**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview the facility failed to revise the comprehensive care plan for 2 of 18 sampled residents (Resident #21 and #51) to reflect the residents ' status related to the use of oxygen and urinary tract infection. The findings include: 1. Review of the facility's policy titled, Comprehensive Care plan, dated 10/24/2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet the resident ' s medical .needs that are identified in the resident ' s comprehensive assessment .The comprehensive care plan shall describe, at a minimum, the following .any specialized services .The comprehensive care plan shall be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment . 2. Review of the medial record revealed Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of Cardiorespiratory Conditions, Heart Failure, End Stage Renal Disease, and Respiratory Failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition, shortness of breath or trouble breathing when lying flat, oxygen and a noninvasive ventilator. Review of the Care Plan dated 11/3/2023, and revised 3/1/2024, revealed there was no documentation Resident # 21 was using oxygen. Review of the Physician Order Sheet dated April 2024, signed on 4/23/2024, revealed .Oxygen .5 liters/minute by BNC [binasal cannula] while in bed and as needed . Observation in the resident's room on 5/13/2024 at 9:23 AM, revealed Resident #21 sitting up in a wheelchair with oxygen infusing through a binasal cannula. Observation on 5/15/2024 at 8:32 AM, revealed Resident #21 in bed with oxygen infusing through a binasal cannula. During an interview on 5/15/2024 at 3:01 PM, the Director of Nursing (DON) was asked if oxygen should be on the care plan. The DON stated, .yes . 3. Review of the medical record revealed Resident # 51 was admitted on [DATE] with diagnoses of Alzheimer's Disease, Hypertension, Hyperlipidemia, Vitamin D Deficiency, Gout and Dementia. Review of the care plan dated 11/20/2023 did not address Resident #51's history of or risk for Urinary Tract Infection. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating severely impaired cognition, and receives moderate assistance with toileting and personal hygiene. Review of the Treatment/Order Update/Change in Condition form dated 4/2/2024, revealed .nitrofurantoin [an antibiotic] .100 mg capsule: give 1 (one) tablet PO [by mouth.] BID [twice per day] x [for] 7 days for UTI. Review of the Medication Administration Record (MAR) dated April 2024 revealed Resident #51 received nitrofurantoin twice daily from 4/2/2024-4/8/2024. Review of the Treatment/Order Update/Change in Condition form dated 5/7/2024, revealed .Rocephin [an antibiotic] 1 gram .Intramuscular Every 1 Day for 3 Days . Review of the Treatment/Order Update/Change in Condition form dated 5/9/2024, revealed .Rocephin [an antibiotic] 1 gram .Intramuscular Every 1 Day for 3 Days .x 3 more doses for 5 total days . Review of the Treatment/Order Update/Change in Condition form dated 5/14/2024, revealed .Rocephin [an antibiotic] 1 gram .Intramuscular Every 1 Day for 3 Days . Review of the MAR dated May 2024, revealed .Rocephin 1 gram .for Three Days Starting 05/07/2024 .URINARY TRACT INFECTION .Rocephin 1 gram .for Three Days Starting 5/9/2024 .URINARY TRACT INFECTION .Rocephin 1 gram .for Three Days Starting 05/14/2024 .URINARY TRACT INFECTION . During an interview on 5/15/2024 at 3:35 PM, MDS Coordinator #1 was asked if Resident #51 was care planned for antibiotic use related to her recent Urinary Tract Infections and current use of antibiotics. MDS Coordinator #1 stated, .we would care plan her for risk for UTI. MDS Coordinator #1 confirmed Resident #51's care plan did not address the risk for Urinary Tract Infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to accurately assess the nutritional status and to follow the Registered Dietician's (RD) recommendations to provide nutritional interventions for 1 of 6 sampled residents (Resident #24) reviewed for nutrition. The findings include: Review of the facility's policy titled, .Dietary: Weight Monitoring, dated 11/09/2023, revealed .The facility shall utilize a systemic approach to optimize a resident's nutritional status .Identifying and assessing each resident's nutritional status and risk factors .Evaluating/analyzing the assessment information .Developing and consistently implementing pertinent approaches .Monitoring the effectiveness of interventions and revising them as necessary .The Registered Dietitian or Dietary Manager shall be consulted to assist with interventions .actions are recorded in the nutrition progress notes .Observations pertinent to the resident's weight status shall be recorded in the medical record as appropriate .The interdisciplinary plan of care shall communicate instructions to staff . Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Chronic Kidney Disease, Diabetes, Malignant Neoplasm of Bone and Kidney Disease. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24's Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition, and required extensive assistance from staff for all activities of daily living (ADL's). Resident #24 was not coded for weight loss during this review period. Review of the Care Plan dated 2/19/2024, revealed Resident #24 with weight loss .5% [percent] or more in last 30 days .3/11/2024 wt [weight] loss documentation .3/21/2024 [named resident] has a SWL [significant weight loss] in 30 days . Review of the Clinical Notes Report dated 2/29/2024, revealed .WT [weight]: 226# [pounds] 2/20/2024 .will recommend glucerna 1.58 oz [ounces] BID [twice daily] between meals for additional calories . Addendum Note on 3/4/2024 revealed, .Glucerna 1.5 unavailable at this time. May use Twocal [dietary supplement] . Review of Resident #24's Dietary Progress Notes dated 3/11/2024, revealed .WT: [weight] 186# [pounds] 3/8/[2024]. Monitored on weekly wts [weights] .Significant wt [weight] loss noted in one week .Will recommend to increase Twocal [dietary supplement] to 8 oz [ounce] TID [three times a day] . Review of Resident #24's Dietary Progress Notes dated 3/21/2024, revealed .WT [weight]: 190# [pounds] 3/21/2024. 15.93% [percent] SWL [significant weight loss] in 30 days . Review of MARCH 2024 MEDICATIONS, revealed .Twocal 0.08 gram-2 k[kilo]cal[calorie]/[per] ml [milliliter] oral liquid (8 oz [ounce] LIQUID(ML) Oral Two Times Daily starting 3/1/2024 . Review of Resident #16's medical record, dated 3/11/2024, revealed no documentation or physician order for Registered Dietician's (RD ' s) recommendation for Twocal [dietary supplement] 8 ounces three times a day. During an interview on 5/15/2024 at 1:27 PM, the RD was asked did she make a recommendation for Resident #24 to increase Twocal (dietary supplement) to three times a day for weight loss. The RD stated, Yes I did and we missed doing that .he [Resident #24] has carcinoma of the bone and kidney, and has a poor appetite, but has since gained some weight back . During an interview on 5/15/2024 at 4:04 PM, the Director of Nursing (DON) was asked did the facility follow the RD recommendations for weight loss for [named resident #24]. The DON stated No. The DON was asked should the facility follow the RD recommendations for weight loss. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately for 2 of 6 medication storage areas (200 Hall Medication Cart and the East Nurses Station) when a schedule II-V medication was open, unlabeled, and not properly secured and when an unidentified, unsecured pill was observed lying on the floor reviewed. The findings include: 1. Review of the facility's policy titled, Medication Administration, dated 8/4/2023, revealed .If medication is a controlled substance, record removal of medication and sign the Narcotic Control Record .Report and document any .refusals .Document med administrations immediately after each patient .Document refusals . Review of the facility's policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, dated 9/5/2023, revealed .It is the policy of this facility to ensure all medications housed on our premises shall be stored in the pharmacy and/or medication rooms .All drugs and biologicals will be stored in locked compartments .Schedule II, III, IV, and V medications are stored under double lock and key . 