Bixby Towers Post-Acute Rehab

In the surveyor’s words

From the most serious findings on record at Bixby Towers Post-Acute Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jun 17, 2026

  Based on interview, and record review, the facility's staff failed to immediately initiate Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of five sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 and CNA 2, who were CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), failed to check Residents 1's pulse, breathing and obtain immediate assistance to initiate CPR, activate a code blue (a specific code used to signal a patient who is having a life threatening medical emergency, typically a patient experiencing sudden cardiac arrest [when the heart stops] and/or respiratory arrest [when a person stops… […]

• Immediate jeopardy, isolatedF678Apr 3, 2026

  Based on interview, and record review, the facility failed to implement its policy and procedure (P&P) titled Cardiopulmonary Resuscitation (CPR an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) which required staff to immediately activate a Code Blue (announcement used in facilities when a resident is experiencing medical emergency), call 911(phone number used to contact the emergency services), and provide basic life support (BLS, a set of emergency medical procedures designed to sustain life by maintaining breathing and circulation), including CPR for one of three residents (Resident 1) who was a full code (a medical term indicating a patient's consent to receive all possible life-saving measures in the event of a cardiac arrest [when the… […]

• Immediate jeopardy, isolatedF600Oct 13, 2024

  Based on interview, and record review, the facility (SNF B) failed to ensure residents were free from sexual abuse (non-consensual sexual contact of any type) for one of three sampled residents (Resident 2). The facility (SNF B) failed to: 1.Ensure Resident 1 did not sexually assault Resident 2. 2. Ensure Certified Nursing Assistant (CNA) 1 and CNA 2 did not leave Resident 1 and Resident 2 alone in the room after Resident 1 sexually assaulted Resident 2 once, thus allowing Resident 1 to sexually assault Resident 2 second time. 3. […]

• Immediate jeopardy, isolatedF742Oct 13, 2024

  Based on interview and record review, the facility (SNF B) failed to ensure a resident, who had a history of schizophrenia (chronic mental illness that affects how a person thinks, feels, and behaves) with disorganized (jumbled, or do not make sense can cause problems with communication) thoughts, aggressive and inappropriate sexual behaviors, had behaviors under control for one of three sampled residents (Resident 1) to prevent Resident 1 from sexually assaulting Resident 2 two times on 10/8/2024. The facility failed to: 1. Ensure Resident 1was evaluated by a psychiatrist (a health practitioner that specializes in the diagnosis and treatment of mental illness) upon admission and as needed during the time he was a resident in the current Skilled Nursing Facility (SNF B). 2. […]

• Actual harm, isolatedF684Aug 1, 2025

  Based on interview and record review, the facility failed to ensure the resident, who had developed behavioral symptoms manifested by increased confusion, cursing staff, yelling at staff, and refusing personal care and treatment, had a medical doctor's (MD) order for urinalysis with cultures and sensitivity (a urine diagnostic test used to detect presence of bacteria) carried out to determine the presence of urinary tract infection (UTI- an infection in the bladder/urinary tract) and to prevent a delay in treatment for one of one sampled resident (Resident 100). The facility failed to:1. […]