**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their pressure ulcer and wound care policies/procedures by failing to ensure Resident #3's wound care Physician's orders were initiated when ordered, and Registered Dietician's (RD) recommendations were promptly followed. The facility also failed to promptly identify, assess, document and notify the resident's Physician regarding the resident's pressure ulcers located on both feet/heels. In addition, the facility failed to ensure Resident #2, who was admitted on [DATE], with a pressure ulcer on the coccyx (the tailbone), had a treatment order in place until 7/1/24, failed to ensure a nurse contacted the physician for a treatment order prior to administering a treatment to the coccyx, failed to ensure the wound care Physician's orders were initiated and the RD's recommendations were promptly followed. The facility identified two residents with pressure ulcers and problems were found with both. The census was 57. Review of the facility Wound Management Program policy dated November 2022, showed: -Policy: It is the policy of this facility to manage resident skin integrity through prevention, assessment, and implementation and evaluation of interventions; -Procedure: 1. The facility is provided with wound care protocols. These are to be utilized to assist in the care and treatment of wounds. Physician orders should be obtained and followed for each resident; 2. The Braden Scale (an assessment used to determine a resident's risk of developing a pressure ulcer (an injury that breaks down the skin and underlying tissue)) will be completed on admission weekly for four weeks post admission and quarterly thereafter to assess skin breakdown risk; 3. Residents identified at risk on the Braden Scale will have this addressed on their care plan and will have interventions put in place for preventative measure. Interventions: pressure reducing mattress and/or cushion, be reviewed by a Dietician and lab values as needed. Resident's identified with wounds will have a care plan initiated regarding impaired skin integrity; 4. The facility will assess residents weekly for current skin conditions; a. The charge nurse for each hall will do skin assessments; b. The skin assessment will be documented on the Weekly Skin Assessment, which is completed as follows: i. Observe the skin for the following: 1. Open areas; 2. Redness; 3. Rashes; 4. Discolored areas; ii. Indicate the location of any identified areas on the body figure; iii. Describe the area(s); c. If any new areas are identified, write a nurse's note describing the area found and the protocol followed to treat it. The new area should also be noted on the 24 Hour Report; d. The nurse will measure the area, call the physician to obtain appropriate treatment order, call the guardian/family member, document the area on the POS (physician's order sheet), and initiate the treatment; 5. The Skin Assessment should be also completed whenever a new skin condition is noted; 6. All wounds will be reported weekly on the Wound Report; 7. It is important that wounds are assessed correctly to differentiate between pressure and non pressure wounds; 8. It is the responsibility of the Administrator to review the Wound Report weekly; 9. Interdisciplinary team meetings will be held weekly. The committee should include at a minimum the nurse responsible for treatments, representative from therapy, Director of Nursing (DON), and representative from dietary; 10. During the meeting, the Wound Report will be reviewed to assess the progress of the residents. Any wounds designated as not improving should be discussed further in the meeting. Review of the facility Dressings, Dry/Clean policy, dated January 2018, included: -Verify that there is a physician's order for this procedure; -Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs; -Check the treatment record; -Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the dressing was changed; 2. Wound appearance, including wound bed, edges, presence of drainage; 3. The name and title of the individual changing the dressing; 4. The type of dressing used and wound care given; 5. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; 9. The signature and title of the person recording the data; -Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #3's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/24, showed: -Severe cognitive impairment; -No functional limitations of the upper/lower extremities; -Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity for: Toileting, shower/bathe, lower body dressing, putting on/taking off footwear, and personal hygiene; -Substantial/maximal assistance - Helper does more than half the effort required to: Roll left and right, sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, and toilet transfer; -Always incontinent of urine and bowel; -Diagnoses of anemia (the capacity of the blood to carry oxygen is reduced), and diabetes mellitus (high blood sugar); -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcers: No; -Hospice care. Review of the resident's Braden Scale dated 5/19/24, showed the resident was at moderate risk to develop pressure ulcers. Review of the resident's progress notes, located in the electronic healthcare record (EHR), showed: -5/19/24 at 10:19 A.M., Stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). May also present as an intact or open/ruptured blister) on coccyx. 4.0 centimeters (cm) (height) x 4.5 cm (width) x 1.0 cm (depth) reported to on-call Physician. Received new order to cleanse with wound cleanser, apply Medihoney (a medical grade honey used for wound care), optifoam every three days and PRN (as necessary); -5/22/24 at 1:02 P.M. and documented by the RD, quarterly note. New onset pressure ulcer on coccyx. Appropriate to consider addition of vitamin/protein supplementation. Currently on no added sodium/salt (NAS), low concentrated sweets (LCS) diet. Appropriate to consider liberalizing diet due to wishes for comfort. Recommend: 1) Discontinue NAS/LCS diet. 2) Add multivitamin with minerals daily. 3) Add liquid protein (for wound healing) 30 milliliter (ml) two times a day; -6/1/24 at 2:21 P.M., Resident seen by the wound care Physician. No new orders. Review of the resident's medication administration record (MAR), dated 5/1/24 through 5/31/24, showed no order for a multivitamin with minerals daily or liquid protein 30 ml daily. Review of the resident's care plan, located in the EHR and last edited on 6/4/24, showed: -7/1/20: Problem: Activities of daily living functional status. Goal: Resident will be able to maintain present level of functioning through next review. Approach: Staff assist 1-2 with transfers, bed mobility and personal care. Resident is non-ambulatory and can self propel in his/her wheelchair. Observe skin condition with daily care; -7/1/20: Problem: Pressure Ulcer/Injury. Goal: Resident will have skin remain intact by next review date. Approach: Provide treatments and medication as ordered. Assist with mobility and transfers. Ensure proper body alignment in bed or chair. Observe skin condition with daily care. Report changes to the physician and obtain treatment as ordered. Weekly body audit; -The resident's care plan had not been updated to include any known pressure ulcers or that the skin was no longer intact. Review of