The ACMA mistakenly believed that the markings on the medication cup indicated 0.5 ml when it actually indicated 5 ml, leading to a potential overdose. The facility's Director of Nursing (DON) later confirmed that the medication should have been measured using a syringe if the correct dosage was not clearly marked on the medication cup. Additionally, a discrepancy was found in the count record of the Dilantin bottle, which should have contained 312 ml but only had 300 ml. The DON was not informed of this discrepancy by the CMAs, indicating a lapse in communication and monitoring of medication administration. This series of errors and miscommunications contributed to the significant medication error for the resident.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to ensure that medications were dated when opened, as observed during a survey. This deficiency was noted across four medication and treatment carts, specifically the 200 hall medication cart, 200/400 hall treatment cart, 100/300 hall treatment cart, and the 600 hall medication cart. During the survey, it was observed that a Ventolin inhaler for a resident on the 200 hall medication cart was opened but not dated. Similarly, on the 200/400 treatment cart, several medications including insulin lispro, fluticasone propionate inhaler, Trelegy inhaler, albuterol inhaler, and a bottle of glucometer test strips were found opened without dates. Further observations revealed that on the 100/300 hall treatment cart, a vial of lidocaine and a house stock vial of sterile water were opened but not dated. On the 600 hall medication cart, Refresh eye drops for two residents and polyvinyl alcohol liquifilm tears for another resident were also opened without being dated. The Director of Nursing (DON) confirmed that staff were expected to date medications such as eye drops, nose sprays, insulin, inhalers, and glucometer test strips when opened, and mentioned that the consultant pharmacist conducted monthly audits of the medication carts.
Failure to Notify Physician of Resident's Constipation
Penalty
Summary
The facility failed to notify the attending physician of a resident's constipation, which lasted for five days without a bowel movement. The facility's policy requires physician notification if a resident has not had a bowel movement for three days. Despite this policy, there was no documentation indicating that the physician was informed of the resident's condition until the resident was sent to the hospital. The resident, who had a diagnosis of constipation and was receiving orthopedic aftercare, was documented to have a bowel movement on one day, followed by a five-day period without any bowel movements. During this time, the resident was noted to be constipated, yet the physician was not notified. The Director of Nursing (DON) and RN #1 both acknowledged the oversight. RN #1 was unaware of the resident's constipation and did not notify the physician. The DON realized the issue upon returning from vacation, noting that the resident's condition had not been addressed. The physician was eventually notified on the day the resident was sent to the hospital, which was several days after the initial period of constipation began. This delay in communication and failure to follow the facility's policy contributed to the deficiency identified in the report.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the Oklahoma State Department of Health (OSDH) for a resident who was reviewed for neglect. The facility's policy on Resident Abuse, Neglect, and Misappropriation of Property requires that all allegations and incidents of abuse and neglect be reported to appropriate federal and state agencies, including OSDH. However, in this case, the facility did not report the allegation of neglect involving a resident who had complained about a nurse aide not providing adequate care. The resident, who had intact cognition and no cognitive impairments, reported that after turning on their call light, an aide shut it off without providing care and did not return as promised. The resident filed a complaint with the Assistant Director of Nursing (ADON) about the lack of care, but no action was taken. The ADON confirmed the complaint was reported to the administrator, and a grievance form was filled out, but there was no documentation of the report to OSDH. The administrator stated they only reported to OSDH if they felt abuse occurred, and in this case, they did not believe it constituted abuse.
Medication Record Discrepancy and Reconciliation Failure
Penalty
Summary
The facility failed to maintain accurate medication records and reconcile controlled drugs for a resident with a diagnosis of an unspecified fracture of the right pubis. A physician's order prescribed oxycodone, an opioid medication, to be administered as needed for pain. However, discrepancies were found between the Medication Administration Records (MARS) and the narcotics sheets. The MARS documented 18 doses of oxycodone administered, while the narcotics sheets indicated 49 doses were given over the same period. The first page of the narcotics count sheet was missing, contributing to the inconsistency in records. Interviews revealed that Certified Medication Aides (CMAs) and Licensed Practical Nurses (LPNs) were responsible for counting narcotics at the end of each shift. However, they often documented medication administration only on the narcotic sheets, neglecting the electronic records. An investigation by the corporate nurse into a missing medication card found no evidence of medication diversion but highlighted documentation issues. Despite efforts to locate the missing narcotic count sheet, it was not provided to the survey team by the end of the survey.
Resident Smoking Incident Leads to Fire
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who required supervision while smoking, leading to a serious incident. The resident, who had dementia and chronic obstructive pulmonary disease, was moderately impaired in daily decision-making and required oxygen therapy. Despite a physician's order for oxygen use and a checklist indicating the need for supervision while smoking, the resident was left unsupervised and attempted to smoke with their oxygen on, resulting in a fire. On the day of the incident, a nurse was notified by a CMA that the resident was on fire. Upon reaching the scene, the nurse found the resident in a wheelchair that appeared burned, with multiple areas of burned skin. The resident was conscious but complaining of difficulty breathing and was transported to a hospital burn center. Staff interviews confirmed that no supervision was provided at the time of the incident, and the resident was not being monitored while smoking. The facility's investigation revealed that the resident was not supervised during the smoking incident. Staff members, including a CMA and a CNA, reported hearing about the fire and attempting to assist the resident. The administrator acknowledged the lack of supervision and noted that fire blankets had been ordered but not yet received. The resident ultimately passed away at the hospital due to the injuries sustained.
