Every finding on record at Heartsworth Center For Nursing & Rehabilitation

Based on record review and interview, the facility failed to ensure a volunteer with adverse actions was not allowed to volunteer at the facility for 1 (Volunteer #1) of 1 sampled volunteer reviewed for adverse actions.The ADON identified seven volunteers performed services in the facility.Findings:An undated facility policy titled Abuse, Neglect and Exploitation, read in part, Background, reference, and credentials' checks will be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. The facility will maintain documentation of proof that the screening occurred.An activity calendar, dated 07/2026, showed karaoke was to be held in the facility on 07/09/26, 07/16/26, 07/23/26, and 07/30/26 from 1:00 p.m. until 4:00 p.m.A review of the sex offender registry showed Volunteer #1 was convicted of lewd or indecent proposals/acts to a child on 09/01/04 and was a registered sex offender.On 07/08/26 at 9:50 a.m., the activities director stated Volunteer #1 had been performing karaoke on Thursday afternoons at the facility for at least two years. On 07/09/26 at 9:40 a.m., the ADON stated Volunteer #1 was on the sex offender registry and should not have been allowed to volunteer at the facility. The ADON stated they had not been screening volunteers, but they were going to start screening the volunteers.On 07/09/26 at 09:50 a.m., the DON stated Volunteer #1 was a registered sex offender and should not have been volunteering at the facility.

Based on record review and interview, the facility failed to provide supervision to prevent elopement for 1 (#3) of 3 sampled residents reviewed for elopement.The ADON identified 11 residents at risk for elopement.Findings:An undated facility policy titled Elopements and Wandering Residents, read in part, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.A quarterly assessment for Resident #3, dated 05/25/26, showed the resident had a brief interview for mental status score of 11, which indicated the resident was moderately impaired for daily decision making and could walk independently.A Wandering Risk Scale, dated 06/07/26, showed Resident #3 was a high risk to wander.An incident report form, dated 06/28/26, showed Resident #3 was returned to the facility at 3:27 p.m. after being located one block away from the facility. The report showed Resident #3 was assessed and no injuries were noted. The report showed the resident was off the property for 10-15 minutes.On 07/08/26 at 10:40 a.m., Certified Nurse Aide #1 stated Resident #3 wandered frequently but the staff kept an eye on them.On 07/08/26 at 11:15 a.m., Licensed Practical Nurse #2 stated they were not sure how Resident #3 got out of the building. They stated the doors were not locked, but they did have an alarm that was functioning properly.On 07/09/26 at 9:40 a.m., the ADON stated Resident #3 had not been adequately supervised when they eloped on 06/28/26.On 07/09/26 at 9:50 a.m., the DON stated they did not believe Resident #3 had been adequately supervised when they eloped from the facility on 06/28/26.

On [DATE], an IJ was determined to exist related to the facility's failure to ensure a resident who had chosen to have a full code status was provided CPR after a life threating medical emergency was discovered. On [DATE] CNA #1 found Res #3 in their room and unresponsive. CNA #1 reported the situation to LPN #1 who checked the blood pressure of the resident then told CNA #1 the resident was dead and to clean them up. CNA #1 stated no code had been called for Res #3 and no CPR had been attempted.On [DATE] at 12:02 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation.On [DATE] at 12:20 p.m., the DON was notified of the IJ situation and provided the IJ template.On [DATE] at 4:09 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health.The facility plan of removal, dated [DATE] at 4:09 p.m., read in part, On [DATE], the facility QAPI members met to discuss this event, root cause, immediate implementation of interventions and auditing/compliance tools.There are DNR Binders located at each nurse's station in the instance PCC is down for any reason. The ADON is responsible to update the binder for new admissions.The DON immediately conducted chart audits regarding code status to ensure accuracy.The Nurse was suspended pending further investigation and later terminated.The Root Cause Analysis identified was that the charge nurse assumed that since the resident was on Hospice, that [gender withheld] had a DNR in place.The failure was due to the charge nurse failing to check and verify code status and follow proper policy and procedure for a resident being unresponsive/not breathing with a full code status.Monitoring will be accomplished by the DON and/or [gender withheld] designee will audit Code status weekly for 90 days to ensure compliance.In addition, any resident death that occur in the facility will be reviewed to be sure code status was followed correctly.The date of substantial compliance: [DATE].On [DATE], after interviews with staff, review of in-service training, review of audits of resident code status, review of code binders, and review of staff competencies, the IJ was lifted [DATE] at 12:12 p.m. when all components of the plan of removal had been confirmed to have been completed. The deficiency remained at an isolated level with the potential for than minimal harm.Based on record review and interview, the facility failed to ensure a resident that chose to be a full code was provided cardiopulmonary resuscitation when the resident experienced a life-threatening medical emergency for 1 (#3) of 5 sampled residents reviewed for code status.The ADON reported 72 residents resided in the facility.Findings:A facility policy and procedure titled Emergency Procedure - Cardiopulmonary Resuscitation, dated February 2018, read in part, If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and all 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the base life support (BLS) sequence of events.An MDS quarterly assessment for Res #3, dated [DATE], showed in Section C the resident had a BIMS score of 15 which indicated their cognition was intact for decision making.A physician's order, dated [DATE], showed Res #3 was a full code.On [DATE] at 9:36 a.m., CNA #1 was asked to describe their involvement in the care of Res #3 that occurred on [DATE]. CNA #1 stated they were working on a different hall than the one Res #3 had resided. They stated CNA #2 had come to them and stated Res #3 had died and they had never done the aftercare before. CNA #1 stated they asked CNA #2 if the resident was a DNR or full code because the aftercare was different. They stated CNA #2 had replied they had not done CPR so they assumed there was a DNR and they would clean the resident up accordingly. CNA #1 stated they went to the hall where Res #3 was and cleaned the body. CNA #1 was asked what Res #3's body looked like. They stated the upper body clothing was covered in a foul-smelling vomit and when they rolled the body to the sides during cleaning, more of the substance exited the resident's mouth. They stated the skin looked normal except the veins looked bluer than a living person. CNA #1 was asked if there was any blue areas of the skin or any stiffness observed. They stated the skin did not have any blue areas and the body was limp.On [DATE] at 9:49 a.m., CNA #2 was asked to describe their involvement in the care of Res #3 that occurred on [DATE]. CNA #2 stated they had gone into Res #3's room for their routine check and the resident did not respond when they spoke with them and did not appear to be breathing. CNA #2 stated they went to LPN #1 and gave them that information. They stated LPN #1 entered the room and put a blood pressure measuring device on the resident's arm and checked Res #3's blood pressure. They stated LPN #1 stated, She's dead. CNA #2 stated they asked LPN #1 what they should do to which the LPN replied, Clean (them) up. CNA #2 was asked what LPN #1 had done after telling them to clean them up. CNA #2 stated they saw LPN #1 go look at their computer but did not know what they were doing. CNA #2 stated they went to get help from CNA #1 because they had never cleaned a deceased body before. CNA #2 was asked to describe what they and CNA #1 had done regarding the cleaning of the body. CNA #2 stated they removed the resident's clothing and brief, then washed the body, brushed the resident's hair, then covered the body with a sheet. CNA #2 was asked to describe the resident's body when they had cleaned it. They stated the skin looked pale all over. CNA #2 was asked if there was any discoloration to the skin such as blue or purple areas. They stated the skin did not have any discoloration. CNA #2 was asked to describe if the body seemed stiff or limp. They replied the body was limp. CNA #2 added the resident's body had vomit on it and when they rolled the body to the side to clean it, and vomit came out of the resident's mouth and nose and looked like there was some blood in it.On [DATE] at 10:54 a.m., the ADON was asked what information they had regarding Res #3's death on [DATE]. The ADON stated they found out about the death from LPN #1 in a text message which stated the resident was deceased and all they had done. The ADON stated LPN #1 texted back and asked if they had performed CPR but did not get a reply. The ADON stated they later texted again and asked if they had performed CPR and LPN #1 then called them. They stated LPN #1 told them the resident had emesis (vomit) on them to which they replied that did not matter if the resident was a full code and if they were, they should have gotten CPR. The ADON stated they then looked up Res #3's code status and found out the resident was a full code. The ADON stated LPN #1 replied the resident was on hospice care and had a DNR. The ADON stated they then went to the facility about 10:00 a.m. and Res #3's body had already been removed from the facility. The ADON stated they checked with the resident's hospice service, and they did not have a DNR. The ADON stated Res #3 should have received CPR on the day they had died.

