Every finding on record at Gregston Nursing Home, Inc.

Based on observation, record review, and interview, the facility failed to ensure dignity was maintained for residents who required staff assistance for eating for 7 (#2, 3, 31, 34, 44, 47, and #52) of 7 sampled residents observed during dining.The DON reported three residents were dependent on staff for eating. Findings:On 08/19/25 at 12:21 p.m., CNA #1 was observed standing up to feed and assist Residents #31, #44, #47, and #52 at the feeding assist table on the East side of the dining room. The CNA was observed to have a chair available at the table but failed it use it and continued to stand over the residents and assist with feeding for the entire meal.On 08/19/25 at 12:25 p.m., CNA #2 was observed standing up to feed and assist Residents #2, #3, and #34 at the feeding assist table on the [NAME] side of the dining room. CNA #1 was observed to have a chair available at the table but failed to use it and continued to stand over the residents and assist with feeding for the entire meal.A policy Assistance with Meals, dated 09/01/13, read in part, Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: Not standing over residents while assisting them with meals.On 08/20/25 at 4:50 p.m., the administrator reported for residents' dignity, staff should not be standing up or standing over residents while assisting them with eating.

Based on record review and interview, the facility failed to ensure all meals were served from the kitchen at an appetizing temperature. The DON reported 54 residents received meals from the kitchen. Findings: A significant change assessment, dated 08/10/25, showed Resident #64's cognition was intact with a BIMs score of 15. The assessment showed the resident was independent with eating. On 08/20/25 at 11:00 a.m., the resident council meeting minutes were reviewed for July 2025. The minutes showed complaints related to cold food. On 08/19/25 at 11:40 a.m., Resident #64 reported the food was served cold a lot. The resident reported this weekend (08/16/25 and 08/17/25) all meals were cold and had to have their soup sent back three times to get it hot enough. The resident reported that they ate their meals in the dining room. On 08/19/25 at 3:18 p.m., a resident council meeting was conducted with Residents #9, 10, 15, 16, 17, 21, 23, 27, 29, 39, 57, and #64. All in attendance were in agreement the food this weekend was served cold and was occasionally cold during the week. The residents agreed there were too many residents in the dining room to have the staff reheat all their meals at the same time. On 08/20/25 at 4:53 p.m., the dietary manager reported being aware of complaints regarding cold food on weekends. The dietary manager reported three new kitchen staff had been hired for the weekends, and they were working on the complaints of cold food.

Based on observation and interview, the facility failed to ensure staff used proper infection control practice while assisting residents with eating for 3 (#2, 3, and #34) of 7 residents observed during dining. The DON reported three residents were dependent on staff assistance for eating. Findings:On 08/19/25 at 12:25 p.m., CNA #2 was observed assisting Residents #2, #3, and #34 with eating. CNA #2 was observed blowing on Residents #34's spoon of beans to cool them off before feeding the resident. CNA #2 was observed touching their face and hair, then picking up a pepper with their bare hands and feeding it to Resident #34. CNA #2 was observed touching Resident #3's arm to arouse the resident to eat and then assisting Resident #2 with eating from a spoon. CNA #2 was observed not to use hand gel or wash hands throughout the entire meal. A policy Assistance with Meals, dated 09/01/13, read in part, All employees who provide resident assistance with meals will be trained and shall demonstrate competence in the prevention of foodborne illness, including personal hygiene practices and safe food handling. On 08/20/25 at 4:50 p.m., the administrator reported staff who were feeding residents should at least be using hand gel between assisting and feeding each resident. The administrator reported staff feeding residents and providing assistance with eating should not touch their hair and should not touch other residents without performing hand hygiene. The administrator reported a staff member blowing on a resident's spoon to cool off the food and touching food with bare hands was an infection control concern.

