**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure one (#31) of three residents reviewed for pressure-related skin conditions out of 19 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing. Resident #31, who was at risk for developing pressure injuries due to a recent surgery to replace his left hip joint, was admitted to the facility on [DATE]. According to the facility's assessment of the resident's skin on 3/8/24, the resident was admitted without any pressure injuries. The facility implemented a pressure reducing mattress upon the resident's admission, however, there were no interventions implemented for offloading the resident's heels, which were at an increased risk for skin breakdown due to the resident's decrease in mobility following the left hip surgery. On 3/11/24, a left heel blister was observed to the resident's left heel and a right heel blister developed later that same day. The facility did begin appropriate treatment of the wounds and implemented further interventions to address offloading the resident's heels after the wounds were identified, however, they failed to implement appropriate interventions of heel booties or an air mattress overlay until after the wounds developed. Despite providing treatment to the wounds after they developed and implementing further interventions, Resident #31's wounds continued to worsen. The resident was discharged to the hospital on 3/27/24 for further treatment of the wounds. Once at the hospital, Resident #31's heel wounds required surgical debridement down to the bone. Due to the facility's failures to identify upon admission that Resident #31 was at risk for pressure injuries related to his recent hip surgery and the facility's failure to implement timely interventions to offload and protect the resident's heels, Resident #31 developed pressure wounds to both of his heels within three days of his admission which resulted in his discharge to the hospital 16 days after the wounds developed for further wound treatment. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: (2019), retrieved from https://www.internationalguideline.com/guideline on 4/17/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss 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. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown 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. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury: Depth Unknown 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. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedures The Pressure Injuries policy, revised on 1/9/24, was provided by the director of nursing (DON) on 4/11/24 at 5:42 p.m. The policy revealed the purpose of the policy was to assure that all residents received an accurate assessment of pressure injuries, and the appropriate documentation was completed. The compliance guidelines revealed skin assessments would be completed by a licensed nurse upon admission and weekly thereafter. The information provided by the initial comprehensive assessment, established baseline data for the ongoing assessment of the resident's skin status. Accurate assessments that addressed each resident's skin status would be conducted by qualified staff and correctly documented in the medical record. A qualified health professional would correctly document the presence, number, size and stage of any pressure injury on the wound documentation form in the medical record. The nurse completing the skin section of the minimum data set (MDS) assessment would record the appropriate number and stage of pressure injuries as reflected in the pressure injury documentation. A licensed nurse would conduct or coordinate each assessment with the appropriate participation of health professionals. The director of nursing (DON) would be notified of any pressure injury. If it was determined a consultation was necessary, the wound nurse would be notified. If the wound nurse was notified, the DON, or designee, would be present during his/her visit. A Weekly Wound Evaluation would be completed and added to the pressure injury log. Education regarding pressure injuries would be provided to the nurses at least annually. Dressing treatments would be determined based on recommendations from the wound nurse, ordering physician, or best practice. The care plan would be updated indicating the presence of a pressure injury, the goal, and appropriate interventions. The physician would be informed of the presence of a pressure injury and treatment orders would be obtained. III. Resident #31 A. Resident status Resident #31, age [AGE], was admitted on [DATE] and was discharged to the hospital on 3/27/24. According to the March 2024 computerized physician orders (CPO), diagnoses included aftercare following joint replacement, left artificial hip joint, chronic atrial fibrillation, cardiomyopathies and chronic kidney disease. The 3/11/24 MDS assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required substantial/maximal staff assistance for upper and lower body dressing. He also required substantial/maximal staff assistance for putting on/taking off footwear. The resident was at risk for the development of a pressure ulcer. The resident did not have any pressure, venous or arterial ulcers upon admission. C. Record review A care plan, initiated 3/8/24, revealed Resident #31 was at risk for a pressure ulcer related to a recent fracture. The goal was for the resident's skin to remain intact with no new open areas caused by pressure or friction throughout his stay in the facility. Interventions included a skin risk assessment Braden Scale would be completed upon admission, quarterly and with a significant change in condition. The resident would use a pressure reducing mattress when in bed (start 3/8/24). A new recliner was ordered to try a different pressure relieving technique (start 3/8/24). The resident would allow staff to float his heels while in bed (start 3/11/24). On 3/18/24, a new boot for his heels was ordered according to physician recommendations. The care plan (started 3/11/24) further revealed the resident had a blister to his left heel and the resident was to wear booties when in bed. On 3/11/24, the resident's room recliner was replaced with a new recliner. On 3/13/24, the new recliner was not comfortable for the resident and another one was ordered by central supply. The staff were to provide treatment as ordered as necessary. An air mattress was placed on the resident's bed. The resident started on a nutritional supplement twice a day. The care plan (started 3/15/24) further revealed the resident had