Based on observation, record review, and interview, the facility failed to ensure equipment in the kitchen was sanitized. The ADON reported 70 residents received meals from the kitchen. Findings:On 09/15/25 at 11:50 a.m., cook #1 was observed recording temperatures of food being held on the steam table. [NAME] #1 was observed to place the thermometer into a container of Brussel sprouts, remove the thermometer from the Brussel sprouts, grab a towel off the counter and wipe off the thermometer. [NAME] #1 then placed the thermometer into the sweet potatoes, removed the thermometer from the container of sweet potatoes and wiped the thermometer off with the same towel. [NAME] #1 then placed the thermometer into a container of sliced ham, removed the thermometer from the container or ham, and wiped it off using the same towel.A facility policy titled Sanitization, revised 11/2022, read in part, The food service area is maintained in a clean and sanitary manner.All equipment, food contact surfaces, and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.On 09/17/25 at 10:05 a.m., the DM stated the thermometer should be sanitized between uses with an alcohol pad.

Based on observation, record review, and interview, the facility failed to ensure that oxygen cylinders were stored securely. The ADON reported 19 residents utilized supplementary oxygen. Findings:On 09/15/25 at 1:00 p.m., an oxygen cylinder was observed in Res #9's room. The cylinder was upright and unsecured next to the head of Res #9's bed.An undated facility policy titled Oxygen Safety, read in part, When small-sized (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to medical equipment designed to receive and hold compressed gas cylinders. On 09/16/25 at 12:20 p.m., CNA #3 stated oxygen cylinders should be attached to the resident's wheelchair or in some type of oxygen tank holder.On 09/16/25 at 12:30 p.m., LPN #2 stated oxygen cylinders should not be unsecured in a resident's room.On 09/16/25 at 1:50 p.m., the ADON stated oxygen cylinders should be stored securely in a carrier.

Based on record review and interview, the facility failed to include a focus of wandering in a comprehensive care plan for one (#4) of two residents reviewed for wandering. The ADON identified two residents in the facility that wandered. Findings: A facility Elopements and Wandering Resident policy, dated 01/01/20, read in part, The facility ensures residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with with their person-centered plan of care addressing the unique factors contributing to wandering or elopement. Resident #34 had diagnoses which included recurrent depressive disorder. A progress note, dated 01/26/24 at 8:08 a.m., documented the Resident #34 had been wandering and continued attempting to enter other residents' rooms. A progress note, dated 01/26/24 at 10:02 a.m., documented the Resident #34 was found in their room with the shoes of a male resident. A progress note, dated 01/26/24 at 5:12 p.m., documented the Resident #34 had attempted to enter the kitchen while calling our for their mother. A progress note, dated 02/05/24 at 3:20 p.m., documented required redirection from wandering into the rooms of other residents. A facility Wandering Risk Scale , dated 0225/24, documented the Resident #34 had score a 14 on the risk tool and was documented to be a high risk for wandering. A progress note, dated 03/11/24 at 12:39 p.m., documented the Resident #34 wanders around the facility. A quarterly MDS assessment, dated 03/14/24, documented the Resident #34 cognition was moderately impaired. A review of Resident #34's comprehensive care plan found no focus, goal, or intervention regarding wandering. A focus for falls was in the care plan that documented the resident had fallen on 02/09/24 due to confusion and wandering. One of the interventions for the fall focus was to speak to the resident's family about a locked unit. The goal and other intervention for the fall focus did not address wandering. On 04/30/24 at 7:26 a.m., the ADON stated Resident #34 did wander. On 05/01/24 at 11:37 a.m., CNA #2 stated the Resident #34 did wander a lot a few months ago but she has since declined and does so less. On 05/01/24 at 11:46 a.m., LPN #2 stated the Resident #34 has really slowed down as far as wandering and that sometimes they may try to go into another resident's room. On 05/02/24 at 09:20 a.m., MDS Coordinator #1 reviewed Resident #34's medical record and stated the resident does not have focus on wandering. They stated they got their ideas for the care plan focuses from documentation in a residents medical record. They stated they do also talk with the staff about each resident when they make out the care plans. They stated that since there were progress notes about wandering in Resident #34's medical record they should have care planned wandering. They stated they were not sure why it was not care planned in the past. On 05/02/24 at 1:14 p.m., the DON stated the care plan system at the facility was broken and the facility leadership will be working to fix it. They stated they need every IDT member to be involved in the care plan meetings.

Based on observation, record review, and interview, the facility failed to serve foods at a palatable temperature from one of two kitchen service areas. The DON identified 40 residents who ate meals served from the satellite kitchen. Findings: The facility policy titled Food and Nutrition Services, read it part, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. On 05/01/24 at 11:15 a.m., the satellite kitchen was observed. The mid-morning meal, including breakfast and lunch style options were observed on the steam table. The steam table was not producing steam. The back and sides of the steam table felt only warm to the touch. The holding temperature of the sausage patties was 94 degrees Fahrenheit. The holding temperature of the soup from 118 degrees Fahrenheit. On 05/01/24 at 11:16 a.m., Cook #1 stated they were not sure what the holding temperature was for hot foods. The cook stated the steam table was turned on about 7:00 a.m. and left until they were finished with the evening meal. The cook stated they thought the steam table was not hot enough to keep the food hot due to one steam table burner not working and the low water level within the steam table. The Cook #1 pointed to a line inside the steam table water reservoir. The water level appeared approximately three inches below the line the cook pointed to. On 05/02/24 at 10:15 a.m., the steam table was observed with Cook #2. The steam table did not produce steam. The sides of the steam table were warm to the touch. Cook #2 stated the holding temperature of hot foods was at least 135 degrees Fahrenheit. The cook measured the water in the steam table reservoir in two places. The water measured 128 degrees Fahrenheit at the back of the reservoir and 146 degrees Fahrenheit on the side where the knobs controlling the steam table temperature were located. The Cook #2 stated they had noticed trouble with the steam table maintaining temperature and had notified the maintenance department last week about it. On 05/02/24 at 1:30 p.m., the dietary manager stated the holding temperature for hot food was to be greater than 135 degrees Fahrenheit. They stated food temperatures were measured just before sending food from the main kitchen to the satellite kitchen and again immediately after placing the food on the steam table and starting service to the residents. The dietary manager stated they did not measure the holding temperature of the food again. The dietary manager was asked if measuring the temperature of the hot food as soon as it was placed on the steam table was an accurate measurement of the holding temperature of the hot foods during the entirety of the meal service. The dietary manager stated no. They stated measuring the temperature at the start of meal service gave the staff what the food temperature was at the start of of the meal and not what the holding temperature was of the food.

Based on record review and interview, the facility failed to ensure three substantive meals were served daily. The ADON reported 73 residents received meals from the kitchen. Findings: An undated facility policy titled Frequency of Meals, read in part, .Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests, and the plan of care . A handwritten document provided by the DM documented that east hall had breakfast served at 7:30 am, the snack cart went out at 7:30 am, brunch was served at 10:30 am, the snack cart went out again around 1:30 pm, supper was served at 4:30 pm, and the snack cart went out again at 6:30 pm. On 04/29/24 at 8:32 am, the DM stated that a breakfast snack was served in the morning and then brunch which has breakfast items was served. They also stated a midday snack was served then an evening meal was served around 4:30 pm followed by an evening snack. On 05/02/24 at 9:10 am, the DM stated that a hot breakfast was served on the skilled unit, but other residents were served a continental breakfast consisting of pastries, cold cereal, oatmeal, or yogurt. The DM further stated that the residents could request a hot breakfast, but it was not offered to them. On 05/02/24 at 11:40 am, CMA #2 stated breakfast was more of a snack than a meal. On 05/02/24 at 11:49 am, LPN #2 stated she would not consider the breakfast served in the facility a substantial meal. On 05/02/24 at 11:54 am, Cook #1 stated the residents on east hall received a hot meal for breakfast but the other residents in the facility did not. On 05/02/24 at 11:58 am, CMA #1 stated the facility served a continental breakfast not a traditional breakfast.