Based on record review and interview the facility failed to ensure MDS assessments accurately reflected the residents status for three (#17, 43, and #45) of eighteen sampled residents reviewed for assessments. The Resident Census and Conditions of Residents form documented 52 residents resided in the facility. Findings: 1. Resident #17 had diagnoses which included dementia, fractures, and diabetes. An incident report, dated 12/04/22, documented the resident had a fall with right femur fracture. The Significant Change Assessment, dated 12/19/22, documented under the section for Fall History Did the resident have a fall any time in the last month It was answered, No. On 01/08/23 at 9:30 a.m., the MDS coordinator reported, I should have marked the resident had a fall as yes not no. 30875 2. Resident #43 had diagnosis which included sleep apnea. The Significant Change Assessment, dated 12/12/22, documented the resident's cognition was intact. The Progress Note, dated on 01/03/23, documented the resident chose not to allow staff to put on BIPAP, with no other behaviors reported. The Progress Note, dated on 01/10/23, documented resident did not allow staff to put on BIPAP at the end of the previous shift or the beginning of this shift. On 01/10/23 at 09:28 a.m., resident #43 reported she used her BIPAP if staff remembered to put it on her at night. On 01/10/23 at 03:04 p.m., the MDS coordinator was asked if the BIPAP was recorded on the MDS. She stated no it was not recorded, but should have been recorded under special treatments and procedures. 3. Resident #45 had diagnosis which included sleep apnea. The Physician's Orders, dated 10/17/22, documented CPAP to be worn at night every night shift related to sleep apnea. The resident's annual Minimum Data Set (MDS), dated [DATE], did not document CPAP under special treatments and procedures. On 01/09/23 at 02:11 p.m., resident #45 was lying in bed with oxygen in place at 2L NC and a CPAP machine was observed on the bedside table. On 01/17/23 at 03:51 p.m., the MDS Coordinator was asked if the admission MDS dated [DATE] included the physician's orders for CPAP. She stated no it did not, but should have been on there.

Based on record review and interview, the facility failed to accurately complete a preadmission screening to determine the need for a PASRR II for one (#43) of one sampled resident admitted to the facility. The Resident Census and Conditions of Residents documented 52 residents resided in the facility. Findings: A .Oklahoma Health Care Authority, Nursing Facility Level of Care Assessment, dated 06/17/22, read in parts, .admitted [DATE] .Level II required [blank] .Diagnosis of a serious mental illness (for example schizophrenic, paranoid, panic, mood or other severe anxiety or depressive disorder, somatoform disorder, personality disorder, or other psychotic disorder, or another mental disorder, or another mental disorder that may lead to a chronic disability? [No] . On 01/10/23 12:42 PM an interview with the DON was conducted. The DON was asked if the PASRR included her diagnosis for Major Depressive Disorder. The DON stated, no. DON was asked if the question in the PASRR was answered correctly. DON stated, no, but she knew the resident had anxiety, dementia, and depression. The facility PASRR POLICY, dated 10/31/22, read in parts, .Prior to admission all potential residents must be screened for the need for a level two PASSR. If a need is established you must contact OHCA .

Based on record review and interview, the facility failed to ensure and document scheduled cleaning for the BIPAP machine for one #43 of one sampled resident with a BIPAP. The Resident Census and Conditions of Residents documented 52 residents resided in the facility. Findings: The Significant Change Assessment, dated 12/12/22, did not document BIPAP on the assessment. The Physician's Order, dated 12/13/21, documented, .BIPAP @HS at bedtime related to sleep apnea . On 01/10/23 at 03:20 p.m., the ADON was asked for documentation for the cleaning/use of the BIPAP machine. She reported she had discussions with the resident's husband that he would clean the BIPAP, and stated she could change the physician's order and have the staff clean the machine. On 01/10/23 at 03:27 p.m., resident #43's BIPAP machine was observed on the bedside table in her room. Resident #43 was asked who cleaned her BIPAP machine. She reported she did not know who cleaned her BIPAP machine. She stated her husband used to clean it and they had asked him to take the cleaning machine home a few weeks ago.

