Every finding on record at Essentia Health Virginia Care Cent

Based on observation and interview, the facility failed to date opened products, dispose of expired products, and failed to have a process to ensure stored food was labeled with an expiration date that staff could understand. This deficient practice had the potential to affect all 15 residents who received food from facility kitchen.Findings include:During the initial kitchen tour on 3/23/26 at 1:27 p.m., nutrition services manager (NSM) stated products were dated when opened. The following was observed during the tour:Dry storage:6 cans of pasta sauce had no discernible expiration date.6 cans of tomato paste had no discernible expiration date.5 cans of carrots had an expiration date of 12/28/25.Cold storage:In cooler 3, there was an open, undated half gallon of heavy cream.In freezer 1, beef stew tray had no expiration date.Kitchen cooking line:Small fridge on kitchen line had an open, undated liquid egg carton.7 open, undated spices. In addition, there were no discernable expiration dates on the spices.Resident dining room on 3rd floor:Open, undated ketchup bottles on 9 tables. In addition, there were no discernable expiration dates on the bottles.During an interview on 3/24/26 at 1:26 p.m., cook (C)-A stated they discard canned goods when beyond the expiration date. C-A was unable to locate the pasta sauce and tomato cans and stated they would need to ask their supervisor to determine the expiration date.During an interview on 3/24/26 at 1:39 p.m., NSM stated the canned goods in dry storage had [NAME] dates on them and stated they had to look them up on computer. NSM's expectation was that staff would discard expired products but confirmed that the products had not been dated in a way that staff could identify the expiration date. They stated there was no facility process to identify an expiration date (in [NAME] calendar format) for products that were delivered with a [NAME] calendar expiration date. NSM stated the concern with not discarding expired food was the potential for residents to become sick if it was served.During an interview on 3/25/26 at 2:07 p.m., the facility administrator stated the kitchen monitors expiration dates until it comes to the dining room or nursing kitchenette. They expect foods would be discarded when expired.Facility Food Storage Chart - Food Storage Guidelines, revised 4/7/25, identifies the following product discard after opening guidelines:cream - refrigerate 3 - 4 dayscatsup - open 1 monthground spices - 6 monthsFacility food storage policy requested but not received.

Based on observation, interview, and document review the facility failed to only leave medications at bedside when there was order to and the resident wanted to self adminster medications. This affected 1 of 1 residents (R5) reviewed for self administration of medication.Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. Diagnoses included diabetes and cerebral vascular accident (CVA)(stroke). R5's Assessment for Resident Self-Administration of Medications/Treatments dated 3/16/26, indicated R5 did not want to self-administer medications and/or treatments (SAM). R5's Physician Order Report (POR) dated 3/26/26 indicated R5 received acetaminophen 500 milligrams (mg), 2 tablets three times a day by mouth. The POR lacked orders for Tums antacids. No staff were in the room. R5's care plan undated, lacked a care plan related to self-administration of medication. During an observation on 3/23/26 at 2:13 p.m., two tylenol were observed in a medicine cup sitting on R5's bedside table along with a second medicine cup which held four tums, and a bottle of tums. During a second observation on 3/25/26 at 2:09 p.m., 4 tums were again observed in a medicine cup, along with the bottle of tums on R5's bedside table. No staff were present. During an interview on 3/25/26 at 2:10 p.m., licensed practical nurse (LPN)-A stated if medications were left at bedside there needed to be an order to leave them at bedside, an order for the medication that is left at beside, and the SAM needed to be fill out and would indicate the resident wanted to self-administer medication and the resident was safe to self-administer medications along with leaving them at bedside. During an interview on 3/26/26 at 8:11a.m., the director of nursing stated an expectation of orders in place and the SAM filled out prior to medications being left at resident bedside.Facility policy Medication Self-Administration last reviewed 9/4/25, indicated medication would never be left unattended with a resident without appropirate assessment and order for self-administration.

Based on observation, interview, and record review the facility failed to wear appropiriate personnal protective equipment (PPE) for a resident on contact precautions. This affected 1 of 1 resident (R11) reviewed for infection control. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 as cognitively intact. R11's diagnoses included ataxia following cerebral infarction, diabetes mellitus type 2, paroxysmal atrial fibrillation, hypertension, and legal blindness. R11's care plan revised 2/24/26, identified left eye blepharoconjunctivitis infection: will resolve infection incurred and not spread same to others. It instructed to implement contact precautions. R11's provider orders dated 3/25/26 identified contact precautions through duration of eye drops and duration of left eye symptoms. During dining observations on 3/23/26 at 5:10 p.m., R11's door had an isolation sign on it which indicated R11 was on contact precautions. The sign indicated gown, and gloves had to always be worn when staff entered the room. Registered nurse (RN)-B was observed taking R11 the dinner tray in. RN-B placed gloves on but did not put a gown on and entered R11's room. During a second observation on 3/23/26 at 5:39 p.m., RN-B again entered R11's room with gloves on but without a gown on. During an interview on 3/23/26 at 5:39 p.m., RN-B stated gown and gloves needed to be worn while in a contact isolation room when staff would come in contact with the resident or the items in the resident's room. If contact was not made, like taking in a food tray, then staff only had to wear gloves in the isolation room. During an observation on 3/24/26 at 9:31 a.m., R11's door had an isolation sign on it which indicated R11 was on contact precautions. The sign instructed that gown and gloves always had to be worn when staff entered the room. Nursing assistant (NA)-A was observed entering R11's room without wearing gloves and a gown to assist R11 to the bathroom. During an interview on 3/24/26 at 9:44 a.m., NA-A stated a gown and gloves must be worn when entering a contact isolation room to prevent spreading an illness. NA-A stated they thought R11 was no longer on contact isolation. They confirmed the contact isolation signage on R11's door and stated they should have worn a gown and gloves when entering R11's room. During an interview on 3/25/26 at 9:48 a.m., the infection preventionist stated gown and gloves needed to be worn any time a staff member was in a contact isolation room, if there was any risk of coming into contact with anything in the resident room, which meant pretty well every time the gown and gloves needed to be worn. During an interview on 3/26/26 at 9:16 a.m., the director of nursing (DON) expected staff to gown and glove when entering a contact isolation room. They stated a concern for spreading the infection if gown and gloves were not worn in a contact isolation room. The DON confirmed that R11 was on contact isolation. The facility process Contact Precautions dated 9/21/23, indicated staff were required to put on an isolation gown and gloves prior to entering a contact isolation room.

Based on observation, interview, and document review, the facility failed to ensure nebulizer tubing/canister was cleaned and allowed to air dry after each use for 1 of 1 resident (R16) reviewed for oxygen therapy. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had moderate cognitive impairment and diagnoses included chronic obstructive pulmonary disease (COPD) and respiratory failure. R16's provider order dated 4/12/24, identified orders for ipratropium-albuterol solution for nebulizer: 0.5 milligram (mg) - 3mg(2.5mg) base/3mililiter (ml) every four hours as needed for shortness of breath. On 1/6/25 at 1:52 p.m., a nebulizer canister was observed in R16's room. The canister was observed to have condensation built around the inside of the canister with water drops also noted in the base of the canister. There was no date on the canister. R16 stated a nebulizer treatment had not been taken since some time on 1/5/25. On 1/7/25 at 1:42 p.m., a nebulizer canister was again observed in R16's room. The canister was dated 1/6/25, but had free standing fluid in the bottom. R16 stated the last nebulizer treatment had been given on 1/6/25, around 8:30 p.m. Review of R16's medication administration report (MAR) dated 1/1/25 to 1/9/25 indicated R16's last nebulizer treatment was given on 1/6/25 at 8:47 p.m. During interview on 1/7/25 at 1:49 p.m., registered nurse (RN)-A stated after every nebulizer treatment the canister was to be emptied of left over fluid, washed out with water and then left apart to air dry completely on a paper towel. RN-A looked at the nebulizer canister in R16's room and confirmed there was freestanding fluid in the nebulizer. R16's MAR was reviewed and confirmed that R16's last nebulizer treatment had been on 1/6/25 at 8:47p.m. RN-A stated the canister should have been cleaned after the treatment on 1/6/25, but had not been. During interview on 1/7/25 at 1:55 p.m., the infection preventionist (IP) stated if the nebulizer canister was not cleaned and left to air dry after each treatment there was an increased risk of the patient getting a respiratory infection due to the fluid harbors bacteria as it sits in the canister. During interview on 1/9/25 at 8:30 a.m. the director of nursing (DON) stated an expectation all staff would clean the nebulizer canister after each use and allow it to air dry completely before using again. Facility policy Respiratory Equipment last reviewed 4/25/24, identified after each use the nebulizer would have all excess fluid removed from the nebulizer, taken apart and parts cleaned with sterile water. All parts would then be placed on a clean washcloth or paper towel to dry.

Based on observation, interview and document review the facility failed to ensure the completed Minimum Data Set (MDS) was accurately coded for 4 of 6 residents (R4, R13, R16 and R19) reviewed for resident assessment. Findings include: R4's quarterly MDS dated [DATE], did not identify the following diagnoses hyperlipidemia (excess fat in blood), idiopathic gout (recurrent attacks of [NAME] arthritis in joints), esophageal mass, or atherosclerotic heart disease (narrowing of heart arteries). R4's physician order report, identified R4 was diagnosed with and receiving treatment for hyperlipidemia starting on 4/10/2023, idiopathic gout starting on 6/23/2023, esophageal mass starting on 8/10/2023, and atherosclerotic heart disease starting on 1/6/2023. R13's quarterly MDS dated [DATE], did not identify the diagnosis of atrial fibrillation (abnormal heartbeat). Additionally, R13's quarterly MDS did not indicate R13 was taking the high-risk hypoglycemic (lower's blood glucose) medication metformin or the high-risk antipsychotic medication quetiapine. R13's physician order report, identified R13 was diagnosed with and receiving treatment for atrial fibrillation starting on 1/16/2023, receiving metformin starting on 12/31/2022, and quetiapine starting on 12/11/2023. R16's quarterly MDS dated [DATE] did not identify the diagnosis of hyponatremia (low blood sodium). Additionally, R16's quarterly MDS identified the diagnosis of non-Alzheimer's dementia. R16's physician order report, identified R13 was diagnosed with and receiving treatment for hyponatremia starting on 4/3/2023 and was not diagnosed with non-Alzheimer's dementia. During interview on 2/28/2024 at 8:55 a.m., registered nurse (RN)-B confirmed he had completed the quarterly MDS's for R4, R13, and R16. RN-B stated all diagnoses a resident was receiving treatment for and all high-risk medications taken during the 7-day observation period should be included on the MDS. During the interview RN-B confirmed following: -R4's quarterly MDS should have included the diagnoses of hyperlipidemia, idiopathic gout, esophageal mass, and atherosclerotic heart disease. -R13's quarterly MDS should have included the diagnosis of atrial fibrillation and indicated R13 was receiving high risk hypoglycemic and antipsychotic medications. -R16's quarterly MDS should have included the diagnosis of hyponatremia and should not have included the diagnosis of non-Alzheimer's dementia. -It was important for the MDS to be accurate because it may affect reimbursement. A modified MDS will be submitted. The Centers for Medicare and Medicaid (CMS) Long-Term Resident Facility Assessment Instrument (RAI) 3.0 User's Manual dated 10/2023, Section I: active diagnoses, instructs to code for diseases that have a direct relationship to the resident's current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring, or risk of death. Section N: medications, instructs to code all high-risk drug class medications taken during the 7-day observation period. 49878 R19's significant change Minimum Data Set (MDS) dated [DATE], identified R19 was severely cognitively impaired and had diagnoses of malignant neoplasm of endometrium (cancer that begins in the lining of the uterus) and glaucoma. R19's quarterly MDS dated [DATE], identified R19 was cognitively intact and had diagnoses of type 2 diabetes mellitus, malignant neoplasm of endometrium, anemia, hypertension, hyperlipidemia, depression, and glaucoma. R19's orders dated 12/22/23, identified venlafaxine (antidepressant medication) 150 milligrams (mg) capsule given once a day by mouth. On medication order, diagnosis is listed as F32.A: Depression, unspecified. R19's care plan revised on 2/27/24, identified diagnoses that included type 2 diabetes mellitus, malignant neoplasm of endometrium, hyperlipidemia, depression, and glaucoma. R19's care plan further identified R19 as receiving antidepressant medication due to a diagnosis of depression. During interview on 2/28/24 at 10:54 a.m., MDS Coordinator (RN-B) confirmed he had completed the most recent significant change MDS for R19 and the quarterly MDS for R19. RN-B confirmed R19's diagnoses were not correct in the most recent MDS and it was an error. RN-B also identified the importance of the MDS and how the care plan was based on the MDS. During interview on 2/28/24 at 12:10 p.m., administrator confirmed the importance of the MDS for resident care and for treatment planning. Administrator expected the MDS to be correct, and to be fixed if there was an error. Administrator further confirmed that audits are done on the MDS by RN-B.