a blister on his right heel. A new air mattress was placed on his bed(start 3/15/24). The staff were to provide treatment as ordered as necessary. An air mattress was placed on the resident's bed. The resident started on a nutritional supplement twice a day (start 3/15/24). A Skin Evaluation Form, dated 3/8/24 at 2.16 p.m. by a registered nurse (RN) did not reveal any pressure injuries to the resident's heels. The Braden Scale assessment for predicting pressure sore risk, dated 3/8/24 at 1:33 p.m., documented Resident #31 was not at risk for the development of pressure ulcer/injury development. A Skin Evaluation Form dated 3/11/24 at 11:35 a.m. by a RN revealed a pressure injury to the left heel with an onset date of 3/11/24. The left heel pressure injury measured 3.8 centimeters (cm) by 2.2 cm by 0.0 cm depth. The wound was an unstageable unopened blister that was purple in color. The wound bed was not visible and there was no exudate. A nurse note dated 3/11/24 at 11:54 a.m. by a registered nurse (RN) revealed the resident complained of pain in his bilateral heels that morning in occupational therapy. The nurse assessed the resident and found a purple blister to the left heel and the wound bed was not visible. The right heel was pink with a blanchable (skin turns white when pressed then returns to pink when pressure is removed) surface. Booties for his heels were requested from supply. An addendum to the 3/11/24 nurse note, documented at 3:24 p.m., revealed during the day the resident developed an unstageable blister to the right heel. The nurse practitioner (NP) assessed and agreed to use the same treatment for both heels. The recommended treatment was skin prep (a skin barrier wipe which creates a thin film on the skin to protect skin by reducing friction) with optifoam (gauze pad) and protective booties while in bed. A Skin Evaluation Form dated 3/11/24 at 3:26 p.m. by a RN revealed a pressure injury to the right heel with an onset date of 3/11/24. The wound was an unstageable blister that measured 3.0 cm by 3.0 cm by 0.0 depth. A nurse note dated 3/12/24 at 2:07 p.m. by a licensed practical nurse (LPN) revealed the resident wore bunny boots (heel protection cushions) to his bilateral feet. The resident had slight edema to his bilateral lower extremities and was also wearing thigh high compression stockings. -The facility failed to implement protective heel booties until after Resident #55 developed the blisters on his heels. A nurse note dated 3/13/24 at 10:56 a.m. by a LPN revealed large fluid filled blisters were noted to bilateral heels that appeared to be from the middle to the lateral (outer) side. The resident had bunny boots to be worn when not working with therapy. The optifoam was removed, skin prep was applied and new optifoam was applied. Facility supply was working on getting a new recliner for the resident so he could elevate his legs. A nurse note dated 3/15/24 at 11:44 a.m. by a RN revealed large blisters on both heels. Skin prep and a dressing were applied. The resident had booties on with compression hose. An air mattress overlay was placed on his bed to help prevent skin breakdown. A recliner was ordered so that the resident could recline with his feet up. -The facility failed to implement the mattress overlay until four days after the blisters on the resident's heels were first noted. A nurse note dated 3/16/24 at 9:29 a.m. by a RN revealed the resident had slight edema to his legs and compression stockings were in place. The dressings to his heels were clean, dry and intact. The resident had booties in place and an air mattress (overlay) on his bed to help prevent skin breakdown. A nurse note dated 3/17/24 at 3:20 p.m. by a RN revealed a right heel blister had opened with drainage on a pillowcase. The left heel blister was intact. The dressings were changed as ordered and the resident was concerned about the blisters/wounds on his heels. The right foot looked swollen and the compression stockings were not on. A nurse note dated 3/18/24 at 10:54 a.m. by a RN revealed no edema was noted to the resident's legs and his legs were elevated on a stack of pillows and the heels were floated. The dressings were clean, dry and intact to bilateral heel blisters. The bunny boots were off due to bruising to the tops of his feet. His bed had an air overlay in place to relieve pressure. A nurse note dated 3/18/24 at 10:48 p.m. by a RN revealed the bandage to the left heel was replaced and a seeping (slow leak) of pink fluid was observed from the site. An absorbent pad was placed under his feet and the resident requested his socks be applied before the placement of the bunny boots. A nurse note dated 3/19/24 at 10:01 a.m. by a RN revealed open blisters to bilateral heels and the dressings were changed. A physician assessed the wounds and new booties were ordered. A new recliner for the resident had arrived and needed to be placed in his room. The resident had low albumin levels and the physician ordered a protein shake in addition to a nutritional supplement. A nurse note dated 3/21/24 at 2:37 p.m. by a LPN revealed the resident's left heel was hurting during a walk to the bathroom with therapy staff. The dressings to his heels were removed and saturated with drainage. The heel wounds were slightly macerated (soft with breaking down of skin due to prolonged exposure to moisture). The heels were cleaned and dried. Skin prep was applied to the periwound and to the wound areas. Calcium alginate was applied to the wound bed and covered with optifoam. Two optifoams were used on the left heel because the wound was too big. Larger heel dressings and blue offloading air boots were requested from facility supply. The resident had a low protein level on his last set of labs and he was now on a nutritional supplement. A nurse note dated 3/21/24 at 11:49 a.m. by a LPN revealed requested offloading blue air boots from supply, as well as bigger heel dressings. A nurse note dated 3/22/24 at 5:11 p.m. by a RN revealed physician orders for vitamin C chewable 500 milligrams tablets twice a day and zinc 220 milligrams, 50 capsules twice a day for 14 days. Wound care orders were to cover the wound bed and periwound with zinc barrier cream and apply calcium alginate with the alginate cut to fit the wound bed. Cover with silicone bordered foam dressing, wrap with kerlix (gauze) and Coban (wrapping material) to keep in place. The dressings were to be changed twice a week. The resident was to avoid walking until further notice. It was okay for the resident to use the Nu step machine (exercise machine) and use a bike. A nurse