Based on observation, interview, and record review, it was determined the facility failed to implement their infection control program to prevent potential spreading of COVID-19 infection for all staff and residents. The facility failed to ensure Oklahoma State Department of Health (OSDH) was notified within 24 hours when residents and staff tested positive for COVID-19. Findings: 1. Resident #1, #2, and #3's electronic medical records, dated 11/17/20, documented the residents tested positive for COVID-19, their families were notified, and the residents were isolated. 2. The assistant infection preventionist nurse (IP) provided documentation of the testing results for staff members. The form indicated a staff member had tested positive for COVID-19 on 11/16/20. The assistant IP stated the staff member had received a positive test result in a community clinic on 11/15/20 and notified the facility on 11/16/20. The assistant IP provided a copy of an OSDH State Reportable form 283. The form documented OSDH was notified of the positive resident and staff tests on 11/20/20. The signature line on the form documented the name of the director of nursing (DON) as the individual who completed the form. On 11/24/20 at 12:04 PM, the DON was interviewed by phone and stated she had not filled the forms out and submitted them in a timely manner. She confirmed the forms should have been completed and submitted to OSDH within 24 hours.

Based on interview and record review, it was determined the facility failed to notify a resident's family of significant change and decline in the resident's condition, including transfer to a quarantine unit, for one (#1) of three residents reviewed for notification. The facility reported 11 residents with significant changes in the previous 30 days and seven residents who required quarantine for signs/symptoms or possible exposure to COVID-19. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/29/20, documented the resident was moderately impaired with cognition. The assessment documented the resident required moderate to extensive assistance with most ADL's. A care plan, dated 06/16/20, documented the resident had chronic pain related to [MEDICAL CONDITION], was treated for [REDACTED]. A progress note, dated 07/07/20, documented the resident was crying from back and shoulder pain. The note documented the physician was notified. The physician informed staff to assess if the pain was new or chest pain, and to send the resident to the emergency room if indicated. The note documented the resident denied chest pain and the physician gave an order for [REDACTED]. A progress note, dated 07/09/20, documented the resident complained of shortness of breath and congestion with a runny nose. The note documented the resident was afebrile and was placed on oxygen for shortness of breath. The note documented other vital signs were within normal limits, labs were obtained as ordered, and a COVID assessment was completed. The note documented the physician instructed staff to watch the resident closely and report to him the following day. The note did not document family was notified. A progress note, dated 07/10/20 at 9:46 a.m., documented the resident continued to complain of back and hip pain, which the resident reported was related to arthritis. The note documented the resident had wheezes to the upper lobes of her lungs, cough, and congestion. The note documented labs were received and faxed to the physician. The note documented vital signs were stable with an oxygen saturation of 95% on 2L/NC. A progress note, dated 07/10/20 at 1:52 p.m., documented the resident would be tested for COVID-19 and moved to a quarantine room until results were obtained. The note documented the physician was notified and agreed. The note did not document family was notified. A progress note, dated 07/14/20 at 10:51 a.m., documented the resident was noted to have a large, round, reddened area to the back. The resident reported it had shown up a couple of weeks previous and had been causing pain. A note later on the same day documented a new physician order [REDACTED]. A progress note, dated 07/15/20 at 3:26 a.m., documented the resident was showing signs of [MEDICAL CONDITION], was restless, and quite anxious. The note documented vital signs were stable with oxygen saturation of 95% on 2L/NC. The note documented the resident had started the antibiotic. The note did not document family was notified. A progress note, dated 07/15/20 at 10:02 a.m., documented the nurse had been called to the resident's room at 8:45 a.m. where the resident had been found to be unresponsive. The note documented the resident was assisted to bed and oxygen increased. The note documented, 911 in building at the time of the resident's passing at 8:51 a.m. The note documented family was notified and arrived to resident's room at 9:15 a.m. A progress note, dated 07/17/20 at 7:50 a.m., documented the physician notified the facility of the resident's negative COVID test and the physician believed the resident had suffered a [MEDICAL CONDITION]. The note documented the resident's family was notified of these findings. On 08/06/20 at 3:15 p.m., the DON reported the resident began to have symptoms so the decision was made to move her to the COVID/quarantine unit while awaiting test results. The DON stated although the resident was not feeling well, it was not considered a significant change in the resident's condition. On 08/06/20 at 4:00 p.m., the ADM reported the resident was their own person and staff might not have notified the family for this reason. The ADM was asked if the resident wasn't feeling well, would staff still expect the resident to be responsible for calling their family. The ADM stated staff probably should have called family to update them on the resident's status and make them aware the resident had been moved to the COVID/quarantine unit.

