Every finding on record at Avera Granite Falls Care Center

Based on observation, interview, and document review, the facility failed to have a system in place to monitor resident room refrigerators for appropriate temperatures and develop a process to ensure food was dated and discarded appropriately for 9 of 9 sampled residents (R1, R8, R17, R19, R20, R21, R25, R37, and R40) with in-room refrigerators to prevent potential food-borne illness. Findings include: Observation and interview on 8/31/26 at 3:05 p.m. through 3:32 p.m. of the following residents in their rooms identified:R17 had a small refrigerator with a freezer located in her room. The fridge appeared clean and had several unopen cans of soda. There was no thermometer located in the refrigerator or freezer and no log to document staff had monitored the temperature for safety.R19 had a dorm style refrigerator with a freezer located in her room. The refrigerator had a clear zipped locked bag of orange slices with no date and an open container of tomatoes with no lid. A thermometer was in the refrigerator that read 39 degrees. R19's refrigerator lacked a date on food items to ensure food was discarded appropriately to prevent food-borne illness. There was also no log to document staff had monitored the temperature for safety.R21 had a small refrigerator with a freezer located in her room. The refrigerator appeared clean and had a thermometer that read 39 degrees. There was also no log to document staff had monitored the temperature for safety.R8 had a dorm style refrigerator with a freezer located in her room. The refrigerator appeared clean with no perishable items. There was no thermometer observed in the refrigerator or freezer and no log to document staff had monitored the temperature for safety.R37 had a small refrigerator with a freezer located in her room. The refrigerator contained unopened cans of soda and a reusable cold pack that was found at the bottom of the refrigerator. A thermometer was in the refrigerator that read a temperature of 39 degrees. The freezer did not have a thermometer. She was not aware if staff checked her fridge on a routine basis. There was also no log to document staff had monitored the temperature for safety. Interview on 9/1/26 at 10:59 a.m., with housekeeping aide (HK)-A identified that housekeeping staff did not complete temperature checks of resident personal refrigerators. Residents and their families were to maintain cleanliness of their personal refrigerators. Observation on 9/1/26 at 2:35 p.m. through 3:02 p.m., the following residents in their rooms identified:R1 had dorm style refrigerator with a freezer located in her room. The top shelf of the refrigerator contained a Ziplock bag of a slice of apple pie with no date. The bottom of the refrigerator contained 3 zip lock bags of sliced cheese and salami meat. Two of the zip lock bags had a date of 7/17. The third bag contained a slice of cheese with the appearance of several small fuzzy black coating, mold-like in appearance, surrounding the outside of the cheese with no date. The refrigerator had a thermometer that read 34 degrees. R1's refrigerator lacked a date on food items to ensure food was discarded appropriately to prevent food-borne illness and no log to document staff had monitored the temperature for safety.R20 had a small refrigerator with a freezer located in his room. The refrigerator contained an open package of [NAME] with no open date. There was no thermometer observed in the refrigerator or freezer. R20's refrigerator lacked a date on food items to ensure food was discarded appropriately to prevent food-borne illness and no log to document staff had monitored the temperature for safety.R25 had a small refrigerator with a freezer located in her room. The refrigerator contained ranch dip with a date of February 2026, an unknown, of what appeared to be fruit, stored in a bag with no date, and 2 containers of ready-to-eat macaroni and cheese with a date of June 2026. R25's refrigerator lacked a date on food items to ensure food was discarded appropriately to prevent food-borne illness. There was no thermometer observed in the refrigerator or freezer and no log to document staff had monitored the temperature for safety. Observation and interview on 9/2/26 at 8:33 a.m., with R40 and Licensed practical nurse (LPN)-A inside of R40's room identified there was a small refrigerator with a freezer. The refrigerator contained an apple, a jar of jelly, and unknown condiments. The condiments were found to be expired and were disposed of during the observation. There was no thermometer observed in the refrigerator or freezer. R40's refrigerator lacked a date on food items to ensure food was discarded appropriately to prevent food-borne illness. R40 stated her daughter brought them from home. LPN-A stated nursing staff were not aware of the process to check and clean resident refrigerators on a routine basis. Returned call on 9/02/26 at 9:31 a.m., with R25's family member (FM)-D identified he received a letter from the facility that included a reminder to ensure cleaning and food products were checked or discarded for R40's refrigerator. On a routine visit to see R40, he provided meat and cheese slices from home and placed the food items in R40's fridge. He agreed with the findings of the expired food items. He identified R40 was visually impaired, and if she had eaten the expired food items it could cause R40 to be sick. Returned phone call on 9/02/2026 at 1:37 p.m., with administrator identified he agreed with the above findings and acknowledged that the facility lacked monitoring of residents' personal refrigerators. He stated a plan of correction would be implemented to ensure residents food and refrigerator temperatures would be monitored on a routine basis to ensure safety. Review of July 2026, Personal Refrigerators policy identified that foods or beverages were to not be outdated and was the responsibility of the resident and/or family member to monitor and comply, including the cleanliness inside and outside of the refrigerator, and must be maintained by the resident/family. There was no indication the facility was aware they were responsible overall for the care and safety of their residents.

Based on interview and document review the facility failed to provide a notification to ombudsman of discharge to hospital for 2 of 2 sampled residents (R8 and R22). Findings include: R8's comprehensive Minimum Data Set (MDS) assessment accepted on 7/15/26, identified she had diagnoses of anxiety, depression, high blood pressure, and a seizure disorder. She was dependent on staff for assistance with dressing, transfers, and hygiene and her cognition was intact. R8's nursing home discharge Minimum Data Set (MDS) assessment accepted on 3/25/26, identified R8 had an unplanned discharge to an acute care hospital on 3/19/26. Interview on 9/2/26 at 10:56 a.m., with the director of nursing (DON) identified they had no documentation to support the Ombudsman had been notified of discharge. When a resident has an unplanned or emergency transfer to the hospital it is the nurse's responsibility to fill out and fax the notice of discharge to the ombudsman. She identified the process needs to be reviewed and changes may be needed. R22 R22's accepted 8/04/26 at 2:02 p.m., comprehensive Minimum Data Set (MDS) identified she was cognitively intact and had a diagnosis of heart failure and anxiety. R22 was dependent on staff for transfers and mobility. R22 accepted 8/04/26 at 8:00 p.m., nursing home discharge MDS identified R22 had a discharge to the hospital on 7/25/26 and on 8/02/26. Interview on 9/2/26 at 10:56 a.m., with the director of nursing (DON) identified they had no documentation to support the Ombudsman had been notified of discharge. When a resident has an unplanned or emergency transfer to the hospital it is the nurse's responsibility to fill out and fax the notice of discharge to the ombudsman. She identified the process needs to be reviewed and changes may be needed. Review of July 2026, Transfer and Discharge Rights policy identified the facility must send a copy of the discharge notice to the State Long-Term Care Ombudsman.

Based on interview and record review the facility failed to ensure a mechanical lift sling was properly secured and free from entanglement hazards following transfer and/or prior to wheelchair transport for 1 of 3 residents (R1) which resulted in harm when R1's left leg became entangled in the strap which caused a traumatic hematoma on the leg that required hospitalization, surgical intervention, and blood transfusion. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance (PNC). Findings include:R1's quarterly [NAME] Data Set (MDS) dated [DATE] indicated R1 had moderately impaired cognition, required maximum assistance with mobility, and was dependent on staff for transfers using a wheelchair. Diagnoses included heart failure, peripheral vascular disease, neuropathy, arthritis, osteopenia, and chronic pain syndrome.R1's activities of daily living (ADL) care plan dated 9/27/22 identified her as at risk for ADL decline, with interventions that included the use of a full-body mechanical lift for all transfers (initiated on 4/19/23). Staff to use purple sling with green trim lift sling and to ensure straps are secured in wheelchair per residents' preference.The facility reported incident dated 9/11/25, identified R1 was being returned to her room by Activity Director (AD)-A following an outing when a lower sling strap became caught in the front wheel of her wheelchair, pulling R1's left lower leg backward and tightly against the chair. Nursing assistant (NA-J) was sitting at the nurses' station, heard R1 say Ow and observed the entanglement. NA-J immediately intervened, stopped the wheelchair and loosened the strap. At the time, no visible injury was noted by NA-J or licensed practical nurse (LPN)-A.R1's hospital Discharge summary dated [DATE], indicated R1 experienced increased, uncontrolled pain, and was transferred to the emergency department. She was diagnosed with a traumatic hematoma, requiring incision and drainage. R1 also required a blood transfusion of 2 units, due to a hemoglobin dropping from 14 to 7.3 grams per deciliter (Normal range is 12.0 to 13.5g/dl). R1 was admitted to acute care, discharged back to the facility on 9/15/25. Hospice consult was ordered. and placed on hospice care the same day. She required ongoing daily dressing changes to the hematoma site.The facility's internal investigation dated 9/11/25, revealed the leg strap of the lift sling that had been left underneath R1 after she was transferred to the wheelchair had not been properly secured or tucked away. Interviews with AD-A and NA-J confirmed that the sling strap had fallen and became wrapped around the front wheelchair wheel, pulling R1's leg backwards.AD-A's typed statement dated 9/11/25, identified that AD-A was returning R1 to her room after an outing at approximately 2:00 p.m., when her straps from her sling dropped down and got caught in R1's front wheelchair wheel. This strap pulled R1's leg back. R1 yelled out and they stopped abruptly. NA-J was sitting at the nurses' station and assisted to get the strap out of the wheel. NA-J returned R1 to her room while AD-A informed licensed practical nurse (LPN)-A of incident.NA-J's Granite Falls Health Vulnerable Adult Witness/Report Form dated 9/12/25 was handwritten by NA-J, identified on 9/11/25 at approximately 2:40 p.m., R1 was being brought back to her room by AD-A. When they were passing the nurses' station on B wing NA-J heard R1 say Ow. He looked over and immediately saw the left leg sling strap had fallen and was wrapped around the front wheel of R1's wheelchair. Trapping R1's left leg backwards against the wheelchair. NA-J had AD-A stop immediately and knelt in front of R1 to loosen the leg strap and re-tuck the leg strap beside R1. NA-J then took R1 back to her room and laid her down in bed. NA-J did not see any bruising, redness or swelling to site.LPN-A's Vulnerable Adult Witness/Report form dated 9/12/25, identified LPN-A was made aware of incident on 9/11/25, by activity staff that R1's sling strap got ran over and caught R1's left leg with it. LPN-A indicated she did not see redness or bruising on R1's leg.During an interview on 9/18/25 at 2:05 p.m., AD-A stated she was the staff person pushing R1 back to her room when the lower strap became entwined in the from wheel of R1's wheelchair. AD-A let NA-J take R1 back to her room while she went to LPN-A to report the incident. AD-A stated she could not remember if when unloading R1 from bus if the sling straps were hanging down but thought had she been aware she would have tucked them in. During an interview on 9/18/25 at 2:16 p.m., NA-J stated he was sitting at Nurses' station B when AD-A was pushing R1 in her wheelchair back to her room. R1' stated Ow. NA-J looked over and saw that the lower strap of the full body lift sheet had fallen and pulled R1's left lower leg back against the chair tightly. NA-J stopped AD-A and assisted with getting the strap loosened and tucked back into the chair. NA-J took R1 back to her room and assisted her to bed. He examined the lower left leg and did not see any redness or bruising. Na-J further stated that when he had gotten R1 up for the outing, he had tucked her straps back and under R1 so they would not be hanging down. During an interview on 9/19/25 at 12:50 p.m., LPN-A stated she was made aware of incident by AD-A. When LPN-A went to look at R1's leg immediately following the incident, R1 did not complain of pain and she did not see any redness, bruising or swelling. LPN-A left that day without documenting the incident in R1's record. LPN-A stated the sling straps needed to be tucked back and under the resident to prevent them from becoming entangled in the wheelchair and/or get caught on something. During an interview on 9/19/25 at 10:59 a.m., registered nurse (RN)-A was working the evening shift on 9/11/25. Around 6:00 p.m., she was notified that R1 had pain and developed bruising. When RN-A went to assess R1, she had increased pain and found a hematoma on R1's left leg that seemed to have increased in size in a short time. RN-A immediately called the ambulance for transport to the emergency department. RN-A stated the staff were supposed to secure the straps back and under R1 while she was in her wheelchair, otherwise they could get caught in the wheels. Since the incident with R1, the resident who required full body lifts care plans were updated with their preference as to whether they wanted to leave the sling under them and how the straps were to be stowed. During an interview on 9/19/25 at 9:50 a.m., director of nursing (DON) stated she made aware of incident right away and implemented the In the Moment training with all staff working and via mass email with those that were not. DON also went to all 9 residents that required total body lifts and clarified their care plan with the preference of resident on the positioning of the straps while resident was in their wheelchairs.During an interview on 9/19/25 at 1:10 p.m., EZ Way representative (REP)-A, stated was up to facility as to whether the lift sling was kept under residents and where the ends were tucked if kept under resident.The facility identified noncompliance and immediately implemented corrective actions, including:-Conducted Just-in-Time training for all nursing and activity staff on 9/12/25, covering:-Proper strap placement after transfers.-Requirement to tuck in all sling straps to prevent dragging or entanglement.-If a strap is seen hanging or crossed between the legs post-transfer, staff are to tuck the straps per resident's care plan.-Consultation with the lift manufacturer (EZ Way REP-A) confirmed the facility is responsible for determining sling storage policies and safety procedures, 9/12/25.-Director of Nursing (DON) and nursing leadership reassessed all 9 residents who use total body lifts to ensure individualized care plans included clear direction on sling storage and strap management preferences, 9/15/25.-DON ensured ongoing visual monitoring of sling use practices and documentation.

Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employees would be able to return to work after an illness, dependent upon their symptoms and resolution of illness for 3 of 3 staff nursing assistant (NA)-A, NA-B, and infection preventionist (IP)-A. This had the potential to affect all 48 residents who resided at the facility. Findings include: Review of the employee illness form and log identified the following information was to be obtained:NamePosition Manager Date/time symptoms startedDates/Shifts worked 48 hours within symptoms starting or date of test if asymptomaticLast day workedDate of covid-19 test Did you have close contact with patient being within 6' for greater than 15 minutes cumulative time?Were you ever within 6' of other employees without a mask? Review of the facility staff illness forms and surveillance logs from August of 2025 through September 8 of 2025 identified the following. On:8/9/25, NA-B had symptoms of cough, congestion, and body aches. Covid test was negative. The log did not identify the last day worked, when the symptoms had resolved, or when the staff returned to work.8/31/25, NA-A had symptoms of feeling unwell. The log did not identify what symptoms the staff was experiencing, the last shift they had worked, when the symptoms had resolved, or when the staff had returned to work.9/8/25, Infection preventionist had respiratory symptoms, was afebrile, a covid test was completed on 9/8 and 9/9, and results were negative. The log did not identify the last shift worked, when the symptoms resolved, or when the staff returned to work. Interview on 9/10/25 at 11:21 a.m., with the infection preventionist identified the facility uses a form that should be completed when a staff calls in an absence due to illness. Staff do not always enter all the information that is required. Since Covid has calmed down and processes have changed, some of the employee illness requirements of documentation have fallen through the cracks. She was hired as the IP in April of 2025, and was still in training. She was enrolled in classes to become certified, but she has not started yet. If she had questions, she could ask registered nurse (RN)-B who is a certified infection preventionist. Interview on 9/10/25 at 1:49 a.m., with RN-B identified She was not the IP at the facility but is certified from previous employment. She is not providing oversite to the new IP. She was delegated to assist the IP if needed. She thought the staff illness logs were being completed and identified if she was to be providing oversite to the IP, nobody had told her. Interview on 9/10/25 at 1:49 p.m., with the director of nursing (DON) identified she should have made it clearer what her expectations were of RN-B regarding providing oversite. RN-B had mentioned in the past to her, that she was unable to find any staff illness logs and had concerns that it was not getting done. The DON believed they had a lack of communication and identified they would be starting a performance improvement project (PIP) immediately to fix this concern. Review of the facilities current Infection Prevention and Control Job Description identified essential job functions included being proficient in surveillance using National Healthcare Safety Network surveillance definitions for healthcare associated infections. Reviews, investigates, and analyzes surveillance data. Works collaboratively with Employee Health and individual departments to educate staff, monitor compliance, and recommend improvements.

Based on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate training and oversight of the infection control (IC) program by management by performing current, daily cumulative infection control surveillance activities, maintain documentation of incidents, findings, and any corrective actions required, and ensure the IC program continued while the newly hired IP completed training. Findings include: Review of the employee illness form identified the following information was to be obtained:NamePosition Manager Date/time symptoms startedDates/Shifts worked 48 hours within symptoms starting or date of test if asymptomaticLast day workedDate of covid-19 test Did you have close contact with patient being within 6' for greater than 15 minutes cumulative time?Were you ever within 6' of other employees without a mask? Review of the facility staff illness forms and surveillance logs from August of 2025 through September 8 of 2025 identified the following. On:8/9/25, NA-B had symptoms of cough, congestion, and body aches. Covid test was negative. The log did not identify the last day worked, when the symptoms had resolved, or when the staff returned to work.8/31/25, NA-A had symptoms of feeling unwell. The log did not identify what symptoms the staff was experiencing, the last shift they had worked, when the symptoms had resolved, or when the staff had returned to work.9/8/25, Infection preventionist had respiratory symptoms, was afebrile, a covid test was completed on 9/8 and 9/9, and results were negative. The log did not identify the last shift worked, when the symptoms resolved, or when the staff returned to work. Interview on 9/10/25 at 11:21 a.m., with the infection preventionist identified the facility uses a form that should be completed when a staff calls in an absence due to illness. Staff do not always enter all the information that is required. Since Covid has calmed down and processes have changed, some of the employee illness requirements of documentation have fallen through the cracks. She was hired as the IP in April of 2025, and was still in training. She was enrolled in classes to become certified, but she has not started yet. If she had questions, she could ask registered nurse (RN)-B who is a certified infection preventionist. Interview on 9/10/25 at 1:49 a.m., with RN-B identified She was not the IP at the facility but is certified from previous employment. She is not providing oversite to the new IP. She was delegated to assist the IP if needed. She thought the staff illness logs were being completed and identified if she was to be providing oversite to the IP, nobody had told her. Interview on 9/10/25 at 1:49 p.m., with the director of nursing (DON) identified she should have made it clearer what her expectations were of RN-B regarding providing oversite. RN-B had mentioned in the past to her, that she was unable to find any staff illness logs and had concerns that it was not getting done. The DON believed they had a lack of communication and identified they would be starting a performance improvement project (PIP) immediately to fix this concern. Review of the facilities Infection Prevention and Control Job Description identified essential job functions included being proficient in surveillance using National Healthcare Safety Network surveillance definitions for healthcare associated infections. Reviews, investigates, and analyzes surveillance data. Works collaboratively with Employee Health and individual departments to educate staff, monitor compliance, and recommend improvements.

Based on observation, interview, and document review, the facility failed to establish an effective system of monitoring for expired medication and ensure expired medication was not used for 1 of 1 resident (R5).Findings include: R5's [DATE], annual Minimum Data Set (MDS) assessment identified R5's cognition was moderately impaired, she required set up assistance for cares, and walked independently with a wheeled walker. R5 had diagnosis of atrial fibrillation (abnormal heart rhythm), heart failure, hypertension, peripheral vascular disease, and constipation. Observation and interview on [DATE] at 8:46 a.m., with registered nurse (RN)-A of the A-side medication room identified RN-A opened the door to the refrigerator inside the medication room for review and took out a plastic cup that was about 1/4 full of what looked like chocolate ensure. The cup was not covered or labeled with a date or a resident name. Further review of the refrigerator identified a box of bisacodyl suppositories with an expiration date of [DATE]. The label on the box identified 12 suppositories were dispensed and only 7 remained in the box. RN-A stated R5 does not use or has not used them in a long time. R5's [DATE], medication orders identified an order for Dulcolax (bisacodyl) 10 milligrams (mg) rectal daily as needed (PRN) for constipation. Give on 4th day without bowel movement (BM). The last administration date was [DATE]. R5's [DATE] and [DATE], Medication Administration record identified R5 was administered Dulcolax Bisacodyl Suppository 10 mg rectally on [DATE] and [DATE] after the expiration date. Interview on [DATE] at 11:00 a.m., with R5 who reported she had a suppository about 2 weeks ago and one not too long ago. She stated I really have not had much trouble with constipation but one of my other pills have caused some constipation. She stated she would rather not have to use a suppository but sometimes you have to do what you have to do. Interview on [DATE] at 11:13 a.m., with the director of nursing (DON) who identified the facility does audits every month however, she had not received any audits from RN-A for the A side of the building which is where R5 resides. She shared an audit completed by RN-B for the B side of the facility that was last completed on [DATE], which identified RN-B removed 2 bottles of expired eye drops. The DON stated she would expect staff to be checking expiration date prior to administering any medications. Review of [DATE], Medication Orders and Administration policy identified medications would be administered only with clear, complete orders. The medication must specify the name of medication, strength of medication, dose to be administered, the frequency of administration, the route of administration, duration, and diagnosis or indication for use. The policy had instructions for new orders, verbal orders, standing orders, discontinued orders, medication labels, reporting of adverse reactions, medication errors, and medication administration. The policy had no mention of monitoring for checking expired medication prior to administration.

Based on interview and document review, the facility failed to ensure 1 of 5 sampled residents (R24) was offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC).Findings include: Review of the current, 10/26/24, Centers for Disease Control (CDC): Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV 21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV 21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV 21) at any age and a PPSV23 at or after the age of [AGE] years old. Review of R24's immunization record identified she had received a PPSV-23 on 11/19/03, and a PCV-13 on 10/7/15. Interview on 9/10/25 at 1:49 p.m., with the director of nursing identified that staff checked the Minnesota Immunization Information Connection (MIIC) online and if there are no recommendations listed, they do not offer any. She noted their process was not up to date as the recommended immunizations per CDC were not always listed on that website. She agreed R24 should have been offered the PCV20 or PCV21 upon admission. A policy was requested but was not provided by the end of the survey.

Based on interview, the facility failed to ensure mail was consistently delivered to residents on Fridays and Saturdays. This had the potential to affect all 48 residents in the facility who received personal mail, including but not limited to, 5 of 5 residents (R1, R22, R28, R30 and R38) who verbally confirmed mail was not consistently received on Fridays and Saturdays. Findings include: Resident Council was held on 7/17/24 at 10:00 a.m. with R1, R22, R28, R30 and R38 in attendance. When asked whether residents received their mail on Saturdays the 5 residents in attendance voiced they did not receive mail on Saturdays. If the administrative assistant was not in the building on Fridays, mail was also not delivered until the following Monday. The residents reported the facility had requested mail delivery be placed on hold on Saturday due to no staff available to distribute it, and to avoid it sitting from Friday/Saturday until Monday. Interview on 7/17/24 at 10:44 a.m. with the activity director reported the administrative assistant delivered the mail to residents Monday through Friday when she was working. She reported the resident council had expressed concern about security of mail delivered on Saturdays since it was delivered into a box located between the two main entrance doors. Mail in the box remained unless someone took it to a secure location or until the administrative assistant returned to work on Monday. She reported she was not aware of anyone else being responsible for mail delivery. Interview on 7/17/24 at 11:11 a.m. with the administrative assistant identified she was responsible for retrieving and delivery of mail during the week, and if she was not working on a weekday the social services designee (SSD) delivered the mail. She reported mail delivery had been suspended on Saturdays after the resident council agreed to have it held at the post office on Saturday because they did not want packages and personal mail left unsecured in the entry. She confirmed if neither she, nor the SSD were working resident mail was not delivered, unless some other person chose to retrieve and deliver the mail. Interview on 7/17/24 1:00 p.m. with the administrator reported his expectation for mail delivery to take place up to 6 days/week unless the post office was unable to provide mail delivery. He identified it was, not acceptable to place mail delivery on hold due to the administrative assistant and/or SSD not available to retrieve and deliver mail to residents. Interview on 7/17/24 at 1:03 p.m. with the SSD reported the issue of mail delivery had been discussed at a resident council meeting with the option offered to have mail held at the post office on Saturday and delivered on Monday to avoid it sitting in the entry and not delivered until Monday when the administrative assistant or SSD returned to work. The option was addressed by the resident council president who agreed, but not presented facility wide to the residents. The SSD confirmed the facility did not have a process for mail delivery when she or the administrative assistant were not available. A policy was requested but not provided and the director of nursing (DON) identified the facility did not have a policy that addressed delivery of resident mail.