the resident's Skin Observation assessments, showed: -6/21/24: Pressure Injury/Blister/Open Areas - Yes, coccyx. Describe any additional body marks or sores: Blank; -6/26/24 and completed by Licensed Practical Nurse (LPN) E: Pressure Injury/Blister/Open Areas - Yes. Wound to bottom and lle (left lower extremity). Describe any additional body marks or sores: Blank; -Review of the resident's progress notes, POS and MAR, showed no assessment, physician notification or treatment order for the resident's left lower extremity. Review of the wound care Physician's progress note, dated 6/28/24, showed: -Wound Location: Coccyx; -Wound Type: Pressure Ulcer - Unstageable (Slough and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin); -Wound Status: Improving; -Pre-debridement Measurement: 4.5 cm x 4.6 cm x 1.5 cm; -Tunneling (passageways underneath the skin): Absent; -Undermining (a pocket of dead space under the skin originating from the edges and spreading outwards): Absent; -Odor: Absent; -Eschar (dead tissue that forms over healthy skin and then, over time, falls off (sheds)): Absent; -Exposure: Tendon/Muscle/Ligament; -Tissue Type: Slough, Granulating (new tissue/healing); -Exudate (is fluid that leaks out of blood vessels into nearby tissues) Amount: Moderate; -Exudate Color: Serosanguineous (thin, clear pink drainage); -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement (removal of tissue): Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional (a scalpel is not used to remove devitalized tissue); -Description of Tissue Removed: Slough. Blood Loss: None. Instrument Used: 4x4's (gauze); -Dressing Order: Cleanse wound with wound cleanser, slightly moistened collagen (protein based) pad, 4x4's gauze lightly packed, Zetuvit (an absorbent dressing for moderate to heavy exudate) plus silicone border dressing, ok to substitute with generic border gauze if unavailable; -Change Dressing: Every 24 hours; -No documentation about the resident's left lower extremity. Review of the resident's physician's orders sheet (POS) on 7/1/24 at 12:43 P.M., located in the EHR, showed: -6/5/24: Liquid protein 30 ml twice a day; -6/5/24: One multi-vitamin with mineral daily; -6/5/24: Regular diet; -The liquid protein, multivitamin with mineral and regular diet were not ordered until 14 days after the RD's recommendations on 5/22/24; -6/9/24: Cleanse coccyx wound with full strength Dakins solution (a diluted bleach solution), pat dry, apply Medihoney in and around wound bed, gently pack with calcium alginate (absorbs exudate (wound drainage)), apply foam dressing daily and PRN; -No order dated 6/28/24 (from the wound care Physician) to cleanse the coccyx with wound cleanser, slightly moistened collagen (protein based) pad, 4x4's gauze lightly packed, Zetuvit (an absorbent dressing for moderate to heavy exudate) plus silicone border dressing, ok to substitute with generic border gauze if unavailable. Review of the resident's MAR, dated 6/1/24 through 6/30/24, showed: -6/5/24: Multivitamin with minerals daily; -6/5/24: Liquid protein 30 ml daily; -5/28/24 - 6/4/24: Cleanse coccyx with wound cleanser, apply Medihoney with bordered gauze daily; -6/4/24 - 6/9/24: Cleanse coccyx with wound cleanser, apply Medihoney with bordered gauze daily; -6/9/24 - 7/1/24: Cleanse coccyx wound with full strength Dakins solution, pat dry, apply Medihoney in and around wound bed, gently pack with calcium alginate, apply foam dressing daily and PRN; -No order dated 6/28/24 (from the wound care Physician progress notes) to cleanse the coccyx with wound cleanser, slightly moistened collagen pad, 4x4's gauze lightly packed, Zetuvit plus silicone border dressing, ok to substitute with generic border gauze if unavailable; -The resident did not have a treatment administration record (TAR). All physician orders were on the MAR. Review of the resident's MAR dated 7/1/24 through 7/31/24, showed: -7/1/24: Cleanse wound with wound cleanser, apply collagen pad and pack 4x4 in wound bed, cover with foam dressing daily. During a telephone interview on 7/10/24 at 8:10 A.M., LPN E said he/she reviewed the skin observation he/she completed on 6/26/24. He/She documented the information wrong. He/She did not mean to document the resident had a wound on the left lower extremity, only the coccyx. There was a piece of Duoderm (a cushioned/absorbent adhesive dressing) on the left lower extremity, but there was no pressure ulcer or wound underneath it. There was no order for the Duoderm. He/She thought it was there as a preventative measure. Observation on 7/1/24 at 9:07 A.M., showed the resident lay in bed for a skin assessment. Certified Nursing Assistant (CNA) C and CNA D assisted the resident onto his/her left side, showing an undressed pressure ulcer with a small amount of yellow slough on the resident's coccyx. CNA D said he/she had to remove the dressing earlier that morning when he/she cleaned the resident because it was soiled. The resident's left foot was wrapped with clean kling gauze (rolled gauze used for wrapping a dressing to a pressure ulcer/wound). There was no date on the left foot dressing. The right foot showed two dark/red circular areas on the right heel. Observation on 7/2/24 at 10:39 A.M., showed the resident lay in bed. CNA G and LPN F prepared the resident for his/her coccyx treatment. LPN F applied collagen to the pressure ulcer and covered it with a dressing. LPN F said he/she was not aware of the dark/red areas on the resident's right and left feet/heels. He/She thought the areas were caused from pressure. He/She worked yesterday and no one told him/her about the areas on the resident's feet/heels. Had he/she been made aware, he/she would have assessed the areas and called the physician. He/She did not know how long the areas had been there. There were no current treatment orders for those areas. At 10:45 A.M., the DON entered the room to assess the resident's heels/ankle. She identified the areas as pressure related. She was not aware of the areas. The CNAs should have reported any new areas to the charge nurse when they were first noted and the charge nurse should have assessed, contacted the physician and documented any new orders. LPN G measured the areas and noted the following: right outer heel 3.6 cm x 4.4 cm, right inner heel 3.4 cm x 2.7 cm, left inner ankle 3.2 cm x 0.9 cm and left heel 4.7 cm x 6.7 cm. During an interview on 7/2/24 at 11:22 A.M., LPN F said he/she worked 6/29/24 (Saturday) and did the resident's treatment. He/She did not use the treatment ordered by the wound care Physician on 6/28/24, because it had not been entered on the MAR. He/She did the previous treatment for Dakins and Medihoney that began on 6/9/24. During an interview on 7/2/24 at 11:50 A.M., CNA D said he/she worked at the facility for about a month and had taken care of the resident several times. The areas on the resident's right/left feet/heels had been there since he/she had been taking care of the resident. He/She told the nurses about the areas, but could not recall who he/she had told. During an interview on 7/2/24 at 12:00 P.M., Registered Nurse (RN) A said he/she did not usually work on the resident's hall. No one reported any pressure ulcers on the resident's feet to him/her. Had that been reported to him/her, RN A would have assessed the areas, called the physician and