Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hennessey Nursing & Rehab during CMS and state inspections, most recent first.
Survey results were not posted in a readily accessible location for residents, family members, or legal representatives. Staff observed no sign in the halls or lobby directing people to the survey results binder, and the binder was found in a wooden cabinet behind closed doors near the front door. During resident council, 10 members said they did not know where to find the state survey results, and the Administrator acknowledged there was no accessible posting for residents or visitors.
RN coverage was not maintained for the required 8 consecutive hours, 7 days per week. The facility policy required an RN on duty daily, but staffing and timecard records showed multiple days with no RN hours. The MDS coordinator confirmed the facility had only three RNs and no RN coverage on those days, and the Administrator stated they were unaware of the gaps.
Dietary Supervisor Not Certified Within Required Timeframe: The facility failed to ensure the food service supervisor completed certified dietary manager certification within the State-required timeframe. Record review showed the dietary supervisor was hired for the role but had no documentation of completing a certified program, and the supervisor stated they had not completed a certification course. The administrator acknowledged awareness that the dietary supervisor was not certified.
The facility failed to notify the physician when a resident repeatedly refused ordered ipratropium-albuterol breathing treatments and reported shaking, shakiness, and weakness with use. The resident had COPD and cough, and staff documented multiple refusals over the month, but there was no documentation that the physician was informed. An LPN knew the resident was getting shaky but did not notify the physician, and both the physician and DON stated they could not locate documentation of notification.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
Failure to document self-administration of breathing medication: A resident with COPD and intact cognition had ipratropium-albuterol neb vials left at bedside and was observed self-administering them, but there was no assessment or physician order for self-medication. The resident said the nurse gave the vials that morning, an LPN confirmed the resident administered the treatment and had no order to keep it at bedside, and the DON stated the resident lacked the required assessment and order.
Inaccurate documentation of a breathing treatment was found for a resident with COPD and cough. An LPN initialed the 8:00 a.m. dose as given on the MAR even though the resident said the nurse gave them the vials and the LPN did not observe the treatment being self-administered. The LPN later acknowledged the entry was not accurate, and the DON stated the treatment should be documented as refused unless witnessed as given.
The facility did not complete bed rail safety assessments, review risks and benefits with residents or their representatives, or obtain informed consent before installing bed rails for three residents. The DON acknowledged the lack of necessary documentation according to facility policy.
The facility did not ensure that influenza and pneumococcal vaccinations were offered to four residents. The DON confirmed that these immunizations should be offered during admission and annually, but there was no documentation in the clinical records showing that the residents or their representatives had been offered or received the vaccines.
A resident with psychiatric disorders was transferred to a VA hospital ER due to behaviors, but the facility failed to document follow-up or discharge. The DON stated the resident was a danger and the facility couldn't meet their needs, yet there was no documentation supporting this decision or a physician's discharge order.
A resident with multiple psychiatric diagnoses was transferred to the VA hospital ER due to behaviors and subsequently discharged from the facility without notification to the resident or their family. The DON acknowledged the lack of notification.
A facility failed to complete a discharge MDS assessment within the required timeframe for a resident discharged at the end of their skilled days. The EHR review showed the assessment was not completed, which was confirmed by a nurse consultant.
A facility failed to complete a baseline care plan within the required 48-hour timeframe for a resident. The resident was admitted, but the care plan was only documented as completed several days later. This issue was identified during a review and interview with a nurse consultant.
A facility failed to implement a comprehensive care plan for a resident with an indwelling urinary catheter, despite having a physician order for catheter changes and documentation of the catheter in the admission assessment. The baseline care plan did not include the catheter, and a nurse consultant confirmed the absence of a comprehensive care plan, stating it was still being completed.
A facility failed to complete a discharge summary and discharge instructions for a resident upon their discharge. The resident's clinical record contained an incomplete 'Discharge Summary' form and an undated, incomplete Discharge Instructions form. The DON acknowledged the oversight.
A facility failed to document a DNR consent form for a resident, despite having a physician's order and care plan indicating DNR status. The DON acknowledged the absence of the form, stating that residents should have both a physician's order and a DNR form upon admission or remain a full code until the form is obtained. An LPN confirmed that code statuses were found in health records and the resident roster.