Based on observation, interview, and record review the facility failed to ensure a homelike, dignified dining experience was provided for 1 of 4 residents (R36). This had the potential to affect all 21 residents who ate meals in the Neighborhood A dining room. Findings Include: R36's 6/26/24, annual Minimum Data Set (MDS) assessment identified she had admitted to the facility in July of 2022, her cognition was intact, and she was independent with activities of daily living (ADL's). Observation on 7/15/24 at 12:17 p.m., registered nurse (RN)-A gathered supplies and insulin pen from the medication cart near the resident dining room. RN-A walked through the dining room and approached a table that had 4 residents (R8, R11, R36, and R22) seated and eating dinner. She told R22 that she had her insulin (a medication that is administered by injection, using a syringe, just under the skin and into the fatty layer). R22 pulled her pants downward to expose her abdomen. RN-A cleaned the site using an alcohol swab and injected the medication. A small drop of blood was visible. RN-A cleaned the blood off using the alcohol wipe and R22 pulled her pants back up. At no time did RN-A ask R22 to leave the public area to administer the insulin. Interview on 7/16/24, at 2:02 p.m., with RN-A identified that as long as it was okay with the resident receiving the insulin, staff can administer insulin in the dining room. It was a routine process to administer insulin injections to residents at the dining room table in the facility. She had not considered how it may affect other residents at the table and was not certain if anyone had asked them if it bothered them. She stated, none of the other residents have mentioned any concerns, they are just used to it I guess. Interview on 7/16/24 at 2:19 p.m., with R8 identified that when she first admitted to the facility she was not used to seeing that, but I got used to it. Nobody has ever asked her how she felt about it or if it bothered her to see a resident being administered an injection while she was eating her meals. Interview on 7/16/24 at 2:30 p.m., with R36 identified watching someone receive an injection at the table during mealtime is bothersome at times. I wish it could be done in another way it happens often but they (other residents at the table) do not complain because they feel bad about what the resident is going through. Nobody has ever asked her if it bothered her. R36 reports it also bothers her when the other resident receiving the injection pulls her clothing down because she is over weight and it is not pleasant to see. She said she does not say anything because she hates to complain. Review of R36's current care plan lacked any indication that staff had asked R36 how she felt about other residents being administered injections in her presence. Interview on 7/16/24 at 9:10 a.m., with the director of nursing (DON) identified she was aware that residents receive insulin injections at the dining room table in front of other residents. She would prefer they receive their insulin injections in a private area, and identified there is a room off to the side of the dining room that staff could bring resident if they did not want to go back to their rooms. Review of the facilities November 2023, Medication Orders and Administration policy identified medications could be administered in the presence of other residents if the resident or representative agreed and is noted on care plan. There was no mention of how to ensure the rights and dignity would be maintained for other residents present during medication administration.

Based on interview and document review, the facility failed to ensure insulin was administered timely for 1 of 1 resident (R27). Findings include: R27's 7/8/24, significant change Minimum Data Set (MDS) assessment identified R27's cognition was intact. She has a diagnosis of diabetes mellitus. Interview on 7/15/24, at 12:54 p.m., with R27 identified that she had not received her a.m., insulin administration until 11:00 a.m., that day and said her blood sugar was well over 300. A different nurse approached her at around 11:30 a.m., to administer her noon insulin but R27 told her she had just had insulin and it would be too close together. The nurse did not administer the insulin. R27's current administration record identified she had an order for Lispro 100 units/milliliter (ml), 2 units before meals plus a sliding scale dose (based on blood sugar levels). Interview on 7/15/24 at 5:52 p.m., with registered nurse (RN)-A identified she had approached R27 to administer her insulin at 11:30, R27 refused the insulin administration and reported to her that another nurse had just administered her morning dose. RN-A held the insulin but did not follow up with the other nurse, did not complete a medication error report, and did not contact the physician for guidance. Interview on 7/16/24 at 1:36 p.m., with RN-B identified it was a hectic morning she had gathered her supplies to administer R27's insulin and signed it off in the medical record, when she went to administer the insulin R27 was exercising so she left the area with the intention of returning in a few minutes, but she forgot. RN-A returned later and administered the insulin around 10:30, she identified that she should have changed the time in the administration record but she got side-tracked and did not make the adjustment. RN-B did not report the late insulin administration to anyone at the facility, she did not complete a medication error report, and did not notify the physician. Interview on 7/16/24, at 4:49 p.m., with the director of nursing identified she would have expected better communication in the nursing department. She would expect nursing to notify the physician for guidance and complete a medication error report. Review of the November 2023 Medication Orders Administration Policy identified medication errors would be reported and the physician will be notified. Staff will document administration of medication immediately after administration.

Based on observation, interview, and record review the facility failed to groom [ROOM NUMBER] of 1 resident (R22) to maintain their highest practicable well-being. Findings include: R22's 7/3/24, quarterly Minimum Data Set (MDS) assessment identified R22's cognition was intact, she had diagnosis of diabetes, depression, heart disease, arthralgia (joint pain), and cataract (visual impairment). She required moderate assistance from one staff for personal hygiene and dressing. R22's current care plan identified that R22 had diagnosis that could potentially affect her ability to complete ADL's (activities of daily living). Staff were to assist her to meals and assist with daily washing. R22's care plan made no mention that staff should assist with facial grooming or shaving. Observation on 7/15/24 at 2:06 p.m., of R22 seated in her recliner in her room. She was observed to have a thick patch of facial hair on her chin, approximately 1/8 inch in length. Interview on 7/15/24 at 2:06 p.m., with R22 identified that she was aware of her facial hair but often forgets to shave. Staff do not remind her or offer to shave her, but she states, I would love it if staff would come in and offer to shave me. She tries to remember to ask the beautician when she is getting her hair done but says she forgets. Observation on 7/16/24 at 2:42 p.m., of R22 seated in room, chin hair remained unshaven and appeared longer than the day prior. Interview on 7/16/24 at 2:43 p.m., with R22 she identified that staff had still not offered to shave her, she has not asked anyone but would like it if someone would just come in to do it because she forgets. Interview on 7/16/24 at 2:48 p.m., with nursing assistant (NA)-E identified that if she notices that a resident is not doing self-care, she offers to assist them. She thinks that morning staff usually assist R22 with shaving. She had not noticed that R22 had thick facial hair on her chin and stated, I guess I hadn't paid attention. Interview on 7/16/24, at 4:00 p.m., with registered nurse (RN)-A identified that she was responsible for updating care plans, she would expect staff to offer to shave female residents who have facial hair regardless of if it is on the care plan or not. She agrees it should have been added to the care plan. A policy was requested, nothing was provided by the end of the survey.

Based on observation, interview, and document review, the facility failed to revise the care plan for 1 of 1 resident (R14) who utilized a self-release belt, she was unable to release. Findings include: R14 received physician orders for a new wheelchair December of 2022 to allow for increased mobility. Occupational Therapy (OT) Evaluation and Plan of Treatment dated 1/25/23 - 3/8/23 with discharge date d 3/1/23 identified discharge instructions to include staff to encourage repositioning into upright seated position when slouching or posterior lean in chair noted. Educated patient to continue bilateral upper extremity exercises to minimize further contracture in bilateral shoulders. There was no mention of a new wheelchair or safety measures identified with use. R14 was hospitalized [DATE] -3/20/24 with a Urinary Tract Infection and pneumonia. Upon return assessment identified decline in cognition, strength, and mobility. R14's, 4/11/24 Significant Change Minimum Data Set (MDS), was completed following hospitalization and completion of therapy on 4/4/24. R14 had moderate cognitive impairment and identified diagnoses of morbid obesity, osteoarthritis, deformity of right foot, left skew foot deformity, degenerative arthritis, and severe scoliosis. The MDS failed to identify a seat belt type lap belt in use on her wheelchair, and a restraint assessment was not completed. R14's, 4/3/24 OT Discharge Summary Recommendations included she was demonstrating requirement for assistance of 1-2 staff for bed mobility, dressing, and toileting. Had an upright positioning wedge to be used on whichever side toward patient leaning when in chair. Hoyer lift for transfers and use of a standard wheelchair with lap belt for mobility in the facility. R14's current 12/21/22 care plan identified she was able to independently remove the seatbelt. Her care plan was not updated to identify her change in status following hospitalization due to no longer able to self-release seat belt when the belt was to be used and when it was to be released. The care plan also failed to include quarterly assessments for use of the lap belt, restraint assessment and review by physician and family or power of attorney for orders, and consent for use of device. Observation/interview on 7/15/24 at 1:09 p.m. as R14 sat in her wheelchair with a lap belt attached to the frame of the wheelchair and fastened in front of her lower abdomen. R14 reported she was comfortable in her chair and did not know why she had the belt on, but that staff put it on in the morning and took it off when she went to bed at night. When asked if she was able to release the belt, she stated she did not know and began fumblingly with the belt, turning it and pressing along the sides and buckle, but she was not able to press the large, square button to release the belt. She continued to fumble with the belt when nursing assistant (NA)-A entered the room and asked R14 if she needed help. NA-A attempted to direct R14 on how to release the belt, but she was not able to do so. R14 reported she knew what she was supposed to do to release the belt, but staff usually helped her to put it on and take it off. R14 reported she was not able to transfer herself and staff used the lift to transfer her. She denied any falls and reported staff were good to come when she pushed her light and needed help. Observation on 7/15/24 at 5:30 p.m. of R14 positioned at the Livingroom table without the lap belt in place. When questioned she stated she had the belt on, and then moved her shirt to reveal her lap and stated they must have forgotten to put it back on. When asked why she needed the lap belt, R14 replied she did not know, but staff put it on in the morning when she got up and took it off when she went to bed at night. Interview on 7/15/24 at 1:15 p.m. with NA-A reported since R14 had returned from her hospital stay she had needed more help and was more confused. She reported for the past couple of weeks R14 had not been able to put on or release her lap belt and staff needed to do it for her. When asked when the belt was put on and taken off, NA-A reported it was on when she was up in her wheelchair, released and reapplied when she was toileted, or transferred to and from her wheelchair. When questioned regarding the lap belt being a restraint, NA-A responded she did not think it was a restraint and replied she thought it was for safety to keep her from falling out of her chair. NA-A identified a restraint was something used to restrain a person's arms and/or legs and she was not aware a lap belt could also be a restraint. Interview on 7/16/24 at 2:44 p.m. with registered nurse (RN)-C who identified she had completed the MDS assessments for R14 reported she had not completed a Restraint Assessment, nor documented the use of the lab belt for R14. She reported she was so used to seeing R14 with the belt in place that she had not thought about the need for an assessment. RN-C reported she was not aware R14 was no longer able to self-release her belt, not that staff were applying and releasing the belt when needed. RN-C identified the lab belt had been in place since December 2022, and had not been included in MDS assessments as it should have been. Interview on 7/16/24 at 11:20 a.m. with the director of nursing (DON) reported R14's utilized a lap belt when in her wheelchair for positioning. and the belt had been consistently utilized since December 2022 when she had been provided a specialized wheelchair for mobility. The DON reported R14 had been able to self-release the belt initially, and she was not aware of when R14's status changed but was likely following her most recent hospitalization [DATE] -3/20/24. Her expectation was for the medical record to contain MD orders, be included in the care plan, have a restraint assessment completed and updated quarterly, in addition to a signed consent from the resident/family or healthcare power of attorney (POA). The DON confirmed R14 had utilized the lap belt when up in her wheelchair until 7/15/24 afternoon when R14 and staff had been interviewed and she was not able to demonstrate self-release of the belt. The DON identified the care plan failed to include any mention of the use of a lap belt, nor was there any monitoring in place. She reported the care plan should have been updated when the lap belt was initially put into use, and again following her most recent hospitalization . Review of the December 17, 2023, policy LTC-Physical Restraint/Bed Rails Policy identified the resident/family/power of attorney must sign a consent for the use of a restraint device prior to its use. The care plan was to include: 1. Restorative Care 2. Identified risk factors and targeted interventions 3. Education to both resident/family/staff 4. Any modifications in environment 5. Supervision/monitoring by staff 6. A plan to address any identified areas of concern Both the Interdisciplinary team (IDT) and MD need to address use of the restraint/device monthly and as needed. Use was also to be reviewed at the quarterly care conferences. Restraints are to be checked by staff every 30 minutes and removed at meals and every 2 hours. Quarterly documentation of attempts for restraint reduction are to be completed with a Restraint assessment and included on MDS assessments and in the Care Area Assessments.

