Every finding on record at Elk City Nursing and Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure:a. proper labeling/dating of stored bread, b. both the large and small ice machines were cleaned and free from debris, andc. hand hygiene was maintained during meal service to prevent cross contamination during kitchen observations. The DON identified 46 residents received food from the kitchen. Findings: A policy titled Receiving and Open Date Policy, undated, read in part, It is the policy of the nursing home to date food products received from delivery trucks upon arrival to facility and upon use. A policy titled Dietary Personnel Hand hygiene Policy, undated, read in part, The goal is to prevent the spread of foodborne illness and ensure the safety of residents, staff, and visitors.Gloves will be worn when handling ready-to-eat foods or other situations where bare hand contact is prohibited or poses a risk of contamination.Staff will be trained on the importance of hand hygiene, proper procedures, and the consequences of non-compliance.After touching any unclean surface or object that could potentially contaminate hands. A policy titled Ice Machine cleaning policy and procedure, undated, read in part, Maintaining a clean and sanitary ice machine in a nursing home is crucial for resident safety and infection control, as ice is considered a food product by the FDA.All ice machines will be cleaned and sanitized regularly according to the manufacturer's policy recommendations and facility policy. Staff responsible for cleaning and maintenance will receive proper training and adhere to safety precautions.Records of cleaning and maintenance activities will be maintained.Daily: Wipe and disinfect external components. Weekly: Thoroughly clean internal surfaces and accessible ice-making components. On 07/29/25 at 11:07 a.m., during the initial kitchen observation with the dietary manager, there were multiple bags of halfway full undated items:a. 2 bags of hamburger buns,b. 2 bags of hot dog buns,c. 1/2 bag of chips,d. 1 and 1/2 loaves of white bread, ande. 1/2 bag of English muffins. On 07/29/25 at 11:13 a.m., the dietary manager stated the policy and procedure was to label when open or when comes in. They stated none of the identified bread was dated. On 07/29/25 at 11:38 a.m., the large ice machine was observed to have brown/black debris on the white plastic piece inside the ice machine. There was no signage of when last cleaned. On 07/29/25 at 11:39 a.m., the dietary manager observed the white plastic piece and stated there was black stuff and was dirty. They stated they were not aware of who was responsible to clean it. On 07/30/25 at 11:02 a.m., observed the small ice machine to have floating gray debris and a dead moth in the water at the bottom of the drip tray. The DM was present and stated that machine was cleaned by dietary on Mondays. The DM stated it did not look cleaned and was partially clogged. There was no cleaning log located near the ice machine. The DM was observed to take a wire to try to unclog. The DM stated maintenance is called to unclog when there is a problem. On 07/30/25 at 11:34 a.m., the meal service started with cook #1 plating from the steam table wearing gloves. The menu was soft shell taco, Spanish rice, and refried beans. On 07/30/25 at 11:48 a.m., cook #1 was observed still wearing the same gloves, open bag of tortillas, remove the tortilla, touch the ladles and plates, all while wearing the same pair of gloves. The Dietary Manager was present during the entire observation of meal service. On 07/30/25 at 11:52 a.m., while meal service continued, the DM stated the policy and procedure was for hand hygiene during meal service from the steam table was to wash hands at start and if something was on hands, then to wash hands and start over. The DM was asked if cook #1 touched the tortillas with the gloved hands. The DM stated they should have had tongs to pull the tortillas with. The DM went to get a pair of tongs and handed to cook #1.The DM stated they did not even notice they did not change gloves after touching the tortillas or before touching the ladles again. On 07/30/25 at 12:13 p.m., the maintenance director stated the big ice machine was serviced and thoroughly cleaned 3 weeks ago. They stated they could not tell when it was last cleaned since then. The maintenance director stated they needed a schedule. They further stated the small ice machine was clean and wiped down and they will unclog it when dietary lets them know and was not notified about it yesterday or today until the DM told him about it after was observed by surveyor.

Based on observation, record review, and interview, the facility failed to ensure:a. a nebulizer mouthpiece was stored in a manner that promoted infection control practice for 1 (#3) of 2 sampled residents reviewed for respiratory care, andb. clean linens were stored appropriately for 1 of 1 laundry room observation.The DON identified 47 residents resided in the facility and 16 residents received nebulizer treatments.Findings:1. On 07/29/25 at 11:50 a.m., a nebulizer machine with a mouthpiece was observed on top of Resident #3's drawer. The mouthpiece was set on top of the drawer.An undated facility Use of Hand-Held Nebulizers policy read in part, All staff involved in the administration must follow infection control procedures and adhere to the treatment protocol to prevent cross-contamination and ensure efficacy.An undated facility Linen Storage Policy and Procedure policy read in part, All linen used in the facility must be stored, handled, and distributed in a manner that maintains cleanliness, prevents contamination, and complies with infection control standards.A physician's order, dated 04/09/25, showed ipratropium/albuterol inhalation solution (duoneb) 3 ml one vial. Administer nebulizer four times a day for chronic obstructive pulmonary disease.Resident #3's significant change in status resident assessment, dated 04/16/25, showed the resident had diagnosis which included chronic obstructive pulmonary disease and their cognition was intact with a BIMS of 14.On 07/29/25 at 11:51 a.m., Resident #3 stated they used the nebulizer daily.On 07/30/25 at 12:36 p.m., CMA #1 stated they administer nebulizer treatments. They stated nebulizer mouthpiece should be stored in a bag or resident drawer when not in use.On 07/30/25 at 12:37 p.m., CMA #1 stated Resident #3's nebulizer mouthpiece was not in a bag.On 07/30/25 at 12:41 p.m., the director of nursing stated the nebulizer mouthpiece was to be set on the nebulizer machine. They stated they were putting them in bags but was told putting them in bags lead to harboring bacteria.On 07/30/25 at 12:46 p.m., CMA #1 stated the nebulizer mouthpiece was set on the resident's beside table.2. On 07/31/25 at 2:15 p.m., two grey barrels lined with plastic bags and had lids was observed next to a clean clothing rack with pants by the entrance of the laundry room. The clothing rack next to the rack with pants had two clothing items touching the floor.On 07/31/25 at 2:24 p.m., a short clothing rack was observed with clothes touching the floor in the clean storage area.On 07/31/25 at 2:30 p.m., There were five bags sitting on the floor in the clean storage area.On 07/31/25 at 2:16 p.m., the laundry supervisor stated the clothes on the clothing racks by the entrance were clean.On 07/31/25 at 2:19 p.m., the laundry supervisor stated the barrels were used for collecting dirty linens. They stated they sprayed them with Lysol after use.On 07/31/25 at 2:21 p.m., the laundry supervisor stated the barrels were not 100% clean. They stated the barrels were not stored in manner that prevent cross contamination.On 07/31/25 at 2:25 p.m., the laundry supervisor stated the clothes on the short rack were clean and not stored appropriately.On 07/31/25 at 2:33 p.m., the laundry supervisor stated the bags had pads to be taken to the dog shelter. They stated the water under the bags was due to the condensation from the air conditioning unit.On 07/31/25 at 2:34 p.m., the laundry supervisor stated the bags were not stored appropriately.