A facility failed to administer oxygen as ordered by a physician and did not change oxygen tubing as per policy for a resident with COPD and respiratory failure. The resident was receiving oxygen at 3.5 LPM instead of the ordered 3 LPM, and the tubing had not been changed weekly as required.
The facility did not complete annual competency reviews for two CNAs, as required by policy. CNA #2, hired in 2022, and CNA #1, hired in 2023, both lacked these reviews in their files. The BOM confirmed the absence of these reviews.
The facility failed to implement a physician order for a GDR for a resident's trazodone medication, resulting in continued administration of a higher dose. Additionally, there was no physician response to GDR recommendations for another resident's psychotropic medications, including buspirone, Abilify, and duloxetine. The DON confirmed the lack of documentation for these GDRs.
A resident receiving IV antibiotic therapy via a PICC line experienced a breach in infection control practices. An LPN used unlabeled IV tubing, placed it on a pillow, and continued using it after it fell to the floor. The DON confirmed that facility policy was not followed, as IV tubing should be changed every 24 hours and labeled.
A resident experienced a significant change in condition, including weakness, irregular heart rate, and mental status decline. Despite being diagnosed with pneumonia and prescribed Augmentin, the facility failed to notify the physician, order the medication, and administer it. The resident's condition worsened, leading to hospital admission.
A facility failed to accurately assess a resident's risk for pressure ulcers and did not initiate necessary dietary measures, leading to the development of pressure ulcers. The RD's assessment contained discrepancies, and the care plan was not updated to reflect changes in the resident's condition, such as weight loss, decreased mobility, and incontinence. The DON acknowledged the inaccuracies and the need for dietary measures and care plan interventions.
The facility failed to ensure proper care of a PICC line for a resident, including timely dressing changes and obtaining physician orders for continued flushes and removal of the PICC line after antibiotic therapy completion. Interviews confirmed that facility policy and professional standards were not followed.
A resident with multiple diagnoses, including insomnia, was prescribed temazepam 15 mg to be taken nightly as needed for sleep. However, the medication was administered at 12 a.m. on multiple dates due to an incorrect transcription of the order by an LPN. The ADON confirmed the medication was not given as per the physician's order.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post the most recent state survey results in a place readily accessible to residents, family members, and legal representatives. During observation of the halls and lobby, there was no posting showing where to find the survey results binder. The facility policy stated that a copy of the most recent standard survey, any subsequent extended surveys, follow-up revisits, and the state-approved plan of correction would be maintained in a 3-ring binder in an area frequented by most residents, such as the main lobby or resident activity room. During resident council, 10 members stated they did not know where to find the state survey results. The Administrator stated there was a little card on the table where the results were located, but the survey results binder was found in a wooden cabinet behind closed doors in the lobby near the front door. The Administrator later stated there was no posting telling visitors or residents where to find the survey results and that the sign showing where to find them was not accessible to residents and visitors.
RN Coverage Not Maintained for Required Hours
Penalty
Summary
The facility failed to ensure RN coverage for 8 consecutive hours 7 days per week. The facility’s staffing policy, updated 10/2023, stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report for 10/01/25 through 12/31/25 showed no RN hours on 10/13/25, 10/14/25, 10/27/25, 11/10/25, 11/11/25, 12/01/25, 12/06/25, and 12/18/25. An Employee Timecard Report for the same period also did not show RN hours for 8 consecutive hours on those dates. During interview, the MDS coordinator stated those were the only three RNs for the facility and confirmed there was no RN coverage on those dates. The Administrator stated they were not aware there was no RN coverage on those dates and said that if they had known, they would have called the Infection Control Preventionist in to cover the shifts.
Dietary Supervisor Not Certified Within Required Timeframe
Penalty
Summary
The facility failed to ensure the food service supervisor completed certification as a certified dietary manager within the State-required timeframe. Record review showed the facility’s Food and Nutrition Services Staff policy required the nutrition service manager, if not already certified, to be enrolled in an accredited or approved program within the regulatory timeframe. An Employee Information Report showed the dietary supervisor was hired on 02/04/20, but there was no documentation that the supervisor had completed a certified program. During interview on 03/23/26, the dietary supervisor stated they had not completed a certification course. On 03/26/26, the administrator stated they were aware the dietary supervisor was not certified and confirmed the dietary supervisor had been hired for the role on 02/04/20.