Based on observation, interview, and document review, the facility failed to ensure residents were free from physical restraints for 1 of 1 resident (R14) who utilized a self-release belt as a restraint Findings include: Observation/interview on 7/15/24 at 1:09 p.m. of R14 as she sat in her wheelchair with a lap belt attached to the frame of the wheelchair and fastened in front of her lower abdomen. R14 reported she was comfortable in her chair and did not know why she had the belt on, but that staff put it on in the morning and took it off when she went to bed at night. When asked if she was able to release the belt, she stated she did not know and began fumblingly with the belt, turning it and pressing along the sides and buckle, but she was not able to press the large, square button to release the belt. She continued to fumble with the belt when nursing assistant (NA)-A entered the room and asked R14 if she needed help. NA-A attempted to direct R14 on how to release the belt, but she was not able to do so. R14 reported she knew what she was supposed to do to release the belt, but staff usually helped her to put it on and take it off. R14 reported she was not able to transfer herself and staff used the lift to transfer her. She denied any falls and reported staff were good to come when she pushed her light and needed help. Interview on 7/15/24 at 1:15 p.m. with NA-A reported since R14 had returned from her hospital stay she had needed more help and was more confused. She reported for the past couple of weeks R14 had not been able to put on or release her lap belt and staff needed to do it for her. When asked when the belt was put on and taken off, NA-A reported it was on when she was up in her wheelchair, released and reapplied when she was toileted, or transferred to and from her wheelchair. When questioned regarding the lap belt being a restraint, NA-A responded she did not think it was a restraint and replied she thought it was for safety to keep her from falling out of her chair. NA-A identified a restraint was something used to restrain a person's arms and/or legs and she was not aware a lap belt could also be a restraint. Observation on 7/15/24 at 5:30 p.m. of R14 positioned at the livingroom table without the lap belt in place. When questioned she stated she had the belt on, and then moved her shirt to reveal her lap and stated they must have forgotten to put it back on. When asked why she needed the lap belt, R14 replied she did not know, but staff put it on in the morning when she got up and took it off when she went to bed at night. Observation on 7/16/24 at 11:09 a.m. when R14 returned from an outside activity, it was noted she was not wearing the lap belt and stated neither she nor the NA were able to get her belt on when she got up for the day. When asked about the reason she wore the lap belt she responded she did not know. Interview on 7/16/24 at 10:51 a.m. with NA-A and NA-B reported R14 moved about independently in her wheelchair, and they were not aware of any safety concerns. They reported R14 did not attempt to self-transfer and called for assistance when she needed to use the toilet. NA-B reported R14's belt had been removed due to not being able to self-release the belt. Both NA-A and NA-B confirmed prior to the 7/15/24 p.m. interview R14 was always wearing the lab belt when she was up in her wheelchair. NA-A and B identified they thought R14's had the lab belt due to scooting and sliding forward in her chair as she was moving about. They both reported they were not aware R14 having any recent falls or attempts to self-transfer. R14's 6/28/24 - 7/4/24 quarterly Minimum Data Set (MDS) assessment was pending at the time of review. R14's, 4/11/24 Significant change MDS following her hospitalization and completion of therapy (4/24/24) identified no restraint or devices in use. R14 had moderate cognitive impairment and identified diagnoses of morbid obesity, osteoarthritis, deformity of right foot, left skew foot deformity, degenerative arthritis, and severe scoliosis. R14's 11/16/23, Annual MDS assessment also failed to document the use of the lab belt. R14 had moderate cognitive impairment and her activities of daily living identified she had functional restrictions and had a potential for falls. Interview on 7/16/24 at 2:44 p.m. with RN-C reported she had completed R14's MDS but did not realize she had a restraint in the form of a lap belt. RN-C reported she had it for a long time, and everyone was used to seeing it. RN-C identified R14's lap belt should have been reassessed and identified in the 4/11/24 MDS as a restraint upon her hospital return, but she had not thought about it. Interview on 7/16/24 at 11:11 a.m., with RN-F identified R14 used a lap belt in her chair due to slouching or sliding forward. Review of the current physician's orders with RN-F failed to identify an order for use of a lap belt. RN-F reported he did not think R14 was able to self-release her lap belt, and he was not aware the lap belt would be a restraint if she was not able to release the belt without staff assistance. Interview and document review on 7/16/24 at 11:20 a.m. with the director of nursing (DON) reported R14's utilized a lap belt when in her wheelchair for positioning. The DON reported R14 had been provided a specialized wheelchair for mobility in the past (unable to recall dates) and was unsafe due to sliding in the chair, because it had a short seat. R14 had been able to self-release the belt initially, and she was not aware of when R14's status changed but was likely following her most recent hospitalization [DATE] -3/20/24. The DON reviewed the medical record and confirmed they failed to include orders for use of a seat belt and a restraint assessment had not been completed. The DON reported her expectation for the record to contain MD orders, be included in the care plan, have a restraint assessment completed and updated quarterly, in addition to a signed consent from the resident/family or healthcare power of attorney (POA). The DON confirmed R14 had utilized the lap belt when up in her wheelchair until 7/15/24 afternoon when R14 and staff had been interviewed and she was not able to demonstrate self-release of the belt. The DON identified R14's last covered Medicare day was 4/4/24 and a Significant Change MDS should have included the restraint assessment, with documentation, orders and updating of the care plan. Review of the 12/17/21 LTC-Physical Restraint/Bed Rails Policy identified the purpose as standardization for use of physical restraints in Avera's Long-Term care (LTC) facilities. A physical restraint definition included manual, physical, mechanical device, material, or equipment that an individual was not able to easily remove and restricted freedom of movement or access to their body. Easily removed was defined in the policy as removed intentionally by the resident in the same manner as it had been applied. If a problem was identified the least restrictive method was to be attempted first with results documented in the record. Use of restraints required clinical justification for protection of a resident from injury to self and/or others. If found to be necessary, the health professional was to document in the medical record the assessment to include the medical condition and include the reason for the restraint as an intervention. Physician notification was required for all restraints prior to initiation and an order must be obtained for use. The order was to specify the type of restraint, when it was to be used, medical symptom requiring use, and documentation for staff to check every 30 minutes and release every 2 hours. Both residents, family/POA were required to be educated on the use of restraints with risks verses benefits reviewed. The facility was responsible to include evaluation of the restraint devise and include the medical practioner in the review. In addition, the resident/family or POA must sign a consent for the use of a restraint. Restraint use was to be evaluated monthly by the interdisciplinary team (IDT) and physician, and quarterly at care conferences. All restraints were to be removed during meals unless there was a physician order or medical condition which identified the need for the restrain to remain in place.

Based on interview and document review, the facility failed to follow physician orders for full code and did not initiate cardiopulmonary resuscitation (CPR) as per the residents wishes for 1 of 3 residents (R1) who wanted CPR. R1 was found without a pulse or respirations, staff did not initiate CPR and R1 expired and resulted in an immediate jeopardy (IJ). The facility implemented immediate corrective action prior to survey and IJ was issued at past noncompliance. The IJ began on [DATE], at approximately 1:00 a.m. when R1 was noted to have no respirations with a fast heart rate, and CPR was not initiated. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 4:27 p.m. The facility implemented corrective action on [DATE], and the IJ was issued at past non compliance. Findings included: R1's 5-day Minimum Data Set (MDS) dated [DATE], indicated intact cognition, diagnoses of coronary artery disease (CAD), heart failure, high blood pressure and anxiety. R1's physician order dated [DATE], included Full Code start date [DATE]. The record did not include a corresponding POLST (physician order for life sustaining treatment) or signed advanced directives. R1's care plan printed on [DATE], did not include R1's code status. Review of R1 progress notes dated [DATE], included R1 will remain a full code with high risk of rehospitalization . Review of R1's progress note dated [DATE] at 2:12 a.m ., licensed practical nurse (LPN)-A documented At 1:15 a.m. was summoned to rm [room] by CNA [nursing assistant (NA)] and said to bring a stethoscope. Upon entering rm [room] could see res [resident] had no color other that [sic] yellowish blue. Listened for heart rate, heard very rapid light heart rate. Ran to call RAT [rapid assessment team] and grabbed AED [automated external defibrillator]. Returned to rm [room] and found no HR [hear rate] and was already cyanotic [bluish gray]. Ambulance crew here in minutes, entered rm [room] and they started CPR and tried to revive him. They worked on him for 40 min [minutes]. They then called [name of doctor] for further instruction and he called time of death at 0152 [1:52 a.m.] Review of R1's ambulance report dated [DATE], indicated ambulance was dispatched on [DATE] at 1:13 a.m., arrived at patient at 1:26 a.m. was met by LPN-A at nurses station, who stated He is gone. They asked for clarification and LPN-A restated he is gone. Confirmed that R1 was a full code. Ambulance crew continued to room to evaluate R1. R1 was found laying in bed, without oxygen on, no signs of rigormortis, no pulse, warm to touch and cyanotic dusky color in face, no effort in breathing, no palatable carotid pulse. LPN-A at bedside and stated around 1:10 a.m., NA-A was in room, came out of room and found her to get the stethoscope, LPN-A came to room and listened to R1's heart, she thought she heard a rapid heart beat but was unsure of what to do other than call 911. No attempt of compressions or ventilation until ambulance arrival. R1 moved from bed to ambulance cot and CPR initiated. Ambulance crew performed CPR until call placed to on call physician at 1:52 a.m. when R1 was pronounced deceased . During an interview on [DATE] at 1:50 p.m., NA-A stated she had checked on R1 during her water pass at about 1:15 a.m. and noticed R1 was breathing but then at 1:30 a.m. when she went back noticed R1 was not breathing. NA-A called for LPN-A to bring a stethoscope to R1's room over the radio and heard no response so stepped out in the hallway and called for LPN-A. LPN-A came into R1's room and listened for heartbeat. LPN-A told NA-A R1 heart rate was rapid and then LPN-A left the room to call 911 and get the AED. NA-A explained, LPN-A returned to R1's room about 5 minutes later and sat the AED on R1's bed. LPN-A did not apply the AED or start CPR, instead told NA-A that R1 was gone. LPN-A had NA-A return the AED to the storage place. NA-A stated the ambulance crew arrived and NA-A heard LPN-A tell them R1 was a full code and ambulance crew asked if they started CPR and LPN-A stated no she did not. The Ambulance crew started CPR and were not able to revive R1. During an interview on [DATE] at 1:10 p.m., LPN-A stated the evening of [DATE], R1 had been anxious and used her call light frequently. LPN-A had checked on R1 at approximately 10:00 p.m. and had appeared to be at baseline. LPN-A had medicated R1 with Tramadol (pain medication used to relieve moderate to severe pain) around 11:15 p.m. LPN-A continued to monitor R1 until she was called to his room around 1:15 a.m. on [DATE] and found R1 with a rapid heart rate and not breathing. LPN-A left the room and went to call a RAT/ 911. She then grabbed the AED and returned to R1's room but upon entrance she had noticed R1 had passed away. LPN-A stated R1 was a full code and CPR should have been started, but it was not. LPN-A stated this was her first code and she did not know why she did not start CPR. During an interview on [DATE] at 11:45 a.m , director of nursing (DON) stated she had not been aware CPR had not been initiated by staff on the night shift of [DATE], until it was reported to by a quality assurance nurse on [DATE]. DON stated she then interviewed LPN-A who confirmed CPR had not been initiated by facility staff. DON reviewed R1's record and confirmed R1 was a full code according to physician orders however a signed POLST could not be located in the record. DON stated CPR should have been initiated per physician orders. DON was unable to find the POLST in R1's record. Review of facility's policy titled, LTC- Emergency Response, CPR, section emergency guidelines: 1. in the event staff come upon a resident without obvious signs of clinical death, staff will start CPR and send someone to check code status. 2. initiation of CPR- prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiating CPR, to a resident who experiences cardiac arrest in accordance with that resident's advanced directives or in the absence of advanced directives or a Do Not Resuscitate (DNR) order. The past non-compliance IJ began on [DATE]. The IJ was removed, and the deficient practice corrected on [DATE] when it was verified the facility had implemented corrective action that included: -Reviewed their policy and systems and made the following changes: A) Implemented full code residents have a red heart at the foot of their bed. B) Implemented the unit group sheets were all revised to identify full code status. -NA-A received education on [DATE], LPN-A was put on administrative leave on [DATE]. -All nursing staff participated in mock code with local ambulance service on [DATE]. -All staff received education on implementation of POLST orders/CPR on [DATE] and participated in a mock code drill with local ambulance. They were reeducated again on [DATE].

