**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that preventative measures to prevent and promote healing of a facility acquired stage III (full thickness tissue loss) pressure ulcer to the coccyx (tailbone) were in place and consistently followed as well as follow facility policy and procedures for Prevention of Pressure Ulcers/Injuries. This deficient practice was identified for 1 of 5 residents (Resident # 27) who was assessed with intact skin on 10/5/23 and identified with a stage III pressure ulcer on 10/8/23 (3 days later). The wound required excisional debridement (removal of dead tissue using a blade or scalpel) on 10/23/23 and was assessed as worsening on 10/30/23. This deficient practice was evidenced by the following: On 10/31/23 at 11:46 AM, the surveyor observed Resident #27 in their room in the presence of a second surveyor. The resident was dressed, groomed and seated in a wheelchair. The resident stated that he/she developed a pressure sore at the facility on the behind due to immobility and was stuck in the room for two weeks due to being COVID-19 positive. The resident stated that two weeks ago the wound care doctor stated that he/she required an air mattress and was still waiting for it. The surveyor did not observe an air mattress at that time. The resident stated the Registered Nurse/ Unit Manager (RN/UM) told him/her the air mattress would be provided today. The resident also stated that his/her roommate was disruptive, however the resident had not requested a room change since he/she thought that would prevent obtaining the air mattress. The resident stated, I don't want to miss it, I need it to heal. On 11/02/23 at 10:30 AM, the surveyor observed the wound treatment performed by the RN/UM. The wound was observed to be clean with no drainage or odor. The surveyor reviewed the medical record for Resident #27. Review of the admission Record (an admission summary) included diagnoses which were not limited to; morbid obesity, Diabetes Mellitus, unspecified abnormalities of gait and mobility, generalized muscle weakness, and congestive heart failure. Review of the admission Minimum Data Set (MDS) dated [DATE], a tool used to facilitate the management of care, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated an intact cognition. It also included that the resident required extensive assistance with one person assistance for bed mobility, transfers, locomotion on and off the unit, toileting and personal hygiene. In addition, the MDS indicated that the resident was frequently incontinent of bowel and bladder. Review of the Braden Scale Pressure Ulcer assessment (a tool that identifies the risk for developing a PU) dated 8/16/23 and 8/24/23, indicated the resident was at low risk for developing a PU. Further review of the Braden Scale Pressure Ulcer assessments dated 8/30/23 and 9/6/23, indicated the resident was at moderate risk for developing a PU. Further review of the Braden Scale Pressure Ulcer assessment dated [DATE] and signed by the RN/UM, indicated that the resident was assessed to be at low risk for developing a PU. Review of the residents comprehensive individualized care plan (CP) revealed a pressure ulcer CP dated 10/23/23, which was 15 days after the resident developed a stage III facility acquired PU. The goal of the CP was to maintain clean and intact skin and to encourage good nutrition and hydration in order to promote healthier skin. The CP interventions dated 10/23/23, included consult dietary for nutritional needs. an intervention dated 10/27/23, the patient refused air mattress and an intervention dated 11/2/23, for adaptive equipment: low air mattress. There was also a nutritional care plan CP dated 10/30/23, which indicated the resident required more protein due to a wound. Review of the Weekly Skin assessment dated [DATE] and signed by the RN/UM, indicated that the resident's skin was intact. Review of the Weekly Skin assessment dated [DATE] and signed by the RN/UM, indicated that the resident had a stage III sacral PU (1.5 centimeters (cm) x 1.5 cm x 0.2 cm). Review of an incomplete Wound Investigation Report dated 10/8/23, indicated the resident had a stage III coccyx wound which measured 1.6 cm x 1.6 cm x 0.2 cm. The wound investigation did not include a summary, a conclusion or a root cause analysis (RCA). According to the investigation, the facility identified a stage III PU for Resident # 27 which was three (3) days after the 10/5/23 Weekly Skin assessment which indicated the resident had intact skin. There was no documented evidence in the medical record that the wound was identified and assessed on 10/8/23. Review of the wound care consult reports included the following: - On 10/9/23, wound location coccyx, wound type PU, wound status unknown, measurements L x W x D 1.5 cm x 1.5 cm x 0.2 cm, stage III, treatment recommendations included cleanse area with normal saline, a primary dressing of Calcium Alginate and bordered foam dressing daily as well as a