Failure to Notify Physician of Resident’s Refusal and Shaking With Breathing Treatments
Penalty
Summary
The facility failed to notify the physician of Resident #24’s change in condition related to repeated refusals of ordered ipratropium-albuterol breathing treatments and complaints of shaking. Resident #24 had diagnoses including chronic obstructive pulmonary disease and cough, and the quarterly assessment showed intact cognition with a BIMS of 15. A physician’s order dated 02/03/26 directed the resident to inhale one vial of ipratropium-albuterol three times a day for wheezing. The March 2026 administration notes showed the resident refused the breathing treatment multiple times, including refusals because it made them shake, caused shaking after use, or made them feel shaky and weak. There was no documentation that the physician was notified of the refusals or the shaking. The resident stated they got shakes from receiving the treatment three times a day and would self-administer it two times a day. An LPN stated they were aware of the shaking but did not personally notify the physician and could not locate documentation of notification. The physician stated they were not aware of any notification from the facility regarding the resident being shaky or refusing treatment, and the DON also stated they could not locate documentation that the provider was notified.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Document Self-Administration of Breathing Medication
Penalty
Summary
The facility failed to ensure a resident had both a physician order and an assessment to self-administer medications. Resident #24 had diagnoses including chronic obstructive pulmonary disease and cough, and the quarterly assessment dated 01/27/26 showed intact cognition with a BIMS score of 15. On 03/24/26 at 8:42 a.m., two vials of ipratropium bromide/albuterol sulfate 0.5-3 mg in 3 ml were observed sitting on the resident’s bedside table. The resident had a physician order dated 02/03/26 for ipratropium-albuterol inhalation solution, one vial three times a day for wheezing. There was no documentation that Resident #24 had an assessment or physician order for self-medication administration. The resident stated the nurse gave them the breathing treatment vials that morning and that they last self-administered the treatment the prior afternoon. An LPN stated the resident administered their own breathing treatment, that there was no order to leave the medication at bedside, and that the resident did not have an assessment for self-administration of medications. The LPN also stated the breathing medications should not be left at bedside. The DON confirmed the resident did not have an assessment and physician order for self-medication administration and stated the facility does not allow residents to self-administer medications.
Inaccurate Documentation of Breathing Treatment
Penalty
Summary
The facility failed to ensure a resident's breathing treatment was accurately documented for one sampled resident. Resident #24 had diagnoses including chronic obstructive pulmonary disease and cough, and the quarterly assessment noted the resident's cognition was intact with a BIMS of 15. A physician's order directed ipratropium-albuterol inhalation solution three times daily for wheezing, and the March 2026 treatment administration record showed the 8:00 a.m. dose was initialed as given on 03/24/26. During observation that morning, two vials of ipratropium bromide/albuterol sulfate were found on the resident's bedside table. The resident stated the nurse gave them the breathing treatment vials that morning and that the last time they self-administered the treatment was the prior afternoon. The LPN stated the resident self-administered the breathing treatments, but also stated they documented the 8:00 a.m. dose as given because they assumed the resident had self-administered it. The LPN acknowledged the documentation was not accurate and stated they did not observe the resident administering the treatment. The DON stated the breathing treatment should be documented as refused unless witnessed as given.
Failure to Complete Bed Rail Safety Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to adhere to its policy regarding the use of bed rails, resulting in a deficiency. Specifically, the facility did not complete necessary bed rail safety assessments, nor did it review the risks and benefits of bed rails with the residents or their representatives. Additionally, informed consent was not obtained prior to the installation of bed rails for three residents. Observations revealed that these residents were using bed rails without the required documentation in their clinical records. The Director of Nursing acknowledged that the necessary paperwork had not been completed according to the facility's policy.
Failure to Offer Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccinations were offered to four of the five residents reviewed for immunizations. The Director of Nursing (DON) confirmed that immunizations should be offered during the admission process and annually. However, there was no documentation in the clinical records of Residents #15, #18, #22, and #82 indicating that they or their representatives had been offered or received these vaccines. This deficiency was identified during a record review and interview with the DON, who acknowledged the lack of documentation for these residents.