Based on document review and interview the facility failed to ensure that laboratory test were followed by provider timely for 1 of 1 (R7) resident for reporting of lab results. Finding include: R7's face sheet identified diagnosis of chronic systolic congestive heart failure (CHF), high blood pressure, history of pacemaker insertion, and open-heart surgery. R7's significant change Minimum Data Set (MDS) dated [DATE], indicated an intact cognition; weight was 169 lbs and received diuretics. R7's physician orders included: -Lasix (diuretic medication) 40 milligrams by mouth once day (start date 9/15/23, stop date of 12/26/23) -Lasix 60 mg by mouth twice daily for four days and then recheck labs, basic metabolic panel (BMP), to monitor kidney functions dated 12/26/23. R7's nursing progress note dated 12/26/23, indicated physician was updated regarding weight increase. Note indicated physician gave new orders for Lasix 60 mg twice daily for 4 days, recheck BMP, and continue to monitor. R7's progress notes and/or physician order did not give instruction on continuation of the diuretic doses after the lab was drawn. R7's lab report dated 12/29/23,indicated lab work completed 12/29/23. In review of R7's record it was not evident the lab results were acknowledged or followed up on by the physician. R7's nursing progress note dated 1/15/24, registered nurse (RN)-A discovered no Lasix order since 12/30/23, R7 had increased shortness of breath, increased weight and edema. RN-A notified physician assistant (PA)-A, orders received to restart Lasix 60 mg by mouth twice daily. R7's nursing progress note dated 1/16/24, identified R7 was sent to the emergency department (ED), for increased edema, increased shortness of breath and increase in weight of 7 pounds over night and a total of 17 pounds since 1/1/24. R7's physician assistant (PA)-A progress note dated 1/23/24, indicated R7 went without Lasix as prescribed and had quite a bit of edema and weight gain. He is not complaining of shortness of breath and his edema has improved. PA-A note indicated extremities with 1+ edema bilaterally. During interview on 2/29/24 at 5:07 p.m., RN-A stated she took the order for Lasix on 12/26/23 and followed the procedure for putting the order in the electronic health record. RN-A stated she put an end date on the Lasix order to stop after 4 days per the physician order. RN-A indicated she remembered the lab was completed, however, did not get any follow-up orders to resume the lasix and did not follow up on the lab orders until 1/15/24 during a chart review. RN-A made PA-A aware of missing Lasix order and received order to resume the order for Lasix 60 mg by mouth twice daily. RN-A stated that the labs should have been followed up on immediately upon receipt by licensed nursing staff. During an interview on 2/29/24 at 3:12 p.m., PA-A stated lab results show up in her work que before the facility gets them, she reviews them, then writes recommendations/orders that are faxed to the facility. PA-A stated that she remembers seeing the labs around R7's 1/2/24 but could not recall that the facility contacting her about resuming the Lasix. It was her expectation the facility follows through with her on labs and orders. PA-A stated the facility was usually very thorough with their labs and orders. When residents do not get their scheduled diuretics they could go into fluid over load causing increased shortness of breath, decreased oxygen saturations, increased weight, lethargy and edema. PA-A stated facility staff should have been assessing R7 regularly. During an interview on 2/29/24 at 3:45 p.m., director of nursing (DON) stated that it was her expectation that labs and orders get followed up on immediately by nursing. Policy for lab work follow up and change of condition asked for but not received.

Based on interview and document review the facility failed to comprehensively assess and monitor for fluid overload for 1 of 1 resident (R7) who had a diagnosis of congestive heart failure. Findings include: R7's face sheet identified diagnosis of chronic systolic congestive heart failure (CHF), high blood pressure, history of pacemaker insertion, and open-heart surgery. R7's significant change Minimum Data Set (MDS) dated [DATE], indicated an intact cognition; weight was 169 lbs and received diuretics. R7's cardiovascular status care plan dated 9/14/23, identified R1 had a potential for alteration in health status and condition related to diagnoses that included congestive heart failure and lower extremity edema. Interventions included only the following: R1 did not want any significant workup done, when using blood pressure cuff use light royal blue cuff due to the size of his upper extremity, and cardiac device check as need. R7's care sheet (abbreviated care plan used by nursing assistants (NAs)) directed staff R7 required daily weights. R7's physician orders included: -Daily weights (dated 11/21/23), -Lasix (diuretic medication) 40 milligrams by mouth once day (start date 9/15/23, stop date of 12/26/23) -Lasix 60 mg by mouth twice daily for four days and then recheck labs, basic metabolic panel (BMP), to monitor kidney functions dated 12/26/23. R7's nursing progress note dated 12/26/23, indicated physician was updated regarding weight increase. Note indicated physician gave new orders for Lasix 60 mg twice daily for 4 days, recheck BMP, and continue to monitor. R7's record identified labs were drawn as ordered on 12/29/23, and were within normal limits. The record did not identify the physician had acknowledged or followed up and/or new orders given. R7's progress notes and/or physician order did not give instruction on continuation of the diuretic doses after the lab was drawn. R7's December 2023 and January 2024 medication administration records (MAR) identified the physician order for 60 mg of Lasix and identified R7 was administered Lasix as ordered on 12/26/23 (afternoon only), 12/27/23, 12/28/23, 12/29/23, and on 12/30/23 (morning only). The MAR indicated R7 did not receive Lasix between 12/30/23 (afternoon dose) and January 15, 20234 (afternoon dose). In review of R7's record between 12/25/23 through 1/15/24, there was no indication R7 was routinely assessed and monitored for signs/symptoms of fluid overload including but not limited analysis of weight gains, edema, and respiratory status. R7's weights were reviewed between 12/25/23 through 1/16/24, identified weights were not obtained per physician order on 12 days which included 12/29/23, 12/30/23, 12/31/23, 1/2/24, 1/3/24, 1/5/24, 1/6/24, 1/7/24, 1/8/24, 1/10/24, 1/11/24, and 1/14/24 Further identified R7 had a 17 pound (lbs.) weight gain between 1/1/24 and 1/16/24. 12/25/23- 179.0 lbs 12/26/23- 179.8 lbs 12/27/23- 179.0 lbs 12/28/23- 177.0 lbs 1/1/24- 173.0 lbs 1/4/24- 173.0 lbs 1/9/24- 183.6 lbs 1/12/24- 178.1 lbs 1/13/24- 183.6 lbs 1/15/24- 183.6 lbs 1/16/24- 190.0 lbs R7's nursing progress note dated 1/15/24, registered nurse (RN)-A discovered no Lasix order since 12/30/23, R7 had increased shortness of breath, increased weight and edema. RN-A notified physician assistant (PA)-A, orders received to restart Lasix 60 mg by mouth twice daily. R7's nursing progress note dated 1/16/24, identified R7 was sent to the emergency department (ED), for increased edema, increased shortness of breath, and increase in weight of 7 pounds over night. Although the progress note dated 1/16/24, indicated R7 had an increase in edema, the degree of increase could not be ascertained as it was not evident of ongoing edema monitoring/assessment. R7's ED note dated 1/16/24, identified R7 had 4+ pitting edema from his feet to his knees and mild non pitting edema to his thighs ED sent R7 back to the facility with the following orders: 1. Continue to perform daily weights, 2. Continue Lasix 60 mg twice daily, 3. Follow up with provider as previously directed 4. if R7 develops new symptoms of shortness of breath, difficulty breathing, increased cough, chest pain or lower extremity discomfort; please have R7 re-evaluated. R7's weight record was reviewed from 1/16/24 through 2/27/24. The record identified there were 20 of 42 days, R7's weights were not obtained according to physician orders. Weights were not recorded on: 1/19/24, 1/20/24, 1/23/24, 1/27/24, 1/28/24, 2/3/24 through 2/5/24, 2/10/24 through 2/13/24, 2/17/24, 2/18/24, 2/19/24, 2/22/24, 2/24/24, 2/25/24, 2/26/24, and 2/27/24. After R7 returned from the hospital on 1/16/24, in review of the record post hospitalization it was not evident assessments and monitoring were completed to ascertain the effectiveness of the prescribed treatment for fluid overload. R7's physician visit for 1/23/24, included he has had trouble with lower extremity edema. It was found that the was not getting his Lasix as prescribed and had quite a bit of edema and weight gain. We now have him back on his regimen of Lasix 60 mg twice daily and his weight is back down to baseline around 174 lbs. He is not complaining of shortness of breath. His edema is improved. During interview on 2/29/24 at 5:07 p.m., registered nurse (RN)-A stated she had taken the order on 12/26/23 for the Lasix and lab was drawn 12/29/23. RN-A does not remember following up with the PA-A about the labs. RN-A indicated she was not aware R7 had a weight gain and/or had increase in edema until she was reviewing R7's record and identified [NAME] had followed up on the labs. She completed an assessment of R7 and notified PA-A of the change, PA-A gave the order to restart the Lasix 60 mg twice daily by mouth. RN-A was unable to articulate how often residents were monitored for fluid overload. During interview on 2/29/24 3:12 p.m., PA-A stated the routine for labs was the results came to her first and she made recommendations/orders. PA-A would then have the recommendations/orders faxed to the facility. PA-A was not able to find communication between her and the facility. It was her expectation that her orders and labs were followed up on immediately when the facility receives them to verify any new orders. When residents do not get their scheduled diuretics they could go into fluid over load causing increased shortness of breath, decreased oxygen saturations, increased weight, lethargy and edema. PA-A stated facility staff should have been assessing R7 regularly. During an interview on 2/29/24 at director of nursing (DON), it was her expectation that labs were followed up on immediately when they were received, even after hours as they have after hours physician support. DON also stated facility staff do assessments on admission and with the residents Minimum Data Sets. DON also stated that staff do an assessment if the resident seems to be having a change in condition. Policy for change of condition or monitoring for was asked for but not received. Policy for LTC Baseline/Comprehensive Care Plans- system standard policy, dated 6/5/2023, was received and reviewed Assessment for MDS policy was received and reviewed.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R13, R32, R34, and R37) were appropriately vaccinated against pneumococcal disease upon admission and/or offer updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 30 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose Review of the 5 sampled residents for vaccinations identified: 1.) R13 was admitted on [DATE]. R13 received her PCV-23 on 10/18/11 and her PCV-13 on 10/17/19. There was no documentation to support R13 had been offered the PCV-15 or PCV-20 to ensure she was updated with current CDC guidance for vaccines. 2.) R32 was admitted on [DATE]. R32 received his PCV-13 on 4/5/21 and his PCV-23 on 4/11/22. There was no documentation to support R13 had been offered the PCV-15 or PCV-20 to ensure he was updated with current CDC guidance for vaccines. 3.) R34 was admitted on [DATE]. R34 received her PCV-13 on 5/19/16 and her PCV-23 on 10/22/19. There was no documentation to support R13 had been offered the PCV-15 or PCV-20 to ensure she was updated with current CDC guidance for vaccines. 4.) R37 was admitted on [DATE]. R37 received her PCV-13 on 9/14/15 and PCV-23 on 9/14/15. There was no documentation to support R13 had been offered the PCV-15 or PCV-20 to ensure she was updated with current CDC guidance for vaccines. Clarification on administration dates had been requested but nothing was provided. Interview on 8/8/23, at 11:40 a.m., with infection control preventionist (IC) identified her expectation was the RN completing the admission would review vaccination status upon admission and contact the primary doctor to obtain an order for the expropriate vaccinations per CDC vaccination guidance. Review of the current, undated immunization policy identified the facility was to follow CDC recommendations for the pneumococcal vaccinations and included a link to assist staff to the most updated CDC vaccination recommendations.

Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority) for 1 of 1 resident (R32) with new onset mental illness. Findings include: R32's 12/14/22, annual Minimum Data Set (MDS) assessment identified R32 had a delusional disorder, dementia, psychotic disorder, and obsessive compulsive disorder. R32's 7/11/23, physician progress notes identified a diagnosis of delusional disorder, paranoid ideation, and cognitive decline. R32's undated care plan printed on 8/9/23, identified problems with delirium and psychosocial well-being with behaviors of being withdrawn, having negative statements, repetitive physical movements, self-deprecation, expression of unrealistic fears, and recurrent statements that something bad was going to happen. R32's 1/4/21, Initial Pre-Admission Screening (PAS), did not identify a diagnosis of mental illness and did not indicate the need for a Level II PASARR to be completed. Interview on 8/9/23 at 8:00 a.m., with social service designee identified that upon receiving the pre-admission screen she reviews to ensure all diagnosis are listed. She was not aware she should notify the county authority when a new diagnosis has been identified. A policy related to Level II PASARR was requested, however none was provided.