note dated 3/22/24 at 10:56 a.m. by a RN revealed wound rounds were completed. The right heel measured 5.6 cm by 6.5 cm by 0.2 cm depth. The left heel measured 6.0 cm by 8.0 cm by 0.2 cm depth. Large serous (pale yellow watery fluid) drainage from both heels that were boggy (soft and watery). Both heels were debrided (removal of dead or unhealthy tissue) and the dressings were to be changed three times a week. The resident was to remain off his heels as much as possible. A Skin Evaluation Form dated 3/22/24 at 11:06 a.m. by a RN revealed a pressure injury to the right heel with an onset date of 3/11/24. The right heel measured 5.6 cm by 6.5 cm by 0.2 cm depth. The wound was an unstageable opened blister that was boggy. There was a large amount of serous exudate and the wound tissue was 50% slough (yellow/white material of dead cells in a wound bed). A Skin Evaluation Form dated 3/22/24 at 11:12 a.m. by a RN revealed a pressure injury to the left heel with an onset date of 3/11/24. The left heel measured 6.0 cm by 8.0 cm by 0.2 cm depth. The wound was an unstageable opened blister that was boggy. There was serous exudate and the wound tissue was slough. A nurse note dated 3/23/24 at 12:37 p.m. by a RN revealed dressings were clean, dry and intact to bilateral feet. No edema was noted in the resident's ankles but he had slight edema in his feet below the Coban wrapping. The resident said, I am off the heels. A nurse note dated 3/25/24 at 4:29 p.m. by a RN revealed the resident sat in a recliner in his room with his feet off the end of the recliner footpad with booties on his heels. The resident said just in case I forget to put my feet up. The dressings were changed to his bilateral heels and a small amount of drainage was observed to the dressings when removed. The dressings for both heels required rolled gauze around the feet so there was a cushion from the protective bootstraps. A nurse note dated 3/26/24 at 3:54 p.m. by a LPN revealed the resident continued to have wounds to his bilateral heels. The resident was seated in a recliner with his feet elevated and floated off the edge of the recliner. He had bunny boots on both feet and his feet were warm with normal color. The resident was accepting the protein shakes and nutritional supplement. The resident said his heels did hurt at times. No edema was observed. A nurse note dated 3/27/24 at 11:40 a.m. by a RN revealed no edema was observed. The resident reported pain in his heels. Wound care was completed. The wounds were smelly with black necrotic (dead cells) tissue on both heels. The right heel measured 4.5 cm by 5.5 cm by 0.1 cm depth. The left heel measured 4.9 cm x 5.0 cm by 0.3 cm depth. There was a new order for skin prep, silver alginate, optifoam with silver and rolled gauze with kerlix to be changed daily. A referral was made to (physician's name) for possible surgical debridement. The referred provider wanted the resident to have restrictions on walking on his heels. A Skin Evaluation Form dated 3/27/24 at 11:54 a.m. by a RN revealed a pressure injury to the left heel with an onset date of 3/11/24. The left heel measured 4.9 cm by 5.0 cm by 0.3 cm depth. The wound was unstageable with black tissue. There was serous exudate and the wound tissue was necrotic/eschar (dry dead tissue in a wound). A Skin Evaluation Form dated 3/27/24 at 11:56 a.m. by a RN revealed a pressure injury to the right heel with an onset date of 3/11/24. The right heel measured 4.5 cm by 5.5 cm by 0.1 cm depth. The wound was unstageable with black necrotic tissue. There was serous exudate and the wound tissue was 100% eschar. A nurse note dated 3/27/24 at 4:18 p.m. by a RN revealed the writer received physician's orders to send the resident out to the hospital for deep tissue concerns to the bilateral heels. The resident was sent out by a transport service at 3:58 p.m. via stretcher to the hospital. A physician's assistant (PA) note dated 3/27/24 at 8:12 p.m. revealed a deep tissue injury (unstageable) to the right heel measuring 4.5 cm by 5.0 cm by 0.1 cm depth. There was no undermining (space that occurs under the wound's edges as tissue erodes) or tunneling (a channel that has opened underneath the skin). There was a large amount of sero-serosanguinous exudate with slough and a foul odor. There was 90% firmly adherent slough and dark purple necrotic tissue with 10% granulated tissue. Last week's measurement was 5.6 cm by 6.5 cm by 0.2 cm depth. The left heel was a deep tissue injury (unstageable) with no undermining or tunneling. There was a large amount of sero-serosanguinous exudate with slough and a foul odor. There was 80% firmly adherent slough with 20% beefy red granulation tissue. The previous week's measurement was 5.0 cm by 8.0 cm by 0.2 cm depth. Both heels were debrided on 3/22/24. The resident was very edematous when the wounds were started and now the edema was controlled. The procedures performed were Sharps debridement (use of forceps, scissors or scalpel to remove devitalized tissue, foreign material or debris from a wound) attempted to remove slough, but nearly all was firmly adhered. An attempt was made to probe to find viable tissue, but the necrosis was too deep and extensive. The resident was in pain and did not tolerate the procedure very well. Very little of the slough was removed due to the resident's pain and the severity of the tissue necrosis. A Hospital History and Physical dated 3/27/24 at 7:20 p.m. revealed a chief complaint of bilateral heel pain. The resident presented with bilateral pressure injuries on his heels. The wounds present with eschar and necrosis. The wounds would need Sharp debridement in the morning. The resident also presented with severe life threatening conditions including pressure injuries that required close monitoring and complex decision-making. It appeared the resident had very limited mobility since his most recent surgery and despite attempts to be more mobile and offloading his heels, the resident had developed bilateral heel wounds associated with significant pain. A Hospital Assessment and Plan dated 4/1/24 at 9:39 p.m. revealed full thickness necrotic pressure ulcers of bilateral heels due to pressure injuries suffered after a hip fracture and fixation (surgical repair). It did not appear there was any arterial compromise to the wounds to complicate the healing, and there was significant tissue space to recover. The relevant laboratory findings, dated 3/28/24, revealed 3+ Proteus mirabilis (A) and Rare Staphylococcus aureus (A). The Proteus isolates (bacterial organisms) from the debrided necrotic tissue did not guarantee