Inadequate Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that a resident was not involuntarily discharged without adequate reason and proper documentation. A resident with multiple psychiatric diagnoses, including anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD, was transferred to a VA hospital ER due to behaviors. However, there was no documentation in the clinical record indicating follow-up on the resident's status after the transfer or stating that the resident had been discharged. The Director of Nursing (DON) later stated that the resident did not return because they were a danger to themselves and others, and the facility could not meet their needs. Additionally, there was no documentation in the clinical record indicating that the facility would not be able to meet the resident's needs upon their return, nor was there a physician's order to discharge the resident.
Failure to Notify Resident and Family of Discharge
Penalty
Summary
The facility failed to provide timely notification of a facility-initiated discharge for a resident diagnosed with anxiety disorder, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. The resident was admitted on an unspecified date and was transferred to the VA hospital emergency room due to behaviors on June 25, 2024, as documented in a nurse's note. A discharge summary dated June 26, 2024, indicated that the resident had been discharged from the facility on June 25, 2024. However, there was no documentation in the clinical record that the facility notified or attempted to notify the resident or their family about the discharge. On August 6, 2024, the Director of Nursing acknowledged that neither the resident nor their family had been informed of the discharge.
Failure to Complete Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a discharge MDS assessment within the required timeframe for a resident who was discharged at the end of their skilled days. The resident was admitted to the facility and discharged on April 12, 2024. A review of the electronic health record (EHR) revealed that the discharge MDS assessment had not been completed. This was confirmed during an interview with Nurse Consultant #1 on August 6, 2024, who acknowledged the oversight.
Failure to Timely Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan in a timely manner for a resident. The resident was admitted on an unspecified date, and the baseline care plan was documented as completed on 07/27/24. However, it was noted during an interview with a nurse consultant on 08/06/24 that the baseline care plan was not completed within the required 48-hour timeframe following the resident's admission. This deficiency was identified during a review of records and interviews conducted by the surveyors.
Failure to Implement Comprehensive Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was admitted with diagnoses including neuromuscular dysfunction of the bladder and hydronephrosis. The resident had a physician order to change the Foley catheter every 30 days, specifically on the 1st of the month during the night shift. Despite the resident's admission assessment documenting the presence of an indwelling catheter, the baseline care plan did not include this information. Furthermore, there was no record of a comprehensive care plan being completed for the resident. During an interview, a nurse consultant confirmed that the resident did not have a comprehensive care plan and stated that they were in the process of completing one.
Incomplete Discharge Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a discharge summary and discharge instructions were completed for a resident upon their discharge. The resident was admitted to the facility and discharged at the end of their skilled days. A 'Discharge Summary' form was found in the resident's clinical record, dated prior to the discharge, but it was not completed. Additionally, a Discharge Instructions form was also found in the clinical record, undated and not completed. The Director of Nursing (DON) acknowledged that these documents had not been completed for the resident.
Failure to Document DNR Consent Form for a Resident
Penalty
Summary
The facility failed to have a process in place to identify a resident's code status, specifically for one resident reviewed for advanced directives. The resident was admitted with a physician's order indicating Do Not Resuscitate (DNR) status, dated 07/23/24, and a care plan dated 07/27/24, also documented the resident's preference for DNR. However, there was no documentation of a completed Oklahoma DNR consent form in the resident's record. On 08/05/24, the Director of Nursing (DON) acknowledged the absence of the DNR consent form in the health record, stating that residents should have both a physician's order and a DNR form upon admission or remain a full code until the form is obtained. Additionally, an LPN confirmed that residents' code statuses were found in their health records and the resident roster at the nurse's station.
Failure to Administer Oxygen as Ordered and Change Tubing
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician and that oxygen tubing was changed as per facility policy for a resident receiving respiratory care. The resident, who had diagnoses including COPD and acute and chronic respiratory failure with hypoxia, had a physician's order for oxygen at 3 liters per nasal cannula to maintain oxygen saturation at 90% or above. However, during an observation, the resident was found to be receiving oxygen at 3.5 liters per minute, contrary to the physician's order. Additionally, the oxygen tubing was dated from 07/22, indicating it had not been changed weekly on Sundays as required by the facility's policy. RN #1 confirmed that the physician's order was not followed and that the tubing should have been changed according to the policy.