documented it in EHR. During an interview on 7/2/24 at 12:37 P.M., the DON said she had no idea who put the dressing on the resident's left foot that was observed on 7/1/24. She reviewed the resident's EHR and there was no documentation about the resident's heels/ankle. She was not aware the wound care Physician wrote a new order for the coccyx on 6/28/24. That treatment should have been implemented before 7/1/24. Review of the wound care Physician's progress note, dated 7/5/24, showed: -Wound Location: Coccyx; -Wound Type: Pressure Ulcer Stage 4; -Wound Status: Improving; -Pre-debridement Measurement: 5.0 cm x 5.0 cm x 1.1 cm; -Tunneling: Absent; -Undermining: Absent; -Odor: Absent; -Eschar: Absent; -Exposure: Tendon/Muscle/Ligament; -Tissue Type: Granulating; -Exudate Amount: Moderate; -Exudate Color: Serosanguineous; -Surrounding Skin: Intact; -Signs of Infection: Absent; -Debridement: In for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough. Blood Loss: None. Instrument Used: 4x4's; -Dressing Order: Cleanse wound with wound cleanser, slightly moistened collagen pad, 4x4's gauze lightly packed, Zetuvit plus silicone border dressing, ok to substitute with generic border gauze if unavailable; -Change Dressing: Every 24 hours; -Wound Location: Right lateral (toward the outside) heel; -Wound Type: Pressure Unstageable; -Wound Status: First Visit; -Pre-debridement Measurement: 4.0 cm x 4.0 cm x 0.0; -Exudate Amount: None; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Debridement not indicated; -Dressing Order: Apply Skin Prep (a liquid that when applied to the skin forms a protective film or barrier) daily. Offloading boots (designed to alleviate pressure) at all times; -Wound Location: Right medial (toward the middle) heel; -Wound Type: Pressure Ulcer Unstageable; -Wound Status: First Visit; -Pre-debridement Measurement: 1.5 cm x 0.3 cm x 0.0; -Exudate Amount: None; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Debridement not indicated; -Dressing Order: Apply Skin Prep daily. Off loading boots at all times; -Wound Location: Left medial heel; -Wound Type: Pressure Ulcer Unstageable; -Wound Status: First Visit; -Pre-debridement Measurement: 4.0 cm x 4.0 cm x 0.0; -Exudate Amount: None; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Debridement not indicated; -Dressing Order: Apply Skin Prep daily. Off loading boots at all times; -Wound Location: Left medial ankle; -Wound Type: Pressure Ulcer Unstageable; -Wound Status: First Visit; -Pre-debridement Measurement: 4.0 cm x 5.0 cm x 0.0; -Exudate Amount: None; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Debridement not indicated; -Dressing Order: Skin Prep daily. Off loading boots. During a telephone interview on 7/10/24 at 10:51 A.M., the Medical Director said he expected CNAs to promptly report any new pressure ulcers or areas of concerns to the charge nurse immediately. The nurse should assess the areas and contact the physician for any new orders. This should be documented on the POS, MAR and in the EHR. During a telephone interview on 7/10/24 at 11:30 A.M., the wound care Physician said he did not do a total skin assessment on the residents he saw. He only looked at what the facility had identified. If a staff member noticed a new pressure ulcer it should be communicated to the nurse and DON and they could call him for new orders. He was not aware of the pressure ulcers on the resident's feet until 7/5/24. The pressure ulcers on the resident's feet could occur anywhere from a few hours to several days. 2. Review of Resident #2's admission face sheet, located in the EHR, showed: -admission date of 6/25/24; -Diagnoses of Alzheimer's disease, dementia, anemia, and pressure ulcer of sacral region (the area between the lower back and the upper buttocks). Review of the resident's Baseline Care Plan, undated, showed: -Respite (short term stay); -Disease/Illness Management: Pain, weight loss, weakness and wound; -Other Special Care Instructions: Follow protocol to care for wound care: Blank. Review of the resident's Braden Scale dated 6/25/24, showed the resident had a very high risk to develop pressure ulcers. Review of the resident's progress notes, located in the EHR, showed: -6/25/24 at 3:10 P.M.: Returned by ambulance, transferred from stretcher to bed by two emergency medical staff. Alert and oriented to self. On hospice and here for respite care for 5 days. All orders verified by physician. Skin issues noted. Area on coccyx 9.0 cm x 9.0 cm with tunneling area 5.0 cm x 4.0 cm x 1.5 cm. Treatment to coccyx changed; -6/26/24 at 7:33 P.M. and documented by the RD: admission on hospice services. Skin with pressure ulcer coccyx. Recommend 1) add liquid protein 30 ml twice a day. 2) Add Boost (nutritional drink) twice daily. Review of a hospice order dated 7/1/24 at 5:39 P.M., and received by the facility on 7/1/24 at 6:56 P.M. from hospice, showed: Late entry 6/26/24. Cleanse stage 4 pressure ulcer to coccyx with wound cleanser, rinse with normal saline, gently pat dry, cover with dry dressing. HSN (hospice skilled nurse) two times a week and FSN (facility skilled nurse) daily and PRN if soiled. May discontinue when wound is healed. Review of the resident's MAR dated 6/25/24 through 6/30/24, showed: -No treatment order for the coccyx, liquid protein or Boost; -The resident did not have a TAR. All physician orders were on the MAR. Review of the wound care Physician's progress note, dated 6/28/24, showed: -Wound Location: Coccyx; -Wound Type: Pressure Ulcer Stage 4; -Wound Status: First Visit; -Pre-debridement Measurement: 13.0 cm x 9.0 cm x 3.0 cm; -Tunneling: Absent; -Undermining: Absent; -Odor: Absent; -Eschar: Absent; -Exposure: Tendon/Muscle/Ligament; -Exudate Amount: Moderate; -Exudate Color: Serosanguineous; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection. and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough. Blood Loss: None. Instrument Used: 4x4s; -Dressing Order: Cleanse wound with wound cleanser. Flagyl (antibiotic) powder. Medihoney gel. Zetuvit plus silicone border dressing, ok to substitute with generic border gauze if unavailable; -Change Dressing: Every 24 hours and as needed. Review of the resident's POS located in the EHR on 7/1/24 at 1:44 P.M., showed: -7/1/24: Cleanse wound with wound cleanser, apply Flagyl powder and Medihoney to wound bed, then cover with border gauze daily; -No order for liquid protein or Boost. Observation of the resident on 7/1/24, showed: -8:21 A.M.: The resident lay in bed sleeping on a low air loss (pressure reducing) mattress; -8:56 A.M.: The resident lay in bed. The Assistant Director of Nursing (ADON), RN A and Certified Medication Technician B turned the resident onto his/her left side. A strong foul odor was immediately noted. The resident's dressing was dated 6/29/24, and heavily saturated with drainage. The ADON said the dressing should be changed daily. She did not know why it was not changed the day before on 6/30/24. RN A packed the pressure ulcer with wet to dry 4x4s (saturated with normal saline) and covered it with a foam dressing; -2:20 P.M.: The DON said the resident did not have an treatment order in the EHR for the resident's coccyx until today. She did not know why. Review of the resident's POS located in the EHR on 7/2/24 at 9:15 A.M., showed: -An order, dated 7/1/24, five days