Based on observation, interview and document review the facility failed to accurately reconcile 1 of 1 resident's (R12) lorazepam (narcotic anti-anxiety medication) upon receipt from the pharmacy and ensure 2 of 2 resident's (R99 and R33) medications were immediately removed from the medication cart and not co-mingled and stored with in-use medication for other residents. Findings include: Observation on [DATE] at 2:26 p.m., with registered nurse (RN)-A and trained medication aide (TMA)-A during a controlled narcotic medication count identified R12 had one unopened blister pack containing lorazepam. Review of the pharmacy label on the medication card listed 28 tablets, however only 27 were filled. Review of the Controlled Drug Receipt/Record/Disposition form for R12's lorazepam noted it had been received on [DATE] and the count was to be 30 tablets. There was no indication staff identified the errors in amounts between the blister pack that was filled, the pharmacy label on the pack or the amount staff recorded on the form. Observation on [DATE] at 2:45 p.m., of the medication cart on B-Wing identified several medications for R99 (who died on [DATE]) and R33 were not removed upon their death and/or after medications were discontinued and remained in the cart co-mingled with in-use medications for other residents. The medications for R99 were: 1.) 2 Ativan (anti-anxiety medication) 0.25 milligram. (mg) blister packs. One had tablet remaining and another contained 20 tablets. 2.) 4 Ativan 0.325 mg blister packs. 5 tablets remained in 1 blister pack, and the remaining 3 had 4 tablets each remaining. 3.) 2 Oxycodone liquid (narcotic pain medication) bottles, 1 with 4 milliliters (ml) remaining and the other full bottle with 5 ml remaining. 4.) 1 box of Fentanyl patches (narcotic pain medication) 37.5 mg/hr. with 4 patches remaining. The medications for R33 were: 1.) Tramadol (medication for pain) 325 mg blister pack with 1 tablet remaining and a 2 tramadol 25 mg blister packs each containing 30 tablets. Interview on [DATE] at 2:57 p.m., with RN-A and TMA-A identified the charge nurse on duty was responsible for receiving and verifying medications delivered from the pharmacy. Both RN-A and TMA-A voiced surprise the inaccurate count of medication in R12's blister pack had not been caught either at the time of receipt or during shift change narcotic counts that had taken place, since receipt of the medication on [DATE] and [DATE]. RN-A reported controlled medications were left in the narcotic box of the medication cart until 2 RN's had time to remove them for destruction as they had to be witnessed. Staff kept narcotic medications for residents who either died or medications were discontinued in the lock box in the medication cart co-mingled with in-use medications for other residents. Interview on [DATE] at 4:33 p.m., with the director of nursing (DON) identified her expectation was medications were to be checked for accuracy upon receipt from pharmacy. If there was an inaccuracy in the amount or dosage received, staff were to immediately contact the pharmacy to report the issue and acquire the correct medication and/or label. She voiced concern that multiple narcotic counts had taken place since R12's medication was received, and the discrepancy had not been caught. The DON was unaware discontinued narcotics had been stored with in-use medications until staff had time to destroy them. Interview on [DATE] at 12:09 p.m., with the consultant pharmacist reported his expectation for discontinued narcotic medications was not to store those medications co-mingled with in-use medications due to the potential for medication errors and/or the potential for diversion. R12's medication discrepancy with the number of tablets of lorazepam indicated the error began at the pharmacy with only 27 pills packaged instead of the 28 listed on the label. Staff should be verifying accurate medication counts upon receipt and during daily counts. Review of the [DATE] policy LTC Controlled Substance Distribution, Storage, Administration, and Destruction identified there was no reference to accurate reconciliation when medication was received from pharmacy, nor was there any mention of the need to immediately remove medications not in use from medications in-use or appropriate destruction of those medications.

Based on observation, interview and document review the facility failed to ensure a Stat Strip facility glucometer was appropriately disinfected between use during 1 of 1 observation. Findings include: Observation and interview on 6/27/22, at 11:05 a.m., registered nurse (RN)-A obtained the Stat Strip glucose monitor from the docking station, retrieved items for checking blood glucose and proceeded to R30's room where he obtained a blood sample on the strip and inserted into the Stat Strip meter. Following the blood sugar check RN-A returned to the medication cart, placed the meter on the surface of the cart, retrieved an alcohol pad from the cart and wiped the pad over the surface of the meter and replaced the meter in the docking station. RN-A reported the meter would then upload the blood sugar reading into the medical record. RN-A identified this was the usual process he utilized when he checked blood sugars and was not aware of a different method for disinfecting the Stat Strip meter following use. RN-A reported he was not aware of the manufacture's recommended method for disinfection of the meter nor was he aware of what the facility policy directed. Interview on 6/27/22, at 11:42 a.m., with the director of nursing (DON) identified her expectation for all staff to follow the facility policy for disinfecting glucose meters with PDI Sani cloth wipes and maintaining wet contact time according to the package directions. Interview on 6/27/22, at 11:45 a.m., with the infection preventionist (IP) identified an alcohol wipe was not an effective disinfectant for use on the Stat Strip glucose meter. She reported PDI purple top wipes were to be utilized and 2 minute contact maintained to achieve disinfection of the unit, before replacing into the docking station. Review of the undated Whole Blood Glucose Testing facility policy identified following use the exterior surface of the meter was to be wiped with one PDI wipe to remove any soil or blood on the surface. The meter was to then be wiped with a second PDI wipe and allow to remain in contact with the meter for 2 minutes for disinfection.