Based on observation, record review, and interview, it was determined the facility failed to ensure the assessment was accurate, ~for catheter use for one (#28) of one resident reviewed for catheter use and ~a hospice resident's documentation of a terminal condition for one (#45) of one resident reviewed for hospice care. This had the potential to affect all 63 residents. Findings: 1. Resident #28 admitted with [DIAGNOSES REDACTED]. A physician's progress note, dated 01/24/19, documented the resident has a chronic indwelling catheter due to incomplete bladder emptying. An assessment dated [DATE], documented the resident was severely cognitively impaired. It did not document the resident had an indwelling urinary catheter. On 03/19/19 11:58 a.m., the resident was observed to have an indwelling urinary catheter. During an interview on 03/20/19 at 1:34 p.m., the assessment coordinator stated the assessment should have documented the resident had a catheter and it was incorrect. During an interview on 03/21/19 11:05 a.m., licensed practical nurse #1 stated the resident was admitted with the indwelling catheter. 2. Resident #45 had [DIAGNOSES REDACTED]. A nurse's note, dated 02/07/2019, documented the resident was admitted to hospice. The significant change assessment, dated 02/14/19, had not documented the resident had a condition or chronic disease that may result in a life expectancy of less than six months. On 03/21/19 at 10:24 a.m., the assessment coordinator was asked if the assessment should have documented the resident had a life expectancy of less than six months. She stated, Yes.

Based on interview and record review, it was determined the facility failed to ensure a pharmacy recommended gradual dose reduction (GDR) was acted upon in a timely manner for one (#2) of five residents whose records were reviewed for unnecessary medications. No other resident had been prescribed a nicotine patch according to the director of nursing. Findings: The resident had [DIAGNOSES REDACTED]. A pharmacy consult, dated (MONTH) 19, (YEAR), documented, She continues on a nicotine patch 21 mg daily .this should now be decreased to the 14 mg patch daily. A pharmacy consult, dated (MONTH) 23, (YEAR), documented, Physician response from last month was not in chart . A pharmacy consult, dated (MONTH) 06, (YEAR), documented, I did not see physician response to (MONTH) drug review regarding her nicotine patch on chart. A pharmacy consult medication regimen fax sheet received by the facility from the physician, dated 10/02/18, documented, If still applicable, yes patch should be decreased to 14 mg. There was no physicians signature on the returned fax. This was noted by the facility on 10/18/18. According to the Medication Administration Record, [REDACTED]. On 03/21/19 at 9:14 a.m., the director of nursing and licensed practical nurse #2 were both in agreement their system on receiving responses back from this physician was broke, the time frame for the physician to respond to the pharmacist request should not take 3 months and should include a physician signature.

Based on interview and record review, it was determined the facility failed to ensure a physicians response to a pharmacy recommended gradual dose reduction (GDR) was clarified and or acted upon for one (#2) of five residents whose records were reviewed for unnecessary medications. This had the potential to affect 53 residents who received a psychoactive medication according to the Resident Census and Conditions of Residents. Findings: The resident had [DIAGNOSES REDACTED]. A significant change, dated 01/21/19, documented, no behaviors exhibited. A pharmacy consult, dated 12/04/18, documented, . she is due for consideration of a gradual dose reduction at this time . [MEDICATION NAME] 2.5 mg Daily (antipsychotic), [MEDICATION NAME] 150 mg at bedtime (HS) (antidepressant), [MEDICATION NAME] 20 mg daily (antidepressant), [MEDICATION NAME] 5 mg three times daily (TID) (anxiolytic). The physician replied by fax on 12/12/18. Do not change [MEDICATION NAME] or [MEDICATION NAME] Stop [MEDICATION NAME] if you wish to stop something. This was signed by the physician and dated 12/12/18. The physician's faxed response had not been noted by the facility. The medication administration records for (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 were reviewed it documented the [MEDICATION NAME] 5 mg TID had continued to be given. On 03/21/19 at 9:14 a.m., the director of nursing (DON) and licensed practical nurse #2 were both in agreement the [MEDICATION NAME] 5 mg TID should have been stopped in (MONTH) (YEAR). The DON pointed out the order had not been noted by them.