after the RD recommendation on 6/26/24, for: Liquid protein 30 ml two times a day; -An order, dated 7/1/24, five days after the RD recommendation on 6/26/24, for: Boost two times a day with meals. During an interview on 7/2/24 at 9:38 A.M., the ADON said she spoke to hospice. Hospice said they verbally told the charge nurse on 6/26/24 about the order for the coccyx, but did not leave the order in writing. She contacted hospice and received the late entry order yesterday evening. If hospice told the admitting nurse about the treatment order for the coccyx, the admitting nurse should have entered the treatment order on the POS and MAR at that time. She was not sure what staff had been treating the pressure ulcer with or how often prior to 7/1/24. The resident was no longer at the facility on respite. He/She would be staying long term. During an interview on 7/2/24 at 11:22 A.M., LPN F said he/she worked on 6/29/24 and completed the resident's coccyx treatment. He/She could not find a treatment order on the POS or MAR. He/She was not aware the resident was being seen by the wound care Physician and was not aware he wrote new orders on 6/28/24. He/She used a Dakins wet to dry dressing on 6/29/24. He/She did not have a physician's order to do that. He/She had experience as a wound nurse and thought the Dakins wet to dry dressing would be best since there was no order. He/She should not have done that. He/She should have contacted the physician or hospice and gotten a treatment order. During an interview on 7/2/24 at 12:00 P.M., RN A said he/she could not find an order on the POS or MAR yesterday. RN A used a wet to dry dressing on the resident's coccyx because he/she had previously heard the hospice Nurse say that was the order. He/She should have contacted hospice or the Physician to confirm the order. He/She was not aware the wound care Physician had written a new order on 6/28/24, or he/she would have used that order. The wound care Physician sent his orders to the DON. When he/she admitted a new resident he/she assessed any pressure ulcers/wounds and contacted the physician for an order. He/She documented all of that at the time of admission and entered it on the POS and MAR. Review of the wound care Physician's progress note, dated 7/5/24, showed: -Wound Location: Coccyx; -Wound Type: Pressure Ulcer Stage 4; -Wound Status: Deteriorating; -Pre-debridement Measurement: 14.0 cm x 12.0 cm x 3.0 cm; -Tunneling: Absent; -Undermining: Absent; -Odor: Absent; -Eschar: Absent; -Exposure: Tendon/Muscle/Ligament; -Exudate Amount: Moderate; -Exudate Color: Serosanguineous; -Surrounding Skin: Intact; -Signs of Infection: None; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough. Blood Loss: None. Instrument Used: 4x4s; -Dressing Order: Cleanse wound with wound cleanser. Flagyl powder (antibiotic). Dakins moistened gauze dressing; -Change Dressing: Every 72 hours. During a telephone interview on 7/10/24 at 10:51 A.M., the Medical Director said it was the facility's responsibility to ensure a newly admitted resident with a pressure ulcer had an order in place upon admission. Someone between the resident's admission date and 7/1/24 should have noticed there was not a treatment order and contacted him, the wound care Physician or hospice for an order. Nurses should not administer any treatment without a physician's order. During a telephone interview on 7/10/24 at 11:30 A.M., the wound care Physician said he did not feel the resident's pressure ulcer would ever heal due to the resident's declining condition. He ordered the Flagyl to help with the odor. 3. During an interview on 7/2/24 at 12:37 P.M., the DON said the facility wound care policies were current and should be followed. The wound care Physician typically made rounds on Fridays. A facility nurse made rounds with the wound care Physician but not always. The wound care Physician would normally tell the nurses if there were any new orders. He sent copies of any order changes via e-mail to her, the ADON and Administrator by Monday the following week. She realized his treatment orders needed to be implemented the same day he wrote the orders. They would start making sure a nurse made rounds with the wound care Physician going forward to ensure any new treatment orders were implemented the day he made rounds. The RD sent her recommendations to her, the ADON and the Dietary Manager the day she was in the building or no later than the next day after she left. They should have any new recommendations followed up on within 72 hours after the RD's recommendations. She was not sure why that had not been done consistently. 4. During a telephone interview on 7/10/24 at 10:51 A.M., the facility Medical Director said the facility should follow their pressure ulcer and wound policies. The RD recommendations should be called to him within a day after she wrote the recommendations. 72 hours was too long to wait. The wound care Physician's orders should be implemented at the time he wrote the orders. It should not take three days to implement the orders. 5. During a telephone interview on 7/10 24 at 11:30 A.M., the wound care Physician said he typically made rounds on Fridays and sometimes on the weekend if he was behind. After he rounded he always told the nurse on duty if there were any new treatment orders. He expected the orders to be changed at that time. He also followed up by e-mailing any orders to the Administrator, DON and ADON. MO00238085

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy by not communicating the significant weight loss of four sampled residents (Residents #38, #50, #42 and #210) to the physician and registered dietician (RD). Furthermore, the facility failed to follow physician orders to obtain weekly weights and monitor nutrition/fluid intakes and failed to implement RD recommendations for nutritional supplements, fortified foods and additional staff assistance to prevent further weight loss for these four residents, two who developed a wound or experienced a decline in their wound condition (Residents #38 and #50). The sample was 14 and the census was 55. Review of the facility weight management policy, dated July 2014, showed the following: Policy: -It is the policy of the facility to manage resident weight through prevention, assessment, and implementation and evaluation of interventions; Procedure: -Upon admission/re-admission, quarterly and with a significant change; -On the first through the fifth days of the month, the Certified Nursing Assistant (CNA) will take the weights for all monthly weights. Weekly weights will be obtained for any resident determined by the weekly weight committee: -Re-weigh required - compare the previous weight to the current weight to determine if there is a various of five or more pounds. If the weight variance is greater than five pounds mark a check in the column; -Re-weight - record the new weight that was just obtained; -Date re-weight - record the date the new weight was obtained; -In the event a different scale is used or the regular scale has been repaired or re-calibrated, this information will be documented on the weight log in the top right hand corner. Information should include the date and what was done, such as scale calibrated or repaired; -Weight committee meetings will be held weekly; -The weight committee will include