Based on observation, interview and document review, the facility failed to comprehensively assess and ensure adequate supervision and interventions were implemented to prevent falls for 1 of 1 resident (R7) reviewed who had sustained multiple falls with injury, resulting in an immediate jeopardy (IJ) with the potential risk of serious harm, injury or death. In addition to the resident in immediate jeopardy, the facility failed to ensure interventions were followed to reduce falls, with the potential for harm that is not immediate jeopardy for 1 of 3 additional residents (R33) reviewed with falls. The IJ began on 1/12/16, at 1:11 p.m. when R7 was observed to be seated unattended in the recliner in his room with both feet elevated on the recliner footrest. The director of nursing (DON) was notified of the immediate jeopardy at 4:03 p.m. on 1/12/16. The immediate jeopardy was removed on 1/13/16, at 11:15 a.m. but non-compliance remained at the lower scope and severity level D- isolated, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R7's quarterly Minimum Data Set ((MDS) dated [DATE], identified [DIAGNOSES REDACTED]. That same quarterly MDS also indicated R7 had moderate cognitive impairment, required extensive assistance with dressing, toileting, and personal hygiene, and needed supervision for bed mobility, transfers and ambulation. A subsequent quarterly MDS dated [DATE], indicated R7 required extensive assistance with all activities of daily living (ADL's) except eating. R7's Care Area Assessment (CAA) dated 2/26/15, indicated R7 was at risk for falls, had short term and long term memory impairment, had [DIAGNOSES REDACTED]. The CAA indicated due to R7's memory impairment he would forget to call for assistance or to use his assistive device. The CAA indicated interventions had been identified for R7 and were in place to help him meet goals and prevent falls with injuries. R7's current care plan, last reviewed on 11/24/15, identified R7 was at risk for falls with potential for injury relate to age, Alzheimer's disease, TIA, glaucoma, hearing loss, urinary incontinence, episodes of confusion and forgetfulness, atrial fibrillation, weakness, and new environment. R7's care plan included the following interventions: (1) Hourly checks and hourly toileting, document on hourly monitoring sheet when intervention completed, (2) do not put feet of recliner up, (3) provide gripper socks if not wearing shoes, (4) body pillows on each side when in bed, (5) ambulate with assistance of 1-2 staff, wheelchair to follow, (6) assist required of 1-2 staff with all other activities of daily living (ADL's), able to eat independently after set up, (7) Sign placed on bathroom door so R7 will not exit or enter from the bathroom into his neighbor's room, and (8) ensure walker within reach. In addition, the plan indicated that if a fall occurred, staff were to complete a post fall assessment, a fall event, and to complete an incident report and assess factors contributing to the fall, and implement interventions dated 3/18/15. The undated nursing assistant (NA) assignment sheets in use on 1/12/16, indicated the following for R7: high fall risk with the following interventions: (1) hourly checks at all times-and document, (2) call light within reach at all times, (3) body pillow on each side when lying down, (4) toilet hourly and (5) staff assist of 1-2 for ADL's. Review of R7's event reports and post fall assessments from 2/27/15 to 1/2/16 revealed he had experienced falls related to impulsivity, decreased strength, improperly fitting shoes, incontinence of urine and poor memory. Although the facility staff had developed interventions post falls, necessary interventions were not always added to the care plan and staff did not always receive adequate instruction on implementation. Review of the fall summaries indicated no injury had occurred with the falls that occurred on 2/27/15, 6/3/15, 6/8/15, 12/1/15, 12/6/15 and 12/13/15. However documentation indicated C7 had experienced minor to significant injuries with the following falls: According to incident documentation, on 8/17/15 at 2:00 p.m., activity staff had witnessed R7 fall in his room when R7 lost his balance after getting up and attempting self-transfer to his walker across the room. R7 landed on the right side of his body and hit his head on the floor. R7 was not wearing his glasses at the time of the fall. At the time, R7 had reported that when attempting to retrieve his walker, he felt dizzy and fell . New intervention: keep walker within range of resident. The resident had sustained bruising to the right side of his head and elbow, a small skin tear to right forearm, and had complained of mild pain to the right upper extremity. R7 had been sent to the emergency room (ER) for evaluation because he'd hit his head and because he was on Coumadin (a blood thinner medication). The ER record dated 8/17/15, revealed the head CT and the cervical spine CT were both negative, with no evidence of significant head injury. Incident documentation indicated on 12/2/15 at 11:40 a.m., R7 had fallen because his recliner chair had tipped forward when R7 attempted to self transfer out of the recliner while the foot rest was in the elevated position. The documentation indicated R7 had been found seated on the floor on his buttocks with his back resting against the elevated foot rest and described blood on the floor from a left wrist skin tear. A documented post fall assessment indicated R7 had his shoes on, walker within reach, call light activated and had his glasses on, but indicated R7 had stated he was attempting to get out of his chair to go to the bathroom and hadn't been able to figure out how to put the foot rest down so had attempted to get out of the chair with it up and the chair had tipped. Additionally, the documentation indicated R7 had reported he'd hit his head on the left side, and that visual assessment had revealed a 3 centimeter (cm) x 1 cm lump to the left side of his head. The documentation indicated staff had applied an ice pack and had initiated monitoring for bruising due R7's continued use of Coumadin to treat atrial fibrillation. The fall summary also indicated R7 had been unable to figure out how to lower the foot rest of his recliner, tried to get out of his recliner, the recliner had tipped and R7 was unable to stop himself from falling due to weakness. As a result of this incident, a new intervention had been identified: do not elevate legs of recliner, sign stating (do not elevate leg rest of recliner) laminated and placed on recliner. The fall summary further indicated R7 usually lays in bed during the day and elevates his legs, and indicated use of the sign would notify all departments the leg rest was to be left down. Incident documentation indicated on 12/11/15 at 10:20 p.m., R7 had been found on the bathroom floor. According to the report, R7 ' s walker had been left in the bed room and R7 had stated he walks around in the room without it all the time. R7 had sustained a skin tear measuring 0.1 cm x 1.5 cm to his right thumb. A new intervention included: frequent reminders to use walker and NA's to remain with R7 while in the bathroom; has UTI. Incident documentation indicated on 12/12/15 at 5:19 p.m., R7 had been found on the floor near the toilet, lying on his left side. The documentation indicated R7 had sustained a 5 cm bump to the left side of his head. The root cause of the fall was identified to include unsteady at times and recent new room. The intervention to prevent futher incident included: initiate every half hour checks by staff. A nurse's progress note dated 12/14/15, indicated R7 had been evaluated by the physician who had modified medication orders, due to the resident's multiple falls and increased weakness to his legs. Fall documentation indicated R7 had fallen again on 12/15/15 at 3:45 a.m., when he'd taken himself to the bathroom. The documentation indicated R7 had been heard yelling help and had been found laying on the bathroom floor with his pants down, on his right side with his head towards the shower. Details indicated R7 had one shoe on and one shoe off, the floor was wet with urine around the toilet base, and R7 had a lump noted to the right side of his head. Documentation indicated R7 had offered no complaints of pain but had slurred speech and rambled conversation. The notes indicated the nursing assistant (NA) had checked on R7 just 10 minutes prior. Root cause: up to bathroom without assistance. New intervention: toilet every 1 hour, night staff updated. At 9:41 a.m. on 12/15/15, the nurse had contacted R7's physician regarding the fall due to R7 experiencing slurred speech and increased confusion. R7 had subsequently been transferred to the local ER (emergency room ) for further evaluation. Follow up nursing progress notes indicated R7 had been admitted to the hospital on [DATE], and a radiology report dated 12/16/15, identified the following injuries: a small left pleural effusion, fracture of right clavicle, right scapula, posterior right 9th and 10th ribs and superior endplate of T2. The CT of cervical spine identified a non-displaced fracture of C2, CT negative. The hospital history and physical/discharge summary for the hospitalization period of 12/15/15 to 12/18/15 revealed: surgical intervention was not required, advised to wear a hard C-collar for 6 weeks. Was admitted to hospital after multiple falls with a C2 compression fracture, CHF, urinary retention, cardiac arrhythmia, and unknown reason for falling. Chest x-ray showed chronic left pleural effusion, stable cardiomegaly and non-displaced fractures of right clavicle. The facility's nursing progress notes from 12/18/15 to 12/26/15, indicated R7 had returned to the nursing home 12/18/15, wearing a neck brace at all times. In addition the notes indicated staff had implemented frequent checks (every 1/2 hour to one hour throughout the night). A physician's progress note dated 12/22/15, identified R7 was at risk for further injury and falls. The physician note also indicated staff had done everything to try to prevent falls, and indicated the C2 spine fracture was stable (not shifted nor moved), and the physician had documented an order for [REDACTED]. Although the facility staff had implemented numerous interventions and had increased monitoring of R7, an incident from 1/2/16 at 2:11 p.m., indicated R7 had again been found on the floor. The report indicated R7 had reported he'd slipped to the elevated foot rest of his recliner and then onto the floor. The documentation indicated R7 had been able to get himself up from the floor, had sustained no injuries, and had no complaints of pain or bruising noted. However, there had been no post fall assessment conducted. Review of previous falls revealed that on 6/3/15, at 6:17 p.m. R7 had been found on the floor in his room. The documentation indicated R7 had stated he was attempting to get out of the recliner with the footrest in the up position, that the recliner chair had tipped forward, and R7 had slid off the end and onto the floor. No injuries had occurred. Additional information documented about this fall indicated that at the time of the fall, R7 had been attempting to self transfer and had been unable to lower the footrest on his own. Interventions developed as a result of the 6/3/15 incident included: lowered footrest, and maintain footrest of recliner in low position, 1:1 discussion related to ask for help when needing assistance and dycem (an anti-slip pad) added to the recliner seat. During continuous observation on 1/12/16 from 1:11 p.m. to 2:12 p.m. R7 was observed sitting unattended in his recliner chair in his room with the footrest elevated, both feet were resting directly on the footrest. R7's lower body was covered by a white blanket, oxygen on via nasal cannula, neck brace was on, eyes closed and appeared to be sleeping. At 1:58 p.m. NA-B entered the room to offer toileting but R7 refused. NA-B repositioned R7's left arm with a pillow, left the footrest of the recliner chair elevated with both of R7's feet resting on the foot rest and exited R7's room. During interview on 1/12/16, at 1:50 p.m. NA-B reported she was aware of R7's previous falls with serious injury but was unsure whether any falls had occurred from the recliner. NA-B stated the only two interventions for R7 included offering hourly toileting and frequent checks. NA-B stated she didn't think there were any specific guidelines related to the recliner chair or the use of the footrest. NA-B then reviewed the current nursing assignment sheet and confirmed no interventions were listed regarding the use of the footrest on the recliner. NA-B confirmed she had elevated the footrest for R7 after lunch on 1/12/16, and that she had offered him the choice of whether to lay in the bed or in the recliner. NA-B also verified she had given R7 a choice about whether to have the footrest on the recliner up or down. NA-B stated staff were made aware of specific resident needs or any new interventions by the facility's communication book which is available to be read at the beginning of each shift, and by the NA assignment sheets. NA-B stated nursing assistants did not have access to the formal resident care plans. R7 was interviewed on 1/12/16, at 2:03 p.m., he was unable to identify whether he'd experienced any falls from his recliner. During interview on 1/12/16, at 2:06 p.m. licensed practical nurse (LPN)-B confirmed R7 had experienced prior falls from the recliner chair and stated he was not supposed to have the footrest elevated. The surveyor then asked LPN-B to check R7's position in his room. At 2:11 p.m. entered R7's room and confirmed R7's legs, which were elevated with the footrest of the recliner, should not have been elevated. LPN-B immediately lowered the footrest and R7's feet and asked him whether he would like to move into his bed. LPN-B reported R7 has multiple fall interventions in place which are documented in the communication book. LPN-B confirmed that a note dated 12/2/15, was documented in the communication book updating staff: do not put feet of recliner up, fell trying to get out of chair with feet up. LPN-B stated although the intervention had been updated on R7's care plan, it had not been transcribed onto the NA assignment sheets so staff would be aware. LPN-B confirmed R7 had received injuries from previous falls, and had most recently required hospitalization for injuries sustained from a fall. When interviewed on 1/12/16, at 2:24 p.m. nursing assistant (NA)-D confirmed an awareness of R7's previous falls from the recliner with the footrest elevated. However, NA-D stated staff continue to put R7 in his recliner with the footrest elevated when he is tired. NA-D further stated the recliner has an electric remote which is supposed to be pinned out of reach to prevent R7 from operating the chair. NA-D stated she is made aware of current fall intervention revisions by checking the communication book, the nursing assignment sheet and checking with the nurse at the beginning of each shift. In addition, NA-D said she reviews changes with the previous staff. During interview on 1/12/15, at 2:32 p.m. registered nurse (RN)-B confirmed R7 had experienced multiple falls while at the facility, including out of his recliner with the footrest elevated (most recently on 1/2/16). RN-B stated R7's footrest were not supposed to be elevated. RN-B explained that after the completion of a fall report, a newly developed intervention is placed in the communication book, and revisions are made to the resident's care plan and NA assignment sheets. RN-B also said the NA sheets are updated weekly on Fridays. On 1/13/16, at 10:46 a.m. RN-B confirmed the intervention to keep the foot rest down for R7, originally initiated 6/8/15, had never been updated on the NA assignment sheet. During interview on 1/12/16, at 4:23 p.m. the director of nursing (DON) confirmed no post fall assessment had been completed after R7's fall from the recliner on 1/2/16. The DON stated the assessment should have been done but was missed. The DON also stated she was not aware of R7's fall from the recliner on 6/3/15; however, was aware of falls involving the recliner on 12/2/15 and 1/2/16. The DON confirmed staff were expected to implement all identified interventions, which for R7 included keeping the footrest of the recliner in the down position. She further verified that intervention had not been transcribed onto the NA assignment sheet. During additional interview with the DON on 1/13/16 at 12:28 p.m., the DON stated R7's condition was very compromised because he'd sustained multiple injuries due to a fall on 12/15/15. The DON further confirmed R7 was still very fragile with many co-morbidities, and remained at high risk for falls and injury. The DON stated R7 continues to have healing fractures and has to wear a cervical collar. A post fall assessment for the 1/2/16 fall was completed on 1/12/16 after interview with the DON. The assessment indicated the root cause of the fall as: confusion and severe cognitive impairment, R7 transferred without assistance and the footrest was elevated on the recliner at the time of the fall. Intervention modifications included: add dycem under the cushion to prevent from slipping. Additional interventions: No foot rests on the wheelchair, footrest on the recliner to be kept down, hourly checks by staff, a laminated sign attached to R7's recliner stating not to bring up the footrest, and a memo to all nursing staff updating them on the care plan updates. The facility's Fall Prevention Policy revised on 10/14, indicated each resident would be assessed for their risk of falling and interventions would be implemented to meet the individual needs of the residents. The immediate jeopardy that began on 1/12/16, was removed on 1/13/16, at 11:15 a.m. when it could be verified by record review and interviews with staff, the facility had completed a comprehensive post fall reassessment, R7 was removed from the recliner with feet elevated, a sign was placed on R7's recliner to leave the footrest down, nursing assignment sheets had been updated, the care plan had been updated, an hourly safety falls checklist had been created and implemented, and staff audits had been conducted on every shift to ensure the hourly safety falls checklist was implemented. However, non compliance remained at the lower scope and severity of a D, no actual harm with potential for more than minimal harm, because the facility failed to ensure ongoing staff compliance with identified interventions to maintain resident safety. R33's electronic health record (EHR) indicated the resident had been admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 11/12/15, identified that R33 had sustained one fall since the last quarterly MDS assessment dated [DATE]. R33's significant change MDS assessment dated [DATE], also identified the resident had sustained one fall since prior assessment and was at risk for falling. The Care Area Assessment (CAA) documentation for the significant change in condition indicated R33 was at risk for falls related to use of anti-depressant medications, weakness at times, shortness of breath (SOB) with activity, obesity, diabetes, hypertension and anemia. The MDS further identified staff should continue her current care plan. Interventions identified indicated R33 needed and received assistance with some of her activities of daily living (ADL) when she was feeling SOB, weak, or tired, and identified she had potential to experience episodes of pain and discomfort. R33's care plan dated 3/9/15, identified R33's risk for falls due to: history of frequent falls when at her home, continued risk for falls, and potential for weakness related to [DIAGNOSES REDACTED].) Assist with ambulation on the unit, 1-2 staff assist with gait belt and wheel chair (w/c) to follow; uses the bathroom in her room; able to ambulate independently in room and to/from bathroom as able; and will need assistance when displaying weakness, increase in shortness of breath (SOB) or tiredness. 2.) Remain in room while R33 is in the bathroom; inform R33 you will be around the corner in the room and to alert staff when she has completed her bathroom task. All staff need to strongly encourage her to use the call light for transfers/assist to prevent falls. R33 is aware and has been explained that she should use staff assist with all transfers; however, she continues to complete tasks such as transfer's independent at times, without calling for staff assist-she did sign a waiver. She is aware of the risks such as injuries that could result in hip FX (fracture), head injuries that can lead to death if she chooses not to call for assist. She continues to make her own decisions regarding when she will transfer, even with her understanding of the risks and benefits. 3.) Attempt to assist with all transfers/encourage her to use call light for assistance. Discussion held with R33 about not waiting for staff assist/and or not using call light when she needs help with walking or transfers in her room. R33 realizes she is not always steady on her feet and that her feet do catch on the floor at times when she walks. R33 is made aware of the risks involved if she should fall and lose her balance because she declines to ask for assistance with transfers and walking in her room. Frequently walks to and from her chair/bed into her bathroom. R33 is made aware that if she chooses not to have staff assist her with transfers and ambulation she has the potential for injures to occur. We talked about the potential injuries that could happen such as head injuries, fractures-and these could lead to death. We also talked about skin tears and bruising. R33 also has refused protective foam from being placed in her door way. She decides at this time that she would like to continue to transfer/walk on her own in her room without calling or waiting for assist, even after the above risks were explained to her. She is alert and oriented x 3 and is able to make decisions. R33 signed a release from responsibility form. See form which is placed into her chart; 4.) Raised edge mattress; 5.) Bedside table moved to right side of the bed; 6.) Walker place in reach next to bed and chair; Keeps wheelchair in the hall just outside her doorway; and encouraged to keep this wheelchair locked. Staff also check to make sure it's locked. 7.) Use nightlight/light in bathroom as R33 requests to use and use as needed. Provide proper and well maintained foot wear. Keep personal items and frequently used items within R33's reach. During observation on 1/11/16, at 5:29 p.m. R33 propelled herself in the wheelchair from her room with the use of her feet and arms. R33 was noted to become SOB and struggled with wheeling the w/c. At 5:31 p.m. NA-A noted R33's difficulty with self-wheeling and transported R33 to the dining room table. Following supper, at 6:18 p.m. R33 was observed to have wheeled herself from the dining room, using her hands and feet to propel the w/c. It was noted that R33 became SOB with the activity. Again, NA-A noticed the difficulty and wheeled R33 to her room. NA-A opened the bedroom door, wheeled R33 into the room, closed the door and left R33 in her room with the door closed. NA-A indicated she would return later to check on R33. No further assistance was offered by NA-A. At 6:29 p.m. R33 was observed seated in her recliner located in her room; breathing heavily and sweating. When interviewed at that time, R33 stated she had transferred herself into the recliner and that it had been difficult. It was observed that R33 had the wheelchair positioned in front of her recliner with the brakes on the chair locked. When questioned why she hadn't asked staff for assistance R33 replied, It takes too long for them to come and I'm impatient. When interviewed the following day, on 1/12/16, at 5:17 p.m. R33 was seated in her room in her wheelchair and was very SOB and breathing heavy. R33 stated she had been in the bathroom and was lucky because staff came in and saw her having a hard time getting onto the toilet. She stated her SOB was terrible today, and that she'd become extremely SOB and weak when attempting to toilet. R33 stated if staff had not entered the room she may have fallen as she did not always ask for help. R 33 stated she is aware of the fall risks but desires to do as much for herself as possible to maintain her independence. R33 indicated the falls she experienced were not the fault of the staff; I'm a bit stubborn. R33 indicated she would utilize the call light when she felt she needed assistance but usually did not use the call light. Review of the medical record identified that R33 had experienced the following falls: 1) 1/9/16, at 3:15 p.m. while attempting to get to the toilet and had incontinence on the floor which caused the floor to be slick. R33 sustained a skin tear. The nursing progress note dated 1/9/16, at 05:04 p.m. identified R33 was incontinent of urine, which caused her to slip and fall, and indicated R33 had not used her walker because she was in a hurry. R33 had sustained a skin tear to the left thumb and index finger, and had required three staff assist into bed with the use of a full lift. Documentation indicated R33 had initially denied pain but at approximately 4:40 p.m. had requested and received Tylenol for right shoulder pain. 2) 9/24/15 a progress note from 11:56 a.m. indicated when an NA had gone to check R33's menu selection, R33 had been found on the floor near her door. R33 indicated she was going to get her walker to go to the bathroom and had fallen. Documentation indicated R33 sustained multiple bruises and a small skin tear to her right middle finger, and had been sent to the hospital due to complaints of shoulder pain on her left side. Fractures were ruled out and R33 returned to the facility. 3) 7/16/15, at 10:25 p.m. a progress note indicated R33 was heard calling out Help! When staff entered the room, R33 had been on the floor lying on her back in the bathroom with her head out into her room. R33 had sustained a hematoma (bruise) to her left hip and elbow, had gone to the hospital, but no fractures were identified. An intervention developed post fall indicated R33 was encouraged by staff to ask for help by using the call light when transferring, and that R33 had agreed. 4) 7/6/15, at 8:35 a.m. a progress note identified that R33 had activated her call light and when staff entered the room R33 was sitting on the floor with her legs crossed. Documentation indicated R33 had sustained a skin tear to her upper right arm on the lateral aspect measuring 3.5 x 2.5 cm. R33 was assisted to a standing position easily with 3 staff and gait belt. 5) 7/1/15 at 6:45 p.m., a progress note identified R33 had been found on the floor in her bathroom in a puddle of urine at 3:10 p.m. that day. The documentation indicated R33 had bumped her head on the high-rise on the toilet, and had sustained a bump about the size of a golf ball to the right of the midline on the back of her head. The notes indicated staff had implemented neurological checks at the time of the fall, but no irregularities had been noted. When interviewed on 1/13/16, at 8:38 a.m. RN-A and LPN-A stated staff should encourage R33 to get assistance when she needs to use the toilet and/or transfer as stated in the care plan. When RN-A and LPN-A were questioned about the evening observation on 1/11/16, when R33 had been wheeled to her room by staff after supper, and left alone with the door closed, LPN-A responded that staff should have offered to assist R33 with transferring into her recliner. LPN-A stated R33 would probably have declined the help, but it still should have been offered. RN-A verified the care plan was not followed as written and reiterated staff should offer to provide R33 assistance because although she may decline, sometimes she will accept the assistance.