Based on observations, interviews and record review, the facility failed to review and revise the care plan to reflect resident preferences for 1 of 2 residents (R5) reviewed for care planning. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was rarely if ever understood and had diagnoses of dementia and congestive heart failure. R5 was dependent on staff for all activities of daily living (ADLs) and was non-ambulatory. R5's care plan dated 1/9/24 identified it was important to R5 to be awake at 9 a.m. During a continuous observation on 2/27/24 starting at 8:09 a.m. to 10:42 a.m., R5 was in bed sleeping with the covers on. During this time staff were not observed to enter the room. During an observation on 2/27/24 at 10:42 a.m., nursing assistant (NA)-B and NA-A worked together to provide R5 with a bed bath, dressing and grooming. R5 was not resistive to the care throughout this observation. During an interview on 2/28/24 at 9:08 a.m., NA-A stated R5 used to have breakfast, but she had so many behaviors in the morning they decided to let her sleep in. If R5 was awake they would offer breakfast, if she was sleeping, they let her sleep and that seemed to go better for her. During an interview on 2/28/24 at 9:22 a.m., registered nurse (RN)-A stated R5 didn't typically eat breakfast, they had found she had more behaviors in the morning and during breakfast. So, if she was awake, they would offer her breakfast. During an interview on 2/28/24 at 12:20 p.m., the director of nursing (DON) stated she would expect the care plan to address resident preferences, such as breakfast. It would be important to plan for that to avoid behaviors and avoid heading toward medications for interventions. Care plans were updated with new orders, changes in condition, or new interventions. The care plans are updated by the RNs, therapy, dietary, and social services. The DON would expect the care plans got updated through the Resident Assessment Instrument (RAI) process. A facility policy, Care Conferences and Care Planning dated 3/15/23, identified the purpose was to ensure quality of care for each resident through a plan of care to receive the necessary to enable them to achieve or maintain their highest practical physical, mental, and psychological well-being. Care plan assessment and changes would be made quarterly and as needed and were reviewed with direct care staff as needed.

Based on observation, interview and record review, the facility failed to follow care plan interventions for pressure ulcer prevention and wheelchair positioning for 1 of 3 residents (R5) reviewed for pressure ulcer care and prevention. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was rarely if ever understood and had diagnoses of dementia, congestive heart failure (CHF), chronic peripheral vascular disease, pre-diabetes, and morbid obesity. R5 was dependent on staff for bed mobility, hygiene, incontinent care, transfers and was at risk for pressure ulcer development. R5's care plan dated 9/2/19, identified R5 was at risk for alteration in skin integrity related to her Braden (a skin risk-assessment) score, impaired mobility, and incontinence. Interventions included licensed nurses to do weekly skin assessments, to provide a foam mattress, encourage turning and repositioning, clean and dry skin promptly after incontinent episodes, perform Braden assessment quarterly, turn and reposition every two hours and as needed using bath blanket. R5's care plan also identified a high risk for falls related to poor safety awareness and dementia. Interventions included providing Dycem (a brand name for a non-skid matt) placement under R5's wheelchair cushion, to provide a proper, safe, and comfortable position while sitting, to provide with a 22-inch wedged wheelchair with foam cushion with Dycem underneath. R5's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE], identified R5 was at risk for pressure ulcer development. During observations on 2/26/24 between 1:10 p.m. and 5:04 p.m., R5 was observed sitting in her wheelchair in the television area. During a continuous observation on 2/27/24 starting at 8:09 a.m. to 10:42 a.m., R5 was sleeping in bed on her back and in the same position for the duration. During this time staff were not observed to enter R5's room. At 10:42 a.m., nursing assistant (NA)-A and NA-B went in to R5's room and provided her with a bed bath, dressing and grooming. NA-B was providing perineal hygiene and commented R5's peri-rectal area was red. R5 was observed to have had red linear strip of redness in the gluteal fold. NA-B applied barrier cream to the area. NA-A and NA-B worked together to transfer R5 into her wheelchair, which did not have a cushion or Dycem. During an interview on 2/28/24 at 9:22 a.m., registered nurse (RN)-A confirmed R5's care plan indicated repositioning every two hours and to have a 22-inch wedged wheelchair with dycem. RN-A confirmed there was no dycem on the seat or R5's wheelchair, nor in her room; a flat wheelchair cushion was found in her bathroom. RN-A stated her expectation was for residents to be repositioned every two hours if the care plan said to reposition every two hours, and she would need to ask therapy what a wedged wheelchair was. During an interview on 2/28/24 at 10:52 a.m., an occupational therapy assistant (OTA)-A stated they hadn't seen R5 for a very long time, looked back several years and did not see an evaluation or treatment for wheelchair positioning or cushions. OTA-A was not sure what a wedged wheelchair meant. During an interview on 2/28/24 at 12:20 p.m., the director of nursing (DON) stated she would expect the things in R5's care plan to be available, and for her to be repositioned according to the care plan to relieve pressure so she didn't have skin breakdown. A facility policy, Skin Care Management dated 9/20/22, identified the purpose was to provide preventative skin care measures for residents by implementing preventative measures and to provide appropriate treatment modalities according to industry standards of care.

Based on interview and document review, the facility failed to ensure a rationale was documented for the extended order of an as needed (PRN) psychotropic (effecting the chemical makeup of the brain) medication beyond 14 days for 1 of 5 residents (R19) reviewed for unnecessary medications. Findings include: R19's significant change Minimum Data Set (MDS) dated [DATE], identified R19 was severely cognitively impaired and had diagnoses of malignant neoplasm of endometrium (cancer that begins in the lining of the uterus) and glaucoma. R19's care plan last revised on 2/27/24, identified diagnoses that included type 2 diabetes mellitus, malignant neoplasm of endometrium, hyperlipidemia, depression, and glaucoma. R19's physician orders dated 1/15/24, identified lorazepam (antianxiety medication) oral tablet 0.5 milligrams (mg) 1/2 tablet dose of 0.25 mg give by mouth every 4 hours PRN anxiety. Order did not have rationale to extend beyond 14 days, nor did it have an end date from the provider. Attempted to reach consultant pharmacist for interview on 2/29/24 without success. During an interview with another pharmacist at consulting pharmacy on 2/29/24 at 12:55 p.m., pharmacist stated R19 was in hospice care and pharmacist believed that medication orders for hospice residents do not require end dates. Pharmacist further stated orders for R19 were acceptable. State Operations Manual from the Centers for Medicare & Medicaid Services dated 2/3/23, identifies S483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days . if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on interview and document review, the facility failed to ensure timely completion of all Minimum Data Set (MDS) sections prior to submission, and to ensure completion of a Care Area Assessments (CAA) worksheet for a significant change in condition assessment (SCSA) for 1 of 6 (R5) residents reviewed for MDS completion. The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023, identified section C's intention was to determine the resident's attention, orientation, and ability to register and recall new information. These items were crucial factors in making care planning decisions. The Manual identified section F's intention was to obtain information regarding the resident's preferences or his or her daily routine and activities. Nursing homes should use this as a guide to create an individualized plan for the resident's preferences. Care Areas are triggered by MDS item responses that indicated the need for additional assessment based on problem identification, known as triggered care areas, which formed a critical link between the MDS and decisions about care planning. Findings include: R5's quarterly MDS dated [DATE], identified R5 was rarely, if ever, understood but did not identify a Brief Interview for Mental Status (BIMS, a cognitive assessment score) for section C. The MDS included a diagnosis of dementia. R5's SCSA MDS dated [DATE], section F was incomplete, and the activity CAA was incomplete. R5's psychosocial well-being CAA referred to the activity CAA, which was incomplete. R5's care plan dated 1/9/24 and written by RN-B, identified R5 preferred not to engage in group settings, may isolate herself, enjoyed conversation, sitting at the end of the hall to look out the window, watching television for short periods, and to propel herself around her community. During an interview on 2/28/24 at 9:16 a.m., activity personnel (AP)-A confirmed he was responsible for section F of R5's SCSA MDS, for writing the care plan for R5's interests, likes, and developing goals. AP-A stated R5 could give short answers at times but seemed to enjoy listening to conversation. Also, nursing staff would bring her to the TV room so she can watch programs or attend Bible sharing group. During an interview on 2/28/24 at 11:05 a.m., registered nurse (RN)-B, who was responsible for MDS coordination, stated social services was responsible for section C. RN-B confirmed the assessment was dashed because the assessment reference date (ARD, the date the assessment period was over) was 2/6/24 and section C wasn't completed until 2/14/24. During an interview on 2/28/24 at 12:13 p.m., the administrator stated their social service designee (SSD) was responsible for section C. That person misunderstood the timing of the ARD and completed her portion late. The SSD was not available for interview. The administrator stated the expectation would be that the person closing out the MDS would reach out to the person who did not have their section done and coordinate with them. The administrator further stated the MDS process was important for quality, would tell them what the resident actually had going on so that they know what to target, and it helped make the care individualized. During an interview on 2/28/24 at 1:55 p.m., RN-B stated he did check for completeness but thinks activities was gone at that time. The administrator added her expectation would be if SSD couldn't complete it before vacation, SSD would let someone know and have it assigned to someone else. A facility document, Minimal Data Set Assessment Completion dated 7/15/22, identified its purpose as ensuring each resident a comprehensive care plan will be developed to assist the resident in meeting their highest practical physical, mental, and psychological well-being. Quarterly updates will be completed as scheduled. The RN clinical coordinator will assist in the development of appropriate MDS schedules and completion date. The RN MDS coordinator will ensure timely completion of CAAS and the MDS and conduct or coordinate each assessment and will sign and certify the completion of the assessment.