Based on observation and interview, the facility failed to maintain the physical environment of the main kitchen and failed to serve cold foods in the satellite dining room in a sanitary manner. The DON identified 79 residents who ate meals prepared in the main kitchen. Findings: On 04/29/24 at 8:32 a.m., the kitchen was observed to not have a dedicated handwashing sink. On 04/29/23 at 8:32 a.m., the dietary manager stated the staff used the two compartment sink to wash their hands. The dietary manager stated the two compartment sink was used to fill pots with with water and other food preparation needs. On 04/29/24 at 8:33 a.m., the kitchen was observed to have: - missing and broken baseboards, - holes in the ceiling, - rusted air vents and lighting fixtures in the ceiling, - multiple yellow and orange water stains on the ceiling, - peeling paint located on the ceiling and above the food preparation areas, - no dedicated hand washing sinks in the main or satellite kitchens, - an unsecured bottom grill hanging from under the left door of the two door refrigerator, and - and two (approximately one inch thick and four inch by eight foot) wood beams nailed across the ceilings stained, sagging, and peeling paint. On 04/29/24 at 8:45 a.m., the satellite kitchen was observed with the dietary manager. The satellite kitchen was observed to not have a sink. On 04/29/24 at 8:45 a.m., the dietary manager stated the kitchen staff assigned to the satellite kitchen were to wash their hands in the sink located on the opposite side of the dining room. On 05/01 at 11:30 a.m., multiple nursing staff were observed passing trays from the satellite kitchen. The staff were observed to: - passed trays to residents in the satellite dining room, - assisted residents with positioning themselves near the table, and - prepared the resident's plate (cutting the food, positioning utensils, plate, and drinks within reach of the resident), and - plate and serve peaches in syrup from a clear container and cottage cheese from a container without sanitizing their hands. The facility staff were observe to place the lid of the peaches container on the island counter with the interior or the lid in contact with the counter top before securing the lid back on top of the container. Between the observations of nursing staff plating cold foods from the dining room island, Resident #20 was observed to plate themselves peaches and cottage cheese from the dining room island without washing or sanitizing their hands. Without sanitizing their hands, the nursing staff were observed to serve cold foods located on the island in the satellite dining room. On 05/02/24 at 1:30 p.m., the dietary manager stated the ceiling damage was there when they started working and they did not know when or how the damage occurred. On 05/02/24 at 2:25 p.m., the DON stated cold foods should be served from the satellite kitchen by the kitchen staff to ensure food was served in a sanitary manner. On 05/02/24 at 2:30 p.m., the kitchen was observed with the administrator. The administrator stated the facility had a pipe burst in the ceiling one holiday and maintenance had made the necessary repairs for food service to continue. The administrator stated there had never been dedicated handwashing sinks in the main or satellite kitchens.

Based on record review and interview, the facility failed to provide residents binding arbitration agreements that: a. informed the resident or their representative of their right not to sign the agreement as a condition of admission or continued care; and b. does contains an explicit acknowledged by the resident or their representative that they understood the provisions of the agreement; and c. does not include the name of a second nursing facility, in which the resident does not reside or is aware of, in the agreement for two (#50 and #63) of two sampled resident reviewed for arbitration agreements. The facility SSD stated 60 residents that resided in the facility had signed binding arbitration agreement. Findings: A facility Binding Arbitration Agreements policy, dated 07/18/19, read in part, This facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility .When explaining the arbitration agreement, the facility shall: a. Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, this facility. b. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement. 1. Resident #50 was admitted to the facility on [DATE]. A review of the residents medical record found a digital copy of a binding arbitration agreement signed by the resident on 02/03/23. The agreement did not document the resident could be admitted to the facility without entering into the agreement and did not contain a statement the resident or their representative explicitly understood the provisions of the agreement. The document also contained in one paragraph the name of a second skilled nursing facility. 2. Resident #63 was admitted to the facility on [DATE]. A review of the resident medical record found a digital copy of a binding arbitration agreement signed by the resident on 03/21/24. The agreement did not document the resident could be admitted to the facility without entering into the agreement and did not contain a statement the resident or their representative explicitly understood the provisions of the agreement. The document also contained in one paragraph the name of a second skilled nursing facility. On 05/02/24 at 11:53 a.m., the SSD stated they understood a resident was not required to sign an arbitration agreement to be admitted and received services at the facility. They stated if a resident did not want to sign the agreement the SSD would make a note at the bottom of the agreement. They stated the binding arbitration agreement they facility used did not state a person could still be admitted and receive services if they did not enter into a binding arbitration agreement. They stated there was not a section of the agreement that stated the resident or their representative explicitly understood the provisions of the agreement. They stated they are unaware of a policy and procedure related to arbitration agreements at the facility. At 12:25 p.m. Resident #50 stated they did not recall signing a binding arbitration agreement when they were admitted and stated the facility staff gave them so much paperwork they did not know what they were signing. The resident had no knowledge of the second nursing facility included in the agreement. At 12:28 p.m., Resident #63 stated they did not know what a binding arbitration agreement was and could not recall if they had signed one. They stated they did not know of the second nursing facility included in the agreement. At 12:58 p.m., the Administrator stated the current owners of the facility did use binding arbitration agreements and had adopted the arbitration agreement form from the previous owners after the purchase of the facility. They stated that was the form they were using. They stated they understood the shortcomings of the agreement.

Based on observation, record review, and interview, the facility failed to assist a resident with their meal in a dignified manner for one (#10) of eight residents observed for dining. The DON identified three residents who required total assistance with meals. Findings: The facility's Assistance with Meals policy, documented that residents who could not feed themselves would be fed with attention to dignity. As examples, the policy documented not to stand over residents while assisting them with their meals and to keep interactions with other staff to a minimum while assisting residents with their meals. On 04/29/24 at 10:53 a.m., Resident #10 was reclined in a geri-chair, in the dining room. Facility staff stood beside the resident and assisted the resident with their meal. The staff member was heard to talk with various other staff members as they stood beside Resident #10. On 05/01/24 at 11:20 a.m., Resident #10 was reclined in a geri-chair, in the dining room. CNA #4 stood beside the resident and assisted the resident with their meal. The staff member was heard to talk with various other staff members as they stood beside Resident #10. On 05/02/24 at 1:09 p.m., CNA #4 stated when they assisted a resident with their meal, they placed a protective cover over the resident's clothing and sat in front of the resident to assist with the meal. CNA #4 stated they thought in was more sociable to sit while assisting a resident with their meal because you could talk with the resident. On 05/02/24 at 1:21 p.m., CNA #5 stated if they assisted a resident with their meal, they sat beside them. The CNA $5 stated when they sat beside the resident, they could have a more casual conversation with them. The CNA#5 stated if they were to stand while they assisted the resident, the act would feel clinical or as though they were looming over the resident. On 05/02/24 at 2:24 p.m., the DON stated they expected their staff to sit down to assist a resident with their meal.

Based on record review and interview, the facility failed to provide education about advance directives and provide an opportunity for a resident to have or decline an advance directive for one (#63) of 24 sampled residents reviewed for advance directives. A facility daily census report, dated 04/29/24, documented 73 residents resided at the facility. Findings: A review of Resident #63's EMR found any documentation of an advance directive. The EMR did contain an order for full code but no paperwork that it was discussed with the resident or a representative was found in the records. On 05/01/24 at 7:25 a.m., the ADON stated they had reviewed Resident #63's records and did not find documentation of an advance directive. They stated they did find a physician's order for full code status but not the paperwork that code status was discussed with the resident or a representative. On 05/01/24 at 7:59 a.m., the ADON stated the resident did not have an advance directive and there was no documentation in their records they were given education on advance directives or given the opportunity to accept or decline the creation of one.