Based on record review and interview, the facility failed to ensure a registered nurse coordinated and signed resident assessments prior to submission to CMS. The DON reported 51 residents resided in the facility. Findings: A Clinical - MDS list, dated 12/02/23 through 03/18/24, documented 112 assessments had been submitted to CMS and accepted. On 03/20/24 at 2:38 p.m., the MDS coordinator reported being a licensed practical nurse not a registered nurse. The MDS coordinator reported she had signed all the assessments that were submitted to CMS between 12/02/23 through 03/18/24. On 03/20/24 2:40 p.m., the DON reported the facility did not have a policy related to completing and submitting MDS assessments. The DON reported being aware that MDS assessments required an RN signature and had failed to sign any of the MDS assessments dated 12/02/23 through 03/18/24.

Based on record review and interview the facility failed to provide timely and complete beneficiary notices to three (#51, #16, #109) of three sampled residents reviewed for beneficiary notices. The Administrator identified 51 residents resided in the facility. Findings: An undated Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 policy, read in part, .The provider must ensure that the beneficiary or representative signs and dated the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed . A Notice of Medicare Non-Coverage (NOMNC) policy, dated 03/18/24, read in part, .It is the policy of this facility that [name of facility] must deliver required notice to residents/resident representatives at least 2 calendar days prior to termination of skilled nursing care . 1. Resident #51's Notice of Medicare Non-Coverage documented skilled services would end on 11/11/23. There was no resident or resident representative signature or date on the document. A Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNFABN), was signed and dated by the resident's representative on 02/01/24. On 03/18/24 at 1:18 p.m., the MDS coordinator was asked if the NOMNC had been signed by the resident. They stated, No. They were asked why the ABN had been signed and dated after the resident was discharged from skilled services. They stated, that was as soon as they got it signed. 2. Resident #16's Notice of Medicare Non-Coverage documented skilled services would end on 12/07/23. The document had been signed by the residents representative but had no date when the notification had been signed. There was no documentation an ABN had been provided to Resident #16. On 03/18/24 at 1:21 p.m., the MDS coordinator was asked if Resident #16 had been provided a copy of an ABN. They stated the NOMNC form was all they had. They were asked when the residents skilled services ended. They stated on 12/07/23. They were asked when the residents representative signed the NOMNC. They stated it was not dated. 3. Resident #109's Notice of Medicare Non-Coverage documented skilled services would end on 01/26/24. The NOMNC documented the form was signed by the resident representative on 02/02/24. A Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNFABN), was signed and dated by the resident's representative on 02/02/24. The ABN did not document what option the resident or representative chose. On 03/18/24 at 1:13 p.m., the MDS coordinator was shown Resident #109's forms and asked why was the form signed on 02/02/24. They stated that was the day the residents representative signed the form and discharged on [DATE]. They were asked to review the ABN and why the options were left blank and if that was a completed form. They stated No.

Based on record review, interview the facility failed to develop a comprehensive care plan related to hospice, antipsychotic, anticoagulant, and opioid medications for two residents (#14 and #46) of 13 sampled residents reviewed for care plans. The Administrator identified 51 residents resided in the facility. Findings: 1. Resident #14 had diagnosis which included Dementia, depression, and pain. Facility had no Care Plan policy until 03/19/24. A care plan, dated 11/30/22, documented no focused area's for antipsychotic, anticoagulant, and opiod medications on the comprehensive care plan. On 03/19/24 at 11:34 a.m., the MDS Coordinator #1 was asked What the policy was for developing a comprehensive care plan. They stated they go by the resident's diagnosis and the cause section from admit MDS. They were then asked to review the comprehensive careplan for resident #14 and determine if the care plan had focus area's addressing the antipsychotic, anticoagulant, and Opioid mediation for Resident #14. They stated No, they are not on the care plan. They were then asked what the process if for updating and revising a care plan. They state, They go by the orders when they get them. 41873 2. Resident #46 had diagnoses which included non-Alzheimer's dementia and non-traumatic brain dysfunction. A physician order, dated 07/03/23, documented Comforting Hands Hospice. A quarterly assessment, dated 12/06/23, documented severly impaired cognition and hospice services. A care plan, revised on 03/18/24, contained no documentation for hospice services. On 03/20/24 at 10:05 a.m., the DON reported hospice should have been on resident #46's care plan.

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised after each assessment for two (#31 and #36) of 13 residents whose care plans were reviewed. The administrator identified 51 residents resided in the facility. Findings: 1. Resident #31 was admitted with diagnoses which included non-Alzheimer's dementia, dementia with other behavioral disturbance, and depression A care plan, revised 09/13/23, documented [name removed] has a mood problem r/t depression. The care plan contained no documentation of being reviewed or revised with quarterly assessments since 09/13/23. A physician order, dated 12/29/23, documented Quetiapine 25 mg 1 tablet by mouth one time a day for behavioral and psychological symptoms of dementia. A quarterly assessment, dated 02/21/24, documented cognition was moderately impaired and routine use of antipsychotic medication. 2. Resident #36 had diagnoses which included non-Alzheimer's dementia, depression, and dementia with other behavioral disturbance. A care plan, revised on 05/31/23, documented [name removed] uses psychotropic medications (Seroquel) r/t sleep/bpsd .[name removed] has dx of depression. The care plan contained no documentation of being reviewed or revised with quarterly assessments since 05/31/23. On 03/19/24 at 11:34 a.m., the MDS coordinator reported the facility had no policy related to care plan review or revision. On 03/19/24 at 2:30 p.m., the MDS coordinator reported the care plan meeting notes documented when the care plans were reviewed and what revisions were made. The MDS coordinator reported no care plan meeting notes were available for resident #31 and resident #36.