Failure to Conduct Annual CNA Competency Reviews
Penalty
Summary
The facility failed to conduct a nurse aide performance review every 12 months for two certified nurse aides (CNAs) out of five employee files reviewed. The facility's policy, revised in October 2017, requires all nursing staff to meet specific competency requirements as defined by state law. CNA #2, hired on April 28, 2022, did not have an annual competency review in their file. Similarly, CNA #1, hired on May 12, 2023, also lacked an annual competency review in their file. On August 6, 2024, the Business Office Manager (BOM) confirmed the absence of these reviews for both CNAs.
Failure to Implement and Document GDRs for Psychotropic Medications
Penalty
Summary
The facility failed to implement a physician order for a gradual dose reduction (GDR) for a resident diagnosed with insomnia and anxiety. A medication regimen review (MRR) recommended reducing trazodone from 150 mg to 100 mg at bedtime. Although the physician agreed to the reduction, and a nurse acknowledged the recommendation, there was no corresponding physician's order until a week later. Consequently, the resident continued receiving the higher dose until the order was implemented, and the reduced dose was first administered the following day. Additionally, the facility did not have a physician's response to GDR recommendations for another resident diagnosed with schizophrenia, anxiety, insomnia, and depression. The MRRs recommended dose reductions for buspirone, Abilify, and duloxetine, but there was no documentation of a physician's response to these recommendations. The Director of Nursing (DON) confirmed the absence of a physician's response to the GDRs upon review of the MRRs.
Infection Control Breach During IV Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during the administration of medication for a resident receiving intravenous antibiotic therapy via a PICC line. During an observation, an LPN was seen using IV tubing that was not labeled with the date, time, and initials as required by the facility's policy. The LPN used the unlabeled tubing to spike a new IV bag and laid the end of the tubing on the resident's pillow. During the process of flushing the PICC line lumens, the end of the tubing fell to the floor. Despite this, the LPN picked up the tubing from the floor, removed the cap, connected it to the PICC line lumen, and started the IV. The Director of Nursing (DON) confirmed that the facility's policy required IV tubing to be changed every 24 hours and labeled accordingly. The DON acknowledged that the proper infection control practices were not followed, and the facility policy was not adhered to. The LPN's actions, including using unlabeled tubing and failing to replace the tubing after it fell to the floor, contributed to the deficiency in infection control practices.
Failure to Monitor and Administer Prescribed Antibiotic Therapy
Penalty
Summary
The facility failed to assess, monitor, and intervene for a resident experiencing a significant change in condition and did not ensure the resident received prescribed antibiotic therapy to treat pneumonia. On 03/08/24, the resident exhibited acute changes such as weakness, inability to stand or sit, irregular heart rate, low oxygen saturation, incontinence, and mental status decline. Despite notifying the MD, the resident was not sent to the ER, and no further MD notifications were documented as the resident's condition continued to deteriorate over the following days. On 03/19/24, the resident requested to be sent to the ER and was diagnosed with pneumonia, receiving an order for Augmentin. However, the facility failed to notify the resident's physician of the new order, did not submit the medication order to the pharmacy, and did not place the medication on the MAR. Consequently, there was no documentation that the prescribed antibiotic was ever ordered, received, or administered to the resident between 03/19/24 and 04/08/24. The resident's condition continued to decline, and on 04/08/24, they were sent to the ER with low blood pressure, labored breathing, erratic pulse, and altered mental status, leading to their hospital admission. The DON acknowledged that the resident had not been properly assessed, monitored, or received necessary interventions according to facility policy after experiencing a significant change in condition. Additionally, the resident did not receive the prescribed antibiotic therapy for pneumonia, as documented in the clinical records and MARs.
Removal Plan
- All Licensed RN/LPN staff educated on how to recognize acute changes in resident baseline condition, orientation, and/or change in vital signs with documentation of notification to the physician and family.
- All newly hired Licensed RN/LPN staff will be educated on how to recognize change in resident baseline condition, orientation, and/or change in vital signs with documentation of notification to the physician and family.
- All direct care nursing staff educated on how to recognize acute changes in resident baseline condition, orientation, and/or change in vital signs and report to charge nurse immediately.
- DON/Designee will review all new hire packets to ensure all training is completed.
- DON/Designee will report any negative findings to the QAPI team.
- All licensed RN/LPN In-serviced on Facility Policy and Procedure properly assessing, monitoring, and intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed.