Based on observation and interview, the facility failed to provide privacy for one (#44) of one resident observed to have a facility camera in their room. The DON identified there were two residents for which the facility had placed a camera in the residents' rooms. Findings: The comprehensive assessment, dated 01/20/24, documented the resident was severely impaired in cognition, experienced an acute change in mental status, and exhibited no behaviors such as wandering or rejection of care. The quarterly assessment, dated 04/10/24, documented the resident was severely impaired in cognition, experienced an acute change in mental status, and exhibited no behaviors such as wandering or rejection of care. On 04/29/24 at 09:30 a.m., Resident #44 was interviewed in their room while they were in bed. There was a camera positioned on the opposite wall from the resident's headboard and faced toward the bed. Resident #44 stated they had difficulty hearing. The resident responded to open ended questions, including questions regarding the use of a camera in their room, with inappropriate responses of yes or no. On 04/29/24 at 9:56 a.m., RN #1 stated Resident #44 had a camera in their room. There was a small portable monitor located on the top of the half wall which ran along the front of the nurses' station. RN #1 pressed a button on a small portable monitor and the screen depicted Resident #44 lying in their bed. The RN #1 stated the resident often fell when they transferred themselves to and from the bed to their wheelchair. The RN #1 stated the camera had been used at least since the first of the year when they had started working with the resident. 04/29/24 at 2:28 p.m., Resident #44 laying perpendicular in bed with legs stretched out and supported by seat of wheelchair. RN #1 performed an assessment on Resident #44. The camera was in the room, pointed toward the bed. On 04/29/24 at 2:30 p.m., the camera monitor was on the half wall in front of the nurses' station. The monitor laid on its back with the screen facing upward toward the ceiling. Other residents, visitors, and staff were observed to walk, propel, and/or stand within a few feet of the monitor. On 04/30/24 at 11:15 a.m., Resident #44 was in bed. The camera was on the wall, facing the bed. The monitor was on the half wall in front of the nurses' station with the screen facing toward the interior of the nurses' station. Other residents and staff were observed to walk, propel, and/or stand within a few feet of the monitor. On 04/30/24 at 2:40 p.m., Resident #44 was in bed. The camera was on the wall, facing the bed. The monitor was on the half wall in front of the nurses' station with the screen facing toward the ceiling. Other residents and staff were observed to walk, propel, and/or stand within a few feet of the monitor. On 05/01/24 at 10:25 a.m., Resident #44 was in bed. The camera was on the wall, facing the bed. The monitor was on the half wall in front of the nurses' station with the screen facing toward the interior of the nurses' station. Other residents and staff were observed to walk, propel, and/or stand within a few feet of the monitor. On 05/01/24 at 2:32 p.m., Resident #44 was in bed. The camera was on the wall, facing the bed. The monitor was on the half wall in front of the nurses' station with the screen facing toward the ceiling. Other residents and staff were observed to walk, propel, and/or stand within a few feet of the monitor. On 05/02/24 at 9:57 a.m., RN #2 stated they did not know of the camera until recently when they noticed it was on the wall. They stated when they had inquired about the camera, they were told it had been there for a few months. On 05/02/24 at 10:06 a.m., RN #1 stated the staff provided for privacy by pulling privacy curtains for the residents in a semi-private room and closing bedroom doors before providing resident care. The RN stated to provide privacy for Resident #44, they kept the monitor facing inward toward the nurses' station. The RN #1 stated the screen timed out after a minute or so but all you had to do was press a button on the monitor to view the screen again. On 05/02/24 at 10:49 a.m., the ADON stated the facility notified the Power of Attorney, family, or other responsible party for the resident of the use of the camera as a fall intervention. The ADON stated the care plan should document the use of the camera as a fall intervention. The ADON reviewed the clinical chart for Resident #44 and stated the resident was their own responsible party. They stated the resident's care plan did not address the use of a camera. The ADON stated there was no physician's order for the use of the camera and no documentation of when or why the camera was used. The ADON stated there was no documentation Resident #44 was notified or agreed to the use of a camera in their room. On 05/02/24 at 10:50 a.m., the DON stated the camera was used as a last ditch effort fall intervention before utilizing a private sitter. The DON stated the monitor was to be secluded in the nurses station or carried by a staff member in a manner to allow for privacy. The DON stated the use of a camera should be routinely reviewed for the appropriateness as a fall intervention. The DON stated the facility did not have a procedure for the use of a facility's camera in a resident's room. On 05/02/24 at 10:51 a.m., the administrator stated the facility did not have a policy or procedure for the facility's use of a camera in a resident's room.

Based on record review and interview, the facility failed to ensure the accuracy of a baseline care plan for one (#219) of two residents sampled for baseline care plan. The administrator reported the census was 73. Findings: An undated facility policy titled Care Plans-Baseline read in part, .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident . Resident #219 had diagnoses which included hypertension and anemia. A baseline care plan, dated 04/17/24, documented the resident had a pressure ulcer upon admission. An admission skin assessment, dated 04/17/24, documented the resident had normal skin with good elasticity and no new wounds. On 05/01/24 at 1:20 p.m., the ADON stated she was unaware the resident had any skin issues at admit. On 05/02/24 at 9:42 a.m., MDS coordinator #2 stated she was responsible for Resident #219's baseline care plan and the information regarding the pressure ulcer was inaccurate. On 05/02/24 at 1:20 p.m., the DON stated that they were ultimately responsible for ensuring the accuracy of baseline care plans.

Based on record review and interview, the facility failed to ensure the consulting pharmacist documented the correct dosage of a psychotropic medication on a request for dosage reduction for one (#11) of five residents whose clinical records were reviewed for unnecessary medications. The ADON identified 16 residents who received psychotropic medications. Findings: The physician's order, dated 05/11/23, documented the resident was to receive Zoloft 200 mg daily. The request for a gradual dose reduction, dated 06/17/23, documented the resident received Zoloft 100 mg daily. The physician's order, dated 06/26/23 was written on the pharmacist's request for gradual dose reduction and documented to decrease Zoloft to 50 mg daily. The physician's order, dated 07/13/23, documented the resident was to receive Zoloft 200 mg daily. On 05/02/24 at 9:42 a.m., the ADON stated the pharmacist documented an incorrect dosage on the request for gradual dose reduction and the physician may have based their decision to reduce the medication on the inaccurate dosage documented on the gradual dose reduction. The ADON stated the resident had gone to the hospital on 07/13/23 and returned to the facility the same day. The ADON stated it was about that time when the facility identified a problem with the floor nurses not reconciling or confirming the orders with the physician once a resident returned from the hospital. The ADON stated they were now responsible for entering new physician's orders.

Based on observation, record review, and interview, the facility failed to notify the physician of a wound for one (# 219) of one resident sampled for wounds. The ADON identified seven residents in the facility with wounds. Findings: An undated facility policy titled Change in a Resident's Condition or Status read in part, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the residents' medical/mental condition and/or status .The nurse will notify the residents' attending physician or physician on call when there has been a . need to alter the residents' medical treatment significantly . Resident #219 had diagnoses which included hypertension and anemia. An admission skin assessment, dated 04/17/24, documented the resident had normal skin with good elasticity and no new wounds. A nurse note, dated 04/28/24 at 5:42 pm, documented the resident had an open sore on their right buttocks. A review of Resident #219's medical record did not document the physician had been notified regarding the open area. On 05/01/24 at 9:40 am, LPN #1 stated they were aware of a spot on the resident's buttocks and that they had been treating it with barrier cream. They also stated they had not contacted the physician regarding the spot. On 05/01/24 at 9:54 am, an open area was observed on Resident #219's right buttock. On 05/01/24 at 9:55 am LPN #1 stated the area was bigger than it was the last time they saw it on 04/29/24. LPN #1 also stated she had not notified the physician on 04/29/24 because the area was not open. On 05/01/24 at 12:08 pm, the ADON stated their expectation is that anyone that notices an open area should report it immediately so the physician could be notified. On 05/02/24 at 1:20 pm the DON stated the physician should have been notified as soon as the wound was discovered.

Based on observation and interview, the facility failed to prevent a medication room door from being propped open by a chair and the medication room being open and unattended by appropriate staff. A facility daily census report, dated 04/29/24, documented 73 residents resided at the facility. Findings: The facility's Medication Labeling and Storage policy, dated 02/2023, read in part, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 04/30/24 at 6:51 a.m., the facility medication room door was found propped open with a chair and the medication room unattended. There were no staff members observed inside the room or in the hallways next to the room who may have been observing the room. Four locked medication carts were located in the medication room. Various types of resident medications were found in bins located on shelves around the medication room. No unsecured controlled medications were observed. On 04/30/24 at 6:55 a.m., LPN #1 entered the medication room. They stated they someone had used a chair to hold the door open but they did not know who. They stated they had not done so. They stated the medication room should never be left open and unattended. They stated a resident could have entered and taken medications which could have harmed them. On 04/30/24 at 7:29 a.m., LPN #2 stated they had left the medication room door propped open with a chair. They stated they were focused on a resident being sent to out to a hospital that they did not think about the door being left open. They stated they it was not something they would normally do. They stated they understood the consequences of leaving the medication room open and unattended could result in a resident or other person taking medications and harming themselves. On 04/30/24 at 7:56 a.m., the ADON stated a search of the medication room found no missing medication. On 04/30/24 at 8:45 a.m., the DON stated LPN #2 had been counseled about the leaving the medication room open. They stated that should have never occurred and the medicating room must be secured at all times.

Based on observation and interview, the facility failed to ensure the lint screens were cleared as recommended for three of three dryers observed in the laundry room. The administrator reported the facility census was 73. Findings: On 04/30/24 at 10:25 am, Laundry Employee #1 reported the sign on the dryer indicated the lint screen should be cleaned every 4 hours, but when they were busy, they only cleaned it every eight hours or so. On 04/30/24 at 10:25 am, signs were observed to be affixed to all three dryers in the laundry room, these signs stated the lint screens were to be cleaned every 4 hours. On 04/30/24 at 10:30 am Laundry Employee #1 was asked to remove the cover to expose the lint screen on one of the dryers. Once the cover was removed a considerable amount of lint was observed to be covering the screen. The employee stated they had not cleaned the lint screens today, but they assumed the screens had been cleaned yesterday. On 05/02/24 at 1:50 pm, the maintenance supervisor stated that laundry employees were responsible for cleaning the lint screen and maintenance staff were responsible for cleaning the lint around the fire box.