Based on observation, record review, and interview, the facility failed to ensure staff maintained infection control measures when passing medications. The Administrator identifed 51 residents resided in the facility. Findings: A Policy and Procedure, dated 03/04/21, read in part, .Precautions are utilized to prevent and control transmission of infectious organisms through direct and indirect contact .Hand hygiene means cleaning your hands by using either handwashing .antiseptic hand wash .antiseptic hand rub .medication preparation areas .Proper cleaning/disinfection of resident care care equipment including equipment shared among residents . On 03/19/24 at 7:32 a.m., CMA #2 obtained a blood pressure with a manual cuff and stethoscope on Resident #15. CMA #2 was observed to place their stethoscope around their neck and put the manual BP cuff back on the cart. CMA #2 did not sanitize the cuff or stethoscope or their hands. On 03/19/24 at 7:44 a.m., CMA #2 was observed to obtain a blood pressure on Resident #39 with a manual cuff and stethoscope. CMA #2 placed the stethoscope around their neck and put the cuff back on the top of the cart without sanitizing the cuff or stethoscope and did not sanitize their hands. On 03/19/24 at 7:53 a.m., CMA #1 was observed to administer medications to Resident #26. CMA #1 did not sanitize their hands then began to prepare Resident #41's medications. On 7:57 a.m., CMA #1 administered medications to Resident #41, returned to the cart and was not observed to sanitize their hands. On 03/19/24 at 8:07 a.m., CMA #1 was observed to prepare resident #49's medications and take to their room. CMA #2 obtained a blood pressure and pulse oximetry on Resident #49 using a manual BP cuff, stethoscope, and finger pulse ox. CMA #1 put the stethoscope around their neck rolled up the blood pressure cuff and returned to the cart. They were not observed to sanitize the blood pressure cuff, stethoscope or pulse ox. On 03/19/24 at 9:11 a.m., CMA #1 was asked how they maintain infection control when using their blood pressure cuff, stethoscope and pulse ox. They stated they wipe them off. They were asked if they had cleaned their equipment. They stated I should have cleaned my equipment but I did not. CMA #1 was asked if they had sanitized their hands prior to and after each medication pass. They stated, No. On 03/19/24 at 9:42 a.m., CMA #2 was asked when they should sanitize their hands when passing medications. They stated after every pass. CMA #2 was asked when should they sanitize their blood pressure cuff and stethoscope. They stated after a blood pressure is obtained. CMA #2 was asked if they had sanitized their equipment during medication pass. They stated No. They were asked what do they use to sanitize their equipment. They stated sanitizing wipes but did not have any on their cart. On 03/19/24 at 10:49 a.m., the DON was asked when should equipment be sanitized to include BP cuff, stethoscope and pulse ox. They stated before and after each use. The DON was asked when should staff sanitize their hands when passing medications. They stated before and after medications are passed.

Based on record review and interview the faciity failed to complete a significant change assessment for one (#57) of two sampled residents reviewed for a significant change. Findings: Resident #57 had diagnoses which included Parkinson's, repeated falls and pain. A Physician Order, dated 01/12/24 documented to admit the resident to hospice services. The clinical health record did not document a significant change assessment had been completed. The last assessment completed was a quarterly assessment on 02/08/24. On 03/18/24 at 4:11 p.m., the DON was asked if a significant change should have been completed when the resident was admitted to hospice. They stated Yes.

Based on record review and interview the facility failed to ensure resident assessments was transmitted within seven days of completion for one (#44) of two sampled residents reviewed for resident assessments. The Administrator identified 51 residents resided in the facility. Resident #44's quarterly assessment, dated 01/21/24, had been completed but still showed In Progress in the clinical health record. On 03/20/24 at 9:02 a.m., the MDS coordinator was asked why does the quarterly MDS, dated [DATE], still say In progress. They stated, I don't know might have missed it.

Based on record review and interview, the facility failed to ensure neurological checks were accurately completed for one (#22) of two sampled residents reviewed for neurological checks. The Administrator identified 51 residents resided in the facility. Findings: A Resident Falls policy, dated 03/19/22, read in part .Assessments of falls with head injury or unwitnessed falls shall include neurological checks as follows: a. Q 15 min x 4, Q 30 min x 2, Q 1 Hr x 2, Q 2 Hrs x 1, Q 8 Hrs x 72 HRS . Resident #22 had diagnoses which included, debility, dementia and arthritis. A nurse progress note, dated 10/29/23 at 7:10 a.m., read in part, .Res observed in floor in sitting position .neuro [checks] initiated . A Neurological Record, dated 10/29/23 at 7:15 a.m., documented neuro checks were started every fifteen minutes for an hour, every 30 minutes times one check, every hour for two checks, every two hours for one check, then every shift for seven shifts. The record did not document neuro check was completed at 30 minutes for a second time, and did not document times eight hour checks had been completed, just shift times. A nurse progress note, dated 11/13/23, read in part, .Staff alerted this nurse to come to residents room STAT. Upon entry res noted on floor laying on [right] side beside bed. Moderate amount of blood noted under head .EMS arrives [and] transports res to .ER . A Neurological Record, dated 11/13/23 documented neuro checks were started when the resident returned from the emergency room at 12:03 a.m., then 3:03 a.m., then documented neuro checks were completed every shift for six shifts. The record did not document times eight hours checks had been completed, just shift times. On 03/19/24 at 3:17 p.m. the MDS coordinator was shown the neurological records for Resident #22 and asked if every 8 hours checks for 72 hours had been completed correctly for the two neurological checks dated 11/13/23 and 10/29/23. They stated No. On 03/20/24 at 08:15 a.m., the DON was asked to review the neurological records dated 11/13/23 and 10/29/23. They stated they do the whole neuro checks for a total of 72, not every 8 hours for 72 hours. They stated the neurological checks had not been completed correctly.

Based on observation and interview the facility failed to ensure staff secured medication carts when unattended. The Administrator identified 51 residents resided in the facility. Findings: On 03/19/24 at 07:32 a.m., CMA #2 was observed to be preparing medications at their cart. They left the cart unlocked and stepped a few feet away with their back to the cart to administer medications. On 03/19/24 at 07:38 a.m., CMA #2 was observed to leave their med cart unlocked to answer the phone. On 03/19/24 at 9:42 a.m., CMA #2 was asked when should the cart be secured. They stated everytime their away from it. CMA #2 was asked if they recalled leaving their cart unlocked. They stated they did not remember. On 03/19/24 10:49 a.m., the DON was asked is there any time when a cart should be left unlocked if the med aide is not present. They stated No.

Based on record review and staff interviews, it was determined the facility failed to prevent the spread of COVID-19 by failing to ensure outbreak testing was completed in accordance to Centers for Medicare and Medicaid Services (CMS) guidelines and a physician's orders [REDACTED].#1, 2 and #3) of three sampled residents who were reviewed for COVID-19 testing. The facility identified 38 residents resided in the facility and 45 staff members who have not tested positive for COVID-19. Findings: The CMS QSO 20-38-NH document, dated 08/26/20, documented, .Testing of Staff and Residents in Response to an Outbreak .Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result . 1. On 12/30/20 at 10:20 a.m., the infection control preventionist (IP) was asked when the most current outbreak started. She stated on 11/15/20. At 11:35 a.m., licensed practical nurse (LPN) #1 was asked when the last time she was tested for COVID-19. She stated she hadn't been tested in three weeks. At 12:07 p.m., LPN #2 was asked when the last time she was tested for COVID-19. She stated it was December 14th or 15th. At 12:40 p.m., the director of nurses (DON) and the IP were asked for copies of documentation of COVID-19 testing. At 12:45 p.m., the DON stated, We did miss some people last week with testing but it hasn't been three weeks. At 12:57 p.m., the IP provided testing documentation. A review of testing documention revealed LPN #1 and #2 and CNA #2 and #3 were not tested from 12/20/20 thru 12/28/20. At 2:46 p.m., the IP was asked how often were staff to be tested . The IP stated, Weekly. She was asked when had weekly testing started. She stated since 11/06/20. The DON and IP were asked when LPN #1, #2 and certified nursing assistant (CNA) #2 were last tested . The DON stated 12/14/20. They were asked when CNA #3 was last tested . The IP stated 12/13/20. The IP was asked how many staff were not tested last week. She stated, 19. 2. Resident #1 was tested for COVID-19 on 11/08/20, 11/13/20, 11/20/20, 11/25/20, 12/05/20, 12/10/20, 12/13/20, 12/15/20 and 12/20/20. Resident #2 was tested for COVID-19 on 11/2/20, 11/07/20, 11/16/20, 11/23/20, 12/05/20, 12/10/20 and 12/13/20. Resident #3 was tested for COVID-19 on 12/22/20. On 12/30/20 at 2:46 p.m., the DON was asked if there was a physician's orders [REDACTED].