Based on observation, interview and record review, the facility failed to ensure residents had access to their personal funds upon request for 1 of 1 resident (R) 4. This had the potential to effect 7 residents who utilized a personal funds account. In addition, the facility failed to have a system in place to protect and manage personal funds for 5 of 5 residents (R8, R20, R17, R14 R16 ) who had given money to the facility to maintain. R4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated cognitively intact and diagnoses included: Alzheimer's disease late onset, type II diabetes, atrial fibrillation, hypertension, and anxiety. R4 was a Minnesota Medicaid recipient. During an interview on 5/21/23 at 2:20 p.m., R4 stated unable to get their money on a Sundays and sometime not until a day or two later after a request. R4 felt it was only when the social worker was working when resident could get their money. R4 gives plenty of notice to the staff. During an interview on 5/22/23 at 9:58 a.m., registered nurse (RN)-B stated residents can get money in the evening and weekends from the petty cash box. The box contains $15 to $20 dollars, and some residents have their own money in the petty cash box too. If a resident wants more money, we must go through the social worker during the week. During an interview and observation on 5/23/23 at 9:41 a.m., the social service designee (SSD) stated the administrator and the SSD had recently taken over some resident account responsibilities and is in transition including learning how to set up a resident account. SSD indicated for a check requests can take one to two days and for cash requests may be done on the same day. SSD said the facilities petty cash box is held at the nurses' station for off hours and weekends request of funds. SSD said there are some residents who have their own cash placed in the petty cash box and each resident's money is kept in an envelope with a paper ledger. SSD said the facility does not have a formal audit process to account for who has money or how much money each resident has in the petty cash box. The SSD stated she has counted the resident individual dollar amounts at least once in the last 6 months. During the observation with the SSD, the medication room had to be opened by a nurse, the petty cash lock box was on the counter with the key in the lock. The SSD counted the money in the petty cash box and verified the following: petty cash fund was $15.00. random resident's monies totaled $610.55 and included: R8 had loose ten-dollar bill with R8's name on it. R20 had a loose ten-dollar bill with R20's name on it. R17's envelope contained $30.00. R14's envelope had $40.00. R18's envelope contained $220.55. R16 had $300.00 dollars in a sealed envelope. After the observation the SSD stated there were 7 residents who had money in a resident trust fund account. The SSD verified R16 did not have a facility account and stated she did not know R16 had money in the petty cash box, nor did she know if a facility interest bearing account was offered to R16 at the time the $300.00 dollars was received and placed in the petty cash box. The SSD indicated the facility should have a better system set up to track resident money in the petty cash box. The SSD stated $15.00 was not an adequate amount of money for seven residents if all seven residents wanted funds during off hours and weekends. During an observation and interview on 5/23/23 at 10:59 a.m., trained medication aide (TMA)-A stated the lock box was kept in the medication room. Upon entry to the medication room the lock box was found on the counter with the key in the lock box. TMA-A stated nurses count and sign off on petty cash. The TMA-A showed a ledger where nurses were to sign off how much money was in the petty cash fund at change of shift. TMA-A verified several count entries were missing. TMA-A stated sometimes a resident will request $40.00 but the nurses cannot provide the resident with requested money because the petty cash doesn't have enough money in it. During an interview on 5/23/23 at 11:04 a.m., RN-C stated the nurses are supposed to count the petty cash at shift change. RN-C stated when we sign-off on the count we are only signing off on the petty cash. We are also supposed to count resident money, but we do not have an official document to sign off, or a formal process for resident personal funds. RN-C reviewed the count sign-off sheet and confirmed money was not always getting counted at change of shift. RN-C also confirmed the petty cash box was always stored on the counter in the medication room with the key in the lock box and stated only licensed nurses and TMAs had access to the medication room. During a phone interview on 5/23/23 at 11:18 a.m., business office representative ([NAME])-E who was off site at a different location indicated the facility was following required notices and accounting practices for interest bearing resident trust accounts managed by the facility. During an interview on 5/23/23 at 1:15 p.m., the director of nursing (DON) stated resident funds should be discussed on admission. Residents should be able to get money from petty cash during off hours and weekends. $15 dollars are not an adequate amount of money to have on hand in petty cash. The off hours petty cash should contain fifty dollars. The facility should not be holding onto cash for residents in the petty cash box. We do not have an accounting process to keep track of personal money like that, that is what the facility interest bearing accounts are for. The petty cash box should not be sitting on counter with the key in it, although behind a locked door, that does not adequately secure the funds. During an interview on 5/23/23 at 1:53 p.m., the administrator stated it was acceptable to hold on to cash for the residents in the petty cash box. Resident money should be kept in a resident trust account or when appropriate sent with a family member. It is a resident choice to keep cash and it should be secured by the resident in a locked drawer in their room. The facility should not be holding resident cash, instead offer the resident or resident representative a facility trust account. It is not acceptable to keep the petty cash key in the lock box lock. The administrator said the petty cash should have more than $15.00 dollars in it for residents to access during off hours and weekends. Review of petty cash balances for 2023 March, April, and May the petty cash balance remained between $14.93 and $15.04. The verification of petty cash change of shift count was not signed off 71 times in March, 52 times in April and 36 times in May. Resident admission packet titled, Trust accounts: a trust account is available for your convenience. Trust accounts are maintained by the business office. Hours for transactions: Monday-Friday 9 a.m. - 12 p.m. and 1p.m. to 3 p.m. Limited money requested after business hours can be obtained through the RN. Larger withdrawals must be requested at least 2 days in advance. The facility document titled Petty Cash Checklist utilized by nursing staff read as follows: Petty cash is to be counted every shift. Box should contain $50 total, if money used place note what/who money was used for in box, if under $50 cash is present, please notify the business office so money can be replaced. Sign the spaces below verifying account money is correct. Turn into the DON [director of nursing] at the end of each month. All facility polices related to resident funds/trust accounts and petty cash were requested and not received.

Based on observation, interview, and document review, the facility failed to maintain a sanitary kitchen and store food properly to reduce the risk of foodborne illness. This had the potential to affect all residents who were provided meals from the kitchen. During an observation of the kitchen on 5/21/23 at 1:26 p.m., with dietary aide (DA)-A, noted the following: Opened box of beef patties, 3 boxes of juice and 10 other boxes stacked on top on the floor in the first walk-in freezer, DA-A picked up the box of patties and placed them on a shelf. DA-A stated boxes containing food should not be on the floor because of risk for possible food contamination. The walk-in refrigeration unit referred to as Cook's cooler contained the following undated food items: chopped onions covered in plastic wrap, and two shallow steam table pans, one containing beef and one containing turkey slices. DA-A stated all food items in the cooler should be dated. In the dry storage area contained a plastic container of sugar. The lid was upside down and there was a 4-inch open area between the lid and the edge of the sugar lid. DA-A stated the lid should be secured on the sugar to prevent contamination. The kitchen had a double basket oil food fryer located next to a grill top stove. The surface area of the front, both sides and the back of the fryer was covered with thick streaks of a congealed yellow to brown substance. The side of the stove next to the fryer was also covered with the same substance. The wall behind the fryer was streaked with the same substance. The back wall also had a pipe that ran along the wall. The pipe was covered with dust. The dust on the pipe directly behind the fryer was covered with drops of the same substance on the fryer. The floor and outlets behind the fryer and stoves also had areas of thick dust and dirt like debris. During a follow up observation on 5/22/23 at 9:16 a.m., the stack of boxes was still on the floor in the walk-in cooler. In addition, another open box containing food was on the floor. Cook (C)-A picked the box up and placed it on a shelf. C-A stated food should not be stored on the floor, all boxes of food are required to be stored 6 inches off the floor. Normally food overflow, is placed on a pallet until it fits on the shelves. During an interview on 5/22/23 at 11:22 a.m., registered dietician (RD) confirmed the back wall, pipe and floor were not clean. The RD looked at the fryer unit, touched the surface and stated the grease on the outside of the fryer and stove did not rub off, indicating it had been there for a while. The RD stated the kitchen needs to be sanitary and should not have dust and grease in the cooking area. The RD was not certain, who was responsible for cleaning the fryer and cooking area but stated it should be regularly cleaned to maintain a safe sanitary kitchen. During an interview on 5/23/23 at 8:44 a.m., DA-A stated we try to have a cleaning schedule but was not able to locate a schedule in the kitchen office files. During an interview on 5/23/23 at 8:56 a.m., dietician tech (DT)-C stated the amount of grease and dust build up along the fryer and stove/oven wall made it clear the area had not been cleaned in a while. DTC stated food storage areas should not have boxes of food directly on the floor because of the risk of food contamination and indicated this was included in education staff received. During an interview on 5/23/23 at 2:21 p.m., the administrator stated it is an expectation the kitchen would have a documented cleaning schedule to ensure the kitchen was regularly cleaned and maintained. All food should be dated and stored in proper conditions and containers on proper shelving. Kitchen cleanliness and properly stored food needs to be in place to maintain infection prevention and prevent food contamination. March, April and May cleaning documentation, and all policies related to kitchen cleaning were requested. In an email sent on 5/24/23 by the DON, the DON explained the facility was not able to find kitchen cleaning policies. The following documents were attached: a blank list of cleaning tasks entitled Cook End of Shift Cleaning with instructions list to be completed at the end of first and 2nd shift and a four page document titled Essentia Health Nutrition Service Department, Cleaning Checklist with instructions to Initial and date when completed. The four-page cleaning list had the following items documented as completed on 11-13-22: storeroom, dish room, all areas of tray line.

Based on interview and record review, the facility failed to revise care plan to reflect new speech recommendations and provider orders for 1 of 2 residents (R7) reviewed for care planning. Findings include: R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R7 had severe cognitive impairment and diagnoses included dementia with psychotic disturbance, hypertensive disorder, heart failure, nutritional anemias, and pre-diabetes. R7's orders included a low sodium minced moist diet with instruction for R7 to be upright at 90 degrees during intake and for 20 minutes after food intake. Staff to assist with meals and report difficulties with eating to registered nurse immediately. R7's provider note dated 2/17/22, requested a swallow evaluation for R7 related to weight loss and coughing with meals. R7's speech evaluation dated 2/18/22, included oropharyngeal dysphagia (A condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink). Assessment summary and recommendations were moderate oral dysphagia impacted by cognition and limited dentition (the arrangement or condition of the teeth in a particular species or individual), resident would benefit from minced moist, and a feeder to encourage intake. The observation section of the evaluation read poor dentition, no dentures, poor oral awareness with difficulty with mastication (chew) of solid food. Tolerating minced moist diet and thin liquids. During an interview on 5/23/23 at 8:31 a.m., registered nurse (RN)-C stated if a resident has new onset of issues with eating, we monitor the resident and get a speech evaluation ordered which would typically be completed the same day. R7 is a feeding assist. Nursing assistants (NA)'s can assist R7 to eat. RN-C said they do not use paid feeding assistants. The activities director and the activities aid can assist R7 with eating because both have their NA certificate, if they do not have their NA, they would not be qualified to assist R7. During an interview on 5/23/23 at 4:00 p.m., RN-B reviewed R7's care plan and stated she could not find where R7 had any special precautions or required assistance with eating. After reviewing R7's speech evaluation dated 2/18/22 and orders, RN-B stated according to the evaluation and provider orders R7 required to be on precautions, with sitting at a 90-degree angle for meals and for 20 minutes after meals, plus R7 should be offered fluids. The speech evaluation and the new orders should have triggered a care plan update. During an interview on 5/23/23 at 4:10 p.m., the director of nursing (DON) stated the speech pathology recommendations and provider orders should have been updated on the care plan and indicated staff refer to the care plan on how to care for a resident including how resident eat. The policy Comprehensive Care Plan and Care Conferences dated 1/8/18 directed each resident shall have a care plan so that he/she will receive the care necessary to enable him/her to achieve and or maintain the highest practical physical, mental and psychological well-being. The care plan should be revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessments and as needed.

Based on observation, interview and document review, the facility failed to ensure residents with difficult swallowing and or special precautions were fed by qualified individual. This practice had the potential to affect 1 of 2 residents (R7) who was assessed at risk for complication with eating. Findings include: R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R7 had severe cognitive impairment. R7's diagnoses included dementia with psychotic disturbance, hypertensive disorder, heart failure, nutritional anemias, and pre-diabetes. R7's orders included a low sodium minced moist diet with instruction for R7 to be upright at 90 degrees during intake and for 20 minutes after food intake. Staff to assist with meals and report difficulties with eating to registered nurse (RN) immediately. R7's speech evaluation dated 2/18/22, included oropharyngeal dysphagia (A condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink). Assessment summary and recommendations were moderate oral dysphagia impacted by cognition and limited dentition (the arrangement or condition of the teeth in a particular species or individual), resident would benefit from minced moist, and a feeder to encourage intake. The observation section of the evaluation read poor dentition, no dentures, poor oral awareness with difficulty with mastication (chew) of solid food. Tolerating minced moist diet and thin liquids. During an observation on 5/22/23 at 8:23 a.m., R7 was seated at a table in the dining room. Nursing assistant (NA)-G started to assist R7 with eating. At 8:56 a.m. the activities director (AD) was observed sitting beside R7, giving R7 bites of food. The AD was noted to be the only staff in the dining room at this time. When NA-G returned to the dining area, the AD reported to NA-G R7 had ate some eggs, juice, and cereal. NA-G took over feeding R7. During the following observations on 5/22/23 at: -11:47 a.m., R7 was seated at a table in the dining room. Activities aide (AA)-B went to get R7's food. -11:59 a.m. AA-B was seated at table with R7. R7's plate had ground meat, potatoes with gravy and squash on it. AA-B started to give R7 bites of food. -12:03 p.m. R7 was holding juice glass and drinking. AA-B continued to give R7 bites of food. -12:07 p.m. the RN left dining area. AA-B and dietary aid (DA)-B were the staff present in the dining room with 10 residents. -12:12 p.m. AA-B continued to feed R7 bites of food. RN-D entered dining room and was walking around dining room talking to residents. -12:19 p.m. AA-B continued to feed R7 bites of food. -12:22 p.m. AA-B left table to remove R7's lunch plate from dining table. R7 was holding a glass and drinking juice. -12:36 p.m. the RN left the dining room. AA-B remained in the dining room picking up dishes while other residents continued to eat. During an interview on 5/22/23 at 8:59 a.m., the AD stated both he and AA-B help set-up trays and feed residents whenever the NAs need to help another resident. AD stated they help R7 the most. During an interview on 5/22/23 at 12:26 p.m., AA-B stated she had been an activity aid for about 10 months and had not completed a feeding assistant education program. AA-B stated I did get some resident feeding education when I took the certified nursing class in 11/22, but I was told I would not be scheduled to test to become a certified NA because I would not be working the floor in my AA position. On 5/23/23 at 8:31 a.m., registered nurse (RN)-C stated if a resident had a new onset of issues with eating, the facility monitors the resident and would order a speech evaluation, which would typically be completed the same day. RN-C said, R7 requires assistance with eating and NAs can assist R7. RN-C was uncertain if AD and AA-B were qualified to assist R7 and indicated the facility does not use paid feeding assistants. During an interview on 5/23/23 at 1:15 p.m., the director of nursing (DON) stated the facility does not have paid feeding assistants (PFA), but our activities director is a PFA. He completed the state approved feeding assistant education, so it was okay for him to feed residents. PFAs can assist with feeding and passing trays but they are not allowed to feed anyone that is a choking risk. The DON stated only NAs, LPNs, and RNs are qualified to help residents who may have complications such as, aspiration precaution, dysphasia, and swallowing issues. The DON also stated when residents remain in the dining room supervision should be provided by the NAs, LPNs, or RNs. The DON reviewed R7's speech evaluation and verified R7 had oropharyngeal dysphasia and orders to have feeding assistance and indicated a PFA was appropriate to assist R7. During an interview on 5/23/23 at 1:58 p.m., the administrator stated paid feeding assistants can provide feeding assistance for uncomplicated residents only. Paid feeding assistants must complete an approved course before they can assist with feeding. Residents with more complex needs should only be fed by NAs or licensed staff. The administrator indicated the importance was due to risks like aspiration and choking. The facility provided skills check off list and a Ontrack Nursing Assistant Training certificate of completion for AA-B dated 11/20/22. A feeding assistant policy and a dysphasia and aspiration protocol/policy was requested. The facility provided the policy Meal and Snack Service dated 9/15/13. The policy line item 20 read Staff and families who assist residents with dining should have received approved documented training on techniques and safety issues related to assisting with meals. Residents who are not appropriate to be assisted at meals by non-nursing staff will be assisted only by nursing staff.

Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) support to supervise and assist with eating and drinking to help reduce the risk for aspiration for 1 of 2 residents (R) reviewed for ADL assistance. Findings include: R8's significant change minimum data set (MDS), dated [DATE], indicated R8 was moderately cognitively intact and had diagnoses of Alzheimer's type dementia and arthritis. Further, R8's MDS indicated he needed supervision with eating and had a mechanically altered diet. R8's care area assessment (CAA), dated 4/4/23, indicated no swallowing disorders and an altered texture diet and thick liquids. R8's care plan, dated 4/5/23, indicated a problem statement for assistance with ADLs with an approach of supervision with set-up assistance for meals. Further, R8 requires pureed food, scrambled eggs and bread products and thin liquids. Sit up at 90 degrees for at least 20 minutes after oral intake. Provide oral care after all oral intake. Encourage oral intake at meals. R8's provider order summary indicated aspiration precautions dated 3/23/23 of one-to-one supervision, to be seated at 90 degrees and remain seated for 20 minutes, minced and moist foods, mildly thick nectar liquids with cyclic feeding (to provide a bite of food alternated with a drink of fluid). R8's documentation indicated: -3/22/2023 at 5:26 a.m. Resident began to cough and struggle to swallow his medications this morning while attempting to swallow two of his pills whole at 5:10 a.m. Resident had been sitting up in his bed during this event. Resident remains sitting upright, continues to have a loose occasional cough, noted crackles in right side of lungs. No shortness of breath, oxygen saturation 90 percent on room air, will continue to monitor. -3/22/2023 at 9:01a.m. Received written orders from provider for a portable chest x-ray for a diagnosis of hypoxia (deficiency in the amount of oxygen reaching the tissues.) Order faxed to x-ray. -3/22/2023 at 10:48 a.m. Verbal order received from certified nurse practitioner (CNP) for a swallow evaluation related to possible aspiration of medications this morning. Also switched med administration to crush as able. During interview and observation on 5/22/23: -8:36 a.m., R8 was seated in a wheelchair at an over-the-bed table in his room. R8's room was at the end of the hallway, away from the nurse's station, with the door closed part of the way. R8 had his head bent and eyes closed. There were scrambled eggs, hot cereal, apple juice, orange juice and silverware on the tray. The spoon was coated with scrambled egg particles, as was a space on the plate empty. There were no staff in or near R8's room. -8:52 a.m., nursing assistant (NA)-A was coming down the hall collecting breakfast trays. When NA-A approached R8's room she commented she didn't know why he had a tray in his room because R8 should be in the dining room. When interviewed, NA-A stated the care plan was where you could find information on how residents eat and what their diet type was, or you could just ask someone else. NA-A further stated she would know to bring a tray to a room if that resident didn't come to the dining room. -9:11 a.m., Activity staff (ACT)-A went into R8's room, asked if R8 was done eating, chatted with R8, left an activities flyer, and left the room. -9:18 a.m., registered nurse (RN)-A stated staff would know what type of diet a resident had by checking with dietary, looking at the care plan or asking other staff. The care plan also indicated what type of assistance the resident needed. RN-A stated he was not aware of R8 having any issues with swallowing. RN-A went into R8's room to find him sleeping, then woke him and asked R8 if he was going to eat breakfast. R8 stated he was resting his eyes. RN-A left the room without helping or removing the tray. R8 closed his eyes and bent his head. -9:29 a.m., NA-B went into R8's room and asked him if he was done with breakfast. R8 stated no. NA-B asked R8 if he wanted the eggs reheated. R8 stated no. When interviewed, NA-B stated a resident's care plan would show their diet type and how to assist them. Care plans were accessible at the computers at the nurse's station. NA-B stated she was not aware R8 had aspiration precautions but stated R8 did normally eat in the dining room. Further, NA-B stated she had heard R8 had choked before but had not witnessed that herself. NA-B left R8's room, cleaned her hands, and went to another room. -10:20 a.m., NA-A came and got R8's tray without helping eat or drink. During an observation on 5/22/23: -11:56 a.m. R8 was in the dining room at table with another resident, a plate of scrambled eggs and melted cheese, a cup of apple juice, and a box of Ensure (a protein supplement drink) R8's head is bent over with eyes closed. There were two activities staff serving and setting up trays. RN-B was preparing plates for a cart. -12:04 p.m., NA-A and NA-B came to the dining room, cleaned their hands, started loading meal trays on carts and left the dining room. -12:07 p.m., RN-B left the dining room with a cart full of trays. There were 10 residents in the dining room. Activities aide (AA)-B was seated at a table feeding a resident. -12:11 p.m., there were no nursing staff in the dining room. R8 was at a table with head bent and eyes closed. -12:13 p.m., the administrator came to the dining room, woke R8 and offered a drink of Ensure. The administrator then brought a chair to sit next to R8 and assisted him with a bite of eggs. -12:18 p.m., the administrator left R8's table. -12:24 p.m., RN-A approached and unsuccessfully attempted to wake R8. RN-A left the dining room. There were no nursing staff in the dining room. -12:27 p.m., R8 lifted his head slightly and pushed the plate away. -12:37 p.m., RN-A made another pass through the dining room, walked by R8, and stated, you're not going to wake up, are you?. RN-A left the dining room. During an interview on 5/22/2023 at 10:54 a.m., NA-A defined supervision as being there to make sure residents are eating, not sleeping, or choking. NA-A defined one-to-one supervision as when a resident needed assistance to eat. During an interview on 5/22/23 at 10:59 a.m., speech language pathologist (SLP)-A stated she performed a swallowing evaluation for R8 after an aspiration incident in March 2023. SLP-A learned R8 was consistently coughing with liquids and wasn't initiating feeding himself. Specifically, R8 needed one-to-one supervision while eating or drinking, needed to be seated at 90 degrees and have someone stay with him the whole time. During an interview on 5/22/23 at 11:14 a.m., RN-B defined one-to-one assistance as someone needed to be with the resident and supervision meant you would need to have eyes on them while they were eating. RN-B added the care plan would tell you if they needed one-to-one assistance. During an interview on 5/22/23 at 11:23 a.m., NA-B defined one-to-one as you had to sit there and feed the resident and supervision is watching over them, and coaching if needed, while they feed themself. NA-B added this information would be found in the care plan. During an interview on 5/22/23 at 2:38 p.m., licensed practical nurse (LPN)-A identified R8 as being someone who needs supervision with eating, and furthermore LPN-A was the nurse who had been assisting R8 to take his medications when he had the choking event that led to the speech evaluation. LPN-A indicated a resident's diet and assistance type was in the electronic medical record. LPN-A stated one-to-one supervision meant having your eyes on the resident. During an interview on 5/23/23 at 8:27 a.m., Certified Nurse Practitioner (CNP)-A stated not following aspiration precautions puts R8 at an increased risk for complications from aspiration and the reason R8 had an SLP evaluation and subsequent precautions was because of an aspiration incident. During an observation on 5/23/23 at 8:38 a.m., R8 was at table, with his head bent and eyes closed, in the dining room. Nursing staff prepped R8's tray but did not sit with him. During an interview on 5/23/23 at 1:28 p.m., the director of nursing (DON) stated a resident who is at risk for aspiration should be in the dining room with supervision of a nursing staff. The DON confirmed R8 had aspiration precautions; she would expect a staff member to be one-to-one with such a resident. The DON further stated supervision for residents with aspiration precautions was important in case they did have a coughing or choking event. During an interview on 5/23/23 at 1:58 p.m., the administrator stated if a resident had an order for supervision with eating, she would expect the resident is in an area that is supervised. Further, the administrator stated staff qualified to provide supervision were nursing aids or other licensed staff. The administrator further stated the expectation for a resident with a provider order for one-to-one supervision would be provided with one-to-one supervision to be there to assist and resuscitate if someone where to start choking. The administrator would anticipate the dining room was monitored by a NA or other licensed staff if there was a resident with aspiration precautions in the dining room.

Based on interview and document review, the facility failed to complete required quarterly Minimum Data Sets (MDS) for 5 of 12 (R4, R2, R19, R6, and R13) reviewed for assessment accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, identified the MDS as an assessment tool which facilities are required to use. The manual provided instructions to ensure accurate and complete coding for each section of the assessment as follows: Section C: Cognitive Patterns, with a written intent of determining the residents attention, orientation and ability to register and recall new information. These items were listed as crucial factors in many care planning decisions. Section D: Mood, with a written intent to address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. Section E: Behavior, with a written intent to identify behavioral symptoms that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Behaviors include those that are potentially harmful to the resident himself or herself. The emphasis is identifying behaviors, which does not necessarily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. R4's Quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C was not coded rather each field was dashed or had no other values recorded. Section Z of the MDS was signed by registered nurse (RN)-A and dated 2/7/22, which indicated the assessment was complete. R2's quarterly MDS dated [DATE] identified severe cognitive impairment with short and long term memory issues with inattention and organized thinking. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section D had no entries, and Section E identified only question one was answered and questions two through eleven were blank. The MDS was signed completed in Section Z by RN-A. R19's minimum data set (MDS) dated [DATE], identified R19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment's Section C: Cognitive Pattern question number one was answered identifying a brief interview for mental status (BIMS), and Section D: Mood question number one identifying the resident's mood interview sections should've been conducted. The remaining questions for both of these sections were not answered or had a dash through them. Section Z of the MDS was signed by the RN-A and dated 12/30/21, which indicated the assessment was complete. R6's quarterly MDS dated [DATE], indicated R6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section D, questions D0100 through D0600 were blank or dashed and no values were recorded. R13's quarterly MDS dated [DATE], indicated R13's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section D, questions D0100 through D0600 were blank or dashed and no values were recorded. During an interview on 2/16/22, at 1:34 p.m. registered nurse (RN)-A verified he had been the MDS coordinator since 2018, for the facility. RN-A stated R4's Section C was completed too early on 1/21/22, and was not conducted during the MDS assessment period. However, RN-A was aware the MDS was not completed correctly. RN-A stated he was responsible to complete the facility resident MDS assessments. Upon review of R4's quarterly MDS dated [DATE], RN-A stated the MDS was missing Section C--it was not assessed or dashed out. However, RN-A explained this was due to Section C being completed on 1/21/22, which was not during the assessment period and was unusable. RN-A stated the MDS was always a shared responsibility at the facility with some assessments completed by nursing staff and others completed by social services. However, RN-A stated he was responsible to ensure this information was entered into the MDS and sign off the completion. RN-A stated the electronic medical record (EMR) would alert him if there was a monetary penalty if the MDS was not entirely completed and he was aware the MDS was not fully completed. RN-A verified R6's and R13's MDS sections C and D were not completed prior to their MDS being submitted. RN-A stated social services should have completed both section C and D. RN-A stated when the due date was near and information was not added he would typically send out an email to the responsible staff to get the information entered. RN-A stated the facility went for a time period--six months to nine months--without a social worker. During that time nursing staff were responsible for completing the assessments for sections C and D. During an interview on 12/16/22, at 2:23 p.m. the social services designee (SSD) stated she was not aware she was responsible for the completion of Section C, had not had any formal MDS training and was thrown into it after starting her role in November 2021. However, she became aware of her responsibility at the beginning of February 2022 and had been attempting to complete them since. During an interview on 2/16/22, at approximately 2:30 p.m. the director of nursing (DON) stated she was aware RN-A submitted MDS corrections the day prior, 2/15/22, but was unaware of the extent or the corrections needed. The DON stated social services was responsible for Section C, but nursing staff had the ability to complete these as well. The DON further stated when submitting a completed MDS, RN-A would be alerted by the system that a MDS was unable to validate and RN-A would be aware of the sections not completed. The DON also stated she provided the SSD with informal MDS training, and she suspected the SSD was completing these sections on paper. Because of this, the DON stated she would need to speak with her staff for further details. On 2/16/22, at 3:09 p.m. the DON verified the SSD was completing observations for C and D on paper. RN-A was not entering this information into the MDS and was adding a dash to those sections. The DON stated she expected the MDS assessments to be completed and to be notified of any concerns with completion. The facility Minimal [sic] Data Set (MDS) Assessment Completion policy dated 7/15/20, directed the registered nurse (RN) MDS coordinator would ensure timely completion of the care area assessments (CAAs) and the MDS. In addition, the policy directed the RN MDS coordinator would conduct or coordinate each assessment and would sign and certify the completion of the assessment. The RN MDS coordinator would transmit the completed MDS assessments to CMS.