low air loss mattress. - On 10/16/23, wound location coccyx, wound type PU, wound status unchanged, measurements L x W x D 1.5 cm x 1.3 cm x 0.3 cm, stage III, treatment recommendations included cleanse area with normal saline, a primary dressing of Calcium Alginate and bordered foam dressing daily, dietitian consult and a low air loss mattress. - On 10/23/23, wound location coccyx, wound type PU, wound status improving, measurements L x W x D 1.2 cm x 1.1 cm x 0.3 cm, stage III, necrotic material (dead tissue) between 0% and 25%, and treatment recommendations included cleanse area with normal saline, a primary dressing of Calcium Alginate and bordered foam dressing daily as well as a low air loss mattress. The PU required excisional debridement. - On 10/30/23, wound location coccyx, wound type PU, wound status worsening, measurements L x W x D 2 cm x 4 cm x 0.3 cm, stage III, necrotic material (dead tissue) between 25% and 50%, and treatment recommendations included cleanse area with normal saline, a primary dressing Honey (Medical Grade) Gel, secondary dressing of Calcium Alginate and bordered foam dressing daily as well as a low air loss mattress. This recommended treatment change was not implemented until 11/1/23, (2 days later) and after surveyor inquiry. The 10/9/23 recommendation for a low air loss mattress was not implemented for Resident # 27 until 10/31/23, (23 days later) and after surveyor inquiry. Review of the Order Summary Report (OSR) included the following Physician's Order (PO): - 10/9/23, for Calcium Alginate-Silver External Pad 2 (Calcium Alginate-Silver) apply to coccyx topically every-day shift for wound healing. - 10/23/23, for Calcium Alginate-Silver External Pad 2 (Calcium Alginate-Silver) apply to coccyx topically every-day shift for pressure wound cleanse with NSS [normal saline solution], pat dry Calcium Alginate to wound base, bordered foam dressing. - 11/1/23, for Calcium Alginate-Silver External Pad 2 (Calcium Alginate-Silver) apply to coccyx topically every-day shift for pressure wound cleanse with NSS, pat dry apply Medi honey to wound base cover with Calcium Alginate and bordered foam dressing. Review of the October 2023 electronic treatment administration record (eTAR) reflected the above corresponding PO for 10/23/23. There was no documented evidence the wound treatment was performed on 10/28/23 and 10/29/23. According to the wound care consult report dated 10/30/23, the wound worsened. Review of the electronic medication administration record (eMAR) for October 2023, included a PO dated 10/30/23 for Prostat SF AWC (a liquid supplement that provides 100 calories, 17 grams (g) of protein, with added arginine (an amino acid that helps the body build protein), vitamin C and zinc per 30 milliliters (ml) portion) 30 ml by mouth one time a day for wound. Review of the resident's Lab Results Reports dated 8/16/23 and 9/19/23, reflected a depleted Albumin (protein in the blood) level of 2.9 grams (g) / deciliter (dl) and 2.8 g/dl, respectively. Review of the Nutrition/Dietary Wound note dated 10/30/23, included the Registered Dietitian (RD) recommended a protein supplement [Prostat SF AWC] once a day to aid in wound healing. The documentation included the resident had a low Albumin level 2.8 g/dl, dated 9/19/23. The recommended protein supplement was not implemented until 22 days later and after surveyor inquiry. Review of the progress notes Skilled Charting reflected the following: On 10/8/23 14:56 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: . On 10/9/23 15:38 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na . On 10/9/23 22:57 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . On 10/10/23 16:00 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na . On 10/10/23 22:01 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na. On 10/13/23 15:43 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na. On 10/13/23 15:45 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na. On 10/13/23 22:54 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . On 10/14/23 15:07 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . On 10/15/23 16:03 Changes to skin integrity: 0, Description of wounds: , Changes to wound: . On 10/16/23 13:48 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na. On 10/17/23 13:56 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na. On 10/18/23 13:58 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na. On 10/18/23 23:09 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . On 10/19/23 13:52 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na. On 10/19/23 14:00 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na. On 10/20/23 23:22 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . On 10/21/23 13:54 Changes to skin integrity: na, Description of wounds: , Changes to wound: . On 10/22/23 12:09 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . On 10/22/23 22:48 Changes to skin integrity: na, Description of wounds: 0, Changes to