- All licensed new hires will be educated on Facility Policy and Procedure on properly assessing, monitoring, intervening effectively and timely in the event of change in resident condition, and following physician orders for antibiotics/medications as prescribed.
- DON/designee will review all new hire packets to ensure all training is completed.
- DON/designee will report any negative findings to QAPI.
- DON/Designee will compare physician orders on all new admissions to MAR and verify all medications are on hand.
- Any staff that are on leave will be educated prior to being placed on the schedule.
- DON/ADON in-serviced on reviewing all physicians' orders to include hospital discharges/doctor's appointment during clinical meeting to ensure orders are not missed.
- DON/ADON will review all physicians' orders to include hospital discharges/doctor's appointment during clinical meeting to ensure orders are not missed. Any negative findings will be corrected immediately.
- All Licensed nurses educated on comparing new orders/hospital discharge orders with the MAR and updating MAR to reflect any new orders.
Failure to Prevent Pressure Ulcers Due to Inaccurate Assessment
Penalty
Summary
The facility failed to accurately assess a resident's risk for pressure ulcers and did not initiate necessary dietary measures to prevent avoidable pressure ulcers. The resident had a history of left toe amputation and a PICC line in the upper right arm. Despite significant weight loss and a decline in nutritional intake, the Registered Dietitian (RD) assessed the resident as being at no/low risk for pressure ulcers. The RD's assessment contained several discrepancies, including incorrect documentation of weight loss, oral intake, mobility, and lab values. Additionally, the resident's care plan was not updated to reflect the changes in their condition, such as decreased mobility and incontinence, which increased the risk of skin breakdown. Physician's orders indicated the presence of open areas on the resident's coccyx, but there were no documented assessments or care plan updates addressing the risk of skin breakdown following the resident's change in condition. The Director of Nursing (DON) acknowledged that the RD's assessment was inaccurate and that dietary measures and care plan interventions should have been implemented to prevent the development of pressure ulcers. The lack of accurate assessment and timely intervention led to the resident developing pressure ulcers, which were not properly documented or addressed in the care plan.
Failure to Ensure Proper Care of PICC Line
Penalty
Summary
The facility failed to ensure the proper care of a peripheral intravenous central catheter (PICC) for a resident who had a PICC line in the upper right arm and was receiving intravenous antibiotics. The facility's policy required dressing changes every 3-7 days or as needed if the dressing became damp, loosened, or visibly soiled. However, there was no documentation that the PICC line dressing was changed between 03/11/24 and 04/08/24, despite a note on 03/11/24 indicating that the dressing was coming loose and was only reinforced with gauze. Additionally, the resident continued to receive PICC line flushes twice a day from 03/12/24 through 04/06/24 without a physician's order, and there was no documentation that the physician was contacted to obtain orders for these flushes or for the removal of the PICC line after the completion of the IV antibiotic therapy on 03/11/24. Interviews with the LPN and the Director of Nursing (DON) confirmed that the physician was not notified for an order to continue PICC line flushes or to remove the PICC line when the antibiotic therapy was completed. The DON also acknowledged that the facility policy and professional standards of practice were not followed, as there were no documented dressing changes or physician orders for the continued care of the PICC line during the specified period.
Medication Administration Error
Penalty
Summary
The facility failed to ensure medication was administered as ordered for one resident reviewed for medications. The resident had diagnoses including multiple sclerosis, insomnia, and abnormal weight loss. According to the hospital discharge summary, the resident was prescribed temazepam 15 mg to be taken nightly as needed for sleep. However, the April 2024 Medication Administration Record (MAR) showed that the medication was given at 12 a.m. on multiple dates. Upon review, an LPN acknowledged that the order had been transcribed incorrectly, and the Assistant Director of Nursing (ADON) confirmed that the medication had not been administered according to the physician's order.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hennessey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cimarron Nursing Center | 18 mi | ★★★★★ | 0 | 0 |
| First Shamrock Care Center | 18.2 mi | ★★★★★ | 6 | 1 |
| Greenbrier Village Health And Rehabilitation | 19.7 mi | ★★★★★ | 0 | 0 |
| The Commons | 20 mi | ★★★★★ | 0 | 0 |
| Enid Senior Care | 20.6 mi | ★★★★★ | 0 | 0 |
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