Based on interview and document review, the facility failed to thoroughly complete an admission Minimum Data Set (MDS) assessment in accordance to the Resident Assessment Instrument (RAI) manual for 1 of 2 resident (R17) identified with incomplete cognitive and mood sections of the MDS. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, identified the MDS as an assessment tool which facilities are required to use. The manual provided instructions to ensure accurate and complete coding for each section of the assessment as follows: Section C: Cognitive Patterns, with a written intent of determining the residents attention, orientation and ability to register and recall new information. These items were listed as crucial factors in many care planning decisions. Section D: Mood, with a written intent of addressing mood distress which was labeled as a serious condition, which was under-diagnosed and under treated in the nursing home setting. R17's annual Minimum Data Set (MDS) dated [DATE], identified R17's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section Z of the MDS was signed by the MDS coordinator and dated 2/8/22, which indicated the assessment was complete. During an interview on 2/16/22, at 1:34 p.m. the MDS coordinator, registered nurse (RN)-A stated he was responsible to complete the facility resident MDS assessments. Upon review of R17's annual MDS dated [DATE], RN-A stated MDS was missing Section C and Section D was not assessed or dashed out. Additionally, R17's Patient Health Questionnaire (PHQ-9) (diagnostic tool used to screen residents for the presence and severity of depression) was not completed. RN-A stated the MDS was always a shared responsibility at the facility with some assessments completed by nursing staff and others completed by the social services designee (SSD). However, RN-A stated he was responsible to ensure this information was entered into the MDS and sign off the completion. RN-A stated the electronic medical record (EMR) would alert him if there was a monetary penalty if the MDS was not entirely completed and he was aware the MDS was not fully completed. During an interview on 12/16/22, at 2:23 p.m. the SSD stated she was not aware she was responsible for the completion of Section C, Section D or the PHQ-9, had not had any formal MDS training and was thrown into it after starting her role in November 2021. However, became aware of her responsibility at the beginning of February 2022 and had been attempting to complete them since. During an interview on 2/16/22, at approximately 2:23 p.m. the director of nursing (DON) stated she was aware RN-A submitted MDS corrections the day prior, 2/15/22, but was unaware of the extent or the corrections needed. The DON stated the SSD was responsible for Section C, Section D and the PHQ-9, but nursing staff had the ability to complete these as well. The DON further stated when submitting a MDS, RN-A would be alerted by the system that a MDS was unable to validate and RN-A would be aware of the sections not completed. The DON also stated she provided the SSD with informal MDS training and she suspected the SSD was completing these sections on paper. Because of this, the DON stated she would need to speak with her staff for further details. On 2/16/22, at 3:09 p.m. the DON verified the SSD was completing Section C, Section D and the PHQ-9 on paper. RN-A was not entering this information into the MDS and was adding a dash to those sections. The DON stated she expected the MDS assessments to be completed and to be notified of any concerns with completion. The facility Minimal [sic] Data Set (MDS) Assessment Completion policy dated 7/15/20, directed the registered nurse (RN) MDS coordinator would ensure timely completion of the care area assessments (CAAs) and the MDS. In addition, the policy directed the RN MDS coordinator would conduct or coordinate each assessment and would sign and certify the completion of the assessment. The RN MDS coordinator would transmit the completed MDS assessments to CMS.

Based on observation, interview and document review the facility failed to follow doctor's orders and update the care plan for 1 of 12 residents (R2) to aide in the prevention of pressure ulcers. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment with long- and short-term memory issues. R2 was a extensive assist with bed mobility, transfers and locomotion on and off the unit. The MDS identified R2 was at risk for pressure ulcers. R2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A provider's order dated 2/7/22, instructed to offload heels bilaterally (both heels) using pillows or foam boots in bed or chair. R2's progress note from 2/7/22, identified R2 returned from an appointment with a medical doctor (MD) at a local clinic and an order was received to offload heels using pillows or foam boots in bed or chair. Return in 3 months. R2's care plan dated 2/14/22, did not identify any interventions of using foam boots or pillows to offload pressure on her heels to prevent skin breakdown. On 2/14/22, at 7:23 p.m. R2 was observed sitting in her wheelchair next to her bed. She was slightly reclined, had socks on her feet and was not wearing foam boots nor did she have pillows under her feet. Foam boots were not noted in her room. On 2/15/22, at 8:48 a.m., R2 was sitting in her wheelchair to eat breakfast. R2 was sitting upright, wearing socks with her left foot directly on the wheelchair footrest and the right foot hanging behind the foot rest. There was not a pillow on the footrest. On 2/15/22, at 9:45 a.m. R2 was sitting in her wheelchair, slightly reclined, wearing socks. R2's left foot was on the footrest and the right foot was hanging behind the foot rest. R2 was not wearing foam boots and there was not a pillow under her feet. On 2/15/22, at 10:32 a.m., R2 continued to be in her wheelchair with both feet on the footrests. R2 was wearing socks, was not wearing foam boots nor did she have a pillow under her feet. On 2/15/22, at 10:44 a.m., R2 continued to be in her wheelchair, but was calling out for help and I want to lay down. R2 was wearing socks, no foam boots and there was not a pillow under her feet. During an interview on 2/15/22, at 10:11 a.m. nursing assistant (NA)-A stated she was not aware of any orders to offload R2's heels and identified it was not on the care plan and she was not told of any new interventions. During an interview on 2/15/22, at 2:46 p.m. NA-B stated the R2's care plan and the nurses aide sheet did not identify R2 needed to have foam boots on, or her heels floated by a pillow. During an observation and interview on 2/15/22, at 2:53 p.m. registered nurse (RN)-C stated the order to offload heels was received, entered, and verified. RN-C stated the care plan should have been updated and the intervention implemented. RN-C then went to check on R2 while in bed and confirmed the order was not being followed as there was no pillow under R2's feet nor was she wearing foam boots. RN-C then placed the blanket back over R2's feet and did not put foam boots on or place a pillow under R2's feet and left the room. During an interview on 2/15/22, at 3:32 p.m. the director of nursing (DON) stated the order was not instituted and currently was noted on the treatment record and was not being done. She stated once the order was entered and verified it should have been implemented immediately per MD order and should be done. The DON also stated new orders should be placed on the care plan so all staff know the intervention and confirmed the order to offload heels and use foam boots or pillows was not on R2's care plan. The facility's Acknowledgement, Coordination and Implementation of Physicians' Orders policy revised 10/16/17, identified once an order was verified the RN was to communicate orders to appropriate staff involved in patient's care.

Based on observation, interview, and document review, the facility failed to ensure the oxygen tubing and oxygen humidifier were changed in a timely manner for 1 of 1 residents (R6) reviewed for respiratory care. Findings include: R6's Face Sheet printed on 2/16/22, indicated R6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 was using oxygen therapy. R6's care plan dated 12/31/20, indicated R6 required oxygen therapy at times during the night. Interventions included monitoring and reporting signs and symptoms of [CONDITION(S)] (deficiency in the amount of oxygen reaching the tissues), keep the oxygen saturation levels greater than 90 percent and administer oxygen per medical doctor (MD) orders. R6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/14/22, at 1:50 p.m. R6 was seated in her wheelchair in her room, she was wearing a nasal cannula with humidified oxygen at two liters per minute. The humidifier and the nasal cannula were not dated. On 2/15/22, at 2:00 p.m. registered nurse (RN)-B stated he did not know when the oxygen tubing was changed, he said he thought maybe nights changed the tubing. RN-B verified the oxygen humidifier was almost out of water and said it needed to be changed. RN-B verified the oxygen humidifier and oxygen tubing was undated. RN-B stated there were not any nursing orders alerting nursing staff to change the oxygen humidifier and oxygen tubing. On 2/16/22, at 7:55 a.m. the director of nursing (DON) verified oxygen humidifiers and oxygen tubing should be changed weekly. The DON verified there was not a process in place to ensure it was done. The facility Storage and Handling of Supplies and Oxygen policy dated 4/5/19, lacked direction on the frequency of replacing oxygen humidifiers and oxygen tubing.

Based on observation and interview the facility failed to maintain good repair of the walls in the residents living space for 1 of 1 resident (R19) reviewed for clean living space. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 required assistance with all activities of daily living (ADL's). R19's diagnoses list included Alzheimer's disease and dementia. R19's care plan dated 1/20/22, identified R19 required extensive assist of one staff and the use of bilateral grab bars for bed mobility. During observation on 2/14/22, at 1:35 p.m. R19's bed had grab bars attached to the frame on either side of the upper portion of the bed. The bed was in the lowest position, pushed up next to the wall but not touching the wall. The wall had scuff marks and chipped paint in an area approximately 12 inches wide x 18 inches high at the level where the grab bars where located. During observation on 2/16/22, at 8:23 a.m. R19's bed was elevated to mid-thigh level and was pushed close to but not touching the wall. A round, black knob on the grab bars was attached to the bed. The knob on the left side of the bed was touching the wall at the level of the scuff marks and chipped paint. During an interview on 2/15/22, at 10:47 a.m. housekeeper (hskp)-A stated housekeepers went through every room, every day and cleaned the bathroom, mopped the floor, high dusted if needed, swept and mopped the room floor, and wiped down the tables. On bath days they also swept and mopped under the beds and dressers. During an interview on 2/16/22, at 7:46 a.m. licensed practical nurse (LPN)-A stated if staff noticed a wall with chipped paint they would notify the nurse manager. The nurse manager would fill out the online maintenance work order to have it repaired. During an interview on 2/16/22, at 11:53 a.m. nursing assistant (NA)-A and NA-D stated housekeepers would mop the floors, complete general cleaning, dust, and take care of any stains if needed. Maintenance would fix any scrapes or tears in the wallpaper or any painting that needed to be done. During an interview with NA-D and the director of nursing (DON) on 2/16/22, at 12:21 p.m. NA-D stated the black knobs on the grab bars hit the wall when the bed was moved back/forth or up/down. The knobs chipped the paint off the wall and left marks on the wall. The DON stated the paint chips on the floor needed to be cleaned up and the wall in R19's room needed to be repaired. The Facility Maintenance policy revision date 2/1/19, directed staff to maintain repairs of walls.

Based on interview and document review the facility failed to provide evidence a comprehensive discharge summary was completed to provide continuity of care for 1 of 3 residents (R4) reviewed for discharge practices. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], identified the following areas required comprehensive assessment: communication, activities of daily living (adl's) functional status/rehabilitation potential, urinary incontinence/indwelling catheters, falls, nutritional status, pressure ulcer/injury, return to community referral. R4's discharge MDS dated [DATE], identified R4 had a planned discharge and discharged from the facility on 5/18/21. Further, R4 was not expected to return to the facility. R4's EH Admission to Discharge Plan of Care/Instructions dated 4/21/21, identified R4's goal was expects to be discharged to another facility/institution after rehab. No other information on form was completed. R4's physician signed discharge orders dated 5/14/21, were faxed to the receiving long term care facility on 5/14/21. R4's medical record lacked a recapitulation of stay identifying the following: diagnosis, course of illness/treatment or therapy, and pertinent lab, radiology, consultation results, reconciliation of all pre-discharge medications with the resident's post-discharge medications. R4's medical record lacked a discharge summary identifying the following: identification and demographic information; customary routine, cognitive patterns, communications; vision, mood and behavior patterns, psychosocial well-wellbeing; physical functioning and structural problems; continence, disease-diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 12/15/21, at 2:00 p.m. director of nursing (DON) reviewed R4's medical record and stated a complete discharge summary and recapitulation of stay was missing from R1's record. This was an expectation to be completed. The facility EH Admission to Discharge Plan of Care/Instructions form dated 4/21/21, identified areas for review and included the following: resident name, date, date of birth, care conference/discharge planning with resident/representative, discharge date , discharge location, discharge needs, home health services/referrals, nutritional needs, post discharge appointments, medications. The Facility Discharge Summary Long Term Care Policy and Procedure dated 11/28/17, identified When the resident nears their discharge goals, the interdisciplinary team (IDT) will gather the information needed for post discharge care and complete the discharge summary. This included reason for discharge, recapitulation of stay and medication reconciliation. The final EH Admission to Discharge Plan of Care Instructions form would be completed and ready to release to post discharge care providers and resident.