Based on record review and interview, it was determined the facility failed to develop a care plan in regard to hospice service received for one (#63) of three residents whose records were reviewed for hospice services received. This had the potential to affect 10 residents receiving hospice care according to the resident census and conditions of residents form. Findings: Resident #63 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The quarterly assessment, dated 10/03/17, documented the resident had severe cognitive impairment. She required extensive to total assistance from staff for activities of daily living. She was always incontinent of bowel and bladder. It documented the resident had received hospice services while a resident at the facility. The care plan, dated 12/27/17, had not addressed hospice services having been received. On 03/15/18 at 10:30 a.m., the assessment coordinator was asked to review the care plan. After review, she was asked if end of life/hospice had been addressed. She stated, No. She was asked if end of life/hospice should have been care planned. She stated, Yes.

Based on record review and interview, it was determined the facility failed to ensure a care plan was updated for a tube fed resident for one of one (#22) resident whose records were reviewed for tube feedings. This had the potential to affect three residents who had tube feedings according to the resident census and conditions of residents form. Findings: Resident #22 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A quarterly assessment, dated 01/06/18, documented the resident's cognition was moderately impaired. She was totally dependent on staff for eating. The resident had a feeding tube for food and medications. The care plan, dated 01/16/18, documented the resident was as risk for nutritional decline related to a decreased appetite. Interventions included she was on a regular diet and was to be served her diet as ordered via open style dining. She was to avoid overeating and her meals were to be small. frequent meals rather than three large ones. On 03/14/18 at 12:45 p.m., the care plan coordinator was shown the care plan that had not been updated concerning the resident's diet. She was in agreement that the regular diet should have been taken off of the care plan. At 1:32 p.m., the director of nursing was shown the care plan and she was in agreement it should have been updated.

Based on record review and interview, it was determined the facility failed to do a quarterly assessment for one (#1) of 16 records reviewed for assessment completion. This had the potential to affect all 61 residents. Findings: Resident #1 had [DIAGNOSES REDACTED]. An admission assessment, dated 11/06/17, documented the resident's cognition was moderately impaired. She required extensive assistance with all activities of daily living except for eating, she required supervision. She was occasionally incontinent of bowel and bladder. There were no other assessments contained in the clinical record. On 03/15/18 at 10:20 a.m., the assessment coordinator was asked if the resident's quarterly assessment had been completed. She stated the resident's quarterly assessment had not been done.

Based on observation, interview and record review, it was determined the facility failed to ensure a quarterly assessment was accurate for two (#44 and #63) of 16 residents' assessments reviewed for accuracy. This had the potential to effect all 61 residents. Findings: 1. Resident #44 was admitted with [DIAGNOSES REDACTED]. A physician's progress note, dated 01/16/18, documented the facility was to continue with bed and chair alarm on the resident. The resident's quarterly assessment, dated 02/11/18, documented the resident's cognition was severely impaired, she had not ambulated, and she utilized a wheelchair for mobility. The assessment had not documented a chair alarm had been used. The resident's care plan, dated 02/12/18, documented the resident was at high risk for falls and a chair alarm was in place while she was up in the wheelchair. The resident was observed several times throughout the survey to have been in the wheelchair with a chair alarm in place. On 03/14/18 at 10:19 a.m., the assessment coordinator was asked if the chair alarm should have been documented on the quarterly assessment. She reviewed the above findings and stated, Yes, it should be coded for a chair alarm. 2. Resident #63 had [DIAGNOSES REDACTED]. The quarterly assessment, dated 10/03/17, documented the resident had severe cognitive impairment. She required extensive to total assistance for activities of daily living. She was always incontinent of bowel and bladder. The assessment had not documented the resident had a condition or chronic disease that would result in a life expectance of less than six months. On 03/15/18 at 10:30 a.m., the assessment coordinator was asked if the resident had been on hospice. She stated, Yes. She was asked if a resident who was admitted to hospice had to have a life expectancy of six months or less. She stated Yes. She was asked to review the quarterly assessment dated [DATE]. After review, she was asked if the assessment was correct. She stated, No.

Based on record review and interview, it was determined the facility failed to follow physician's orders for medications for one (#61) of thirty sampled residents whose clinical records were reviewed. Findings: Resident #61 had [DIAGNOSES REDACTED]. A telephone order, dated 10/29/15, documented the resident was to receive [MEDICATION NAME] 10 milligrams (mg) daily for depression, [MEDICATION NAME] 40 mg four times a daily before meals and at bedtime to improve appetite and [MEDICATION NAME] 25 mg daily. The above physician's orders had not been documented on the resident's November 2015 medication administration record (MAR). On 11/04/15 at 9:45 a.m., the director of nursing (DON) was shown the telephone order in the resident's clinical record. At 9:55 a.m., the DON stated she had failed to transfer the orders from the October 2015 MAR to the November 2015 MAR and the resident had not received the medications as prescribed by the physician.

Based on observation and interview, the facility failed to store discontinued, controlled narcotics in a permanently affixed compartment. This affected one of one discontinued narcotic storage compartments. Findings: On 11/03/15 at 3:36 p.m., the discontinued narcotic storage file cabinet located in the director of nurses (DON) office was observed not to be permanently affixed. On 11/03/15 at 3:37 p.m., the DON was asked if the discontinued narcotic storage file cabinet was permanently affixed. She stated it was not. She stated the cabinet should have been permanently affixed.

Based on observation, interview and record review, it was determined the facility failed to develop measurable goals to address the care and treatment related to a resident's indwelling catheter for one (#71) of two residents who were reviewed for urinary catheter use. Findings: Resident #71's [DIAGNOSES REDACTED]. A quarterly assessment, dated 07/26/15, documented the resident's cognition was moderately impaired. She was independent with eating. She needed extensive assistance with all of her other activities of daily living. She was frequently incontinent of bowel and bladder. A nurse's note, dated 10/02/15, documented the resident was returned from a local hospital and her entire body had open sores and fluid filled blisters. A physician's telephone order, dated 10/22/15, documented for the resident to have an indwelling catheter for wound healing. The catheter was to be changed on the 22nd of each month. A care plan, dated 10/22/15 documented, .Indwelling Foley catheter: skin breakdown, Inserted 10/22/15. Change catheter on the 22nd of each month . On 11/04/15 at 10:24 a.m., the resident was observed receiving catheter care. On her bottom there were two large areas and numerous small areas with the epidermis layer missing. At 11:04 a.m., the director of nurses was asked about the resident's Foley catheter being used for wound healing. She stated the physician had ordered the catheter to be used only until the areas on the resident's bottom were healed. She stated the resident had a history of [REDACTED]. The goal was to remove the catheter as soon as the areas were healed. She was in agreement the careplan should have been more specific for the reason the Foley was being used and should have included a goal date of when it would be discontinued.