Based on record review and interview, the facility failed to prevent a nurse aide whose CPR certification did not include hands-on training and an in person skilled assessment, from providing chest compressions to a resident who was deemed by staff to require cardiopulmonary resuscitation for one (#1) of one sampled resident reviewed for quality of care. A midnight census report, dated [DATE], documented 72 residents resided in the facility. Findings: Resident #1 had diagnoses which included Cardiomyopathy, chronic congestive heart failure, atherosclerotic heart disease, and morbid obesity. A Emergency Procedure - Cardiopulmonary Resuscitation policy, revised date February 2018, read in part, .Preparation for Cardiopulmonary Resuscitation 1. Obtain and/or maintain [organization names withheld] certification in Basic Life Support (BLS/Cardiopulmonary Resuscitation (CPR) . A certificate of completion for CPR, dated [DATE], documented CNA #1's training was the online only version. A progress note, created date [DATE] at 10:40 p.m., documented on [DATE] at 8:00 p.m., Resident #1 had received cardiopulmonary resuscitation at the facility. On [DATE] at 10:52 a.m., RN #1 reported Resident #1 had required CPR. They stated they had told CNA #1 they needed to start CPR then departed to find assistance to transfer the resident from a recliner to the floor. They stated, another nurse called 911 and when they returned with assistance, they transferred the resident to the floor and began CPR. They stated they had not witnessed CNA #1 do any part of the CPR. At 1:18 p.m., CNA #2 stated they had witnessed CNA #1 doing CPR. They stated EMT's had taken over within five minutes of the resident having been placed on the floor but could not give the exact time. At 2:05 p.m., CNA #1 stated they had performed chest compression on Resident #1 while they were still in the recliner for a period of less than one minute. They stated it was very brief and they were uncertain of the time as they were not paying attention to a clock at the time. They stated the other staff returned quickly and transferred the resident to the floor and performed CPR. They stated that EMT's were on the scene in about five minutes from the time the resident was found without a pulse. On [DATE] at 11:27 a.m., the ADON stated they were unaware that CNA had performed chest compressions without the required training, and they would ensure all staff were certified correctly as required in their policy.

Based on record review, observation, and interview, the facility failed to ensure residents were free from physical restraints for one (#7) of three residents reviewed for physical restraints. The Resident Census and Conditions of Residents form documented 78 residents resided in the facility. Findings: Res #7 had diagnoses which included arthritis. An annual MDS, dated [DATE], documented Res #7 was moderately cognitively impaired, was independent with ADLs, and used a rollator walker for mobility. On 03/27/23 at 11:21 a.m., Res #7 was observed in bed with the bed pushed against the wall. A bed rail was raised on both sides of the head of the bed, and a single rail was raised in the middle of the bed on the side facing the middle of the room. Res #7 stated regarding the bed rails, I just climb over them. On 03/28/23 at 1:07 p.m., Res #7 was observed in bed with a bed rail raised at the head of the bed and middle of the bed facing the middle of the room. On 03/28/23 at 1:34 p.m., RA #2 stated she was unsure why Res #7 had bed rails, but possibly because she could get out of bed. RA #2 was then observed lowering both rails. On 03/28/23 at 1:50 p.m., RN #1 stated the side rails had always been there and she had never questioned their use. RN #1 stated there was no side rail assessment, physician order, or consent in Res #7's chart. On 03/28/23 at 2:24 p.m., the ADON stated Res #7 did not need side rails for positioning or mobility. She stated the bed rails were a restraint for Res #7.

Based on observation, interview, and record review it was determined the facility failed to ensure required supervision to prevent a resident from acquiring a fracture during a transfer for one (#7) of three residents reviewed for accident hazards. The DON identified 46 residents who required physical assistance with transfers. Findings: A lifting policy, dated 09/2015, documented the purpose of the policy was to protect the health of the residents during the transferring of residents. The policy documented that the resident would be placed into one of four lifting categories. One, being those that required a two person assist with no mechanical lift needed. It further documented, the requirement for each resident would be placed on the daily assignment sheet and residents would be transferred using the appropriate method, without exceptions. A quarterly assessment, dated 11/02/19, documented the resident required extensive assistance and a two person physical assist with transfers. It documented the resident required extensive assistance and a two person physical assist for toilet use. A daily assignment sheet, dated 12/13/19, documented two RN's, one LPN, two CMA's, and six CNA's were on duty on the 3:00 p.m. to 11:00 p.m. shift. The assignment sheet also indicated the daily census was 77. A nurse note, dated 12/13/19 at 9:28 p.m., documented the resident had complained of left knee pain following a transfer to the toilet. A nurse note, dated 12/14/19 at 9:20 a.m., documented a mobile x-ray company employee had arrived to take two views of the resident's left knee. A radiology report, dated 12/14/19, documented x-rays of the left knee found, .an acute complete [MEDICATION NAME] femur just superior to the prosthesis with medial and posterior displacement of the distal fracture fragment . A nurse note, with an effective date of 12/14/19 at 10:45 a.m. and a created date of 12/15/19 at 7:18 a.m., documented the resident's physician had been notified of the left knee x-ray results, that the resident was transferred to an acute care hospital, and the resident's family member had been notified. An investigation statement, dated 12/16/19 at 10:30 a.m., and written by CNA #1 documented, the resident requested CNA #1 to assist her to the toilet. CNA #1 stated she assisted the resident to a wheelchair and took the resident into the restroom. There, the CNA assisted the resident to a standing position using a, bear hug while facing the resident. The resident was standing independently while using both hands to grasp a bar when the CNA documented the resident's legs buckled and began to move toward the floor. The CNA then standing behind the resident grabbed the resident by her pants pulling her up and onto the toilet. The CNA's account then stated the resident was moaning in pain and indicating the pain was coming from her left knee. The statement documented the CNA then transferred the resident again from the toilet to the wheelchair and left the resident to find a nurse. An undated incident report (ODH form 283), documented on 12/13/19 at 6:30 p.m., CNA #1 had assisted the resident to a toilet using a grab bar. The form further documented CNA #1 had admitted to, bear hugging the resident during the transfer. The form documented CNA #1's employment was terminated on 12/17/19, for not following protocols for safe resident transfer. A medical discharge summary, dated 12/23/19 at 9:36 a.m., documented the resident was admitted to a community acute care hospital on [DATE], with a [DIAGNOSES REDACTED]. It further documented the resident was discharged back to the facility on [DATE], with a discharge [DIAGNOSES REDACTED]. On 01/16/20 at 12:20 p.m., the administrator was asked if he was aware of a resident having suffered a fracture during a transfer in the past 3 months. He stated (resident #7) had in December 2019. He was asked what had occurred. He stated CNA #1 had transferred the resident without assistance and it was during that transfer the resident complained of pain and later x-rays identified a fracture. He was asked if he discovered why CNA #1 had transferred the resident alone. He stated, that during the facility investigation of the incident, CNA #1 stated she did not want to wait for help. He was asked if CNA #1 was available for an interview. He stated the employee was terminated for her actions during that transfer. He was asked if CNA #1 had a history of [REDACTED]. At 12:51 p.m., the employment and training records for CNA #1 were reviewed. The records indicated the employee had an active certification as a nurse aide at the time of employment and received the required training at the facility to perform her duties, including transfers. On 01/21/19 at 9:05 a.m., the DON was informed that an incident that had occurred in the care of resident #7 on 12/13/19 was deemed to reach the level of actual harm. The DON was asked to provide any documentation of the steps that had been taken by the facility to correct the deficient state. The following documentation was presented and reviewed: documentation that OSDH was notified of the incident in a timely manner; documentation of QAPI committee involvement and monitoring; documentation of training and monitoring related to transferring residents by the PT coordinator, the DON, and ADON; documentation of the investigation of the incident; and documentation that CNA #1's employment was terminated and she was reported to her certifying board. At 1:00 p.m., the physical therapist coordinator was interviewed. He was asked what part he had played in staff training following the resident's improper transfer and subsequent injury. He stated, immediately after the fall, he began to train each staff member (who transferred residents) on proper transferring techniques. He stated, he had the initial training with those individuals and now he and the DON would monitor staff during their shifts, and select random individuals weekly, so they could demonstrate a transfer. He stated, the monitoring would continue for at least 3 months and they would also conduct in-services more frequently in the future.