wound: na. On 10/24/23 03:16 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . On 10/25/23 13:03 Changes to skin integrity: na, Description of wounds: , Changes to wound: . On 10/25/23 22:45 Changes to skin integrity: 0, Description of wounds: , Changes to wound: . On 10/26/23 01:09 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . On 10/27/23 12:14 Changes to skin integrity: 0, Description of wounds: , Changes to wound: . On 10/28/23 19:16 Changes to skin integrity; 0, Description of wounds: 0, Changes to wound: . On 10/29/23 14:40 Changes to skin integrity: , Description of wounds: Sacral, Changes to wound: . On 10/30/23 19:49 Changes to skin integrity: , Description of wounds: Sacral, Changes to wound: . On 10/31/23 16:05 Changes to skin integrity: none, Description of wounds: 0, Changes to wound: none . On 10/31/23 19:15 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . On 11/1/23 06:26 Changes to skin integrity; 0, Description of wounds: 0, Changes to wound: . On 11/1/23 16:01 Changes to skin integrity: none, Description of wounds: 0, Changes to wound: none . On 11/2/23 03:48 Changes to skin integrity: 0, Description of wounds: 0, Changes to wound: . Review of a Skin/Wound Note dated 10/23/23 21:28, included Seen by [name redacted] wound care for PU on coccyx. Treatment and care plan in progress. Review of the General Note dated 10/31/23 12:44, included Spoke with patient again about risks vs (verse) benefits associated with wound healing. Patient agreed to try an air mattress for the night. Patient OOB (out of bed). Maintenance notified to change mattress. Further review of the medical record revealed there was no documented evidence that Resident #27 refused an air mattress which was recommended on 10/9/23, not until 23 days later and after surveyor inquiry. On 11/01/23 at 10:34 AM, the surveyor interviewed the RN/UM in the presence of a second surveyor. She stated that wound care rounds were conducted on Monday mornings at approximately 7 AM or earlier. The RN/UM further stated that the updates/assessments were available to review by the end of the day on Monday's. She stated, I believe [name redacted] scans their assessments into the electronic medical record [EMR]. She stated the previous Director of Nursing (DON) used to conduct wound care rounds with the wound care consultant and now the Licensed Practical Nurse (LPN)/UM has been conducting rounds recently since the DON resigned. She stated that the UM's were ultimately responsible to ensure that the wound care consultant's recommendations were followed and implemented. On that same date and time, the RN/UM stated maintenance kept the air mattresses in the building and if a resident needed one, she can get it almost immediately. She stated that originally Resident #27 did not want an air mattress which the wound care consultant recommended as part of the treatment plan. The RN/UM further stated that she spoke to the resident yesterday and reviewed risk verse benefits of the air mattress and the resident agreed to use it last night. She acknowledged that on 10/31/23, was the first time the resident had an air mattress in place. During this same interview, the surveyor inquired how often careplan's were updated. The RN/UM stated, care plans are updated as needed and further stated, I try to do mine as soon as possible. She also stated that if a resident refused a treatment, it should be documented in the progress notes or in a change of condition/risk management report (a report that was completed after the residents skin change was identified). The RN/UM was unable to provide a change of condition/risk management report or show the surveyor documented evidence in the progress notes. At that same time and in the presence of both surveyors, the RN/UM reviewed the wound care report dated 10/30/23 in the EMR. She acknowledged that there was a recommendation to add Medi honey (a medical grade honey for wounds that's has antibacterial and bacterial resistant properties) to the wound treatment plan. The RN/UM acknowledged that she had not seen, addressed or added this to the resident's PO's prior to surveyor inquiry. In the presence of both surveyors, she reviewed the PO's in the EMR and stated, it's not there, I am gonna add it right away. She could not speak to why the recommendation was not addressed timely. She further acknowledged that the 10/30/23 wound care report identified the wound status as worsened. She could not speak to why the wound may have worsened but added nutrition plays a role. In addition, she stated, I think it's based solely on measurements and its growing in size. On 11/02/23 at 9:25 AM, the surveyor interviewed the LPN/UM in the presence of a second surveyor. She stated that the previous DON used to conduct wound care rounds with the wound care consultant and would implement all the recommendations and update the care plans for all units. The LPN/UM stated that she used to assist the DON but since she left, now I do wound