Based on observation and interview, the facility failed to have the facility name and date on the nurse staff posting. This had the potential to affect all 57 residents residing in the facility Findings: On 11/02/15 at 8:00 a.m., the nurse staff posting was observed to not have contained the facility name or date. On 11/02/15 at 8:11 a.m., licensed practical nurse #1 stated the posting had not contained the name of the facility and it should have. She was informed the date was missing on the staff posting for 11/02/15. She stated she knew it was missing and she had forgot to put the date on the posting that day. On 11/02/15 at 12:03 p.m., the nurse staff posting was observed to not have contained the facility name or date. On 11/02/15 at 4:00 p.m., the nurse staff posting was observed to not have contained the facility name or date. On 11/03/15 at 8:11 a.m., the nurse staff posting was observed to not have contained the facility name.

On 08/26/14 an Immediate Jeopardy (IJ) situation was determined to exist in regard to the facility's failure to follow their policy and procedure for contact isolation and act upon laboratory results that indicated a contagious microorganism which required isolation. The facility failed to address uncontained wound drainage. On 08/26/14 at 12:58 p.m., the Oklahoma State Department of Health was notified and the IJ situation was verified. At 1:25 p.m., the administrator and the director of nurses were informed of the IJ situation. At 6:45 p.m., the plan of removal was accepted. The plan of removal documented the following: "Plan of Removal 08/26/14 Infection Control System Failure On 08/26/14 at 1:25 p.m. the director of nursing and administrator were notified of a IJ deficiency regarding (name deleted) with a failure of infection control system. (The resident) had a positive culture for MRSA (methicillin resistant staphylococcus aureus) on 07/17/14 to the right heel. His physician was notified via fax. The physician ordered antibiotic therapy which was not susceptible to MRSA and there was no other follow-up with the case of MRSA. (The resident) also has copious amount of drainage to left stump that has not been identified. (The resident) has been placed on isolation precautions. His physician, (name deleted) was notified of drainage. New order received to culture drainage on left stump. Wound nurse cultured wound and took specimen to (hospital name deleted) lab at 2:00 p.m. on 08/26/14. -Staff present here at facility were inserviced at 2:00 p.m., on (the resident) being in isolation at this time. His room was cleaned by housekeeping with contact precautions. -Wound nurse was instructed to review all residents with any open wounds and (the named resident's) roommate for any signs or symptoms of MRSA such as redness, drainage, thick pus, odor, or any other signs and symptoms at 2:00 p.m. This was completed at 4:30 p.m., with no findings on any other residents. -The director of nursing and/or administrator will inservice all staff over infection control and signs and symptoms of infection that need to be reported to nurses. Housekeeping, laundry and all other staff will be inserviced over general universal precautions, contact precautions, and reporting any concerns to the charge nurse. This will be completed by 08/27/14 at 12:00 p.m. All nursing staff will be inserviced by this time as well. Nursing staff will also be inserviced when to place a resident in isolation until infection is identified. This will be done by 08/27/14 at 12:00 p.m. -Protocol for lab results to physicians will be revised and all nursing staff will be inserviced over procedure by 08/27/14 at 12:00 p.m. The director of nursing and assistant director of nursing will check labs daily for 2 weeks. They will continue to monitor nurses over properly faxing results to physicians, follow-up with physicians, and proper isolation and precautions to use. After 2 weeks of daily monitoring, the DON and/or ADON will continue to monitor quarterly and as needed. -The quality assurance team will meet by 08/28/14 at 12:00, to discuss this matter and the plan put in place. They will continue to monitor infection control and ensure that the infection control system is effective in preventing the spread of infection. Administrator and director of nursing will continue to inservice staff twice yearly over infection control." The facility provided documentation the nursing staff had been inserviced on 08/26/14 at 2:00 p.m. The facility provided documentation the housekeeping/laundry and general staff had been inserviced on 08/26/14 at 3:30 p.m. On 08/27/14 the staff members on all shifts were interviewed regarding the above inservices and their knowledge related to isolation. The staff verbalized their understanding of infection control, isolation, and reportable occurances. The IJ situation was removed on 08/28/14 at 9:45 p.m. after all components of the plan of removal had been implemented. The deficient practice remained widespread at a level of no actual harm with potential for more than minimal harm. Based on observation, record review, and interview, it was determined the facility failed to ensure the infection control program was implemented to prevent cross contamination for 2 (#10 and #18) of 4 residents sampled for infection control. The facility failed to ensure: 1. The infection control policy and procedure for contact isolation was followed, a laboratory (lab) result that indicated a MRSA was acted upon, and wound drainage was contained for resident #10. The facility identified two sampled residents who had been identified with MRSA. 2. Infection control practices were followed during the administration of eye drops for resident #18. This had the potential to affect 58 residents who resided in the facility. Findings: The facility policy for infection control documented the type of isolation would be in accordance to the type of infection. 1. Resident #10 had [DIAGNOSES REDACTED]. The annual assessment dated [DATE] documented the resident was cognitively intact and was able to move about the facility with supervision. The care plan reviewed/revised 07/14/14 documented the resident had a right heel ulcer and breakdown to the left stump. The care plan documented the stump wound was to be cleansed with normal saline, patted dry, calcium alginate applied, covered with a foam dressing, reinforced with abdominal pad, wrapped with kerlix, and secured with tape. A lab report dated 07/17/14 documented the results of an aerobic culture of the right heel. The lab report documented the resident had MRSA and the results had been faxed to the physician on 07/17/14 at 3:12 p.m. A weekly summary note dated 07/22/14 documented a right heel wound had light brown serous drainage. A wound care, skin integrity evaluation dated 07/31/14 documented the resident had a right heel wound with serosanguinous drainage and wound to the left stump. The sheet documented the wound had copious amounts of exudate which saturated the dressing. It documented the heavy drainage caused displacement of the dressing and discomfort related to wet clothing. A weekly summary note dated 08/11/14 documented the right heel wound had serous drainage. A weekly summary note dated 08/17/14 documented the right heel wound had serous drainage yellow in color. A fax memo form to the resident's physician dated 08/17/14 documented the resident had copious amounts of yellowish serous drainage from the left stump. The fax documented it had been sent on 08/25/14. On 08/25/14 at 3:30 p.m., a resident in the group interview stated the resident had been in her room and the wound drained onto the floor. She stated she had asked a housekeeper to clean up the drainage from the resident's wound. She stated the housekeeper cleaned the area and then used the same water to clean the hall floor. At 4:50 p.m., at the end of the group interview, resident #10 was observed to have a large pool, larger than a dinner plate, of drainage on the floor beneath his wheelchair. When the resident left the room the drainage made a trail down the hallway and into the dining room. As other residents exited the group interview, several walked or rolled their wheelchairs through the puddle and/or trail of drainage in the hall. On 08/26/14 at 9:45 a.m., the director of nurses (DON) was asked what type of infections required isolation. She stated she normally isolated for MRSA, but fortunately had not had any in the facility for quite some time. The DON was shown the resident's culture results for MRSA. She stated she did not know about the culture. At 9:50 a.m., the resident was observed in hall 300 in his wheelchair, rolling up the hall. The bottom of his left pant leg was saturated with drainage and was dragging on the floor. Other residents were rolling through the drainage. At 9:55 a.m., the resident was observed on hall 300 near the whirlpool room. There was a puddle of drainage approximately 4 by 4 inches in size under his wheelchair. A medication cart was pushed through the puddle and residents walked and wheeled through the puddle going to the lobby for activities. 08/26/14 at 9:57 a.m., the resident was taken into the whirlpool room for his bath. Certified nurse aide (CNA) #6 assisted the resident to undress. She placed his soiled clothing into the soiled linen barrel. She removed the resident's dressings from the right heel and the left stump. She started to place it in the trash. The trash can did not contain an isolation bag. LPN #3 entered the room and stated the dressings needed to be placed in a red bag. She stated she was unaware he had MRSA until that day. At 9:59 a.m., while the resident was being lifted over the whirlpool tub the left stump was visibility dripping into the tub. 08/26/14 at 10:10 a.m., CNA #7 stated if a resident was in isolation the nurse would put a isolation sign on the door of the resident's room. She stated this was done usually as soon as the lab results returned. At 10:10 a.m., the resident's room was observed. There was no isolation sign on the resident's room door. There was no isolation equipment in the hall by the resident's room or inside the room. At 10:17 a.m., wound care was observed for the resident. The left stump wound was open. The wound bed was red with granulation tissue. The wound measured 5.2 centimeters (cm) by 6.4 cm by 0.2 cm in depth. The wound had heavy serous drainage. On 08/26/14 at 10:25 a.m., housekeeper #1 stated a resident had reported resident #10 had been in her room and his leg had drained. The housekeeper stated she did a deep clean of the room. She stated she had no other reports concerning drainage. At 10:35 a.m., housekeeper #2 stated they had not used any special precautions while cleaning the resident's room. At 11:00 a.m., the DON stated the wound nurse had faxed the culture results to the physician. She was asked if the wound nurse had read the culture results before she faxed it. The DON stated the wound nurse had not. 08/26/14 at 11:45 a.m., CNA #6, the bath aide, was asked how the resident's soiled clothing and dressings had been handled. She stated she put the clothes in with all the other resident's and the bandages went into the regular trash. At 12:07 p.m., the surveyor asked licensed practical nurse (LPN) #3 (wound nurse) if she had faxed the wound culture with a result of MRSA to the physician. She stated, "Yes, that is my writing." She was asked if she had read the culture results prior to faxing it to the physician. She stated she had not read it. She was asked if the resident had been placed in isolation due to the MRSA. She stated, "No." On 08/26/14 at 12:07 p.m., LPN #3 was asked if the physician had been notified concerning the heavy drainage from the resident's stump. She stated she had not. The LPN was asked what would require a resident to be placed in isolation. She stated she would isolate a resident if the drainage from a wound had become heavier or if there were changes in the wound appearance. At 1:10 p.m., the wound specialist from a wound management company was contacted. She stated no one had informed her the resident had a positive culture for MRSA. The clinical record contained no documentation the resident had been placed in isolation at the time the positive culture of MRSA had been received. 2. Resident #18 had [DIAGNOSES REDACTED]. The admission assessment dated [DATE] documented the resident was cognitively intact. The physician's orders [REDACTED]. On 08/25/14 at 4:10 p.m., certified medication aide (CMA) #3 was observed as she administered Muro eye drops to the resident. She removed the cap from the medication container and placed it on the over bed table on its side with the edge touching the table. She did not place a barrier or sanitize the table prior to placing the cap on the table. On 08/26/14 at 8:25 a.m., CMA #2 was observed as she administered Muro eye drops to the resident. She removed the cap from the medication container and placed it on the over bed table on its side with the edge touching the table. She did not place a barrier or sanitize the table prior to placing the cap on the table. On 08/26/14 at 1:40 p.m., CMA #3 and #2 were informed of the observation regarding the placement of the Muro eye drop cap on the overbed table. They were asked what the facility protocol was regarding how the eye drop cap was to be handled. They stated they did not know. They were asked what they were taught in CMA class. CMA #2 stated they were taught to use a barrier.