Based on observation, record review, and interview, it was determined the facility failed to ensure a care plan was developed for catheter use for one (#28) of one resident reviewed for catheter use. This had the potential to affect all 63 residents. Findings: Resident #28 admitted with [DIAGNOSES REDACTED]. An assessment dated [DATE], documented the resident was severely cognitively impaired. It did not document the resident had an indwelling urinary catheter. The resident care plan did not address the resident's catheter. A physician's progress note, dated 01/24/19, documented the resident has a chronic indwelling catheter due to incomplete bladder emptying. On 03/19/19 11:58 a.m., the resident was observed to have an indwelling urinary catheter. During an interview on 03/20/19 at 1:34 p.m., the assessment coordinator stated the residents catheter should have been on her care plan. During an interview on 03/21/19 11:05 a.m., licensed practical nurse #1 stated the resident was admitted with the indwelling catheter.

Based on observation, record review and interview, it was determined the facility failed to ensure a resident's care plan was updated to reflect an indwelling catheter had been inserted for one (#42) of three residents reviewed for catheters. This had the potential to affect three residents with catheters according to the residents census and conditions of residents form. Findings: Resident #42 had [DIAGNOSES REDACTED]. The admission assessment, dated 02/26/19, documented the resident had an indwelling catheter. The care plan did not contain documentation in regard to the resident's indwelling catheter. On 03/19/19 at 10:00 a.m., the resident was observed in her recliner and a catheter bag containing urine was seen hanging below her. On 03/20/19 at 02:54 p.m., the care plan coordinator was interviewed and stated the catheter should have been on the care plan.

Based on record review and interview, it was determined the facility failed to follow the physician's orders for one (#1) of three residents reviewed for following physician's orders. This had the potential to affect all 61 residents. Findings: Resident #1 had [DIAGNOSES REDACTED]. The admission assessment, dated 05/10/18, documented her cognition was moderately impaired. She had received oxygen therapy while in the facility. A physician's order, dated 05/03/18, documented the resident was to have oxygen at 4 liters a minute via nasal cannula to keep her oxygen saturation above 89 percent. A nurse's note, dated 06/21/18, documented the resident had been receiving oxygen at 6 liters a minute. On 07/17/18 at 12:35 p.m. the licensed practical nurse (LPN) that had worked and documented the nurse's note for 06/21/18 was interviewed and asked if she recalled the resident's oxygen having been at 6 liters a minute. She stated she would not have documented incorrectly and that it was at 6 liters/minute. The director of nurses (DON) was present and was in agreement the LPN would not have documented incorrectly. The DON stated the physician's orders were not followed.

Based on record review and interview, it was determined the facility failed to notify the physician when the resident had a change in condition for one (#1) of three residents whose records were reviewed. This had the potential to affect all 59 residents. Findings: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 10/08/17 at 3:37 a.m., documented the resident was unable to move his right arm. A nurse's note, dated 10/08/17 at 6:43 a.m., documented the resident had shortness of breath, oxygen saturation of 86%. The physician's standing orders documented to notify the physician if a resident's oxygen saturation levels was below 89%. There were no records which documented the physician had been notified of the resident's changes in condition. An assessment, dated 10/17/17, documented the resident was moderately cognitively impaired. It documented the resident needed extensive assistance with transfers, dressing, hygiene, and physical help with bathing with two or more person assistance. It documented the resident needed limited assistance with eating with one person assistance, no range of motion limitations, and was frequently incontinent of bowel and bladder. A care plan, dated 10/30/17, documented interventions to notify the physician if there are changes in skin changes, wound healing, decline in function, signs or symptoms of immobility, and signs or symptoms of respiratory distress. A weekly skin assessments form, dated 10/25/17, documented the resident had a stage II pressure ulcer on his sacrum which measured 2.5 centimeters (cm) by 2 cm. There were no records the physician had been notified of the resident's pressure ulcer until 11/05/17 when orders had been obtained to treat the pressure ulcer. On 11/20/17 at 1:30 p.m., the director of nurses was asked if the physician had been notified of any of the resident's changes in condition. She stated he had not been. She was asked if the physician should have been notified. She stated Yes.