rounds. She added that she did not work on Monday 10/30/23. She stated that wound care rounds were on Monday mornings. The LPN/UM stated she maintained a list of which residents needed to be seen on all units, including the wound locations but she did not track sizes and staging. She further stated that the wound care consultant sent the reports Monday evening. She stated that each UM was responsible to review the reports, implement recommendations, and update care plans. She further stated the new DON had not been involved with wound rounds as of yet. On that same date and time, the LPN/UM stated if the consultant identified that a resident required an air mattress, she communicated that to maintenance right away via phone. She further stated, we communicate right then and there. She stated that maintenance had air mattresses in the facility and even if they had to order one, it would be available the same day. The LPN/UM stated the purpose of an air mattress was to assist wound healing, it relieves pressure, it provides off-loading. In addition, she stated that weight, nutrition, comorbidities (the simultaneous presence of two or more diseases or medical conditions in a patient), hydration and positioning played an important role as well. She also stated that a new wound or a change in status should have been documented in the progress notes. During this same interview, she stated that a new Braden scale should have been completed after the wound was identified to determine a RCA. This tool would determine what had changed in the resident's status, how the risk assessment had changed and what could have contributed to a skin change or PU. She stated, if a resident refused a treatment, it should have been documented in the medical record as soon as it occurred. The LPN/UM added, she was unaware that Resident #27 had refused the air mattress. She also could not speak to why the wound had worsened and stated that if it did, the nurse/UM should have done an RCA to determine why this occurred. The LPN/UM stated, Resident #27 was so eager to have it healed. On 11/02/23 at 10:06 AM, the surveyor interviewed the Director of Maintenance (DOM) in the presence of a second surveyor. He stated that a nurse would contact him via phone when a resident required an air mattress. He stated that he kept seven to eight air mattresses in the building. He stated, we provide the air mattress the same day, and that he ensured the air mattress functioned properly before it was provided. He could not speak to if or when there was a request for an air mattress for Resident #27 and would look into it. On 11/02/23 at 10:45 AM, in the presence of the survey team, the DOM provided a list of residents that had an air mattress which included Resident #27. He stated that the first time an air mattress was requested for Resident #27 was on Tuesday, 10/31/23 (22 days) after the recommendation for an air mattress was made. On 11/02/23 at 11:32 AM, the surveyor conducted a phone interview with the wound care Physician's Assistant (PA). She stated she conducted wound care rounds on Mondays and she usually rounds with the LPN/UM except on 10/30/23. The PA stated she conducted rounds with someone else on 10/30/23. She further stated the LPN/UM maintained a list of which residents needed to be seen and during rounds the LPN/UM took notes related to the wound status and new recommendations. She stated at the end of rounds she verbally communicated updates and any required treatment changes to the UM's so they could make changes right away. In addition, the PA stated that she sent an email to the facility at the end of the day with her signed reports. On that same date and time, the PA stated that her expectation was that changes are carried out the same day or at least by the next day. She stated that Resident #27 was relatively new to her and stated that she reviewed the notes during the phone interview. The PA stated she expected to be informed by the nurse if a resident refused a treatment; however, she was not informed that Resident #27 refused an air mattress. The PA acknowledged that she assessed the resident's coccyx wound on 10/30/23 as worsened, and stated it was larger in size. She also stated that on 10/30/23 the LPN/UM was out, and the RN/UM was unavailable to speak with after wound rounds. The PA stated that she verbally informed the DON about wound changes (improvements and worsening) prior to leaving the facility. On 11/02/23 at 11:50 AM, the surveyor interviewed Resident #27 who stated that he/she never refused the air mattress and the first time he/she received the air mattress was two days ago. On 11/02/23 at 1:49 PM, the survey team met the Licensed Nursing Home Administrator (LNHA), DON, Regional RN (RRN) #1 and RRN #2. The surveyor discussed the above findings for Resident #27. RRN #1 stated that Braden scales were completed on admission, quarterly and when there was a change in condition. She acknowledged that last Braden scale