or clearly imply direct pathogenicity. The local isolates would be considered when choosing the covering antibiotics during the preoperative and post-operative period. The resident complained of heel pain when his legs were moved dependently. The wounds initially came from pressure ulcerations after he had a hip fracture that required hospitalization and surgical stabilization. He had significant debridement of both necrotic heels on 3/28/24 (during hospitalization) that required debridement down to the bone. The resident was currently tolerating the ampicillin/sulbactam (antibiotics). IV. Staff interviews The DON and the assistant director of nursing (ADON) were interviewed on 4/15/24 at 3:30 p.m. The DON said the resident was admitted to the facility on [DATE] and the admission skin assessment did not reveal the resident had any skin issues with his heels. The DON said the resident was ambulatory and liked to wear slippers. She said during the last two days in the facility, the resident only walked to the bathroom. The DON said on 3/11/24 (after the resident developed the wounds) an air mattress overlay was placed on the resident's mattress. The DON said the 3/11/24 nurse note revealed the resident had a blister to his right heel and a purple blister to his left heel. From 3/11/24 at 11:54 a.m. to 3:30 p.m. the right heel went from a blister to an unstageable (fluid filled) pressure ulcer. The DON said bunny boots were put in place on 3/11/24. His heels were also floated on pillows at times. They agreed on measurements in the clinical record that were taken by a physician assistant (PA) that had wound certifications. They said the resident never refused any treatments, never refused to offload his heels and was compliant with interventions such as wearing the bunny boots. The DON said the facility thought the resident's heel pressure ulcers might be due to the resident digging his heels into the carpet to engage his chair recliner into the reclining position. The facility purchased a new electric recliner to remedy the action and to help him to be able to elevate his feet easier. She said the facility ordered the resident a special set of boots (more padding past the ankle and up to the calf) for the resident two days before he left the facility. The resident was provided with protein smoothies and a nutritional supplement. The DON said the resident was sent to the hospital on 3/27/24 at 4:00 p.m. using non-emergent transportation due to the fast progression of his bilateral heel pressure ulcers. The PA at the facility had recommended the resident be assessed by a wound physician, however the next available appointment was not until 4/17/24. The resident's family was okay with waiting until that date, but the PA spoke with the family and the resident's son, who was a physician, and they were in agreement to send the resident to the hospital. The PA called the hospital and provided a detailed report on the resident's wounds. The DON and registered nurse (RN) #2 were interviewed on 4/16/243 at 9:00 a.m. RN #2 said she did the resident's admission assessment and he had no skin issues on his heels. The DON and RN #2 agreed the resident was observed, on 3/11/24, to have blisters on his heels. RN #2 said a PA assessed and measured the resident's bilateral heel wounds on three separate dates. RN #2 said on 3/11/24 (after the development of the wounds) the resident had facility bunny boots applied to both heels. The facility ordered a specialty set of bunny boots on 3/19/24 and they arrived at the facility on 3/26/24. RN #2 said the resident's room recliner was too short for him and the facility purchased a new recliner for the resident. The new recliner was electric and kept the resident from digging his heels into the floor to push back in the recliner. She said the resident had a standard mattress and an air overlay was placed on his mattress. She said he did ambulate in the facility while wearing his own shoes. She said the only time he did not ambulate was when the PA did not want him to make his heel worse by walking. She said the PA debrided both heels only once at the facility and he was not seen by another wound physician. She said that he was sent to the hospital because the PA wanted the heels to be debrided better. She said the pressure wounds were unstageable and had a foul odor when he went to the hospital. They both said they were unsure how the pressure ulcers started. V. Physician letter The facility sent a typed/signed physician letter dated 4/16/24 at 5:11 p.m. (after the survey exit date). The letter revealed the resident had bilateral heel blisters with acute and rapid onset due to comorbidities of poor cardiac perfusion, and frailty, recent hip fracture with surgical repair and malnutrition per labs. The blisters escalated to pressure wounds quickly despite close monitoring, intervention with wound care and nutritional supplementation. This was unavoidable despite close monitoring, and rapid and appropriate interventions including wound care by a wound specialist, off-loading, and nutritional supplementation. -However, the facility failed to implement appropriate interventions, such as heel booties or a specialty mattress to offload Resident #31's heels, until after Resident #31 developed the bilateral heel wounds. -Additionally, the facility failed to have the physician document the wounds were unavoidable until after the survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, dementia, abnormalities of gait and mobility, difficulty in walking, and lack of coordination. The 11/20/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a BIMS of 13 out of 15. He required one-person extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. He required two-person extensive assistance for dressing. The Fall History on Admission/Entry or Reentry section of the MDS assessment was not completed. B. Observations On 1/4/23 at 1:27 p.m., Resident #26 was lying in bed with his eyes closed. There was a thick padded fall mat on the floor beside the bed. On 1/9/23 at 9:26 a.m., Resident #26 was in his room seated in his wheelchair. His wife was present in the room. The fall mat was folded up and leaning against the wall at the end of the bed. On 1/10/23 at 2:16 p.m., Resident #26 was seated in his recliner in his room. His wife was sitting on the resident's bed talking to him. C. Record review Review of Resident #26's electronic medical record (EMR) revealed the resident had sustained 13 falls since his initial admission on [DATE]. -Of the 13 falls sustained by Resident #26, six of the falls occurred after