Based on interview, and document review, the facility failed to ensure the care plan was followed to prevent falls with injuries for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who sustained a scalp laceration and [MEDICAL CONDITION]. Finding include: R1's Face Sheet printed 1/29/21, included [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 had moderately impaired cognition, required extensive assistance from staff for transfers, and had experienced one fall with injury. R1's care plan initiated 4/2/20, indicated R1 required extensive assistance for grooming, toileting, and transfers. R1's care plan further indicated R1 had several falls since admission, with a goal of not to be injured by avoidable falls. R1's updated care plan 11/20/20, directed staff to provide 15-minute checks while R1 was asleep. R1 was to be in direct line of sight of staff when out of bed until 2:00 p.m., and staff was to provide one-on-one supervision from 2:00 p.m. to 8:00 p.m., or until R1 was in bed asleep for the evening. On 12/4/20, an Event Report indicated at 3:02 p.m. R1 was found on the floor face down in her room. The facility's root cause conclusion was R1 attempted to transfer herself from her wheelchair to bed, and may have tripped over the call light which was around R1's right ankle. R1's care plan was updated to place the call light on R1's left side, and not to place the call light between the wheelchair and the bed. On 12/4/20, a progress note indicated R1 was found face down on the floor in her room near her bed. Upon examination, R1 obtained a large hematoma on the right upper part of the eye, and an abrasion to the right knee. The note further indicated R1 tried to self transfer into bed, and fell to the floor. R1 was transferred to the emergency department (ED) for evaluation. On 12/4/20, the ED note indicated R1 was seen in the ED for an evaluation post fall. R1 presented with a contusion (bruise) to her right eye/head. Facial imaging was completed and suggested a contusion on the forehead and around the orbit (eye socket) with no evidence of a fracture. R1's elbow x-ray was negative for a fracture. On 1/25/21, an Event Report indicated at 9:00 a.m. R1 was found in her room on the floor with her left arm on her side rail, and her wheelchair was behind her. R1 had increased pain, was bleeding from the right side of her scalp, and was sent to the emergency room . On 1/25/21, a progress note indicated R1 had an unwitnessed fall in her room. R1 attempted to self-transfer, obtained a laceration to the right region of the scalp, and was sent to the ED. On 1/25/21, another progress note indicated R1 was impulsive related to cerebral infarction, and preferred to lie down after meals. During the time R1 fell , staff were not in R1's room and staff were answering call lights. On 1/25/21, the ED note indicated R1 was admitted post fall and was treated for [REDACTED]. R1 was hospitalized . On 1/28/21, at 1:20 p.m. nursing assistant (NA)-A was interviewed and stated R1 was in the hospital following a fall with a fracture which occurred on 1/25/21. NA-A stated when R1 was in her room awake, R1 needed to have someone with her because she would try to transfer herself into bed, usually after meals. NA-A stated if R1 was supposed to be in line of staff's site, and if R1 was in her room, staff could not see her, so R1 was supposed to sit in the hallway or buy the nurse's desk. On 1/29/21, at 9:59 a.m. registered nurse (RN)-A was interviewed and stated R1 had poor judgement of safety awareness, and would attempt to transfer herself into bed from her wheelchair. RN-A stated according to R1's care plan, R1 was to be in line of site when up until 2:00 p.m., then from 2:00 p.m.- 8:00 p.m., one-on-one with staff. RN-A further stated R1's falls on 12/4/21, and 1/25/21, both occurred in R1's room, and R1 was left unsupervised both times. RN-A stated if R1 was in direct line of sight, or on one-on-one with staff as the care plan directed, R1 would not have self-transferred and fallen. On 1/29/21, at 10:32 a.m. RN-B stated she worked 1/25/21, the morning R1 fell and obtained a [MEDICAL CONDITION]. RN-B stated she was summoned by NA-A, who found R1 in her room on the floor. RN-B stated R1's care plan interventions included R1 to be in line of sight with staff during the day, and one-on-one with staff supervision from 2:00 p.m. until R1 went to bed for the night. RN-B stated at the time R1 fell , R1 was alone in her room, while staff were busy with breakfast trays. On 1/29/21, at 10:58 a.m. NA-D stated she was passing linen on 1/25/21, and noticed R1's door was closed. NA-D stated she opened R1's door, and R1 was on the floor next to her bed. NA-D stated R1 said she was trying to go to bed when she fell . NA-D stated R1's care plan indicated R1 was to be in line of sight, and R1 would normally be in the hallway doing an activity, or by the nurse's desk. NA-D stated staff would rotate and sit with R1 during the one-on-one times, and there was not staff directly assigned to only R1. On 1/29/21, at 11:49 a.m. NA-E stated she found R1 on the floor in her room on 1/25/21. NA-E stated she had taken R1's breakfast tray our of her room that morning, and about five minutes later NA-E returned to R1's room and found R1 on the floor with blood coming from her head. NA-E stated she was not aware at that time R1's care plan directed R1 to be in line of sight from the time R1 got up in the morning, and from 2:00 p.m. to 8:00 p.m. R1 required one-on-one staff until she went to bed for the night. On 1/29/21, at 12:14 p.m. an interview was conducted with the administrator in training. The administrator in training stated when residents were to be in line of sight, it would include being able to always visualize the resident, and one-on-one would include one staff to one resident. The administrator in training stated there was not one staff member assigned to R1, and staff rotated to sit with R1. The administrator in training verified R1 should have been in line of sight from the time R1 got up in the morning until 2:00 p.m., and from 2:00 p.m. to 8:00 p.m. had one-on-one staff supervision until in bed for the night, and checks every 15 minute check during the night. The administrator in training stated R1's care plan was not being followed which contributed to her falls on 12/4/20, and 1/25/21, both resulting in injuries. The administrator in training verified R1 remained hospitalized . The facility policy Baseline Care Plan Policy reviewed 11/26/20, directed the facility staff or those acting on behalf of the facility would implement the interventions to assist the resident to achieve care plan goals and objectives. The policy further directed direct care staff would be educated about the care plan interventions. The facility policy Care Conferences/Care Planning reviewed 3/15/20, indicated each resident shall have a plan of care so that he/she will receive the care necessary to enable him/her to achieve and/or maintain the highest practical physical, mental and psychological well-being. The policy further indicated care plan assessment and changes would be made quarterly and as needed. Care plans are reviewed with direct care staff as needed.

Based on interview and document review, the facility failed to implement adequate supervision and/or care plan interventions to prevent a fall with injury for 1 of 2 residents (R144) who sustained harm when she slid out of her wheelchair and fractured her ankle. However, the facility had implemented corrective action so the deficiency is being cited at past non-compliance. Findings include: R144's Resident Face Sheet, included [DIAGNOSES REDACTED]. A history and physical (H&P) note dated 3/5/19, indicated R144 had sustained a stroke following surgery, and suffered from left sided [MEDICAL CONDITION]. The H&P further indicated R144 had cognitive impairment and was far below her functional baseline status and required rehabilitation. R144's discharge Minimum Data Set (MDS) assessment dated [DATE], indicated R144 had intact cognition, was totally dependent upon staff for transfers, and had experienced one fall with major injury since admission. R144's Care Area Assessment (CAA) for vision dated 4/3/19, indicated R144 had a left sided visual field cut which limited her visual acuity due to a stroke. The CAA further indicated items were to be placed to the right side of R144 to avoid neglecting or not seeing. R144's CAA for communication dated 4/3/19, indicated R144 had a hearing deficit and was not always able to understand what was being asked or spoken. R144's care plan dated 3/29/19, indicated R144 had impaired vision related to no midline or left-sided vision. The goal was for R144 to remain physically safe, and not experience negative consequences of vision loss. R144's interventions included: adapt environment and keep everything to R144's right side, provide visual cues to enhance independence, and put items within her direct line of vision. R144's care plan dated 3/28/19, indicated R144 had a potential for falls related to impaired mobility, increased weakness, and left sided impaired mobility related to a stroke. The goal was for R144 not to be injured by a fall. Interventions included: keep frequently used items within reach, call light within reach at all times, and keep things to R144's right side. The care plan dated 3/27/19, indicated R144 needed activity of daily living (ADL) assistance related to left-sided [MEDICAL CONDITION], impaired mobility, impaired vision, and impaired cognition. R144's care plan further indicted R144 was unable to ambulate, required prompts and cues for completion of tasks related to grooming, required Maxi-lift (mechanical lift) for transfers, and required total assistance with wheelchair mobility. A progress note dated 3/27/19, at 11:28 a.m. indicated R144 was neurologically intact however, required repetition to stay orientated. The progress note further indicated R144 had a severe left field vision cut with no midline vision, and had cognitive deficiencies that she masked with humor. A progress note dated 4/14/19, at 10:45 p.m. indicated R144 was seated in her wheelchair with a mechanical lift sling under her. The progress note further indicated staff had to quickly help another resident, and R144 slid out of her wheelchair and onto the floor. A progress note dated 4/16/19, at 7:38 a.m. indicated R144's left calf was dark colored and painful. The progress note further indicated R144 did not tolerate a TED stocking being applied. A provider note dated 4/16/19, indicated R144 was evaluated due to increased pain and swelling to her left lower leg. The provider note further indicated R144 had a fracture, and orthopedics recommended to immobilize R144's ankle, and have a splint applied. The facility's root cause analysis (RCA) tool dated 4/16/19, indicated R144 was found on the floor in her room on 4/14/19, at 3:00 p.m. Staff indicated R144 was in her wheelchair, in the process of being transferred, and a mechanical lift sling was left underneath her. A nursing assistant (NA) left R144's room to respond to an emergency, and R144 slid forward from her wheelchair due to a slippery sling in place. According to the RCA tool, R144 had stated she couldn't find her call light and was wiggling in her chair attempting to find it when she slid off her chair. The RCA identified fall precaution interventions were not followed at the time of the fall related to improper placement of equipment or material. Resident contributing factors to the fall included mobility and eyesight. The root cause conclusion indicated, NAR (NA) distracted and responded to an emergency in another room. Had left resident in w/c (wheelchair) believing her to be safe. Call light placement was poor. Resident unable to find call light when in chair. Hoyer sling still remained underneath her. This caused her to slip from chair. NAR returned after responding to other area to find resident on floor. Hoyer sling caused slippery surface for resident due to resident impaired mobility and inability to self adjust in chair she was not able to stop from slipping in wheel chair. An orthopedic office note dated 4/18/19, indicated R144 was injured on 4/14/19, when she slipped out of her wheelchair as she was searching for her bed controller. The orthopedic office note further indicated R144 had a bimalleolar fracture of her left ankle, and a fiberglass splint was applied to R144's leg in an urgent care department. The orthopedic office note also identified conservative treatment (immobilization) was recommended due to R144's recent medical issues and conditions. On 8/21/19, at 11:59 a.m. an interview was conducted with NA-B. NA-B stated generally mechanical lift slings were not slippery when placed in resident wheelchairs however, this may change based on the type of wheelchair cushion used. NA-B also stated mechanical lift slings could only be left under residents if directed by the care plan. On 8/21/19, at 12:57 p.m. an interview was conducted with NA-C. NA-C stated mechanical lift slings were usually not left under residents when they were sitting in their wheelchairs. NA-C further stated if staff noticed a mechanical lift sling was slippery in a wheelchair, non-skid material was available to be placed to prevent sliding. On 8/21/19, at 1:19 p.m. an interview was conducted with the director of nursing (DON). The DON stated R144 had an obstructed visual filed due to a stroke. The DON further stated on 4/14/19, staff had transferred R144 to her wheelchair using a mechanical lift, and the NA did not remove a mechanical lift sling from R144's wheelchair. The DON verbalized another resident was on hospice, and staff who were attending to R144 had left R144's room to attend to the family of the hospice resident. The DON stated she believed the call light was clipped to R144 however, R144 was unable to see it at the time of her fall. The DON stated the NA told R144 that the call light was clipped to her, but was unable to confirm this. The DON also verbalized R144 stated she was unable to find her call light, and had wiggled out of the chair. The DON stated the call light placement was poor, the mechanical lift sling caused a slippery surface, and R144 was unable to stop herself from sliding out of her wheelchair. The DON confirmed call light placement and a mechanical sling being left in R144's wheelchair contributed to the fall. The DON confirmed R144 sustained a left ankle fracture. Facility policy titled Fall Prevention Program, reviewed 1/28/19, directed Each facility shall use a risk adjusted screening tool to identify risk for falling prior to admission. The admissions nurse will communicate to staff pre-admission and assure interventions are in place at time of admission. Although R144 fractured her ankle after staff left her alone in her wheelchair without her call cord in vision, and while seated on a lift sling, by 4/16/19, the facility had implemented corrective action to prevent recurrence including a root cause analysis, staff education and updates to the resident's care plan.