the Director of Nursing (DON), the Minimum Data Set (MDS) coordinator, dietary manager and other departments as needed; -The weight loss tracking is to be used during the meeting to aide in the discussion/assessment of residents who have had a five pound or more weight loss. Residents who have not had weight loss will not be reviewed; -The weight loss tracking is completed by reading the list of interventions, selecting the appropriate ones, writing the date the intervention was used, the initials of who a completing the form, and any follow up needed or comments; -The interventions used will be documented on the weight committee meeting minutes; -The weight review committee meeting minutes is completed as follows: -Date -write the date the meeting is being held; -Resident - write the name of the resident who is being discussed; -Interventions - write the new interventions determined to be appropriate from the discussion/assessment; -Follow up - write any actions or activities that need to be completed as a result of these new interventions; -Committee member sign in - all members present at the meeting should sign the committee minutes form; -The DON or his/her designee will list all residents who have had a weight loss or gain greater than five pounds, poor intake, pressure ulcers, chewing or swallowing problems, receive tube feedings, all new admissions, all readmissions, or abnormal lab results will be given to the registered dietician for assessment and recommendations; -The DON will then distribute the registered dietician recommendations per wing to the charge nurse; -The charge nurse will notify the attending physician of the current resident's condition and of the registered dietician's recommendations, and document the physician's order on the physician's order sheet not the 24 hour report sheet; -The charge nurse will then initiate a diet order and communication form to the dietary manager who will chart the change in the dietary progress note and to the MDS coordinator to update the care plan. 1. Review of Resident #38's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/20, showed the following: -admitted to the facility on [DATE] and last re-entry 7/22/20; -Severe cognitive impairment; -Extensive assistance required for transfers, bed mobility, dressing and personal hygiene; -Unable to ambulate; -Weight 114 pounds (lbs) and height 59 inches; -Swallowing disorder: No; -Weight loss of 5% or more in the last month or 10% or more in the last six months? No -Diagnoses included heart failure, diabetes, Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), dementia and depression. Review of the care plan, dated 4/22/20 and last updated 7/22/20, showed the following: -Problem: Resident at risk for weight loss; -Goal: Resident weight will remain stable with no loss or gain of 3% or more per month per quarter; -Interventions: Assess medications effects to appetite, assess resident's food preferences often to update likes and dislikes, pureed diet, dietary consult at least quarterly and as needed, during periods of decreased appetite monitor for constipation/intestinal obstruction/pain/mood/behavior problems, encourage oral intake of food and fluids, monitor and record intake of food, monitor and record weight, notify physician of any weight changes, offer available substitutes if resident has a problem with the food being served, provide set-up help/cueing/physical help, etc., assistance for meals as needed, speech therapy consult if noted changes in swallowing, when resident leaves 25% or more of food, determine why and assist if needed to complete meal; -Problem: Nutritional status, risk for weight loss; -Goal: Will maintain current weight; -Interventions: Eats in room, provide appropriate diet, monitor intake, provide food likes. Review of the current physician's orders sheet (POS), showed the following: -An order, dated 1/17/20, to administer Remeron (antidepressant and can cause increase in appetite) 15 milligrams (mg) one tablet every bedtime for a diagnosis of depressive episodes; -An order, dated 5/4/20, to administer Ensure clear (nutritional supplement) three times a day with meals; -An order, dated 5/7/20, for a mechanical soft (ground meat and easy to chew soft foods) diet; -An order, dated 5/19/20, for a dietician consult; -An order, dated 5/19/20, to obtain weekly weights every Wednesday. Review of RD C's progress note, dated 6/4/20, showed consult as ordered by physician. Poor intake since original admission due to stomach issues. Resident is able to feed self and make needs known. Often orders broth and mashed potatoes and calls daughter when unhappy with meal. Remeron may affect intake/weights. Cater to resident's preferences as much as possible and offer snacks between meals. Has order for Ensure clear and does not like health shake. Review of RD D's progress note, dated 6/23/20, showed resident readmitted from the hospital and receiving mechanical soft diet with Ensure clear. Noted decreased intakes. Daughter encouraged to bring in food and daughter stated resident is not eating the food so will try fruit smoothies. Continues to order bland foods. Order for Remeron daily has the potential for appetite stimulation. Continue current interventions. Review of RD D's progress note, dated 7/28/20, showed resident readmitted from the hospital. Twelve teeth extracted on 7/27/20. Remains on mechanical soft diet with Ensure clear three times a day. Noted decreased intakes. Daughter encouraged to bring in food. Remeron has the potential for appetite stimulation. Continue current interventions. Review of the RD E's progress note, dated 8/13/20, showed weight history of 117.8 pounds on 5/8/20, 113.6 pounds on 5/27 and 114 pounds on 7/28/20. No updated weight for August. Antibiotic for tooth extraction noted. Continues mechanical soft diet with ensure clear. Refused breakfast and had soup for lunch on 8/11 and 8/12. Remeron 15 mg daily which may cause increased appetite. Stage II pressure ulcer (PU -partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured blister) to sacrum. Continue to monitor weights and intakes. Offer snacks between meals. Recommend: 1. Trial fortified mashed potatoes with lunch and supper for calorie support and 2. update weight. Review of the RD D's progress note, dated 9/3/20, showed weight of 107.2 pounds on 8/12/20 which shows a significant weight loss of 8.9% for three months. Receiving mechanical soft diet with Ensure clear three times a day. Remeron 15 mg which can help with appetite stimulation. Noted declining condition and frequently refusing meals. Has snacks in room. Recommend: Increased supervision/assistance with meals and Med Pass (nutritional supplement) 90 milliliters (ml) three times a day for calorie support with poor intakes. Further review of the POS, showed no order for fortified mashed potatoes or Med Pass nutritional supplement. Review of weights, showed the following: -Weight not obtained weekly as ordered; -A total of five weights obtained from 5/8/20 through 9/7/20; -Weight recorded as 102.4 pounds on 9/7/20, which indicated another 4.4% loss in three weeks. Review of the progress notes from 5/1 through 9/10/20, showed the following: -Multiple entries recorded that resident refused meal or intake inadequate; -Family member encouraged to provide pleasure foods and resident