that was completed on 9/13/23, and that there should have been another completed after the coccyx wound was identified on 10/8/23. RRN #1 stated the purpose of the Braden scale was to identify and determine the possible causes and risks associated with a skin status change and to identify interventions needed to prevent further decline. The facility provided an incomplete Wound Investigation Report dated 10/8/23. The RRN #1 stated the investigation was an internal quality assurance tool and was not part of the medical record. On 11/06/23 at 9:34 AM, the survey team met with the LNHA, RRN #1, RRN #2 and the Regional RD (RRD). The RRD stated the facility RD worked full time and was not at work today. She acknowledged that the RD's wound note dated 10/30/23, was not comprehensive and could not speak to how the RD assessed the resident's protein needs. She stated the RD typically received weekly wound updates. The RRN #1 further stated, the RD was always part of the communication related to wounds. She stated that 10/6/23 was the previous DON's last day and she used to conduct wound care rounds with the consultant and provided updated information to the team via email, but now there was a new DON. She further stated that the LPN/UM conducted rounds but did not provide updated information to everyone. The RRN #1 and RRN #2 also stated, the RD attended morning meetings at which time wounds were discussed. During this same interview, the LNHA stated the RD attended morning meetings and new wounds and wound changes were discussed. The RRD stated the RD should have received information about the wounds and could not speak to how this one was missed. On 11/06/23 at 9:42 AM, the RRN #1 acknowledged that a few nursing notes stated the wound location was sacral and that the wound was always on the coccyx. She stated those were documentation errors. The RRN #1 and RRN #2 acknowledged but could not speak to why nursing did not document the development and assessment of a new PU on 10/8/23 and thereafter. In addition, they acknowledged and could not speak to the following: why a care plan for the PU was not initiated until 10/23/23; why the CP intervention Consult dietary for my nutritional needs dated 10/23/23, was not communicated to the RD; why the CP intervention Patient refused air mattress dated 10/27/23, was the first-time refusal was documented in the medical record; and how the resident developed a stage III coccyx wound on 10/8/23 (three days after a skin assessment dated [DATE] reflected intact skin) for a resident assessed as low risk for developing a PU on Braden scale dated 9/13/23. The RRN #1 stated that the facility's standard process was distracted. On 11/06/23 at 9:55 AM, the RRN #1 acknowledged that if she observed omissions on the eTAR she would have followed up with staff because if there was a blank and no progress note I could not be sure if the treatment was done or not. On 11/06/23 at 11:30 AM, the surveyor conducted a phone interview with the RD. She stated she typically received weekly wound reports which she reviewed for any changes in resident's skin status (worsened or improved). She further stated that she received wound information from the LPN/UM. The RD also stated that she had not received a wound tracking sheet and although new or changes in wounds were typically discussed in morning meetings which she attended, she was not informed of Resident #27's wound until last week. The RD could not recall the date she was notified. She also stated that she was unaware that there was an intervention on the wound care plan Consult dietary for my nutritional needs, dated 10/23/23. On this same date and time, the RD acknowledged that her wound note dated 10/30/23, was not comprehensive. She acknowledged that the resident was not consuming enough protein via the diet and that was why she added a protein supplement. The RD acknowledged that she had not compared the resident's nutritional needs verse what the resident consumed to ensure supplementation was adequate. She stated, she typically documented on resident's with wounds once a month. In addition, she stated that she would document timelier if a resident was determined to be at high risk and/or had a high risk wound. The RD further stated that she considered a stage III PU a high risk wound. She acknowledged that nutrition played a role in wound healing. She stated that adequate calories, protein, vitamins and minerals are needed to help the wound healing process. The RD also stated the protein supplement she recommended provided zinc, arginine and protein which are very good source of nutrients to promote wound healing, and was used for advanced wounds such as stage III and IV wounds. On 11/06/23 at 12:46 PM, the survey team met with the LNHA, DON, RRN #1 and RRN #2. No additional information was provided at this time. Review of the facility policy titled Pressure Ulcer/Injury Risk Assessment dated 10/2023, included the purpose of a structured risk