Based on observation, record review, and interview, it was determined the facility failed to ensure body weight was maintained within acceptable parameters. This affected 5 (#1, 3, 4, 7, and #8) of 7 sampled residents who were reviewed for weight loss. ~ Resident #3 experienced a severe weight loss of 11.11% in 180 days with no notification of the physician, physician's orders were not followed for weekly weights and supplements, and no identification of actual weight loss was on the care plan. ~ Resident #1 experienced a severe weight loss of 12% in 30 days and 16.6% in 90 days with no notification of the physician, physician's orders not followed for weekly weights, no interventions were implemented, and no identification of actual weight loss was on the care plan. ~ Resident #7 experienced a severe weight loss of 11.53% in less than 30 days with no notification of the physician and no registered dietician (RD) referral. ~ Resident #8 experienced a severe weight loss of 12% in 180 days with no notification of the physician and no interventions implemented in the care plan. The facility failed to ensure physician's orders were followed for weekly weights for resident #4. This had the potential to effect 58 residents who resided in the facility. Findings: 1. Resident #3 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] documented the resident was severely cognitively impaired and required limited assistance of 1 person for eating. The assessment documented the resident had not experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The care plan last reviewed 07/25/14 documented the resident was at risk for nutritional decline and had no signs/symptoms (s/s) of malnutrition through the review date. The care plan documented as of 05/30/14 the resident was to have a house supplement 3 times per day between meals and as of 06/06/14 was to be weighed weekly. As of the last review date of 07/25/14 there were no changes and the facility was to continue the current plan of care for 90 days. The quarterly assessment dated [DATE] documented the resident was severely cognitively impaired and required limited assistance of 1 person for eating. The assessment documented the resident had experienced a weight loss of 5% or more in the last month or 10% or more in the last 180 days and was not on a physician prescribed weight loss regimen. Current weights per the resident weight list provided by the facility were as follows: ~ 02/2014 - 162 pounds (lbs). ~ 08/2014 - 144 lbs. This constituted a severe weight loss of 18 lbs (11.11%) in 180 days. The care plan had not been updated to identify the resident's actual severe weight loss of 11.11% in 180 days from 02/2014 through 08/2014. There was no documentation to indicate the physician had been notified of the resident's severe weight loss of 11.11% from 02/2014 through 08/2014. On 08/28/14 at 3:00 p.m., the director of nurses (DON) was shown the resident's weight loss from 162 lbs to 144 lbs for a weight loss of 11.11% in 6 months and asked if the physician had been notified. She stated, "No." The consultant RD note dated 08/07/14 documented the resident's weight as 144 lbs and on a regular diet with a house supplement 3 times per day between meals. The note documented the resident had lost 18 lbs for a weight loss of 11% in the past 6 months. The note documented the resident's appetite varied from usually fair to poor and the resident had been on an antibiotic for an upper respiratory infection the past month. The RD recommended the staff to continue to encourage increased oral intake and she would review the weights the next month. There was no documentation to indicate the RD recommended a change or additional interventions for the resident's weight loss. Current physician's orders dated 08/2014 documented the resident was to be offered a regular diet with a house supplement 3 times per day between meals. Meal intake records dated 07/2014 and 08/2014 documented the resident was to be offered a meal (alternate) if the resident ate less than 50% of the meal. The July intake record documented the resident ate less than 50% or refused the meal 47 of 93 opportunities for a meal. The intake record documented a meal supplement or alternate was not offered 10 times and no meal intake, supplement, or alternate was documented 10 times. The area on the meal intake to document snacks for the month was blank. The August intake record from the 1st through the 28th documented the resident ate less than 50% or refused the meal 67 of 84 opportunities for a meal. The intake record documented a meal supplement or alternate was not offered 7 times and no meal intake, supplement, or alternate was documented 4 times. The area on the meal intake to document snacks for the month documented the resident accepted a snack 1 time and the rest of the documentation area was blank. The resident was observed multiple times during the survey as she sat in the lobby during activities and as she was assisted in the dining room. The resident was seated at an assisted feeding table with a staff member facing her. The staff member assisted the resident to eat. The resident was alert, but due to her severe cognitive impairment did not always appear to understand questions. On 08/29/14 at 9:05 a.m., the certified dietary manager (CDM) was shown the meal intake records for July and August and asked about the documentation of the supplements 3 times per day. She stated they were documented on a daily sheet sent out with the snacks and then she (the CDM) documented them on the meal intake sheet at the end of the month. The daily snack sheets were provided for August. At 5:25 p.m., the CDM was shown the July meal intake sheet which was blank for documentation of the 3 times per day supplements. She stated she did not know what happened, that maybe she missed that sheet. She was asked if she had saved the July daily sheets. She stated, "No." August daily snack sheets from 08/15 through 08/28 were reviewed. The resident was to be offered a supplement 3 times per day between meals. Eighteen times the area to document the supplement was blank. 2. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission assessment dated [DATE] documented the resident was cognitively intact and had an admission weight of 150 lbs. The care plan last reviewed on 07/09/14 documented the resident was at risk for nutritional decline. The care plan documented the physician was to be notified of signs/symptoms of malnutrition such as greater than 5% weight loss in 1 month, greater that 7.5% weight loss in 3 months, and greater that 10% weight loss in 6 months. The care plan documented the RD was to evaluate and make diet recommendations as needed. The care plan did not address the resident's actual severe weight loss. The quarterly assessment dated [DATE] documented the resident was moderately impaired in cognition and required extensive assistance with most activities of daily living. The assessment documented the resident required supervision with eating only and had experienced a weight loss of 5% or more in the last month or a weight loss of 10% or more in the last 6 months. The facility's weight records documented the following weights: 04/2014 - 150 lbs. 05/2014 - 131 lbs. A severe weight loss of 12.6% in one month. 06/2014 - 138 lbs. 07/2014 - 125 lbs. Severe weight losses of 9% in one month and 16.6% in three months. There was no documentation the physician had been notified of the severe weight loss that had occurred in one month (05/2014). On 08/27/14 at 9:50 a.m., the DON was shown the resident's clinical record and asked if the physician had been notified of the resident's severe weight loss in one month. She reviewed the clinical record and stated there was no documentation the physician had been notified of the weight loss. The consultant RD note dated 04/10/14 documented the resident's weight was 150 lbs and recommended the diet be liberalized to a general diet. There was no consultant RD note in 05/2014 to address the resident's severe weight loss. A dietary progress note written by the CDM on 05/19/14 documented the resident had lost 19 lbs and the resident's weight would continue to be monitored. There was no documentation of interventions initiated to prevent further weight loss. On 08/29/14 at 9:00 a.m., the CDM was asked if the consultant RD had been notified of the resident's 19 lb severe weight loss in 05/2014. She stated she had notified the RD, but did not document it. The CDM was asked if interventions had been put in place when the resident had experienced the severe weight loss. She stated no interventions had been put in place for the weight loss that occurred in 05/2014. A consultant RD note dated 07/10/14 documented the resident had experienced a 13 lb weight loss (9%) in the past month and a 25 lb weight loss (16%) in the past 3 months. The RD recommended weekly weights and if weight declined to consider adding health shakes three times a day (TID). A fax notification to the physician's office dated 07/11/14 documented the RD recommended weekly weights due to significant weight loss for 1 month and 3 months. The RD recommended if weight decreased to add health shakes TID. A physician's order dated 07/13/14 documented weekly weights and if weight decreased to add health shakes TID. The weekly weight monitoring report dated 08/2014 documented the following: 08/06/14 - blank. 