Based on interview and document review, the facility failed to ensure a comprehensive assessment was completed to prevent development of a pressure ulcer for 1 of 3 residents (R90) reviewed for pressure ulcers. This resulted in actual harm for R90 due to the development of an avoidable pressure ulcer to the left heel. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). R90's Face Sheet indicated R90 was admitted on [DATE], and [DIAGNOSES REDACTED]. R90's admission Minimum Data Set ((MDS) dated [DATE], indicated R90 was cognitively intact, required extensive assist of one staff for bed mobility, was at risk for pressure ulcers, and did not have a current pressure ulcer. R90's discharge MDS dated [DATE], indicated R90 required limited assistance with bed mobility, and had a suspected deep tissue injury. R90's Care Area Assessment (CAA) dated 6/13/17, indicated R90 was at risk for pressure ulcers related to pain, pelvic fracture, [MEDICAL CONDITION] with hemorrhage, and use of antihypertensive medications. R90's CAA further indicated R90's skin was dry and intact at that time. R90's care plan initiated 6/6/17, indicated R90 was at risk for alteration in skin integrity related to pelvic fractures, hemorrhage, indwelling urinary Foley catheter, and [MEDICAL CONDITION] (low iron levels in the blood). Approaches initiated 6/6/17, included encouraging good nutrition and adequate fluid intake, encourage participation and compliance with turning and repositioning, turn and reposition every 2-3 hours and as necessary, monitor and report any signs of skin breakdown, remind resident of the benefits of lying down including relief from sitting and improved circulation, skin assessment, Braden scale (tool used to assist in determining risk of impaired skin integrity) and tissue tolerance (tool used to assist in determining the ability of the skin to withstand the effects of unrelieved pressure without signs of skin breakdown over specific periods of time) assessments. R90's care plan further indicated R90 had pain and required assistance in repositioning as necessary to enhance comfort, and required required extensive assist for bed mobility. R90's care plan indicated a geofoam cushion in the recliner for pressure reduction was initiated on 7/2/17. The care plan lacked interventions to reduce pressure to R90's heels. R90's Admission Head-to-Toe documentation dated 6/6/17, indicated R90 did not have any pressure-related skin impairments. R90's Admission Skin Assessment progress notes dated 6/6/17, indicated all of R90 was at risk for skin integrity impairment due to decreased mobility. R90's Braden Scale for Predicting Pressure Sore Risk dated 6/6/17, indicated R90 was at risk for the development of pressure ulcers. R90's Skin Observation laying tissue tolerance assessment dated [DATE], indicated R90 had a standard therapeutic mattress, and was independent in repositioning or offloading (changing positions to relieve pressure). The assessment indicated no skin and ulcer treatments were provided, including no pressure reducing devices for bed or chair, and no turning and repositioning program. R90's Braden Scale dated 6/12/17, indicated R90 was not at risk for pressure injuries. R90's nutrition progress notes dated 6/13/17, indicated R90's intake had improved since admission, and he was eating well. The note indicated R90's skin was intact, and there were no nutritional concerns. R90's Braden Scale dated 6/19/17, indicated R90 was not at risk for pressure injuries. R90's progress note dated 6/19/17, indicated R90 had no new skin issues during his weekly shower. On 6/24/17, a Wound Management note indicated R90's heel had a purple area measuring 3.2 centimeters (cm) x 2.5 cm with a white rim around the top of the purple area measuring 5.5 cm x 0.5 cm. The documentation also indicated the overall size was 8.7 cm x 3 cm, and it was an unstageable suspected deep tissue injury (SDTI) with well-defined wound edges. R90's progress notes dated 6/25/17, indicated R90 did not want to ambulate due to the blister recently found on heel. Heels were free floating at that time. In a later progress note on the same date, R90's blister was described as purple in color and intact. Another progress note on the same date indicated R90's family member was informed of R90's SDTI, and the family member requested a dietary supplement due to R90's poor nutritional intake. R90's Skin Observation dated 6/25/17, indicated R90's risk factors included R90 had impaired or decreased mobility and decreased functional ability, advanced age, decreased food intake and increased pain. The Skin Observation note indicated R90's skin and ulcer treatments included a pressure reducing device for chair and bed, and a turning and repositioning program. The Skin Observation note indicated R90 had developed a SDTI on his left heel, and the care plan was updated to float heels off all surfaces. The Skin Observation note also indicated R90 was at further risk for skin breakdown due to decreased mobility secondary to pain, advanced age, [MEDICAL CONDITION], presence of a Foley catheter, and decreased oral intake. The Skin Observation note indicated a request was made for a nutritional supplement, pain was being managed with narcotic pain medications, and R90 was to be assisted to turn and reposition every 2-3 hours. A new tissue tolerance assessment was to be completed. R90's Braden Scale dated 6/25/17, indicated R90 was not at risk for pressure ulcers. R90's Skin Observation sitting tissue tolerance assessment in chair dated 6/25/17, lacked identification of the chair R90 was assessed in. R90's tissue tolerance indicated R90 had a custom order cushion, had initial redness and interventions included elevation. R90's tissue tolerance lacked identification of skin and ulcer treatments, and what measure were being taken to reduce pressure to R90's heel. R90's care plan revised 6/25/17, indicated R90 had a new SDTI on the left heel. R90's care plan approaches included assessing the pressure ulcer for stage, size, presence or absence of granulation tissue (new connective tissue that is created when the wound surface area is healing) and [MEDICATION NAME] (covering with healing tissue), and condition of surrounding skin weekly, complete a systematic skin inspection weekly and report any signs of further skin breakdown. R90's care plan further directed both heels to be floated with pillows off all support surfaces to relieve pressure on the heels. R90's NP progress notes dated 6/26/17, indicated R90 was seen for a new skin impairment, which was a large intact blood blister on the bottom of the left heel. R90's NP note indicated R90 spent much of the day laying in a recliner with his heels usually on the recliner foot rest. The plan was to monitor at that time, keep all pressure off heel, keep shoe off, and float heels when in bed. R90's occupational therapy (OT) progress note dated 6/26/17, indicated R90 reported a painful heel. R90's OT progress note further indicated R90 was non-weight bearing due to ulcer on left heel. R90's physical therapy (PT) progress note indicated R90 was toe touch weight bearing (TTWB) on left leg due to left heel blister, but R90 was unable to follow the limited weight bearing on the left heel. R90's Tissue Tolerance and Bed Evaluation dated 6/27/17, indicated R90 had a standard therapeutic mattress, and initial redness that dissipated with off loading. R90's Wound Management documentation dated 6/28/17, indicated R90 had a new intact blister covered with [MEDICATION NAME] tissue that measured 4.9 cm x 6 cm. R90's progress note dated 6/29/17, indicated R90's left heel blister remained intact, R90 continued with toe touch transfers, and R90 was able to maintain TTWB. R90's restorative progress note dated 6/30/17, indicated R90 was unable to complete restorative ambulation program that week due to the left heel blister. R90's progress notes dated 7/2/17, indicated R90's left heel blister was intact, and a cushion was placed in the recliner. R90's progress notes dated 7/4/17, indicated R90 complained of pain of the pelvis and both heels, and rated pain at 6 out of 10. R90's heels were free-floating and pain medication was administered. R90's progress notes later on the same day indicated R90 complained of left heel and foot pain, rated as 8 out of 10 and requested pain medication. R90's Wound Management documentation dated 7/5/17, indicated R90's pressure ulcer measured 4.7 cm x 6 cm and was covered by granulation and [MEDICATION NAME] tissue. R90's NP progress notes dated 7/5/17, indicated R90 continued with a large intact blood blister on left heel which appeared to be reabsorbing and resolving. R90's progress notes dated 7/7/17, indicated R90 complained buttock and left heel pain rated at 10 out of 10. R90 was given pain medication with minimal relief. R90 requested an increase in pain medication for adequate pain control. R90's heels were floated on pillows. R90's progress notes dated 7/10/17, indicated R90's left heel blister was absorbing and intact. R90's progress notes dated 7/11/17, indicated R90 complained of left heel pain rated as 10 out of 10, was given pain medication with minimal relief. Heels were free-floating, and the blister remained intact. R90's Wound Management documentation dated 7/12/17, indicated R90's pressure ulcer measured 4.5 cm x 5.6 cm and was covered with granulation and [MEDICATION NAME] tissue, with well defined wound edges. R90's progress notes dated 7/12/17, indicated discharge orders included, [MEDICATION NAME] to heel outer eschar blister only, protect central blister, continue to off-load pressure. R90's Braden Scale dated 7/13/17, indicated R90 was at risk for pressure ulcers. R90's progress notes dated 7/13/17, indicated R90 was discharged from the facility to an assisted living facility. On 8/31/17, at 9:06 a.m. registered nurse (RN)-D verified R90 had no pressure ulcers on the initial skin assessment when admitted to the facility. RN-D verified R90 was at high risk for pressure ulcers, a nutritional referral was made, and R90 had physical and occupational therapy and a restorative nursing program. RN-D stated R90 had a standard mattress on his bed, which was a pressure reduction mattress. RN-D stated R90 had decreased intake at meals, was admitted with a fracture of sacrum and pelvis, and bone density disorders. RN-D stated R90 required extensive assist with bed mobility upon admission. RN-D verified R90's left heel pressure ulcer was identified on 6/24/17, and started as a purple color to the heel. RN-D stated R90 had not been wanting to get out of bed, and OT noted R90 had been doing a lot of sitting in the recliner, and he had refused to come out to meals. RN-D stated R90's heels must have been resting on foot rest. RN-D stated R90's skin was looked at daily with dressing and cares, and weekly with showers. RN-D stated nursing assistants (NAs) inform the nurse of even very small changes in residents. RN-D stated interdisciplinary team (IDT) meetings are done when new pressure ulcers develop, and the IDT discuss and develop a plan of action. RN-D verified there were no IDT notes in R90's medical record. On 8/31/17, at 11:57 a.m. the director of nursing (DON) verified R90's left heel pressure ulcer was identified on 6/24/17, and she deferred to RN-E. On 8/31/17, at 12:08 p.m. RN-E stated R90 spent most of his time in a recliner with his feet up on the foot rest. RN-E verified R90 had developed a pressure ulcer on the left heel, and described it as a blood blister, which was unstageable. RN-E verified a tissue tolerance assessment was initially only done in bed, but should have also been done in the recliner. RN-E stated R90 was able to move around and could stand up, but was in pain and did not like to get up. RN-E stated R90's pressure ulcer was from sitting in the recliner with the footrest up and his heels resting on the foot rests. RN-E verified R90's pressure ulcer could have been prevented, and if the tissue tolerance assessment had been done with R90 sitting in the recliner chair, initiation of floating R90's heels would have been been sooner, prior to breakdown. On 8/31/17, at 12:15 p.m. the DON verified a tissue tolerance assessment should have initially been completed while R90's was in the recliner. DON stated a tissue tolerance assessment should be completed for all surfaces used by the resident. The facility policy and procedure for Skin Monitoring/Assessment/Documentation revised 9/10, directed a tissue tolerance to be completed on all residents upon admission and with any change in positioning and/or skin integrity, and all residents with impaired skin integrity would be discussed at the IDT meeting the following business day. The facility policy and procedure for Pressure Sore Treatment, Assessment, and Prevention, indicated a Tissue Tolerance Assessment revised 10/16, would be completed upon admission, transfer, quarterly and with a significant change in status, a pressure reduction or pressure relief surface would be placed in bed and wheelchair, and heels would be elevated off the bed as indicated. The facility policy and procedure lacked direction for pressure relief or assessment of positioning and tissue tolerance on all surfaces.