did not eat them; -No documentation the physician had been notified of poor intake and weight loss. Review of the intake section of the chart for 5/1 through 5/31, 6/1 through 6/30, 7/1 through 7/31, 8/1 through 8/31 and 9/1 through 9/10/20, showed no documentation regarding food or fluid intake and no documentation regarding consumption of Ensure clear. Review of the activities of daily living (ADL) section of the chart for 5/1 through 5/31, 6/1 through 6/30, 7/1 through 7/31, 8/1 through 8/31 and 9/1 through 9/10, showed no documentation regarding food or fluid intake and no documentation regarding amount of Ensure clear consumed. During an interview on 10/5/20 at 11:10 A.M., the DON said the resident's family member requested that all of resident's teeth be removed and resident fitted for dentures. She said she does not know the reasoning for that, but the resident's intake decreased even more after his/her teeth were removed even though they gave him/her soft food. She said since the weights were ordered to be completed weekly, she would expect them to have been done and recorded. The physician also should have been informed of the weight loss and resident's poor intake and refusal of food. She did speak with the family member the day before the resident went to the hospital this last time, that they may have to start talking about a g-tube (small rubber tube surgically inserted into the stomach to provide nutrition and fluids) versus hospice, but then he/she declined very rapidly. She said she wrote a note in the chart, however, no note was found. During an interview on 10/5/20 at 12:15 A.M., the social worker said she had never spoken with the daughter about a g-tube or any other options regarding the lack of intake and weight loss. During an interview on 10/9/2020 at 11:00 A.M., RD D said she receives consults from the dietary manager. She is presently working off site and obtains most of her information on the computer. She looks for weight loss and any other issues that may arise. If she has a recommendation, she e-mails it to the dietary manager, the DON and anyone else who needs it and would expect those individuals to follow up with the physician regarding those recommendations. For Resident #38, she was not sure why the recommendations were not passed along to the physician. During an interview on 10/15/20 at 10:50 A.M., the medical director and resident's physician said that he was not contacted regarding the recommendation for fortified foods and Med Pass supplement. He said if he had, he would have ordered them and believes it could have possibly helped with the resident's weight loss and wound care. He went on to say that he believed the resident had little fight left in him/her and at that time was not a good candidate for a feeding tube. 2. Review of Resident #50's medical record, showed the following: -On 3/2/20, a weight of 142.2 lbs; -Diagnoses included high blood pressure, depression and malnutrition. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Sever cognitive impairment; -Required extensive assistance with transfers, dressing, personal hygiene and limited assistance with eating; -One or more pressure ulcers (Pressure injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction) Stage 1 or higher: Yes. Review of the resident's medical record, showed the following: -An order, dated 5/1/20, for staff to monitor and record the percentage of food and fluid intake for dinner; -An order, dated 5/2/20, for weekly weights on Wednesdays. Review of the resident's intakes, showed the following: -Staff documented the resident's dinner and fluid percentage 7 out of 31 opportunities in May 2020; -Staff documented the resident's dinner and fluid percentage 2 out of 30 opportunities in June 2020. Review of the resident's weekly weights, showed the following: -On 5/13/20, a weight of 133.6 lbs; -On 5/19/20, a weight of 133.8 lbs; -On 5/27/20, a weight of 126.4 lbs (a significant loss of 5.53% in one week); -On 6/9/20, a weight of 122.6 lbs (a weight loss of 3% in two weeks); -Staff failed to document the resident's weight weekly as ordered. Further review of the resident's medical record, showed the following: -An order, dated 6/17/20, for Mirtazapine (Remeron) 7.5 mg, give one tablet at bedtime for depression; -An order, dated 6/17/20, for weekly weights; -An order, dated 6/17/20, for Ensure with all meals; -An order, dated 6/17/20, for dietary consult; -A dietary consult completed on 6/24/20. Further review of the resident's daily dinner and fluid intake percentages, showed staff documented the following: -Four out of 31 opportunities in July 2020. -Five out of 31 opportunities in August 2020. Further review of the resident's weekly weights, showed the following: -On 6/24/20, a weight of 129.8 lbs (a significant weight increase of 5.87% in two weeks); -On 7/2/20, a weight of 131 lbs; -On 7/8/20, a weight of 133.2 lbs; -Staff failed to document the resident's weekly weights as ordered. Review of the RD note, dated 7/10/20, showed weight on 7/8/20 was 133.2 lbs. Weight has shown an increase of 10.6 lbs in one month (8.6%) and a decrease of 10.4 lbs in 6 months (7.2%). Receiving mechanical soft diet with health shakes at meals and consuming per dietary manager (DM). Resident's appetite still has been fair/poor. Resident usually chooses an alternative at meals, but DM first offers facility meal and encourages to consume. Mirtazapine 7.5 mg in place which can help aid in appetite stimulation. On weekly weights to monitor. Due to weight trend up, continue current interventions. If weight starts to decline, consider providing Ensure clear between meals as resident used to receive this and did consume. Monitor. RD following. Further review of the resident's July weekly weights, showed the following; -On 7/22/20, a weight of 129.8 lbs; -No other weights documented. Further review of a nurse's note, dated 8/1/20, showed the resident has change in appetite. Resident has been declining meals. All vitals are within normal range. No mental status change. Resident's physician notified and gave order for UA and Mirtazapine 7. 5 mg at bedtime. Review of the RD note, dated 8/13/20, showed the resident's most recent weight available (7/22/20) as 129.8 lbs. No updated weight for August available at this time. Mechanical soft diet with health shakes with meals continues. Also receives Ensure with meals. Change in appetite with resident declining meals per nursing note on 8/1/20. Encourage intakes and offer alternatives and snacks as accepted. Monitor Mirtazapine 7.5 mg daily which may cause increase appetite. Decline in wound with notes of area bigger in size and foul odor on 8/3/20. Continue to monitor weight and intakes. Recommend: -Update weight; -Juven (nutritional supplement used to promote wound healing) twice a day to promote skin integrity; -Trial fortified mashed potatoes with lunch and supper for calorie support. Review of the resident's medical record, showed the following: -An order, dated 8/13/20, for Juven powder in packet. Give one packet twice a day; -An order, dated 8/13/20, for mechanical soft diet, health shake with meals, mashed potato with lunch and dinner; -Staff documented the resident's dinner and fluid intakes five out of 31 opportunities in August; -On 8/13/20, a weight of 126.8 lbs (significant weight loss