08/13/14 - 129 lbs. 08/20/14 - blank. Meal intake records dated 04/2014 through 06/2014 documented the resident was to be offered a meal (alternate) if the resident ate less than 50% of the meal. The 04/2014 intake record documented the resident ate less than 50% or refused the meal 2 out of 63 opportunities for a meal. The intake record documented a meal supplement was refused. Twenty-two meals out of 63 opportunities were blank. The area on the meal intake to document snacks for the month was blank. The 05/2014 intake record documented the resident ate less than 50% or refused the meal 5 out of 63 opportunities for a meal. The intake record documented a meal supplement had not been offered. Six meals out of 63 opportunities were blank. The area on the meal intake to document snacks for the month was blank. The 06/2014 intake record documented the resident ate less than 50% or refused the meal 11 out of 75 opportunities for a meal. The intake record documented a meal supplement had not been offered. Four meals out of 75 opportunities were blank. The area on the meal intake to document snacks for the month was blank. On 08/29/14 at 9:05 a.m., the CDM was shown the meal intake records for 04/2014 through 06/2014 and asked about the documentation of the meals and supplements. She stated if the snacks and supplements were not documented on the sheet sent out with the snacks, she was unable to determine if the resident had received them. The resident was observed seated in her recliner. She was pleasant and answered questions appropriately. She stated she had a choice of what she wanted to eat, but had many days in which she did not have much of an appetite. 3. Resident #7 had [DIAGNOSES REDACTED]. The significant change in status assessment dated [DATE] documented the resident was severely cognitively impaired, required supervision for eating, and had experienced a weight loss of 5% or more in the last month or 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen. The care plan last reviewed 07/18/14 documented the resident was at risk for a nutritional problem. The care plan documented as of 07/31/14 the resident was to have a house supplement 3 times per day with meals due to weight loss. The care plan documented the consultant RD was to evaluate and make diet change recommendations as needed. The care plan documented the physician was to be notified of significant weight loss of 3 lbs. in 1 week, more than 5% in 1 month, more than 7.5% in 3 months, and more than 10% in 6 months. The resident monthly weight list provided by the facility and a readmission nurse's note on return from a hospital stay documented the following: ~ 08/2014 - 130 lbs. ~ 08/13/14 - 115 lbs. ~ 08/20/14 - 118 lbs. - return from hospital. This constituted a severe weight loss of 11.53% in less than a month from 08/2014 to 08/13/14 and a severe weight loss of 8.46% in less than a month from 08/2014 to 08/20/14. The CDM note dated 08/01/14 documented the resident received a regular diet and healthshakes with meals. The note documented the resident's weight as 130 lbs. There was no documentation by the CDM to indicate the resident's severe weight loss had been identified or a referral made to the consultant RD. There was no documentation to indicate the physician had been notified of the severe weight loss. The resident was observed multiple times during the survey as she ambulated around the facility with a walker. She was alert and pleasant during conversation, but seemed confused at times. On 08/28/14 at 2:45 p.m., the CDM and licensed practical nurse (LPN) #1 were shown the resident's weight loss on return from the hospital and asked if the physician had been notified. LPN #1 stated, "No." They were asked if a referral to the consultant RD had been made. The CDM stated, "No." 4. Resident #8 had [DIAGNOSES REDACTED]. The care plan dated 09/03/13 documented the resident was endentulous. The care plan documented the resident ate whatever she wanted without difficulty. The staff were to monitor for difficulty with chewing food. The care plan documented the resident was at risk for nutritional problems and/or potential weight loss. The staff were to reinforce the importance of maintaining proper intake, invite the resident to activities that promoted additional intake, and provide a calm, quiet setting at meal times with adequate eating time. The staff were also to offer snacks between meals, and provide house supplements when less than 50% of the meal was consumed. The care plan for nutritional risk updated 03/03/14 documented to continue the current plan of care. The quarterly assessment dated [DATE] documented the resident was severely impaired in cognitive skills for daily decision making. The assessment documented the resident required assistance with activities of daily living and set up assistance with eating. The care plan for nutritional risk updated 06/03/14 documented to continue the current plan of care The facility weight book documented the resident lost 2 to 4 pounds per month consistently from 02/2014 through 07/2014.. The facility weight book documented the following weights: 02/2014 - 131 lbs., 03/2014 - 128 lbs., 04/2014 - 124 lbs., 05/2014 - 122 lbs., 06/2014 - 119 lbs., 07/2014 - 114 lbs., and 08/2014 - 115 lbs. This constituted a 12% weight loss in 6 months from 02/2014 to 08/2014. A fax dated 07/11/14 documented notification of the physician of a 14% weight loss in 6 months and a request for an appetite stimulant. An order was received for [MEDICATION NAME] 40 milligrams twice daily. On 08/25/14 at 6:10 p.m. the resident was observed during the meal. She ate in her room and fed herself potatoes with gravy, chicken nuggets, chocolate pudding, and chocolate milk. The resident did not respond to questions. On 08/29/14 at 1:15 p.m., the assistant director of nurses was shown the consistent weight loss each month and the care plan that documented the current plan of care was to be continued. She was asked if continuing with the plan of care while the resident was losing weight was effective. She stated it was not. At 2:30 p.m., the DON was asked if the physician had been notified of the 12% weight loss from 02/2014 to 08/2014. She stated he had not. The DON was shown the care plan and asked if any new interventions had been put in place as a result of the resident's monthly weight loss. She stated, "No." 5. Resident #4 had [DIAGNOSES REDACTED]. A physician's order dated 05/12/14 documented the resident was to be weighed weekly due to weight loss. The quarterly assessment dated [DATE] documented the resident was severely impaired in cognition and required limited assistance with eating. The care plan reviewed/revised on 06/02/14 documented the resident was at risk for nutritional complications due to poor intake. The care plan documented the resident was to be weighed weekly. The weekly weight monitoring sheet for 08/2014 documented the resident was weighed biweekly on 08/13/14 and 08/28/14. On 08/28/14 at 12:10 p.m., licensed practical nurse #1 was shown the weekly weight monitoring sheet and asked if weekly weights were done during 08/2014. She stated the doctor's orders were not followed. The facility's percent of meal consumed and meal replacement policy documented, "Dietary will document daily percentage of each meal consumed for each resident in their permanent record and meal replacement will be offered when meal intake is inadequate to maintain good nutritional status...A meal replacement shake will be offered if a resident eats less than 50%..."