Based on observation, record review, and interview it was determined the facility failed to maintain the nutritional status for four (#1, 2, 4, and #5) of 5 sampled residents who experienced a severe weight loss. This resulted in actual harm when residents #1, #2, and #4 had developed new or worsening pressure ulcers. The facility identified 10 residents with significant weight loss. Findings: A weight assessment and intervention policy documented, "The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss...Any weight change of 5% or more since the last weight assessment will be retaken immediately and the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing...The physician and multidisciplinary team will identify conditions and medications that may cause anorexia, weight loss or increasing the risk of weight loss...cognitive or functional decline...environmental factors...inadequate availability of food or fluids...Interventions for undesirable weight loss shall be based on careful consideration of the following: Resident choice and preferences...nutrition and hydration needs...functional factors that may inhibit independent eating...environmental factors that may inhibit appetite or desire to participate in meals...the use of supplementation..." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The facility's weight records documented the following weights: [DATE] - 150.6 pounds [DATE] - 147.0 pounds [DATE] - 144.0 pounds [DATE] - 138.4 pounds [DATE]- 138.0 pounds [DATE] - 134.4 pounds [DATE] - 127.0 pounds [DATE] - 118.8 pounds [DATE] - 105.6 pounds February 2014 - 105.0 pounds This was a severe weight loss. A weight loss care plan, dated [DATE], and reviewed on [DATE], documented, "...Focus: I have had actual wt loss due to I don't always eat at every meal...Goals: I will not have complications from wt loss...Interventions: assit (sic) me to eat when showing signs and symptoms of fatigue...Dietician to monitor monthly and PRN...If my weight decline persists, contact physician and dietician...offer substitutes as indicated..." There were no new interventions to prevent further weight loss. A dietary progress note, dated [DATE], documented, "Aug wt 138.4# Sig wt loss 8.10% 3 mos, 10.13% 6 mos. Res eats in the D.R. @ brunch/dinner. Feeds self, per dietary mgr. would benefit from assist c meals..." The weight loss care plan did not address the resident's weight loss and the need for assistance with meals. There were no new interventions to prevent further weight loss. A pressure ulcer care plan, dated [DATE], documented, "Focus: I have pressure ulcer's R/T disease process, immobility...Goals: My pressure ulcer's will show signs of healing and remain free from infection through review date...Interventions: ...EATING: Monitor nutritional status. Serve diet as ordered, monitor intake and record...I require supplemental protein, vitamins, minerals as ordered to promote wound healing..." A dietary progress note, dated [DATE], documented, "Current skin assessment - stg I R heel 1.6 x 1; skin not open; L heel- blister 3.2 x 5.3, buttocks .1 x. 1 cm R inner buttock...With respect to dietary needs; Rec: 1) Decubivite daily, Vit C 500 mg daily; [MEDICATION NAME]/Juven BID; 2) Rec 1 svg prune juice q A.M. (secondary) chronic constipation. Rec weekly wts x 4 weeks. 3) Rec 1 addl svg Pro q meal, ie - ensure - fortified juice, 1 egg, 1 extra svg meat..." Review of the clinical record revealed no documentation to show the resident was provided the additional serving of protein every meal, as recommended by the dietician. The weight loss care plan had not been updated to include the dietician's recommendations or the pressure ulcers. There were no new interventions to prevent further weight loss. A quarterly assessment, dated [DATE], documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had altered levels of consciousness that fluctuated and the resident required limited assistance with one person physical assist for eating and extensive assistance to total dependence with transferring, bathing, bed mobility, locomotion on and off the unit, dressing and toilet use. The assessment documented the resident weighed 131 pounds with no loss of 5% or more in the last month or loss of 10% or more in the last six months. A physician's orders [REDACTED]...1 additional serving of protein every meal..." A dietary progress note, dated [DATE], documented, "Annual nutrition risk assessment completed. Res @ high nutrition risk secondary to sig. wt. loss...Res feeds self in dining room with supervision and at times requires assistance. Res is offered Ensure when PO intake is not adq. Per conversation with nursing, res enjoys sweets. Consider pouring pancake syrup on food on occasion to encourage better PO intake..XXX[DATE] wt. 138; [DATE] 130.6# Sig. wt. loss 5.64% x 1 mos, 11.16% x 3 mos, 14.08% x 6 mos." No changes had been made to the weight loss care plan. A dietary progress note, dated [DATE], documented, "Oct wt. 134.4# wt. up 3.8# x 1 mos. Sig. wt. loss 10.04% x 6 mos...Diet order continues as Regular. Cont. current interventions. A dietary progress note, dated [DATE], documented, "Sig. wt. loss 5.51% x 1 mos, 8.24% x 3 mos, 15.67% x 6 mos...Receives extra svg protein q meal...Offer high calorie snacks throughout the day; ie. health shakes/Ensure/Magic Cups/Ice cream for addl cal/protein..." Meal intake records, dated [DATE] through [DATE] documented out of 88 meals and 60 snacks, the resident consumed the following: ~refused - 17 meals and 30 snacks; ~0 - 25% - 1 meal and 1 snack; ~26 -50% -8 meals and 0 snacks; ~51 - 75% - 19 meals and 2 snacks; ~76 -100% - 35 meals and 24 snacks. A weekly pressure ulcer report dated [DATE], documented, "...L heel 1 x 2...treatment: pad c 4 x4..." A weekly pressure ulcer report dated [DATE], documented, "...L heel 1.5 x 2.5...treatment: skin prep foam pad...R heel 4 x 3...treatment: skin prep, foam pad..." No changes had been made to the weight loss care plan. An annual assessment, dated [DATE], documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident had delusions, rejection of care occurred one to three days, required limited assistance with one person physical assist for eating, and required extensive assistance to total dependence with transferring, bathing, bed mobility, locomotion on and off the unit, dressing and toilet use. The assessment documented the resident weighed 119 pounds and had a loss of 5% or more in the last month or loss of 10% or more in last six months. A weekly pressure ulcer report, dated [DATE], documented, "...L heel 2 x 3.5 x 0.1...treatment: foam pad, skin prep...R heel 4 x 4...treatment: Skin prep, foam pad..." A physician's orders [REDACTED]. Meal intake records, dated [DATE] through [DATE] documented out of 60 snacks, the resident consumed the following: ~refused - 32 snacks; ~0 - 25% - 1 snack; ~26 -50% - 0 snacks; ~51 - 75% - 2 snacks; ~76 -100% - 11 snacks. A dietary progress note, dated [DATE], documented, "Sig. wt. loss 6.46% x 1 mos, 9.04% x 3 mos, 19.18% x 6 mos. PO intake fluctuates from refusals to 100% per meal intake documentation. Res will fluctuate from feeding self independently to requiring extensive assist @ meals. Alternates are offered. PO intake is encouraged. REC: weekly wts. x 4 weeks. Cont. to monitor...Dec. wt. 118.8#..." A weekly pressure ulcer report, dated [DATE], documented, "...L heel 1.5 x 2.5 x 0.1...treatment: [MEDICATION NAME], foam pad...R heel 4 x 4...treatment: Skin prep, foam pad..." No changes had been made to the weight loss care plan. A dietary progress note, dated [DATE], documented, "Jan wt. 105.6# Sig. wt. loss 11.11% x 1 mos, 21.43% x 3 mos, 26.67% x 6 mos. PO intake fluctuates from refusals to 75%. Diet order continues as regular with health shake q meal. High calorie snacks are offered TID secondary to wt. loss. Interventions to aid wound healing in place..." Meal intake records, dated [DATE] through [DATE] documented out of 90 meals and 60 snacks, the resident consumed the following: ~refused - 14 meals and 19 snacks; ~0 - 25% - 12 meals and 1 snack; ~26 -50% - 9 meals and 0 snacks; ~51 - 75% - 19 meals and 9 snacks; ~76 -100% - 15 meals and 16 snacks. A weekly pressure ulcer report dated [DATE], documented, "...L heel 1.3 x 2.1...treatment: [MEDICATION NAME] foam...R heel 0.5 x 0.7...treatment: [MEDICATION NAME], foam..." A weekly pressure ulcer report, dated [DATE], documented, "...L heel 1.3 x 2.0...treatment: hydrogel...R heel 0.4 x 0.5...treatment surprep...L buttock stage I 0.2 x 0.1...treatment: [MEDICATION NAME]" A weekly pressure ulcer report, dated [DATE], documented, "...L buttock stage II 1.6 x 1.4...treatment: [MEDICATION NAME] heel 0 x 0...treatment: sureprep...L heel 2.1 x 2.0...treatment: hydrogel." A dietary progress note, dated [DATE], documented, "Feb wt. 105# Sig. wt. loss 17.32% x 3 mos, 24.13% x 6 mos. PO intake fluctuates from refusals to 100%. Res feeding ability ranges from independent with supervision to total dependence...Dietary interventions in place..." No changes had been made to the weight loss care plan. On [DATE] at 11:05 a.m., the resident was observed sitting at the dining room table with CNA #1 sitting next to her assisting with feeding her brunch. A dietary aide brought the resident a health shake to the table during the meal service. The CNA offered the resident the health shake and the resident turned her head and did not take a drink. The resident was observed picking up grapes from her bowl and placing them in her mouth. At 11:21 a.m., CNA #2 sat down at the table and offered the