the resident's readmission to the facility on [DATE]. Review of Resident #26's fall care plan, initiated 10/31/22 and revised 11/16/22, revealed that the resident was at risk for falling related to seizures, weakness, and Parkinson's disease. Pertinent interventions included frequent checks of the resident, putting the resident's bed in the lowest position while in bed and a mat next to the bed for safety, obtaining physical therapy consult as needed and following therapy recommendations, providing the resident an environment free of clutter, keeping the call light in reach at all times, and keeping personal items and frequently used items within reach of the resident. The Fall Risk assessment dated [DATE] revealed Resident #26 was at significant risk for falls. Review of the incident reports for Resident #26's falls revealed the following: 7/4/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 7/4/22 at 8:15 p.m. The incident report for the fall read in pertinent part: Nurse went into the resident's room to give medication and found the resident sitting on the floor with back against the bed and wheelchair in front of him. Resident stated 'I got up to get undressed and could not make it back to bed. 'When asked about pain and injury he stated he had no pain or injury. Assessed for injury, two people assisted to bed, started neuro (neurological) assessments/frequent checks, instructed the resident to use call light for help. -The Quality Indicators section of the incident report was not completed. -There was no fall investigation/follow-up by the interdisciplinary team (IDT) documented on the incident report. 7/6/22 fall Review of Resident #26's EMR revealed the resident sustained a witnessed fall on 7/6/22 at 5:00 p.m. The incident report for the fall read in pertinent part: Resident sitting on shower chair. When he was ready to transfer to wheelchair with certified nurse aide (CNA) assisting, he pushed up using his arm rests and slid to the left side. His left thigh was wedged between the cushion on the chair. Staff was able to unwedge his leg and return him to his wheelchair. Left thigh reddened with bruising, no swelling noted. Complained of slight discomfort. Physician faxed. Resident's wife to be notified in a.m. (morning) -There were no immediate fall interventions documented on the incident report. -The Quality Indicators section of the incident report was not completed. 7/24/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 7/24/22 at 5:20 p.m. The incident report for the fall read in pertinent part: Resident was found on both knees, kneeled down in front of recliner. Resident stated 'I did not fall. I went from the bed to the chair and kind of crumbled.' No injury. CNA found the resident and reported it to the nurse. Vital signs stable. Nurse assessed. Notified provider and next of kin. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 8/2/22 at 9:42 a.m., nine days after the incident occurred. -The IDT investigation did not reveal any new fall interventions put into place to prevent further falls for Resident #26. 9/14/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 9/14/22 at 6:25 p.m. The incident report for the fall read in pertinent part: CNA reported to the nurse that she found Resident #26 in his bathroom by his wheelchair. CNA said that she told him if he needed help he should use the call light, but he tried to go to the bathroom by himself and lost his balance and fell. No injury. Resident assessed by the nurse for any injury. Neuro assessments and vital signs all checked and all within normal limits. He did not complain of pain or signs of discomfort. No skin issues noted except old bruise to his right arm. It is important to prevent this kind of fall, check the resident more often after dinner because after dinner the resident might need to go to the bathroom. -The intervention to check on the resident after dinner and take him to the bathroom was not added to Resident #26's fall care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 9/21/22 at 11:54 a.m., seven days after the incident occurred. The note documented an intervention to remind the resident to use his call light. -The fall intervention to remind Resident #26 to use his call light was not updated on the care plan. 9/21/22 fall Review of Resident #26's EMR revealed the resident sustained a witnessed fall on 9/21/22 at 8:45 p.m. The incident report for the fall read in pertinent part: CNA was assisting resident to bed when he became unstable and started falling backwards. CNA assisted the resident to the floor on his knees. Resident sustained a 4 centimeter (cm) by 1 cm abrasion to the left shin and a 1 cm by 0.5 cm skin tear to the right knee. Staff assisted the resident to bed with a gait belt, assessed for injury. Cleaned shin and knee applied triple antibiotic ointment and bandaid to right knee and dressing to left shin. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -There was no fall investigation/follow-up by the interdisciplinary team (IDT) documented on the incident report. 10/5/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 10/5/22 at 8:00 p.m. The incident report for the fall read in pertinent part: CNA found the resident laying flat on floor by bed between window and bed. The resident sustained a 2 cm by 1 cm skin tear to the right shin. Assessed resident for injury, reported no pain or injury, three persons assisted with gait belt, resident able to lift hips to get gait belt around him, assist to sitting, then to sitting on bed, started neuro assessments. Later while getting the resident undressed for bed, found skin tear to right shin, cleaned and steri-stripped. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/8/22 at 8:35 a.m., 34 days after the incident occurred. -The IDT note documented an intervention to remind the resident to use his call light, the same intervention the facility documented after the resident's previous fall. -The fall intervention to remind Resident #26 to use his call light was again not updated on the care plan. 10/14/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 10/14/22 at 8:40 p.m. The incident report for the fall read in pertinent part: Resident found on floor face down between bed and recliner. Assessed resident for pain or injury, moved recliner away, rolled resident to back, asked resident if anything hurt. He stated 'My pride.' Three-person assisted with gait belt to bed, assessed skin and found abrasion from rug burn on right knee, cleaned and left open to air. Started neuro assessments. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/8/22 at 8:34 a.m., 25 days after the incident occurred. The note documented an intervention that staff was educated to check the resident's floor for objects when leaving the resident's room. -The fall intervention to check Resident #26's floor for objects when leaving the resident's room was not updated on the care plan. 11/13/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/13/22 at 5:30 p.m. The incident report for the fall read in pertinent part: Resident found on the right side of his bed positioned on his right side. He sustained multiple skin abrasions. Resident stated he wanted to stand up and stretch. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The IDT note, dated 11/16/22 at 8:54 a.m., documented an intervention to remind the resident to use his call light, the same intervention the facility documented for two previous falls. -There were no new interventions updated on Resident #26's care plan. 11/18/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/18/22 at 8:00 a.m. The incident report for the fall read in pertinent part: At 8:00 a.m., resident sitting on the fall mat perpendicular to the bed, no new injury, pain, or discomfort noted on assessment, resident denied pain. Two people assisted the resident up on the chair, assessed for pain, injury, neuro assessments, pupil reaction, vital signs, and mobility. Wife, hospice, and nurse practitioner notified. Neuro assessments initiated. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/29/22 at 8:30 a.m., 11 days after the incident occurred. -The IDT note documented an intervention that the resident had a low bed with a fall mat, which was not a new intervention. -There were no new interventions updated on Resident #26's care plan. 11/20/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/20/22 at 7:45 p.m. The incident report for the fall read in pertinent part: CNA found resident on mat with back against bed, perpendicular to bed. Assessed resident for injuries, three people assisted to bed, started neuro assessments. Resident was still restless and kept trying to get out of bed when checking him for neuro assessments. Frequent checks and CNA one on one in the room until the resident was more calm. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/29/22 at 8:29 a.m., nine days after the incident occurred. -The IDT note documented an intervention that the resident had a low bed with a fall mat and that the resident was reminded to use his call light, which were not new interventions. -There were no new interventions updated on Resident #26's care plan. 11/22/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/22/22 at 6:40 a.m. The incident report for the fall read in pertinent part: CNA found the resident lying on the floor mattress. He said that he put himself on the mattress. He was covered with a blanket. He looked comfortable. No new bodily injuries noted. Neuro assessments within normal limits. Vital signs stable. Assisted back to wheelchair with two person assist. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 11/29/22 at 8:23 a.m., seven days after the incident occurred. -The IDT note did not document any new fall interventions for Resident #26. -There were no new interventions updated on Resident #26's care plan. 11/26/22 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 11/26/22 at 11:30 a.m. The incident report for the fall read in pertinent part: CNA reported resident on floor on his knees at 11.30am (11:30 a.m.). This writer observed the resident on his knees between bed and recliner. Per resident, he was trying to get up out of his recliner to say thank you to choir singers, and he slid off his chair. Denies hitting his head, no injury noted. Neuro assessments initiated. Resident assisted to bed with a gait belt and two person assist. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT note, dated 11/29/22 at 8:26 a.m., documented an intervention to remind the resident to use his call light, the same intervention the facility documented for several previous falls. -There were no new interventions updated on Resident #26's care plan. 1/1/23 fall Review of Resident #26's EMR revealed the resident sustained an unwitnessed fall on 1/1/23 at 11:40 a.m. The incident report for the fall read in pertinent part: At 11:40 a.m., the resident was found on the floor lying facing down next to bed in front of his recliner in his room. Resident was conscious and alert, explained he transferred himself and fell on his left buttock, denied hitting head. Left buttock had a 4 cm by 4 cm bruise on skin assessment, mobility of extremities is intact with mild pain on his left shoulder. Assessed pupil reaction, mobility, skin, and injuries. Three staff assisted the resident into his wheelchair, gave education to call and wait for staff. Neuro assessments and vital signs initiated. Wife, physician, and hospice were notified. -There were no immediate fall interventions documented on the incident report other than education to resident to call and wait for staff. -The Quality Indicators section of the incident report was not completed. -The IDT note, dated 1/5/23 at 12:21 p.m., documented the resident had a low bed with mat, wife and staff have educated the resident to call for assistance and not to transfer by himself. Staff provides frequent checks and wife visits with resident daily. -The fall interventions documented in the IDT follow up note were interventions previously implemented. There were no new fall interventions documented in the note or updated on the Resident #26's fall care plan. -Review of the January 2023 CPO revealed the facility did not obtain a physician's order for Resident #26 to receive a physical therapy evaluation for restorative therapy as an intervention for the resident's falls until 1/3/23, after the resident had sustained six falls between 10/31/22 and 1/1/23. D. Staff interviews Registered nurse (RN) #2 was interviewed on 1/10/23 at 11:05 a.m. RN #2 said when a resident had a fall, the nurse was to assess the resident for injury. She said if the fall was unwitnessed or the resident was witnessed hitting their head, neurological assessments were to be initiated. RN #2 said the nurse was to investigate the fall to determine what had occurred to cause the fall. She said the fall incident report was to be filled out by the nurse. She said she did not think the nurse was supposed to fill out the Quality Indicators section of the incident report. RN #2 said management determined the fall interventions to put in place for the residents. She said Resident #26 had lots of falls and staff tried to do frequent