Based on observation, interview, and document review, the facility failed to ensure care and services were provided to prevent the development of, and worsening of pressure ulcers for 1 of 3 residents (R41) reviewed for pressure ulcers. This resulted in actual harm for R41 who developed multiple unstageable pressure ulcers. Findings include: Pressure Ulcer Stages according to the National Pressure Ulcer Advisory Panel Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. R41's face sheet printed 9/15/16, indicated [DIAGNOSES REDACTED]. R41's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R41 had moderate cognitive impairment. R41's MDS further indicated R41 required assistance of 2 staff for bed mobility, toilet use, and transfers. The MDS also identified R41 was frequently incontinent of bowel and bladder. R41's MDS indicated R41 was at risk for the development of pressure ulcers, had no unhealed or unhealed pressure ulcers, and had a pressure reducing device for chair and bed. R41's care plan dated 9/6/16, indicated R41 had an unstageable pressure ulcer to the right buttock and right outer foot. R41's care plan indicated interventions included Mighty Shakes (increased protein drinks) three times daily, notify the nurse practitioner, physician assistant, or physician if the area worsened, turn and reposition every 2 hours, wound nurse to follow weekly, dressing changes as ordered by the physician, and a referral to the surgical certified nurse practitioner. R41's care plan further indicated R41 required assist of one staff for turning and repositioning, had a geo-mattress (a pressure reduction mattress) on the bed, a special boot on the right foot at all times (start date of 12/3/11), and a pressure relieving cushion in the wheelchair. The care plan directed staff to keep linens as free from wrinkles as possible and notify the nurse immediately regarding any redness or discoloration of the skin. R41's Care Area Assessments (CAAs) dated 4/27/16, indicated R41 was at risk for altered skin integrity, required extensive to total assistance for activities of daily living, and was frequently incontinent of bowel and bladder. R41 was to be repositioned every 2 hours and as necessary, toileted or changed every 2 hours and as requested, and lotioned with cares. The goal was to keep R41's skin free of pressure ulcers, clean, warm and dry. R41's Skin Risk Assessment with Braden Scale dated 7/17/16, indicated R41 was at moderate risk of skin breakdown and indicated there were no current pressure ulcers. On 8/20/16, a Skin Integrity Pressure Sore Event Report indicated R41 had a new occurrence of a Stage II pressure ulcer on the coccyx measuring 0.5 centimeters (cm) x 0.5 cm, with a shiny, moist, granular appearance of pink or red tissue. Interventions included a pressure reducing device for bed and chair, pressure ulcer care and dressings to the pressure ulcer, along with pain management. The related progress note indicated the [MEDICATION NAME] (foam) dressing was initiated and the nurse practitioner was notified. A progress note dated 8/20/16, indicated a new open area measuring 0.5 cm x 0.5 cm on the coccyx had been identified, as noted on the Skin Event Report. The progress notes indicated R41 had received orders from the nurse practitioner for a [MEDICATION NAME] dressing to be changed every 3 days and as necessary. On 8/21/16, a Physician order [REDACTED]. An order of 9/6/16, directed nursing to refer R41 to a wound care nurse practitioner for a wound consult of the unstageable pressure ulcer to the buttock. The physician orders [REDACTED]. On 8/29/16, a Skin Integrity Pressure Sore Event Report indicated R41's left buttock pressure ulcer (area incorrectly identified by the facility) had increased in size to 1.4 cm x 0.6 cm and was unstageable, 100% covered with slough (yellow or white tissue that adheres to the ulcer bed). Interventions remained the same in addition to a turning and repositioning program. On 8/30/16, a progress note indicated R41's right foot was cool to touch, nurse was unable to feel the foot pulses, capillary refill and skin color were within normal limits. On 9/4/16, a progress note indicated R41's right buttock pressure ulcer (area incorrectly identified by the facility) was larger and measured 3 cm x 2.5 cm with a 0.9 cm x 1.5 cm slough/eschar in the center. Yellowish drainage with a foul odor was noted. The physician's assistant was to be notified on that Tuesday, 9/6/16. On 9/6/16, a nutrition progress note indicated the dietary tech was notified on that date, of R41's pressure ulcer on the buttocks (area incorrectly identified by the facility), with recent weight loss and decreased intake. The dietary tech was notified that the registered nurse (RN) had initiated Mighty Shake supplements. The nutrition note indicated R41 was receiving a multivitamin and would be monitored. On 9/9/16, a nutrition progress note indicated R41 had a significant change initiated due to skin issues. The progress note indicated R41 had a 3% weight loss over a month and had been started on Mighty shake supplements. The progress notes lacked documentation of the pressure ulcer on R41's right outer foot. A nutrition progress note dated 9/13/16, indicated R41 had two pressure areas, without identifying the location of either pressure ulcer. On 9/7/16, a Skin Integrity Pressure Sore Event Report indicated R41 had a new outer right foot unstageable pressure ulcer measuring 0.5 cm x 1.1 cm, and was considered to be a suspected deep tissue injury. The report indicated R41 wore a heel Medix boot (designed to relieve pressure on the heel) on the right foot, and the physician was not notified. On 9/7/16, a Skin Integrity Pressure Sore Event Report indicated R41's right buttock pressure ulcer (area incorrectly identified by the facility) increased in size to 1.1 cm x 2.1 cm with the surrounding redness measuring 3.3 cm x 3.1 cm. The pressure ulcer was unstageable, was covered with slough, and had a scant amount of drainage. R41's interventions remained the same with the addition of a nutrition or hydration intervention to manage skin problems. Measures indicated a geo mat was applied to the bed and an appointment was made with a wound care nurse practitioner. On 9/11/16, a Tissue Tolerance Assessment (a test which helps determine time period the resident's skin tolerates continued pressure to an area) indicated R41 had an initial redness of the coccyx (tail bone) and buttocks which dissipated immediately with offloading (relieveing pressure to an area) in bed and chair. On 9/11/16, a Skin Risk Assessment with Braden Scale (an assessment used to assist in determining a resident's risk for skin breakdown) indicated R41 was at moderate risk for skin breakdown. R41's Skin Risk Assessment note identified risk factors, including current skin issues and history of skin issues. The note indicated R41 had a pressure ulcer on the coccyx, and had slight bogginess (soft tissue which indicates possible deep tissue breakdown) on the right heel, and wore a heel protector on the right foot. On 9/12/16, a nursing home physician's progress note lacked documentation of R41's pressure ulcers. On 9/13/16, an office visit progress note, indicated R41 was seen by surgical nurse practitioner (NP) for wound care of an ulcer of the buttock. The NP documented the pressure ulcer was painful to R41, and R41 recently began taking protein supplements. The NP further documented the wound measured 2 cm x 1 cm x 0.1 cm. The documented plan was to treat the coccyx ulcer with the [MEDICATION NAME] AG (silver sulfate-for medium-exuding chronic or acute wounds where antimicrobial action is indicated), and change the dressings every 7 days or as needed. R41 was to be turned or repositioned every 1-2 hours as this wound will not heal and will likely worsened (sic) if pressure is not kept off the wound area. The NP note lacked documentation regarding the right foot pressure ulcer. On 9/14/16, a Skin Integrity Pressure Sore Event Sore Event Report indicated R41's coccyx pressure ulcer had increased in size to 2.7 cm x 1.4 cm with the surrounding redness measuring 4.7 cm x 3.1 cm. The documentation indicated the pressure sore was a Stage 2, though it contained slough, which would indicate the ulcer was unstageable. The report indicated the pressure ulcer had a scant amount of clear drainage. The interventions remained the same. The report lacked documentation of the pressure ulcer on the right outer foot. On 9/14/16, at 9:25 a.m. registered nurse (RN)-D and RN-C entered R41's room to do a wound check. R41 was lying in bed on her back. RN-D and RN-C turned R41 to the left, and RN-D peeled back the dressing that was positioned on R41's right coccyx area. RN-D measured the open area, which was described as peanut shaped with slough at the base, blanchable, with redness around it. The dressing had a small amount of serous drainage on it. RN-D placed the same dressing over the pressure ulcer. R41 was returned to her back. RN-D was asked about the ulcer on R41's right foot. RN-D stated he thought R41 did have an area on her foot, and proceeded to remove R41's heel protector. RN-D noted a scabbed area on the right distal right great toe. RN-D measured the scabbed area and stated it was 0.4 cm x 0.4 cm. RN-D replaced the heel protector to R41's right foot. RN-D stated R41 had a geofoam overlay on top of a regular mattress, and had a pressure-relief cushion on her wheelchair. Following the procedure, RN-D verified there was documentation on 9/7/16, indicating R41 had a pressure ulcer on the outside of her right foot. RN-D thought the nurse had mistakenly written right outer foot but meant the scabbed area on R41's right great toe. On 9/14/16, at 1:31 p.m. RN-D verified R41's pressure ulcers developed at the facility about 3 weeks ago. RN-D stated there was little to no drainage on the dressing, so he did not change the dressing. R41 had been seen by the wound care nurse practitioner the previous day, so had a new dressing put on at that time. RN-D stated R41's pain is managed with a [MEDICATION NAME] (narcotic medication) patch and Tylenol. RN-D verified R41 is repositioned every 2 hours and as necessary, and stated R41 is compliant with that. RN-D denied seeing a pressure ulcer on the right outer foot. RN-D was unaware R41 had a pressure ulcer on the right foot. On 9/15/16, at 8:42 a.m. nursing assistant (NA)-E stated R41 had an open area on her bottom and a red area on her foot, which has improved since she got her new mattress. NA-E stated R41's mattress was put on her bed last week. NA-E stated R41 had a regular mattress prior to receiving the new mattress. On 9/15/16, at 9:27 a.m. RN-D stated before R41 had skin breakdown, she was turned and repositioned every 2 hours and as necessary. Food and fluid intake was to be encouraged, R41 was to be promptly cleaned and dried after incontinence, linens were to be free from wrinkles, and staff were to monitor and report signs of breakdown. RN-D stated R41 had a pressure relieving cushion in the wheelchair, and got the new geofoam overlay on 9/9/16. RN-D stated initially after skin breakdown, an order for [REDACTED]. RN-D verified R41 was noted to have a pressure ulcer of the right outer foot on 9/7/16. On 9/15/16, at 10:17 a.m. the director of nursing (DON) verified R41 had developed pressure ulcers and had risk factors prior to skin breakdown. The DON stated R41 had not received Mighty Shakes prior to skin breakdown, though had been on a multi-vitamin and had been repositioned every 2 to 3 hours. The DON stated a [MEDICATION NAME] dressing was initiated and a new mattress was put on her bed. The DON verified dietary should have been notified right away. The DON stated they had a new consultant dietician and the dietary tech was on vacation, though the nurse could have initiated the Mighty Shakes, and the dietician could have been called. The DON stated R41 was on a pressure reducing mattress previously and on 9/9/16, a geo-foam overlay was put on R41's bed. The DON stated R41 wears a heel protector and hadn't had any breakdown of the heel. The DON verified R41 has not had occupational therapy assessments for positioning. On 9/15/16, at 1:33 p.m. RN-D went to do a wound check of R41's right foot upon surveyor's request. RN-D removed R41's right heel protector and stated R41's heel was normal and without bogginess. RN-D located the pressure ulcer on R41's right outer foot without a dressing on it and measured it. The pressure ulcer was dry and without drainage. RN-D measured the pressure ulcer and replaced R41's foot back in the heel protector. During an interview following the procedure, RN-D stated the open area was 0.7 cm x 0.8 cm with the blanchable redness around it measuring 1.0 cm x 1.0 cm. RN-D stated it was not warm to touch and had no drainage. RN-D stated it was a deep tissue injury and decided it was unstageable due to some eschar in the open area. RN-D verified the pressure ulcer could be caused by pressure from the boot. RN-D also verified he did not think the nurse practitioner had been notified of the pressure ulcer on R41's right foot. RN-D stated an acute care form would be filled out so the NP would look at the following day. Despite the increase in size of the pressure ulcer on the coccyx, the facility failed to reassess to promote the healing of the pressure ulcer, and failed to reassess to prevent the development of the pressure ulcer on the right foot. The facility policy and procedure for Skin Monitoring/Assessment/Documentation revised 9/10, directed the RN to assess reported signs of impaired skin and monitor weekly. The RN was to initiate a Weekly Skin Monitor and appropriate treatment. The policy directed the RN to notify the primary physician of skin integrity changes and implement the skin protocol. The policy further directed a tissue tolerance to be completed on all residents upon admission and with any change in positioning and/or skin integrity. Nursing was to notify nutritional services, restorative services and discuss at the IDT (interdisciplinary team) meeting.