Based on record review and interview, it was determined the facility failed to ensure a pressure ulcer was treated in a timely manner for one (#1) of three residents whose records were reviewed for pressure ulcers. This had the potential to affect 8 residents at risk for pressure ulcers identified by the director of nurses. Findings: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An assessment, dated 10/17/17, documented the resident was moderately cognitively impaired. It documented the resident needed extensive assistance with transfers, dressing, hygiene, and physical help with bathing with two or more person assistance. It documented the resident needed limited assistance with eating with one person assistance, no range of motion limitations, and was frequently incontinent of bowel and bladder. A care plan, dated 10/30/17, documented a problem of the resident was at risk for pressure ulcers with interventions which included: .follow facility protocols for the prevention/treatment of [REDACTED]. A weekly skin assessments form, dated 10/25/17, documented the resident had a stage II pressure ulcer on his sacrum which measured 2.5 centimeters (cm) by 2 cm. A decubitus/pressure ulcer risk assessment and record, dated 11/02/17, documented the stage II pressure ulcer had measured 2.4 cm by 1.5 cm A physician's orders [REDACTED]. The dressing was to be changed every 3 days and as needed. The 10/2017 treatment administration record (TAR) had not documented any treatment for [REDACTED]. The 11/2017 TAR documented the first sacral pressure ulcer treatment had occurred on 11/05/17. On 11/20/17 at 1:30 p.m., the director of nurses was informed the resident had developed a pressure ulcer on 10/25/17 and it had not been treated until 11 days later on 11/05/17. She was asked if the resident's pressure ulcer should have been treated before 11/05/17. She stated it should have been.

Based on observation and interview, it was determined kitchen staff failed to handle food being prepared for residents without wearing contaminated gloves for one of two meals observed being prepared. This had the potential to affect all 55 residents residing in the facility. Findings: On 12/27/17 at 12:00 p.m., the dietary manager (DM) was observed with gloved hands in the kitchen. She opened the freezer door and reached into the freezer and grabbed a frozen food item, then went to the fryer and opened the fryer door and placed the frozen food item in to the fryer. At 12:02 p.m., cook #1 was observed to be wearing gloves. She was observed to touch the ladles of three separate food items she was serving on to each plate and then she would grab an egg roll with the same gloved hand and put it on to the residents' plates. This occurred throughout the lunch plate preparations for several residents. At 12:07 p.m., dietary aide #1 was observed with gloved hands. She was observed to grab a loaf of bread in it's plastic wrapper and proceed to pull out bread slices from it. She opened a package of cheese slices then got one slice and closed up the cheese package. She then grabbed a plate, opened the refrigerator door and retrieved a peanut butter container and grape jelly jar from the refrigerator. She then grabbed a lid for a resident's cup and handed it to another staff member per their request. She then grabbed the food surface part of a butter knife and got peanut butter on it and then put it on a slice of bread. She then opened the refrigerator door again and retrieved a container of ginger sauce while never removing her gloves. At 12:20 p.m., the DM was asked if wearing gloves continuously while serving and preparing food was sanitary. She was in agreement gloves should have been removed and hands washed with new gloves donned before food items were touched.