resident a bite of food. The resident ate approximately 50% of her meal. She removed the plate and left the grapes and health shake on the table. The resident continued sitting at the table and did not attempt to drink the health shake. The CNA offered the resident a drink of her health shake. The resident took a small sip. CNA #2 then assisted the resident out of the dining room and wheeled her to her room. She placed the resident in front of her television and placed her health shake and water container on the table across the room from the resident. At 2:00 p.m., the resident was observed sitting in her recliner with her feet propped up. Her water container was sitting next to her on the table. No snack was observed in her room. At 5:10 p.m., the DON was asked if the resident was not drinking her health shakes with the protein powder added, was she receiving her additional protein as ordered. She stated "No." She was asked if the staff had followed the dietician's recommendation of pouring pancake syrup on the resident's food. She stated they had tried, but it only helped for one day. She was asked if they offered finger foods in addition to what was served at meals. She stated, "No, I haven't thought about that." During the two days of the survey the resident was observed at random times being taken to the dining room for brunch and being assisted during the meals. The resident was not observed being offered finger foods, health shakes, or high calorie snacks when the resident was in her room or during times meals were not offered. The DON was asked if she knew why the health shake or high calorie snacks were not on the care plan. She stated, "No." She was asked if the resident had experienced any skin breakdown. She stated, "Only on her buttocks and heels." At 5:40 p.m., the care plan coordinator was asked how she was informed of new interventions or changes that needed to be made to care plans. She stated, "Normally the orders and dietary recommendations come to us. I may have missed it." She was asked why the weight loss care plan was not updated with the new interventions the dietician had recommended. She stated, "I wasn't aware new interventions were ordered for her." On [DATE] at 11:20 a.m., the dietary manager was asked what high calorie snacks were offered to the resident. She stated, "Peanut butter sandwiches, some kind of sweet snack such as brownies, cookies, and occasionally ice cream." She was asked when the resident was offered the high calorie snacks. She stated that the snacks were passed out at 2:00 p.m. and 8:00 p.m. She was asked when the resident received her third snack each day as ordered by the physician. She stated they provided a continental breakfast in the mornings. The dietary manager was asked if the resident did not wake up for the continental breakfast when was the third snack given. She stated she did not know when the staff offered the third snack. She was asked when the health shakes were started. She stated, "They were started when the extra protein was ordered. We find it is easier to use protein powder in the shakes for residents who don't like to eat." She was asked if she was aware the resident was not drinking her health shakes with the protein powder added. She stated, "Yes." The dietary manager was asked if the dietician was aware the resident was not drinking her health shakes with the protein powder added. She stated, "I'm not sure." At 11:26 a.m., CNA #5 was asked if the resident would drink her health shakes with the protein powder mixed in. She stated, "Sometimes, it depends on her mood." At 11:30 a.m., RN #1 was asked if the resident would eat the high calorie snacks. He stated, "Not very well." He was asked if the resident would drink her health shakes with the protein powder mixed in. He stated, "Not the whole thing, ,[DATE]% on a good day and most days she won't drink it at all." He was asked if the resident had any skin breakdown. He stated, "Her left heel, but it's getting better. Her left buttock is fairly new. It started opening up last week." At 2:24 p.m., the dietician was asked if she was aware the resident was not drinking her health shakes that the extra protein powder was being added to. She stated, "No, I was not fully aware." 2. Resident #2 was admitted with [DIAGNOSES REDACTED]. The facility weight loss records documented the following weights: [DATE] - 165.5 pounds [DATE] - 165 pounds [DATE] - 162.5 pounds [DATE] - 151.5 pounds [DATE] - 140.5 pounds February 2014 - 136.5 pounds This was a severe weight loss. A weight loss care plan, dated [DATE], documented,"...Focus: I have had actual wt loss. Goals: I will have no complication with weight...Interventions: Enc. me to eat at siesta snack time for added cal/pro intake...Offer me supplement if eat 50% or less of any meal. Serve me a regular diet and record amt eaten at each meal and snack time. Weight as ordered by physician." The skin care plan, dated [DATE], documented, "Focus: I have actual skin impairment to my heels. Goals: I will not have complications from pressure areas on my heels....Interventions: ...Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin PRN. Provide peri-care with every incontinent episode as needed...Skin assessment weekly...Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface..." A dietary progress note, dated [DATE], documented, "September wt. 165.5# Sig.wt gain 5.75 % x 1 mos. Wt has fluctuated between 155 and 166 x 12 mos. PO intake ,[DATE]%. Res feeds self with supervision. Diet order continues as Regular. No skin breakdown noted. Cont. current POC." There were no dietary progress notes for the months of [DATE] and [DATE]. A weekly pressure ulcer report, dated [DATE], documented, "...L heel .2 x 6 centimeters...treatment: Duo-Derm Gel...foam dressing...L heel blister...R heel .3 x .4 centimeters...Duo-Derm Gel...foam dressing. A weekly pressure ulcer report, dated [DATE], L heel, 1 x 4 centimeters, serous drainage, R heel, 1 x 4 and 1 x 3 ulcers... clean, apply duo-derm gel with foam dressing to both heels. The weight loss care plan had not been up dated to address the weight loss and pressure ulcers. A weekly pressure ulcer report, dated [DATE], documented, R heel, 2 x 2.5 centimeters, L heel, 6 x 5 centimeters, L heel ...eschar area 3.5 x 4 centimeters, small serous drainage, clean with normal saline and apply duoderm gel and foam dressing, float heels...wrap with kerlix and secure with tape The pressure ulcer care plan had not been updated to address the increased size of the pressure ulcers...dressing changes, floating the heels or nutritional interventions to aide in wound healing. A dietary progress note, dated [DATE], documented, "Sig. wt. loss of 6.77% x 1 mos, 8.46% x 3 mos. PO intake is poor. Diet order continues to be Regular textured. Res continues to feed self with limited assistance with meals. Res has wounds to BL heels...REC: 1) Offer Ensure Plus TID for 350 cal, 13 gm Protein 3 x daily for a total of 1050 cal, 39 gms Protein. 2) Rec weekly wts x 4 weeks. Cont to monitor wt status et wound healing." The weight loss care plan did not address the weight loss or the dietician's recommendations. There were no new interventions to prevent further weight loss. A weekly pressure ulcer report, dated [DATE], documented L heel, 5 x 8 centimeter, 85% eschar, interventions Santyl 4 x 4 wrap with Kerlix. R heel, 3 x 3 centimeter, eschar, Sure prep with Foam wrap with Kerlix. A weekly pressure ulcer report, dated [DATE], documented R heel 1.5 x 1.8 ...black eschar..treatment Sure Prep..interventions float heels. L heel outer,stage III...0.5 x 0.5, L center heel, stage III, 3 x 2.8 centimeters, L largest, Stage III, 2.2 x 6 centimeters, coccyx 0.5 x 2.8 centimeters...L buttocks 2 x 8 centimeters...pink in color, [MEDICATION NAME]. A dietary progress note, dated [DATE], documented weight 140.5 #, sig.wt loss 7.26% x 1 mos, 14.85% x 3 mos, 15.62% x 6 mos. Wounds cont to be treated, interventions... Decubivite...offer health shake TID with meals... The weight loss care plan did not address the weight loss, the dietician's recommendations or the stage III pressure ulcers to the left heel. There were no new interventions to prevent further weight loss. A weekly pressure ulcer report, dated [DATE], documented R heel 1.5 x 1.5 centimeter, L heel 6 x 9 centimeters, eschar, intervention Sure Prep and foam dressing and kerlix. Santyl 4 x 4's kerlix, [MEDICATION NAME] and Band-Aid. A significant change assessment, dated [DATE], documented the resident had a BIMS score of 1. This score indicated the named resident was severely impaired with daily decision making. The assessment documented the resident required extensive assistance of one person with activities of daily living. The assessment documented the resident weighed 139 pounds. The assessment documented the resident had 1 unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar ulcers. A dietary progress note, dated [DATE], documented, the resident had a 16.00 % weight loss the past three months, from [DATE] through [DATE]. Regular diet continued to be served. Resident required extensive assistance with meals. Recommended to offer health shakes TID with meals. The weight loss care plan did not address the weight loss, the stage III pressure ulcers to the left heel or any of the dietician's recommendations. On [DATE], at 11:27 a.m., CNA#4 was observed feeding the resident a bottle of ensure supplement. The weight loss care plan was updated on [DATE], to assist the resident to eat when showing signs of fatigue. At 3:50 p.m., CNA#3 was asked if there had been a significant change with the resident. She stated, "Yes, she used to be up moving around in wheelchair. She has heel breakdown." She was asked, if she knew what was being done for her weight loss. She stated, "She is offered ensure and healthy shakes about every two hours, sometimes she will drink it, but not always." At 4:05 p.m., LPN# 1 was asked, if the resident had a significant change. She stated, "She appears to be declining, doesn't eat well, was eating pretty good and all of a sudden she stopped. She takes ensure and milk well. At 4:25 p.m., the DON was interviewed. She was asked, if she knew why the resident had declined. She stated, "No, she just doesn't want to get up and needs more help." At 5:40 p.m., the care plan coordinator was asked how she was informed of new orders. She stated, "Orders come to us from dietary or staff will let me know." She was asked if she knew why the resident had a significant weight loss. She stated, "I didn't know there was a weight loss with her." She was asked why the weight loss care plan was not updated with the new interventions the dietician had recommended. She stated, "I wasn't aware new interventions were ordered." 