2. Observation of the 200 Hall Medication Cart on 5/14/2024 at 11:40 AM revealed an unlabeled medication in a cup in the top drawer of the medication cart. During an interview on 5/14/2024 at 11:41 AM, Licensed Practical Nurse (LPN) A confirmed the unlabeled medication in the cup was Hydrocodone (a narcotic used to relieve pain) she had pulled for administration to Resident #26. Review of the facility ' s Controlled Drug Receipt/ Record/ Disposition Form, dated 4/29/2024, revealed Resident #26 ' s Hydrocodone/Apap (Acetaminophen) 5/325mg (milligrams) showed there were 4 pills remaining. Observation of the 200 Hall Medication Cart on 5/14/2024 at 11:42 AM, revealed Resident #26 ' s Hydrocodone/Apap 5/325 mg pill count was 3. During an observation of 200 Hall Medication Cart on 5/14/2024 at 11:42 AM, revealed a white, oblong tablet in an unlabeled medication cup sitting in top drawer of medication cart. During an interview with the Director of Nursing (DON) on 5/14/2024 at 12:09 PM, The DON confirmed that the narcotic count and the narcotic medication card should match. The DON confirmed that controlled medications should be stored under a double lock. 3. Random observation on 5/15/2024 at 12:51 PM, revealed a peach-colored pill lying on the floor, unsecured and unattended, near East Hall nurses ' station. During an interview on 5/15/2024 at 3:02 PM, the DON confirmed that there should not be medication in the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to promote a resident's dignity during dining for 1 of 18 (Resident #48) residents reviewed for dignity. The findings include: The facility's .Promoting/Maintaining Resident Dignity revised 11/2017 documented, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Compliance Guidelines .When interacting with a resident, pay attention to the resident as an individual .Groom and dress residents according to resident preference . Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Anemia, Diabetes, Hypertension, and Osteoarthritis. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had moderately impaired cognition, required extensive assistance of staff for dressing and personal care, and was independent when eating. Observations in Resident #48's room on 10/1/19 at 8:39 AM, revealed Resident #48 was seated in her wheelchair with her breakfast tray on the overbed table in front of her. Resident #48 was dressed in a long sleeved sweatshirt and a brief. Resident #48 stated, I need some pants on. Observations in Resident #48's room on 10/2/19 at 8:18 AM, revealed Resident #48 sitting up in bed with her breakfast tray on the overbed table in front of her. Resident #48 pulled back the sheet to reveal she was naked from the waist down. Resident #48 stated, I would sure like to have some pants on while I eat my breakfast. Interview with Certified Nursing Assistant (CNA) #1 on 10/3/19 at 11:00 AM, beside the 300 Hall Kiosk, CNA #1 was asked if she assisted Resident #48. CNA #48 confirmed that she regularly assisted Resident #48 with her care. CNA #1 confirmed Resident #48 liked to be dressed for breakfast. CNA #1 was asked if a resident should be naked or dressed in a brief from the waist down while eating breakfast. CNA #1 stated, No . Interview with the Director of Nursing (DON) on 10/3/19 at 11:26 AM, in the 200 Hall Utility Room, the DON was asked if a resident should be naked or dressed in a brief from the waist down while eating breakfast. The DON stated, They should be dressed, if that is their preference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to provide reasonable accommodations for toilet use as ordered by the physician for 1 of 18 (Resident #72) sampled residents reviewed. The findings include: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Psychotic Disorder with Delusions, Dementia, and Delirium. The PHYSICIAN'S ORDER SHEET AND PROGRESS NOTES dated 9/25/19 documented, .Bedside Commode . Review of the admission Minimum Data Set (MDS) with an assessment reference date of 9/26/19 revealed Resident #72 required extensive two person assistance for toileting, was frequently incontinent of bladder, and occasionally incontinent of bowel. Observations in Resident #72's room on 9/30/19 at 3:45 PM, on 10/1/19 at 7:56 AM, 12:54 PM, and 4:27 PM, on 10/2/19 at 7:50 AM, 10:00 AM, and 3:45 PM, and on 10/3/19 at 7:37 AM and 4:27 PM, revealed there was n o bedside commode. Interview with Certified Nursing Assistant (CNA) #2 on 10/3/19 at 8:32 AM, in the 400 hall, CNA #2 was asked if Resident #72 knew when she needed to use the bathroom. CNA #2 stated, Yesterday she did . Interview with Physical Therapy Assistant (PTA) on 10/3/19 at 8:36 AM, in the Therapy Gym, the PTA was asked if Resident #72 was able to stand and transfer. The PT stated, It takes 2 people [to assist her]. The PTA was asked if he had assessed Resident #72 to be able to use a bedside commode. The PTA stated, No .That would be more for OT [Occupational Therapy] . Interview with the Occupational Therapist (OT) on 10/3/19 at 9:09 AM, in