of 10.8%in 6 months); -Staff failed to document any other weights for the month of August; -The resident was hospitalized from [DATE] through 8/27/20 for wound treatment; -Staff failed to document notifying the resident's physician or representative regarding the significant weight loss. Review of the resident's care plan, last revised on 8/31/20, and in use during the survey, showed the following: -Problem Start Date: 4/17/20 Category: Nutritional Status. Resident is at risk for weight loss due to prior history of weight loss. Resident feeds self and consumes a mechanical soft diet. He/she likes soul food, honey buns, hamburgers and payday candy bars. Has snacks in his/her room. Has Ensure clear, power potatoes and shakes ordered. November 2019 weight 142 lbs; April 2020 weight 141 lbs; May 2020 weight 133 lbs; May weight triggers significant weight loss. June 2020 weight 122.6 lbs; July 2020 weight 131 lbs; August 2020 weight 129.8 lbs; -Goal: Resident will have weight remain within 4% of current body weight in a 30 day period by next review; -Interventions included diet as ordered, encourage fluid with meals and between meals, honor food preference as needed, monitor weight. Review of the RD note, dated 9/2/20, showed the resident readmitted from the hospital with an open wound to the right foot and is on antibiotics. Weight on 8/13/20 was 126.8 lbs. Significant weight loss triggering 16.8 lbs loss in 6 months (11.7%). Weight fluctuating between 122.6 lbs and 133.2 lbs since 5/27/20. Currently receiving mechanical soft diet with multiple nutritional interventions in place: Ensure with meals, health shake with meals, mashed potatoes with lunch and dinner, Juven twice a day. Noted declining condition per DM. Resident was feeding self but now needing more assistance. Mirtazapine 7.5 mg in place which can help with appetite stimulation. Weekly weights to monitor nutritional status. Continue current interventions. Encourage intakes and provide alternatives at meals as desired. RD to follow. Review of the resident's September 2020 intakes, showed staff documented the resident's dinner and fluid percentage four out of 30 opportunities. Review of the resident's September 2020 weekly weights and intakes, showed on 9/7/20, a weight of 120 lbs (significant loss of 15.7% in 6 months and 5.36% loss in one month). Further review of the resident's progress notes, showed the following: -Staff failed to document notifying the resident's physician or representative of the severe weight loss; -An RD note, dated 9/10/20, showed weight on 9/7/20 was 120 lbs. Significant weight loss triggering loss of 6.8 lbs (5.4%) in one month and loss of 22.4 lbs 6 months (15.7%). Currently receiving mechanical soft diet with multiple nutrition interventions in place: Ensure with meals, mighty shake with meals, mashed potatoes with lunch and dinner, Juven twice a day. Noted was feeding self but now needing more assistance. Sending grilled cheese sandwich along with regular meal per preference. Mirtazapine 7.5 mg in place which can help with appetite stimulation. Weekly weights to monitor nutritional status. Continue current interventions. Encourage intakes and provide alternatives at meals as desired. Recommend: -Start multivitamin with minerals daily for skin integrity; -Trial nutritional treat twice a day to help aid in weight maintenance and monitor acceptance. Review of the resident's September 2020 physician order sheet (POS), showed: -No order for a daily multivitamin with minerals; -No order for nutritional treat twice a day. Further review of the resident's medical record, showed the following: -A weight, dated 9/30/20 of 113 lbs (a significant weight loss of 20.64% in 6 months and 10.88% loss in one month); -No documentation staff completed a re-weight; -No documentation staff notified the resident's physician or representative. Observations of the resident on 9/29/20 at 8:32 A.M., showed the resident lay in bed with the head of bed up and an over the bed table to the left of the resident's bed. A plate with mechanical soft food sat on the over the bed table. The resident was not eating. He/she had eaten approximately 25% of the meal. No Ensure or health shake was observed on the table. No staff present to assist the resident. Further observations of the resident on 9/30/20 at 12:38 P.M., 10/2/20 at 9:20 A.M., and 10/5/20 at 8:50 A.M., showed, the resident was served a mechanical soft meal. No Ensure was served to the resident. No staff observed assisting the resident with eating. Further observation of the resident between meals on 10/1/20 at 9:10 A.M., 10/2/20 at 5:20 A.M., 10/5/20 at 11:50 A.M., and 10/6/20 at 10:00 A.M., showed no nutritional treats served to the resident by staff. No snacks were available to the resident in his/her room. During an interview on 10/5/20, the facility's social worker said she has not noticed any change with the resident's mood. The resident does not seem depressed. The resident is spending more time in bed due to his/her wound. During an interview on 10/6/20 at 7:47 A.M., Nurse A said he/she thought the weight from last week was inaccurate. If the weight was accurate and the weight loss significant, he/she would call the doctor and suggest hospice. The resident has had a poor appetite since he/she has been sick. He/she used to eat 50-75% of breakfast. He/she has been downgraded to mechanical soft but still isn't eating. He/she won't accept assistance. He/she tried giving soup and he/she usually really likes grilled cheese, but has not been eating them. He/she did consume supplements and liquids okay. Nurse A will obtain a re-weight this morning. During an interview on 10/6/20 at 10:05 A.M., the DM said the resident has had a decline in appetite. She has been taking snacks into him/her between meals sometimes. The resident will usually only eat a couple of bites. Before the pandemic, the resident always liked grilled cheese and would eat them. Now he/she only ate a few bites. She was unaware of how much of the supplements were consumed by the resident. Dietary staff put the health shakes on the tray. The resident received health shakes with all meals and fortified potatoes for lunch and dinner. The resident would benefit from assistance, but since on isolation, he/she no longer ate in the dining room. If he/she ate in the dining room, he/she would receive assistance with eating. During an interview on 10/6/20 at 11:28 A.M., Certified Nurses Aide (CNA) B said he/she reweighed the resident and his/her weight was 113.4 lbs. The resident has had a decrease in appetite. He/she was given a pureed meal this morning and refused it. After being weighed, CNA B got the resident a new plate of pureed food and tried to get the resident to eat, but he/she refused. Review of the resident's dietary card, showed the following: -Dietician consult, ordered 6/17/20; -Ensure with meals ordered 6/17/20; -Mechanical soft, health shakes with meals, mashed potatoes with lunch and supper, ordered 8/13/20; -Staff failed to include the RD's recommendation for nutritional treats between meals. During an interview on 10/6/20 at 12:00 P.M., the administrator and DON said the nurse should have obtained a re-weight and then notified the doctor if there was a significant weight loss. If there was no documentation, then it most likely was not done. The