checks on him to prevent falls. She said it was difficult to monitor residents. RN #2 said staff provided repeat education to Resident #26 to use his call light to get help from staff. CNA #3 was interviewed on 1/10/23 at 2:04 p.m. CNA #3 said Resident #26 had had several falls. He said the resident had a low bed with a fall mat. CNA #3 said he did not know if there were any other fall interventions in place for Resident #26. IV. Resident #54 A. Resident status Resident #54, age [AGE], was admitted on [DATE]. According to the January 2023 CPO, diagnoses included Parkinson's disease, weakness, and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down that can cause dizziness, lightheadedness and possibly fainting.) The 12/6/22 MDS assessment revealed that the resident was cognitively intact with a BIMS of 15 out of 15. He required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. He had a history of falls in the six months prior to admission, and had had one fall without injury since admission to the facility. B. Observations and resident interview On 1/4/23 at 12:25 p.m., Resident #54 was seated in his wheelchair in his room. There was a walker folded up and propped against the wall under the television (TV). Resident #54 had a thick purple scab on his left temple just above his left eyebrow. He had a large purple bruise that encompassed the upper left side of his face and left eye and extended around the bottom portion of his left eye. He said he fell out of his chair recently while he was reaching for something. He said he had had several falls at the facility. Resident #54 said staff reminded him to wait for help to do things like go to the bathroom. On 1/5/23 at 2:41 p.m., Resident #54 was seated in his wheelchair in his room watching TV. His bedside table was in front of him and he had his feet resting across the bar on the bottom of the table. His walker was folded up and propped against the wall under the TV. On 1/9/23 at 9:35 a.m., the privacy curtain in Resident #54's room was observed to be pulled halfway across the entrance to the room, and the resident could not be seen from the doorway of his room. Upon entry into the room, the resident was observed seated in his wheelchair watching TV. The resident's walker was folded up and propped against the wall under the TV. On 1/10/23, Resident #54 was observed from 10:35 a.m. to 10:53 a.m. The resident could not be seen from the doorway of his room. Upon entering the room, Resident #54 was observed seated in his wheelchair on the side of the bed closest to the bathroom. The resident was facing the head of the bed with his back to the wall containing the TV. The resident was observed leaning way over to the right side of his wheelchair reaching toward the floor. He said he was trying to get his TV remote. The TV remote was on his bedside table on the opposite side of the bed. There was nothing on the floor. The resident's call light was on the floor at the head of the bed. His walker was folded up and leaning against the dresser under the TV. Resident #54 stopped leaning to the right side of his wheelchair, however he continued to lean forward in the wheelchair. No staff came to check on the resident during the continuous observation. At 10:53 a.m., registered nurse (RN) #1 was notified Resident #54 was leaning forward in his wheelchair and the RN went down to the resident's room to check on him. C. Record review Review of Resident #54's EMR revealed the resident had sustained four falls since his admission on [DATE]. Review of Resident #54's fall care plan, initiated 11/25/22, revealed that the resident was at risk for falling related to being very weak and having close calls for falls in the prior two weeks. Pertinent interventions included frequent checks of the resident, obtaining physical therapy consultation as needed and following therapy recommendations, providing the resident an environment free of clutter, keeping the call light in reach at all times, and keeping personal items and frequently used items within reach of the resident. Further review of Resident #54's care plan revealed he had impaired functional status with bed mobility, transfers, walking, toileting, eating, grooming, and bathing. Pertinent interventions included leaving the resident's walker or wheelchair near the resident for safety when he was in his room due to the resident's high fall risk. The Fall Risk assessment dated [DATE] revealed Resident #54 was at moderate risk for falls. Review of the incident reports for Resident #54's falls revealed the following: 11/29/22 fall Review of Resident #54's EMR revealed the resident sustained an unwitnessed fall on 11/29/22 at 6:30 p.m. The incident report for the fall read in pertinent part: Resident was found on floor by staff after being notified by resident's roommate's son. Resident was noted to be lying on his right side, with his legs bent in a sort of fetal position. Resident asked what he was trying to do and stated 'I heard a little boy yelling for help.' It is noted that a resident down the hall was yelling 'Help' several times prior to fall. When asked if he only heard the little boy or if he saw him as well, the resident stated that he had heard them, and then stated he saw them down the hallway. Resident stated that he did not fall, but that he got on the ground to see if he could crawl to go help them. Resident denied pain when asked, and denied hitting his head. No injury noted. Neuro assessments initiated. Call placed to wife with no answer and unable to leave voicemail. Resident assisted back into his recliner via assistance of three staff members. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -There was no fall investigation/follow-up by the IDT documented on the incident report. 