3. Resident #4 was admitted with a [DIAGNOSES REDACTED]. The facility weight loss record, documented the following weights: [DATE] 192.5 pounds [DATE] 184 pounds [DATE] 185.5 pounds [DATE] 174 pounds February 2014 153 pounds This was a severe weight loss. A dietary progress note, dated [DATE], documented, "...Current diet order is Full Liquid, PO intake ,[DATE]%. Res feeds self independently with some supervision. Cont. to monitor wt status..." The weight loss care plan, dated [DATE], addressed potential for nutritional problem. Interventions were to follow the diet as ordered by the physician, provide supplements as ordered by the physician and weigh the resident as ordered by the physician. A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 15. This score indicated the resident was independent with cognitive skills for daily decision making. The assessment documented the resident weighed 193 pounds. A dietary progress note, dated, [DATE], Jan wt. 174# sig. wt. loss 6.20% x 1 mos, 9.61% x 3 mos...offer health shake TID with meals secondary to wt. loss. Weekly wt's x 4 weeks. The potential nutritional problem care plan did not address the resident had experienced a 11.5 pound weight loss (9.61%) in three months from [DATE] through [DATE]. The weight loss care plan did not address the resident had experience an 11.5 # weight loss in one month. The weight loss care plan had not been updated to include dietician's recommendation to offer health shakes and record weekly weights x 4 weeks. There were no new interventions to prevent further weight loss. Weekly pressure ulcer report, dated [DATE], documented, pressure ulcers, on right buttocks 3 x 0.5 centimeters, 2 x 0.1 centimeters on right buttocks, no drainage, on left buttocks 3 x 1 centimeters, no drainage, and right heel 5 x 4 centimeters, unstageable. Hydrogel/abd pad to buttocks. Sureprep BID/float heels. Weekly pressure ulcer report, dated [DATE], documented, Stage 2, 1 cm x 2 cm, clean with N/S, apply hydrogel, to coccyx, Cover with ABD or Foam dressing. R heel 2 x 2.5 cm, unstageable, sure prep, float heels. Dietary progress note, dated [DATE], documented Feb weight at 153 pounds, sig. wt loss (12.07%) weight loss x 1 mos, (16.85 %) x 3 mos...res requires some assist at meals. Wounds to buttocks, L heel continue to be tx'd, Resident continues to receive Ensure QID with 2 scoops of protein in each serving. Continues to receive Decubivite to aid wound healing. Consider appetite stimulant secondary to wt. loss, wounds, and po intake. Rec weekly wt's x 4 weeks. The weight loss care plan did not address the resident had experienced a 21# weight loss in one month. The weight loss care plan had not been updated to include dietician's recommendations to offer health shakes and record weekly weights x 4 weeks. Ensure QID with 2 scoops of protein in each serving. Continue to receive decubivite to aid wound healing. Consider appetite stimulate. There were no new interventions to prevent further weight loss. The potential for skin impairment care plan did not address the development of new pressure ulcers to the R buttocks and R heel, or no new nutritional interventions to aide in wound healing. On [DATE], at 12:03, LPN #3, was observed returning the resident's lunch tray to the dietary cart, the resident had eaten approximately ,[DATE] of the beans and ,[DATE] glass of tea. Resident's full glass of protein shake with plastic still on cup was on the tray. At 12:07 p.m. CNA #6, was observed, returning to the resident's room with the protein shake. She assisted the resident, he drank 100% of his protein shake. At 4:28 p.m. the Care plan coordinator was asked if she was aware that the resident had three pressure ulcers. She stated, there was only one and would check. She reported back that the resident had only one pressure ulcer, 3 x 1 centimeter, at a stage III and stated, "The documentation is wrong and I don't know why." At 4:45 p.m., the resident was asked how he liked the food. He stated, "It ain't bad." He was asked, if he wanted to eat. He stated, "No." He was asked, if the health shake tasted good. He stated, "Yeah." At 5:00 p.m., the DON was asked if she knew why the resident was losing weight. She stated, "He got really depressed." She was asked, why the resident was depressed. She stated, "He was told that he wouldn't get better; he thought he was going home, his wife died , and then took his dog from him." She stated, "he went to a really dark place, depressed, put him on some anti-depressants." 4. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The facility's weight records documented the following weights: [DATE] 178.6 pounds [DATE] 178.3 pounds [DATE] 174.4 pounds [DATE] 173.8 pounds [DATE] 167.4 pounds [DATE] 162.4 pounds February 2014 149.0 pounds This was a severe weight loss. A care plan, dated [DATE], documented, "Focus: I have the potential for weight loss or gain related to my disease process and impaired mobility...Goals: I will not have more than 5% weight loss or gain through this review period...Interventions: Assist me to meals as needed or allow me to eat in my room as I request...Labs as ordered by my physician...Medications as ordered by my physician...Regular diet...weights as ordered..." A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact. The assessment documented the resident exhibited no behaviors and required setup only for eating. The assessment documented the resident weighed 174 and had not experienced a loss of 5% or more in the last month or loss of 10% or more in last 6 months. A dietary progress note, dated [DATE], documented, "Diet order is regular. Res. eats in room and consumes 76%-100% of meal...Dec. wt 167.4 lb down 3.68% (6.4#) 30 days...down 6.11% (10.9#) 90 days...down 6.48% (11.6#) 180 days..." A meal percentage sheet, dated [DATE], documented out of 69 meals the resident refused to eat 44 meals. A nurse's note, dated [DATE], documented, "...Offered pt. pre-packaged food secondary to her being paranoid re: being poisoned and she stated, 'I don't need it because I have a food pump'..." A discharge assessment, dated [DATE], documented the resident was independent with cognitive skills for daily decision making. The assessment documented the resident experienced fluctuated disorganized thinking, physical behavioral symptoms directed toward others 4 to 6 days, but less than daily, verbal behavioral symptoms directed toward others daily, and rejection of care daily. The assessment documented the resident's weight was 162 and had experienced an unplanned loss of 5% or more in one month or loss of 10% or more in last 6 months. There was no dietary progress note documented for the month of [DATE]. The weight loss care plan had not been updated to include the resident's refusal to eat 44 of 69 meals, the resident's paranoia of her food being poisoned or new interventions to prevent further weight loss. A dietician's note, dated [DATE], documented, "Feb wt. 149# sig. wt loss 8.25% x 1 mos, 14.27% x 3 mos, 16.57% x 6 mos. PO intake is fair. Res fluctuates from eating independently to requiring limited assistance to refusal of meals. REC: weekly wts x 4 weeks. Offer health shakes TID with meals..." The weight loss care plan had not been updated to include the resident had experienced a weight loss of 13.4 pounds in one month from [DATE] through February 2014, 24.8 pounds in 3 months from [DATE] through February 2014, 29.6 pounds in 6 months from [DATE] through February 2014, and to offer health shakes three times a day with meals. On [DATE] at 4:07 p.m., the resident was asked why she had gone to the hospital in January. She stated, "I don't know why. They sent me for my depression I think." At 4:28 p.m., the DON was asked if she knew why the dietician had not written a monthly note for [DATE]. She stated, "Her scheduled visit may have been while the resident was in (geri-psych hospital)." She was asked why the resident had been sent out to (geri-psych hospital). She stated, "Because she is [MEDICAL CONDITION] and she was paranoid she thought her food was poisoned." The care plan coordinator was asked why the health shakes three times a day with meals was not on the care plan. She stated, "I have not seen the orders on that." She was asked if the care plan should have been updated to include the weight loss and the health shakes. She stated, "Yes."