Based on record review and interview, it was determined the facility failed to notify the physician for a resident's repeated refusals to weigh and for a documented weight loss for one (78) of three residents reviewed for nutrition. This had the potential to affect 14 residents with unplanned significant weight loss according to the Resident Census and Conditions of Residents form. Findings: Resident #78 had [DIAGNOSES REDACTED]. A form the facility used at the nurses' station for the resident's weights documented: . June-fight everyone in room July-Refused wht (weight)/Government is out to get her August-Refused wht/Tried to hit me Sept. Refused wht/Need Dr. Oct. Refused wht/is going to call son Nov. Refused-saying she is to sick Dec. Refused-her arm is dead. Jan. Refused-she threw up all day. Feb. refused-she can't step on it (scale) it hurts. The resident's meal percents were reviewed from July 2016 through the present and documented no drastic changes in her percents eaten for meals. They varied from 0 %-25 % and 76 %-100 % with the most usually consumed as 76 %-100%. The care plan, dated initially as 07/31/15, documented the resident had potential for nutritional problems. An intervention documented the resident's weight was to be monitored, recorded and reported to the physician if there was a significant weight loss of greater than 10 % in six months. A nurse's note, dated 07/20/16, documented the resident adamantly refused to allow her weight to be obtained, she actually threw her walker against the wall, and shoved the CNA (certified nurse aide) back from her and stated she can not get her wt (weight), when she stands on the scale it makes her dizzy. no distress noted after failed wt attempt. The resident's documented weight on 07/24/16 was 124.1 pounds. A nutritional risk assessment, dated 10/31/16 by the dietician, documented the resident's weight as 124 pounds. The quarterly assessment, dated 01/05/17, documented the resident's cognition was severely impaired. She was independent with transfers, ambulating in her room. She required supervision/set-up with ambulating outside of her room, dressing, eating and personal hygiene. She required limited assistance with bathing. On 01/29/17, the next documented weight in the resident's clinical record was 110 pounds. A nutritional risk assessment by the dietician, dated 01/29/17, documented the resident's weight as 110 pounds and no weight change. On 03/02/17 at 10:00 a.m., the the assistant director of nurses stated the resident's eating habits had not changed and her clothes continued to fit as always. She was in agreement there was no documentation the physician had been notified of the resident's repeated refusals to weigh or the documented weight loss. At 10:20 a.m., the director of nurses was in agreement the physician should have been notified of the resident's repeated refusals to weigh and the documented weight loss. At 11:00 a.m., the resident was observed ambulating with her walker in the dining area. She was well groomed. Her clothes had not looked too big on her. She stated to me she used to be a doctor and she was in charge. The CNA who had obtained the resident's weight for January was unable to be interviewed. At 11:18 a.m, the restorative aide who is responsible for obtaining weights on residents stated the weight she obtained in February was probably incorrect because the resident would not stay on the scale for any length of time. She would move one foot off constantly. She stated the CIA (central intelligence agency) was out to get her. At 11:21 a.m., the dietician stated she had not notified the physician of the resident's refusals to weigh or the documented weight loss and should have. On 03/06/17 at 9:00 a.m., the administrator stated she had got the resident to weigh alongside her on the scale and subtracted her own weight. The resident's weight was 122.6.

Based on record review and interview, it was determined the facility failed to identify psychoactive medication use on the careplan for one (#107) of five residents whose records were reviewed for unnecessary medications. This had the potential to effect 49 residents in the facility who received psychoactive medications. Findings: Resident #107 had [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The start date was 02/01/17. An admission assessment, dated 02/09/17, documented the the resident's cognition was severely impaired. The 7-day medication look back on the assessment documented she had taken an antipsychotic drug for the past 7 days. The care area assessment (CAA) had documented the resident had [MEDICAL CONDITION] drug use. The Medication Administration Record [REDACTED]. There was no careplan for [MEDICAL CONDITION] drug use. On 03/01/17 at 2:30 p.m., the assessment/careplan coordinator was interviewed. She was asked if there should have been a careplan for this resident for her antipsychotic/antidepressant/antianxiety medication. She stated, Yes, there should have been one. At 2:40 p.m. the director of nursing was in agreement there should have been a careplan for the resident's [MEDICAL CONDITION] drug use.

Based on record review and interview, it was determined the facility failed to accurately document a resident's significant weight loss and tube feedings for one of one (#79) residents reviewed for tube feeding. There were no other residents in the facility with a feeding tube as identified by the Resident Census and Conditions of Residents form. Findings: Resident #79 was admitted with [DIAGNOSES REDACTED]. A nutrition assessment, dated 12/31/16, documented the resident had weight fluctuations of a 10% decrease in the past 6 months. The resident's caloric and protein needs were met with tube feedings. A physician's orders [REDACTED]. A significant change assessment, dated 01/17/17, documented the resident had severely impaired cognition, required extensive assistance of staff for all activities of daily living (ADL's), had a current weight of 114 pounds, which was not identified as a weight loss or gain, and was receiving a mechanically altered diet. The resident's care plan, updated 02/06/17, documented the resident required tube feedings related to dysphagia, swallowing problem, and weight loss. On 03/02/17 at 10:30 a.m, the assessment coordinator was in agreement the weight loss and the tube feedings had not been documented on the significant change assessment.