Based on observation, interview and document review, the facility failed to comprehensively assess for all risk factors and failed to implement preventative measures timely for 1 of 1 resident (R16) reviewed in the sample that developed a stage III pressure ulcer while in the facility. R16, assessed to be at low risk for pressure ulcers, sustained actual harm when a stage III pressure ulcer developed. Findings include: R16 was observed with one stage III pressure ulcer on the coccyx area. (A stage III pressure ulcer involves full thickness skin loss involving damage to or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). R16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], identified R16 as severely cognitively impaired, needed minimal assistance with all activities of daily living including transfers and mobility. In addition, R16 was ambulatory with use of walker, occasionally incontinent of bladder and was not at risk for pressure ulcers and a pressure reducing device was used on bed. The clinical documentation-monthly summaries, completed by licensed staff from 11/05/12 through 04/02/13 were reviewed. The summaries had a check mark in the skin integrity box for questions if a resident was at risk for pressure ulcer; other wound issues; skin ulcer treatments and foot problems. It also had boxes to place a check mark in for pain management; nutritional status; clinical monitoring; dental issues and sensory concerns. There was no documentation to indicate a visual inspection of the skin had been conducted. None of the summaries included a comprehensive analysis including pertinent risk factors, comorbidity, pertinent labs, medication uses and resident concerns.The summary dated 11/05/12 had a check mark indicating R16 was not at risk for pressure ulcers and intervention was a pressure reducing device on the bed. 2/05/12 summary indicated R16 was at risk for pressure ulcers and a pressure reducing device on the bed was listed. The 11/30/12 quarterly skin risk assessment did not take into consideration all significant risk factors for R16, which included poor nutritional intake, urinary incontinence, long term use of [MEDICATION NAME], increase need for daily care assistance, repositioning needs, respiratory congestion, low blood oxygen levels and increased mental confusion. The assessment did not include a comprehesive analysis. A Braden scale tool was used to predict pressure ulcer risk which identified R16 to be at low risk for pressure ulcer development. The 01/09/13 summary indicated pressure ulcer risk factors were not assessed. The nursing progress notes were reviewed from November 2012 through December 2012, which indicated R16's general health was gradually declining. R16 was experiencing increased chest congestion, cough, decrease in blood oxygen saturation levels, decreased nutritional intake and required increase in assistance from the nursing staff with daily cares. A nursing progress note dated 12/29/12, indicated R16, "Activated her call light x 1 this a.m. and asked for CNA (nursing assistant) to assist her with peri care. CNA reported that bottom is slightly pink." Although R16's bottom was noted to be slightly pink, a skin assessment was not conducted, there was no documentation to indicate a change in skin monitoring frequency and there was no change in the plan of care. Fourteen days later, the nursing progress note, dated 01/11/13, identified a stage III pressure ulcer on R16's coccyx which was observed and reported by a nursing assistant during bathing. The open area on R16's coccyx, was identified as a stage III pressure ulcer with measurements of: length (L) 1.8 centimeters (cm), width (W) 0.7 cm and depth (D) 0.4 cm. The nursing progress note, dated 01/11/13, after discovery of the stage III pressure ulcer on R16's coccyx, facility staff implemented ROHO (pressure reducing) cushion in the chair, assist R16 with hourly offloading (repositioning) and nutritional supplements to promote tissue healing and prevent pressure ulcer from becoming worse. The physician's documentation, dated 01/11/13 indicated a pressure ulcer on coccyx was noted, which measured L=1.8 cm, W= 0.7 cm, D= 0.4 cm. In addition, it revealed, "The patient has very redundant skin in this area, which seems to lapse over and makes visualization difficult and may have accounted for this not being seen before." The documentation further indicated according to the patient (R16) had been complaining of pain to the nursing staff for the past few weeks that, "something hurts back there, but it was unable to be discovered." The computerized weekly wound care nursing progress notes from 01/11/13 through 4/16/13 and paper documentation of wound monitoring from 01/11/13 through 04/16/13 revealed R16's stage III pressure ulcer on coccyx, measurements ranged, L = 1.2 cm to 2.0 cm; W=0.4 cm to 0.8 cm and D=0.2 cm to 0.6 cm. The pressure ulcer was not healing and also was not becoming worse. According to 03/03/13 nursing progress note, R16 was diagnosed with [REDACTED]. The resident's current plan of care updated 3/3/13, identified R16's altered skin integrity related to the stage III pressure ulcer on coccyx. The goal included to prevent the ulcer from becoming worse and interventions included Gel mattress overlay on top of the speciality mattress, hourly offloads, proper infection control practices, weekly wound assessments, pain monitoring, ROHO cushion on all sitting surfaces, and wound care treatments as prescribed by the physician. During observations on 04/17/13 from 8:25 a.m. through 9:45 a.m. R16 was in her room, sitting in the same position in her chair on top of a ROHO cushion, which was covered with a cloth mat. R16 was not assisted by staff with offloading for an hour and twenty minutes. During an interview with nursing assistant (NA)-B on 4/17/13, at 1:40 p.m. regarding R16's offloading schedule, NA-B stated R16 was on an hourly offloading schedule, however added that this was a very busy unit and there was, "only me and the RN (registered nurse) on this unit and it's tough to help everyone," since there were multiple residents needing hourly checks. NA-B stated she might have forgotten to offload R16, and stated hourly checks are documented on the paper forms kept at the nursing desk. During observations of wound care on 04/17/13 at 2:20 p.m., R16 was observed to have a stage III pressure ulcer on the coccyx area. The wound care registered nurse (RN)-C with assistance from RN-A, after the physician's round, provided debridement (the process of removing nonliving tissue from pressure ulcers to speed the healing of pressure ulcers) to the deep coccyx ulcer with an instrument. RN-C measured the ulcer, L= 1.6 cm, W= 0.8 cm, D=0.5 cm with 20% of wound base covered with slough and cleansed it with normal saline solution. RN-C applied Medi Honey to the wound base and covered it with [MEDICATION NAME] dressing. R16 tolerated the procedure well and was cooperative. No foul odor or drainage noted, the surrounding skin tissue was normal color. RN-C stated the onset of this ulcer was due to a sinus tract to sacrum; however, when asked for documentation, RN-A and RN-C had no comments. RN-C exited room after washing hands and RN-A remained in R16's room and asked if R16 wanted to get up or continue to lay in bed. When inquired regarding the thick cloth mat on top of ROHO cushion, RN-A stated, as she removed the cloth mat from ROHO, that a staff might have placed it to prevent ROHO cushion from getting wet. RN-A verified the cloth mat should not be placed on top of the ROHO cushion as it prevents pressure relief from the cushion. During an interview with RN-A on 04/17/13 at 2:45 p.m. she stated the nursing assistants inspected the residents' skin during weekly baths and report any unusual findings to the nurses on duty. The nurses then assess the area, initiate a computerized and paper documentation on skin monitoring and inform the physician and legal guardian of the findings. Also, the plan of care would be revised to address all pertinent interventions. In addition RN-A stated a clinical documentation-monthly summary is completed by the nurses, which included the skin issues. After reviewing the clinical documentation-monthly summary completed by nurses, RN-A verified the summaries were not comprehensive and lacked pertinent data. After reviewing R16's monthly summary, dated 01/09/13, for skin section, RN-A stated it was inaccurate, the nurse would have needed to complete the risk assessment section,which was marked as not done. RN-A indicated that when a nurse completes a summay, a visual skin inspection from head to toe should be conducted and findings documented in the computerized monthly summary. RN-A stated not being sure that it was being done in a consistent manner. RN-A further added, R16's coccyx ulcer was hidden between the folds of her skin and it was difficult to find because of it's location and perhaps that might be the reason that it was not discovered earlier, "I had a hard time to find it." During an interview with the primary physician (MD) on 4/17/13, at 3:55 p.m. he stated, it was difficult to know exactly when R16 developed the pressure ulcer and it was rare that a stage III pressure ulcer occurred overnight. The MD further stated he'd been made aware of R16's stage III pressure ulcer on the coccyx on 1/11/13. The MD also stated R16 had reported to him during the 1/11/13 visit that she had been telling the staff that she had some pain in her bottom area however, because of her excessive skin folds in the coccyx area, the pressure ulcer might not have been easily visible for the nursing staff to detect. The MD said this might explain the delay in finding this pressure ulcer. He added that on routine visits he does not inspect patients peri areas and stated that when the pressure ulcer was identified, treatment was started immediately. During an interview with the director of nursing (DON) on 4/18/13, at 10:40 a.m., the DON stated that to prevent this type of incident from happening they had implemented paper forms for nursing assistants to complete during bathing regarding each resident's skin condition. The DON indicated the form had been initiated after the discovery of R16's stage III pressure ulcer. During additional interview with the DON on 4/18/13, at 11:00 a.m., the DON verified that after review of the paper and computerized documentation regarding R16's skin condition, the comprehensive skin assessment was not completed and the skin summary dated 1/9/13, was inaccurate. The DON stated the nursing staff will need to be re-educated on skin assessments and monitoring. The facility's policy for skin care, undated, instructed staff to complete a visual inspection to determine if any skin issues exist. Then, if a resident was at risk for developing pressure ulcers appropriate interventions needed to be started.