resident was receiving cues from staff when he/she ate in the dining room. The resident now eats in his/her room due to being on contact precautions for going out of the facility for treatment of his/her wound. During an interview on 10/9/20 at 11:00 A.M., the facility's RD said she would expect staff to implement her recommendations. She forwards her recommendations to the DM, DON and administrator and then they are entered as orders. The DM provided resident weights, and the RD also tracked resident weights. During a telephone interview on 10/13/20 at 11:00 A.M. the facility Medical Director and resident's physician said he was unable to access the resident's record at the time of the interview. He is in the facility about once a week. He was aware the resident was having weight loss but he was not sure if he had been notified the resident had a significant weight loss of 5.83% on 9/30/20. He would have ordered an RD consult. He was aware the resident was on isolation and was being confined to his/her room. If the resident required assistance to eat in the dining room, he would expect staff to assist the resident with meals in his/her room as well. He was not aware the resident was refusing to eat. Had he been notified, he would have explored possible tube feeding or hospice or palliative care for the resident. He would expect the facility to document any discussion or orders in the resident's medical record. 3. Review of Resident #42's MDS, dated [DATE], showed the following: -An admission date of 1/22/20; -Cognitively intact; -Required supervision with eating, extensive assistance with dressing, personal hygiene and transfers; -Diagnoses included malnutrition, muscle weakness, high blood pressure and Alzheimer's disease; -Height 58 inches, weight 84 lbs; -Weight loss of 5% or more in the last month or 10% or more in the last 6 months? Yes, not physician prescribed weight loss regimen; -Oral/dental status: blank. Review of the resident's medical record, showed an order, dated 1/31/20, for mechanical soft diet with thin liquids. Review of the resident's monthly weights, showed the following: -admission weight, dated 2/4/20, 84 lbs; -3/2/20, 83.2 lbs; -3/25/20, 82.4 lbs; -4/4/20, 84.6 lbs; -5/19/20, 77.4 lbs (significant weight loss of 8.5% in six weeks). Review of the resident's medical record, showed staff failed to notify the resident's physician and representative of the significant weight loss on 5/19/20. Review of the resident's therapy screenings, showed the following: -A therapy screening on 5/6/20, no reason given. Comments: Resident requires increased time at meals due to slow mastication (chewing); -No interventions ordered; -A speech therapy screening on 6/9/20 due to weight loss. Comments: Physical therapy referred to speech therapy due to weight loss. Resident observed during meal. Resident reports no change in appetite, mouth pain, difficulty swallowing. No increase or signs or symptoms of dysphagia (difficulty swallowing) observed. Continue to monitor, resident is a poor historian; -No interventions ordered; -No other assessments available. Review of the resident's RD notes, dated 5/29/20, showed the resident was assessed per significant weight loss. Weight at 77 lbs, 9% loss in one month. Ordered mechanical soft diet. Per nursing, fair intake at meals, though does take a while to eat. Will ask to leave the trays way past mealtime so he/she can finish. Has been on Ensure clear in the past, but did not consistently drink. Isolation precautions have not affected resident as he/she preferred to eat in room alone prior to COVID. Tolerating diet. Noted that resident refuses medications often. Recommend to trial health shakes between meals or nutritional treat for additional calories or protein. RD following. Further review of the resident's medical record, showed the following: -An order, dated 7/8/20, for a dietary consult; -An order, dated 7/8/20, for Ensure (nutritional supplement) with each meal; -An order, dated 7/8/20, for weekly weights on Wednesdays. Review of the resident's medical record, showed the following: -No documentation from the RD regarding the dietary consult ordered on 7/8/20; -A nurse's note, dated 7/27/20, showed resident was refusing to eat, stating he/she was doing a liquid diet. Staff reported resident's urine appeared very cloudy, almost milky-like. Collection of urine in progress at this time, with resident's cooperation; -A nurse's note, dated 7/28/20, showed resident's urine collected for urinalysis (UA) and culture and sensitivity (C & S). Resident's physician and representative made aware; -A nurse's note, dated 8/3/20, showed UA results received and faxed to resident's physician. Awaiting response; -A nurse's note, dated 8/6/20, showed follow up with resident's representative during care plan meeting. Explained resident does have a urinary tract infection (UTI) and is taking an antibiotic (ABT) to treat it; -A nurse's note, dated 8/9/20, showed resident continues on ABT for UTI and is alert and oriented to time and place with confusion present. Non-compliant with medication. Refused breakfast and lunch. Encouraged alternative choices, but resident declined. Verbalized to be left alone. Review of the resident's care plan, last revised on 8/16/20 and in use during the survey, showed the following: -Problem Start Date: 6/13/2020. Category: Nutritional Status. Resident has had a significant weight loss and noted fluctuation in weights since admission. He/she is edentulous and consumes a mechanical soft diet with thin liquids. He/she feeds self and will sometimes use his/her fingers. Prefers to remain in his/her room for meals. Requires staff supervision related to poor consumption and right wrist contracture. Does not like to talk to anyone while he/she is eating. Has health shake ordered with meals. February 2020 weight, 85 lbs; March 2020 weight, 83 lbs; April 2020 weight 84 lbs; May 2020 weight 77.4 lbs. Significant trigger; June 2020 weight 86.8 lbs; July weight 90 lbs; August 2020 weight 84 lbs; -Goal: Resident will have weight remain within 4% of current body weight in a 30 day period by next review; -Interventions included: Diet as ordered, encourage fluids between meals, honor food preferences, monitor tolerance, monitor weight; -Staff failed to include the interventions for Ensure with each meal and weekly weights. Further review of the resident's weights, showed the following: -7/13/20, 90 lbs; -8/5/20, 84 lbs; -8/13/20, 84 lbs (6.6% loss in one month); -9/2/20, 83.6 lbs (7.1% loss in six weeks); -9/7/20, 83.6 lbs; -Staff failed to obtain weekly weights as ordered. Further review of the medical record, showed the following: -Staff failed to notify the resident's physician or representative of the resident's significant weight loss from 7/13/20 to 8/13/20; -An RD note, dated 9/10/20, showed resident's weight on 9/7/20 was 83.6 lbs. Weight overall stable compared to admission weight. Mechanical soft diet with ensure with meals. Fair intakes per DM. Does choose to fast at times per own preference. Continue to monitor this. Stability guarded with overall disease progression. Continue current intervention. Encourage intakes and provide alternative if consumes less than 50% at meal. RD to follow as needed. Further review of the resident's monthly weights, showed a weight on 9/30/20 of 75.8 lbs