assessment was to identify all risk factors and then to determine which can be modified and which cannot, which included but were not limited to; under nutrition, impaired/decreased mobility and decreased functional ability, exposure of skin to urinary and fecal incontinence, diabetes and refusal of care and treatment. It further indicated to complete a Braden scale to determine the risk factor for skin injury and repeat when there is a change in condition. The policy also included information that should be documented in the resident's medical record. This information included but was not limited to; a change in the resident's condition, the condition of the resident's skin (size and location, etc.), if the resident refused any treatment, the reason for the refusal, the resident's response to the explanation of the risks of refusing the treatment and the benefits of accepting and available alternatives. Review of the facility policy titled Prevention of Pressure Ulcers/Injuries dated 5/2023, included to conduct a risk assessment for pressure ulcer/injuries on admission and when there is a change in condition. It further identified areas for prevention which included moisture, to keep skin clean and free of exposure to urine and fecal matter; nutrition, monitor the resident's intake of food and fluids and include nutritional supplements to increase calories and protein as indicated; mobility and repositioning, reposition the resident based on mobility, the support surface in use, skin condition and tolerance; support surface and pressure redistribution, select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors; and monitoring, evaluate, report and document potential changes in the skin. In addition, it also included to review interventions and strategies for effectiveness on an ongoing basis. Review of the facility policy titled Physicians Orders dated 12/2022, included the nurse should notify the attending physician the findings and recommendation from a consultant. The attending physician, if in agreement, will order specific treatments as outlined by the consultant. Review of the facility policy titled Documentation of Mediation Administration dated 10/2023, included The facility shall maintain a medication administration record to document all medications administered. It further included that a nurse should document all medications administered to each resident on the resident eMAR and treatment administration on the eTAR. It also included that administration of medication or treatment must be documented immediately after it was given. In addition, it included that if a medication was withheld, not administered or refused, the nurse should document the reason. Review of the facility policy titled Charting and Documentation dated 1/2023, included all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, or functional condition should be documented in the medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. It further reflected treatments or services performed and changes in the resident's condition should be documented in the medical record, which included whether a resident refused a treatment. Review of the facility policy titled Care Plans, Comprehensive Person-Centered dated 10/2023, included A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further included that the care plan should describe services that would otherwise be provided for the above but are not provide due to the resident's right to refuse treatment. In addition, the care plan should incorporate identified problem areas, risk factors associated with identified problems, and reflect treatment goals, timetables and objectives in measurable outcomes. The policy included that the care plan should be reviewed and updated if the resident experienced a change in condition. Review of an undated policy titled Medical Nutrition Therapy (MNT) Documentation, included the focus of a comprehensive MNT assessment is to identify risk factors that may contribute to undernutrition, protein energy malnutrition, dehydration, unintended weight loss, pressure injuries and other nutrition problems, as well as identifying other nutritional needs. It also included that an MNT reassessment should be completed when there is a significant change in the resident's condition. In further included that each time an MNT assessment or reassessment is completed, a care plan or care plan revision should be completed, and the person-centered care plan is based on the MNT assessment, identified risk factors and nutritional needs. Problems, risk factors, or concerns are described along with nutrition interventions and goals for improvement. In addition, it included progress notes should be completed according to facility policy and state and federal guidelines. When significant changes occur, notes should be updated. Individuals with high-risk conditions will need to be reviewed more frequently. Each time a re-assessment or progress note is completed, the care plan should