the Private Dining Room, the OT was asked if she had evaluated Resident #72 for use of a bedside commode. The OT stated, We have assessed her for transfers, and right now she is requiring the assist of 2 persons. Interview with the Assistant Director of Nursing (ADON) on 10/3/19 at 2:44 PM, in the Private Dining Room, the ADON was asked about the physician's order for the bedside commode that was written on 9/25/19 after the Physical Therapy evaluation on 9/19/19. The ADON stated, All I can think of is that the doctor may have made rounds and they [family] may have asked for it, and he may have just ordered it without looking at the therapy notes. The ADON was asked if he had spoken with the physician about the order. The ADON stated, No, I haven't.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of The National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide 2014, medical record review, observation, and interview, the facility failed to assess and implement interventions as ordered for pressure ulcers for 1 of 4 (Resident #72) sampled residents reviewed for pressure ulcers. The findings include: 1. The NPUAP Prevention and Treatment of Pressure Ulcers: Quick Reference Guide dated 2014 documented, .Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Effective assessment and monitoring of wound healing is based on scientific principles, as described in this section of the guideline .1. Complete a comprehensive initial assessment of the individual with a pressure ulcer .Document the results of all wound assessments .Address signs of deterioration immediately .Assess and document physical characteristics including: location .Stage .size .tissue type .color .periwound condition .wound edges .sinus tracts .undermining .tunneling .exudate .odor . Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time .Select a consistent, uniform method for measuring depth .Stage II: Partial Thickness Skin Loss .presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Suspected Deep Tissue Injury: Depth unknown. Purple maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure . 2. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Glaucoma, Hypothyroidism, Psychotic Disorder with Delusions, Dementia, Delirium. Review of the Braden scale assessments dated 9/13/19 and 9/27/19 revealed Resident #72 was at high risk for development of pressure ulcers. The Physician Order Sheet documented, .Skin Prep Wipes .apply skin prep to bilateral heels and cover with protective dressing daily until resolved .Order date: 9/25/2019 . The physician's orders dated 9/26/19 documented, .apply splint .Notes: Physical Therapist recommends that patient have B [bilateral] heel floatation soft [NAME] boots donned when in bed and when out of bed, as much .as tolerated in order to reduce risk of wound/ulcer/skin breakdown of heels . The Care Plan dated 9/30/19 documented, .at risk of pressure ulcer related to incontinence and decreased mobility .Interventions .PT [Physical Therapy] Recommendation for B/L [bilateral] heel floatation soft [NAME] boots as tolerated . Medical record review of the Wound Assessments dated 10/1/19 revealed Resident #72 had a Stage 2 Pressure Ulcer to the right heel and a blister that was now a Deep Tissue Injury to the left heel. Both of these pressure ulcers had an onset date of 9/23/19. There were no wound assessments prior to 10/1/19. Observations in Resident #72's room on 9/30/19 at 11:18 AM and 3:45 PM, on 10/1/19 at 7:56 AM and 4:27 PM, on 10/2/19 at 7:50 AM, 9:31 AM, and 3:25 PM, and on 10/3/19 at 3:41 PM, revealed Resident #72 was lying in bed without heel protector boots. Observations at the Nurses' Desk on 9/30/19 at 12:24 PM, revealed Resident #72 sitting in a reclined geriatric chair without heel protector boots. Observations in resident #72's room on 10/1/19 at 4:27 PM, revealed Resident #72 lying in bed. The Wound Care Nurse removed her socks and an adhesive dressing from both of her heels, which revealed a large pink wound to her right heel and a large pink wound with purple edges to her left heel. The Wound Care Nurse stated the right heel felt soft to touch. The Wound Care Nurse was asked what type of wounds they were. The Wound Care Nurse stated, I can't think off the top of my head .at first we were calling them [wounds] fluid-filled, but I will be staging them [wounds] . Interview with the Wound Care Nurse on 10/1/19 at 4:42 PM, in the Private Dining Room, the Wound Care Nurse stated, .We would not write it up .it [wound] started as a fluid-filled blister . Telephone interview with Medical Doctor (MD) #1 on 10/2/19 at 1:05 PM, MD #1 was asked if he expected nursing staff to assess wounds upon identification. MD #1 stated, Yes. MD #1 was asked what he expected nursing staff to do. MD #1 stated, Stage it [wound], measure it, do an assessment overall, why they're [wounds] there, if they [resident] ever had problems before, if they [resident] are diabetic or not, renal status, mobility of patient, everything . Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 10/3/19 at 9:34 AM, in the Sky and Ivy Room, the DON and ADON were asked what they expected staff to do upon identification of a wound. The DON stated, They [nursing staff] do a new wound process .notify the doctor and the family .put an intervention in place, and monitor it [wound] from there . The DON was asked if there should have been an assessment upon identification of Resident #72's heel wounds. The DON stated, They [staff] notified me 2 days ago of the blisters to her [Resident #72's] heels .on 9/23 they [staff] noted blisters to her [Resident #72's] heels .when they [staff] notified me that she [Resident #72] did have those [blisters] on there, I did the new wound process, we clarified with the doctor and with [Named Wound Care Nurse] that they [blisters] were pressure wounds .Therapy also initiated .the boots [heel protector boots]. They [wounds] were being addressed, just not appropriately documented . The DON was asked if Resident #72 should be wearing the heel protector boots. The DON stated, I would have to look in the order. The facility was unable to provide any wound assessments for the stage 2 pressure ulcer to Resident #72's right heel and for the suspected deep tissue injury to Resident #72's left heel from the time of identification on 9/23/19 until 10/1/19, after the surveyor wound observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, thirteenth edition, provided by the American Society of Consultant Pharmacists, medical record review, and interview, the facility failed to ensure accurate documentation of diagnoses for prescribed medications for 3 of 5 (Resident #31, #57, and #76) sampled residents reviewed for unnecessary medications. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, thirteenth edition, beginning on page 7, documented, .Medication Class [Classification] .Analgesics: Opioids . Hydrocodone . Antidepressants .Mirtazipine [Remeron] .Anxiolytic: Benzodiazepines [Xanax] .Gastrointestinal (GI) Agents: Laxative .Magnesium Hydroxide [Milk of Magnesia] .GI Agents: Proton Pump Inhibitor .Pantoprazole .GI Agents: Stool Softener .Docusate [Colace] .Respiratory Agents: Steroids (Nasal) .Fluticasone . 2. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses of Venous Insufficiency, Cerebral Infarction, Hypertension, Peripheral Vascular Disease, Mood Disorder, Dysphagia, Psychosis, and Senile Degeneration of Brain. A physician's order dated 9/26/19 documented, .HYDROcodone .acetaminophen . Related Diagnoses .Psychosis . A Medication Administration Record (MAR) dated September 2019 documented, .HYDROcodone .acetaminophen . PSYCHOSIS . Hydrocodone/Acetaminophen is a drug combination used to treat pain. A physician's order dated 9/26/19 documented, .Xanax .Related Diagnoses .Dementia . A MAR dated September 2019 documented, .Xanax .Dementia . Xanax is a medication used to treat anxiety. 3. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses of Anemia, Diabetes, Hypertension, Atherosclerosis, Hyperlipidemia, Atrial Fibrillation, Hypothyroidism, Peripheral Vascular Disease, Hemiplegia, Anxiety, Insomnia, and Depression. A physician's order dated 9/27/19 documented, .Colace .Related Diagnoses .Muscle Weakness . A MAR dated September 2019 documented, Colace .MUSCLE WEAKNESS . Colace is a medication used to treat constipation. A physician's order dated 9/27/19 documented, .fluticasone .nasal spray .Related Diagnoses .HYPERTENSION . A MAR dated September 2019 documented, .fluticasone .nasal spray .HYPERTENSION . Fluticasone is a medication used to treat nasal allergy symptoms. A physician's order dated 9/27/19 documented, .pantoprazole .Related Diagnoses .Hypertension . A MAR dated September 2019 documented, .pantoprazole .HYPERTENSION . Pantoprazole is a medication used to treat acid reflux. 4. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses of Wedge Compression Fracture, Acute Pain due to Trauma, Constipation, Hyperlipidemia, Hypertension, Retention of Urine, Anxiety Disorder, Muscle Weakness, Overactive Bladder, Peripheral Vascular Disease, Otitis Media, and Diabetes. A physician's order dated 7/13/19 documented, .pantoprazole .Related Diagnoses .HYPERLIPIDEMIA . The September MAR documented, .pantoprazole .Hyperlipidemia . Pantoprazole is a medication used to treat stomach ulcers. A physician's order dated 8/5/19 documented, .Remeron .Related Diagnoses .MUSCLE WEAKNESS . The September MAR documented, .Remeron .Muscle Weakness . Remeron is a medication used to treat depression. Telephone interview with the Consultant Pharmacist on 10/3/19 at 8:29 AM, the Consultant Pharmacist was asked who was responsible for ensuring medications prescribed for residents in the facility had accurate diagnoses. The Consultant Pharmacist stated, .nursing, medical doctor, and pharmacist . The Consultant Pharmacist was asked if muscle weakness was an accurate diagnoses for Remeron. The Consultant Pharmacist stated, .it's used for depression and appetite .I don't know what the logic was for that. The Consultant Pharmacist was asked if generalized weakness was an accurate diagnosis for the use of Colace. The Consultant Pharmacist stated, I wouldn't think so .it's for constipation . The Consultant Pharmacist was asked if dementia was an accurate diagnosis for the use of Xanax. The Consultant Pharmacist stated, Xanax is for anxiety. The Consultant Pharmacist was asked if he had identified incorrect diagnoses for prescribed medications in the facility. The Consultant Pharmacist stated, .In the past we have asked for corrections .about 8 months ago we hit them pretty hard on diagnoses .gave them 24 hours to get it corrected .they are still picking the wrong diagnoses .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure nutritional interventions were provided to prevent further weight loss for 2 of 5 (Resident #46 and 58) sampled residents reviewed for weight loss. The findings included: 1. The facility's Weight Monitoring policy dated 11/27/17 documented, .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status .Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem .The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes .Developing and consistently implementing pertinent approaches .Monitoring the effectiveness of interventions and revising them as necessary . 2. The facility's Dietary Services Training Manual dated 10/13, documented, .In the case where fortified foods and/or extra portions of food items are provided as a result of a nutritional concern .weight loss .these items must have a physician's order .Super Oatmeal .oatmeal .Super Spuds .instant potatoes . 3. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Osteoporosis, Alzheimer's Disease, Anxiety, Cognitive Communication Deficit, Constipation, Epilepsy, Expressive Language Disorder, Depression, Schizoaffective Disorder, Insomnia, and Vitamin D Deficiency. The quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 1, which indicated severe cognitive impairment, required extensive staff assistance for eating, had a weight loss of 5 percent (%) or more in the past month or 10% or more in the past 6 months, and was not on a physician-prescribed weight-loss regimen. The Care Plan dated 8/2/18 documented, .At risk for weight loss .Interventions .Dietary supplements as ordered .Weight loss; 5% or more in last 30 days or 10% or more in last 180 days .Monitor and document weight with interventions implemented as indicated . Review of the Patient Weight Report revealed a weight of 132 pounds on 5/21/18, and a weight of 109 pounds on 11/12/18, which indicated a significant weight loss of 17.42% over 6 months. The physician's orders dated 11/14/18 documented, .super spuds at lunch related to weight loss .First scheduled time is 11/14/2018 at 11:30 AM . Resident #46's lunch tray card documented, .Diet .Puree .super spuds . Observations in the dining room on 11/15/18 at 12:00 PM, revealed Certified Nursing Assistant (CNA) #1 seated next to Resident #46 and assisting her to eat her pureed lunch meal. CNA #1 was asked what she was having to eat. CNA #1 stated, Pinto beans, greens, and Polish sausage. There were no Super Spuds (fortified mashed potatoes) on the tray. Interview with the Registered Dietician (RD) on 11/15/18 at 2:08 PM, in the conference room, the RD was asked what interventions had been implemented to prevent further weight loss. The RD stated, .Super Spuds were ordered yesterday to provide more calories .That would have been started today at lunch. The RD was asked why Resident #46 did not receive the Super Spuds on her tray at lunch today. The RD confirmed Resident #46 should have received the Super Spuds on her lunch tray and stated, .a miscommunication . 4. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease, Hypertension, Cognitive Communication Deficit, and Dementia. The Care Plan dated 10/11/18 documented, .At risk for wt [weight] loss .Interventions .Dietary supplements as ordered . The physician's orders dated 11/7/18 documented, .Super Cereal 1 Bowl .Every Morning Starting 11/07/2018 . Review of Resident #58's breakfast tray card revealed the physician's order for the Super Cereal was not transcribed on the tray card. Observations in Resident #58's room on 11/15/18 at 10:37 AM, revealed Resident #58 was sitting in a wheelchair, and Sitter #1 was assisting her to eat her breakfast meal, which consisted of bacon, pancakes, ice cream, and orange juice. There was no Super Cereal (fortified oatmeal) on the tray. Interview with Sitter #1 in Resident #58's room on 11/15/18 at 12:18 PM, Sitter #1 was asked if Resident #58 received any cereal or oatmeal for breakfast this morning. Sitter #1 confirmed she did not. Review of the Patient Weight Report revealed a weight of 139.6 pounds on 10/3/18, and a weight of 131.2 pounds on 11/3/18, which indicated significant weight loss of 6% in 1 month. The weight for 11/13/18 was 124.5 pounds, which was a total loss of 10.8% since admission on [DATE]. Interview with the Food Service Supervisor on 11/15/18 at 1:05 PM, in the conference room, the Food Service Supervisor was asked who was responsible for putting the Super Cereal on the breakfast tray. The Food Service Supervisor stated, Kitchen .It should print on the tray card . Interview with the RD on 11/15/18 at 1:51 PM, the RD was asked what interventions had been implemented to prevent further weight loss. The RD stated, .Super Cereal was started on 11/7. That comes out on her breakfast tray. Interview with the RD on 11/15/18 at 2:08 PM, in the conference room, the RD was asked why the Super Cereal was not documented on Resident #58's breakfast tray card as ordered, and why Resident #58 did not get the Super Cereal on her breakfast tray. The RD stated the Super Cereal was ordered by the Nurse Practitioner instead of by the weight team, who usually adds the food item on the tray card. The RD confirmed Resident #58 should have received the Super Cereal on her tray.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 1 of 1 (Licensed Practical Nurse (LPN) #1) nurse failed to perform hand hygiene or wear gloves during a blood glucose test, and failed to discard a used glucometer strip in the biohazardwaste . The findings included: 1. The facility's Hand Hygiene policy with a revision date of 4/18 documented, .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection . 2. The facility's Infectious Waste policy with a revision date of 9/17 documented, .Infectious Waste will be disposed .Waste containers must be closable and ensure that waste will be contained. The design of the container must be such that it is able to retain the waste over an extended period of time between pickups by a specialized waste service .Regard non-absorbent disposable .devices that have been contaminated with blood, body fluids or blood contaminated secretions or excretions as infectious waste . 3. The facility's Glucose Monitoring inservice documented, .Perform hand hygiene .Apply gloves .Insert test strip into glucometer . Observations in Resident #40's room on 11/15/18 at 4:50 PM, revealed LPN #1 performed a blood glucose test on Resident #40 using her bare hands without performing hand hygiene, and then discarded the used blood glucose strip in the regular uncovered trash in Resident #40's bathroom. Interview with the Assistant Director of Nursing (ADON) on 11/15/18 at 5:16 PM, in the conference room, the ADON was asked if she expected nurses to wash their hands before performing an accucheck (a fingerstick blood glucose test). The ADON stated, Yes. The ADON was asked if she expected nurses to wear gloves when performing an accucheck. The ADON stated, Yes. The ADON was asked how the used blood glucose test strip should be discarded after the test. The ADON stated, .put it in the sharps.