Based on observation, record review and interview, it was determined the facility failed to identify the presence of an unstageable left heel pressure ulcer for 1 (#3) of 1 sampled residents with an unidentified pressure ulcer. This failed practice constituted actual harm for resident #3. The facility's "Resident Census and Condition of Residents" identified 4 residents with pressure ulcers. Findings: Resident #3 had [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE], documented she had no short/long term memory problems, was independent in cognitive skills for daily decision-making, was totally dependent on staff for transfers and hygiene, did not ambulate and was continent of bowel/bladder. There was no documentation to indicate minimum data set (MDS) assessments had been completed since 04/06/10. The care plan dated 07/06/10, documented a problem of risk for pressure ulcers related to bed mobility and bowel incontinence. The care plan did not document the presence of an unstageable pressure ulcer to the left heel. The "Braden Scale For Predicting Pressure Sore Risk" dated 11/11/10, documented the resident was at mild risk for the development of pressure sores. The weekly "Wound/Skin Record" dated 11/11/10, documented no presence of pressure ulcers. On 11/15/10 at 9:45 a.m., the facility manager was asked for a current list of residents with wounds. Resident #3 was not identified as a resident with wounds. There was no documentation in the nurses' notes to indicate the presence of a wound to the left heel. On 11/17/10 at 9:15 a.m., the surveyor observed the skin of resident #3 with the assistance of licensed practical nurse (LPN) #2, who was also the treatment nurse, and certified nurse aide (CNA) #1. The left heel had an area approximately 2.5 centimeters (cm) by 1 cm, which was black, dry and hard with peeling edges. LPN #2 and CNA #1 were asked if they had seen the area on the left heel before. They stated they had not seen the area prior to the current examination of the skin. CNA #1 was asked if she had assisted the resident with dressing during her shift. She stated the night shift dressed the resident. LPN #2 and CNA #1 were asked when the resident had last been bathed. They stated the day before (11/16/10), by CNA #2. At 9:40 a.m., LPN #3 was asked if she had received report from the previous shift in regard to resident #3's skin. She stated, "No." At 9:45 a.m., CNA #2 was asked if she bathed resident #3 the day before. She stated, "Yes." She was asked if she noticed open or scabbed areas on her skin. She stated, "Just on her feet." She was asked to whom she reported the finding. She stated, "No one, I thought they knew." At 10:00 a.m., 2 surveyors observed the resident's skin with the facility manager (also a registered nurse) and the director of nurses (DON). The left heel was called to their attention. The DON stated the heel was hard and leathery. The facility manager stated the heel was "scabby" and the black, hard area was "loose", because her fingernail would "catch" under the edge. She was asked if the depth could be determined. She stated, "No."