Failure to Provide Required Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents were offered or provided showers as required. Resident #2, who had a left femur fracture and required moderate assistance with bathing, was documented to have received only one shower between 11/20/23 and 12/02/23. Similarly, Resident #4, who had right and left humerus fractures and required maximum assistance with bathing, was documented to have received only one shower since their admission on 04/01/24. The DON and ADON monitored showers during Q2 meetings and asked residents on Fridays if their showers had been completed. Despite realizing that showers were not being completed and staffing shower aides in January 2024, the facility still failed to ensure that showers were consistently offered or provided, as evidenced by the lack of documentation in the electronic health records and the statements from the Regional Nurse and DON.
Failure to Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to ensure weights were monitored as ordered by the physician for two residents. Resident #8, who had diagnoses including osteoporosis, was at risk for a nutritional problem related to anemia and GERD. The care plan required weekly weights, but the electronic health record did not contain documentation of the weight values on several dates. The DON acknowledged that weekly weights should be documented in the electronic health record but noted there might not be a space to document them on the treatment record. Resident #4, who had diagnoses including right and left humerus fractures, was at risk for unplanned weight loss. The care plan included monitoring for signs of malnutrition and providing a regular diet with superceral at breakfast. However, Resident #4 reported not eating breakfast and had unintentionally lost weight since admission. The resident's weight dropped from 136 pounds to 123 pounds in 14 days. The DON confirmed the lack of further documentation of weight values for both residents.
Failure to Provide Snacks to Residents
Penalty
Summary
The facility failed to ensure snacks were provided to residents as required, particularly affecting four residents with specific medical conditions. Resident #2, diagnosed with diabetes mellitus, had no documentation of snacks being offered or provided from 11/20/23 through 11/30/23 and on 12/01/23. Resident #6, also diagnosed with diabetes mellitus, had no record of snacks being offered or provided from 04/09/24 through 04/18/24, and stated on 04/19/24 that they were unaware snacks were available. Resident #10, diagnosed with GERD and cognitively intact, was documented to have been offered and accepted a snack only once during a 30-day period. This resident had to wheel themselves to the nurses station to obtain snacks, as staff did not offer them proactively. Resident #9, diagnosed with cerebrovascular disease, reported receiving snacks but not always eating them. The electronic clinical record showed snacks were offered only seven days out of a 30-day review period, with no documentation of refusals. Interviews with staff revealed inconsistencies in the process of offering snacks. The dietary manager stated snacks were delivered to the nurses stations at specific times, but residents had to go to the nurses station to obtain them. CNAs confirmed that they did not routinely offer snacks to residents, and there was confusion about where to document snack distribution. The DON stated that CNAs were supposed to pass snacks at bedtime and that bed-bound residents needed to use their call light to request snacks. The lack of a consistent and documented process for offering snacks, especially to diabetic residents with specific orders for bedtime snacks, led to the identified deficiencies.
Failure to Notify Physician of Change in Resident's Status
Penalty
Summary
The facility failed to ensure notification to the physician of a change in status for one resident reviewed for notification of change. The resident had diagnoses including congestive heart failure, chronic kidney disease, and a sacrum pressure ulcer. A physician's order required blood pressure monitoring twice a day and to report to the physician if the systolic blood pressure was greater than 170 or below 90, and if diastolic blood pressure was greater than 100 or below 70. On two occasions, the resident's blood pressure readings were outside the specified range, but there was no documentation that the physician had been notified. An LPN confirmed they had not called the physician, and the nurse practitioner stated they were not notified via telephone of the low blood pressure. The nurse practitioner identified the low blood pressure during a review of the clinical record, and the resident was subsequently sent to the hospital for evaluation and treatment.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to ensure wound care was provided as ordered for a resident with a sacral pressure ulcer. The resident had a physician's order to cleanse the sacrum with normal saline, apply medihoney/durafiber ag (silver), and cover with bordered foam daily, but the Treatment Administration Record for March 2024 revealed that wound care was not documented as completed eight times out of 22 opportunities. Additionally, a physician's order to paint the left heel with skin prep and leave it open to air every shift and as needed was not documented as completed nine times out of 31 opportunities. Another order to cleanse the sacrum wound with normal saline, pack it with dakins soaked gauze, cover with an ABD pad, and secure with tape daily was not documented as completed one time out of eight opportunities in April 2024. The wound nurse was unable to explain why the wound care was not documented, and the DON stated that corporate staff monitored wound treatments and usually received reports if treatments were missed.
Failure to Document Pain Management Effectiveness
Penalty
Summary
The facility failed to ensure proper pain management for a resident with a sacral pressure wound and cervical spine fractures. Despite a physician's order to administer hydrocodone/acetaminophen every six hours for pain, the Medication Administration Record and electronic health record lacked documentation of the medication's effectiveness. Interviews with a CMA and an LPN revealed that staff did not monitor or document the effectiveness of routine pain medication, although they verbally inquired about it. The DON confirmed that pain assessments were supposed to be completed every three months and that charge nurses were to monitor effectiveness one hour after administration, but this was not documented in the clinical record.
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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