12/20/22 fall Review of Resident #54's EMR revealed the resident sustained an unwitnessed fall on 12/20/22 at 2:15 p.m. The incident report for the fall read in pertinent part: Resident was found on the floor between his recliner and his wheelchair. He was able to stand with the help of staff. No bumps, bruises or abrasions. Resident had no complaints of pain. Wife and physician notified in person. Resident was assisted into his wheelchair. Resident placed on incident follow up with neuro assessments. Room was rearranged to allow more room for moving around. Will continue to monitor. -The Quality Indicators section of the incident report was not completed. -The IDT fall investigation/follow-up by the IDT was not documented on the incident report until 12/29/22 at 8:29 a.m., nine days after the incident occurred. -There were no new fall interventions documented in the IDT follow up note or updated on the Resident #54's fall care plan. 12/28/22 fall Review of Resident #54's EMR revealed the resident sustained an unwitnessed fall on 12/28/22 at 11:15 p.m. The incident report for the fall read in pertinent part: Resident was found by staff on floor in front of his recliner next to the wheelchair. When asked what happened the resident stated that he was trying to see if anything on the wheelchair needed to be tightened. He stated he was pretty handy back in the day. Denied pain. Neuro assessments started. Denied hitting head. Message left for physician, wife not called as it is late. -There were no immediate fall interventions documented on the incident report or on the resident's care plan. -The Quality Indicators section of the incident report was not completed. -The IDT fall note dated 12/29/22 at 8:30 a.m. documented an intervention to remind the resident to use his call light. The note further documented the recliner was assessed for safety. -The fall intervention to remind Resident #54 to use his call light was not updated on the care plan. 12/31/22 fall Review of Resident #54's EMR revealed the resident sustained an unwitnessed fall on 12/31/22 at 4:55 a.m. The incident report for the fall read in pertinent part: At 4:55 a.m., CNA found the resident lying on the floor. The resident said 'I was trying to get out of bed and I fell down. I hit my head.' He sustained a 1 cm by 1 cm lump to his left eyebrow, and a skin tear of 5 cm by 3 cm to his left elbow. Cleansed with normal saline and applied triple antibiotic ointment and wrapped with non-adherent dressing. Neuro assessments within normal limits. Denied pain. Assisted back to bed after toileting with two person assist. Resident was confused. Reminded resident of using the call button. -The Quality Indicators section of the incident report was not completed. -There was no fall investigation/follow-up by the IDT documented on the incident report. -There were no new fall interventions updated on Resident #54's care plan. D. Staff interviews CNA #4 was interviewed on 1/10/23 at 11:00 a.m. CNA #4 said she was not sure what interventions were in place for Resident #54 to prevent his falls. She said staff did try to check on the resident frequently. CNA #4 said she tried to encourage the resident to sit in a recliner in the common area. RN #1 was interviewed on 1/10/23 at 1:54 p.m. RN #1 said Resident #54 had had falls while at the facility. She said staff checked on him and reminded him to use his call light for help. RN #1 said she thought those were the only interventions in place for the resident. She said he did not want to come out of his room very often. RN #1 said when a resident fell, nurses assessed the resident and attempted to find out how the fall occurred. She said the nurse was to fill out an incident report after every fall. She said she put a fall intervention on the incident report if she could think of one, otherwise she did not add an intervention. RN #1 said she did not fill out the Quality Indicators section of the incident report, but she said that was probably a section that should be completed. She said she did not know who reviewed the fall incident reports once the nurses completed them. V. DON interview The director of nursing (DON) was interviewed on 1/10/23 at 12:18 p.m. The DON said when a resident sustained a fall, nurses were to assess the resident for injury and attempt to identify the reason the fall occurred. She said nurses were to fill out an incident report for every fall. She said immediate fall interventions should be put into place after every fall and documented on the incident report and the resident's fall care plan. She said the facility needed improvement on implementing immediate and different fall interventions. The DON said all fall interventions for residents should be care planned. The DON said the Quality Indicators section of the incident report had never not generally been filled out for each fall, however, she agreed that it should be completed. She said if the Quality Indicator section was not filled out she would consider the incident report incomplete. The DON said the facility did not have a team in place to review the falls and incident reports. She said the facility did not meet very often as an IDT team to discuss falls. She said she was the person who reviewed most of the falls. She said after the nurse filled out the incident report for a fall, she would get an email alert that an incident report had been submitted. The DON said she would then review the fall and the incident report. She said she tried to make sure residents had interventions in place after each fall. She said she did not always complete a timely review of resident's falls. The DON said she needed to ensure she was documenting the follow up investigation more timely on the incident reports. The DON said the facility implemented a Performance Improvement Project (PIP) in November 2021 because the facility had identified that there were a lot of residents who sustained multiple falls in the facility. She said the goal of the PIP was to decrease the number of falls in the facility and the number of residents who sustained multiple falls. She said the facility had met monthly and worked on the PIP. She said the facility met the goal of the PIP and the PIP was completed in January 2022. The DON said the facility started the PIP again in September 2022 because they identified that fall numbers and multiple falls were increasing again. The DON said the facility also wanted to address implementing timely fall interventions and completing thorough incident reports. VI. Facility follow up The DON provided a copy of the facility's PIP on 1/10/23 at 2:23 p.m. The PIP documented the facility was working to decrease multiple falls for residents. The PIP had been initiated in November 2021 and ended in January 2022 when the facility's goal for falls was met. The facility restarted the PIP in September 2022 when falls again increased. The committee for reducing multiple falls had been meeting monthly since September 2022 and had implemented interventions such as increasing activities and adding team members to the Fall Review Committee. -The PIP did not address ensuring incident reports were filled out completely, ensuring immediate fall interventions were put into place, ensuring interventions were updated on the care plan, or ensuring review of falls occurred more timely. Based on observations, record review and interviews, the facility failed to implement timely interventions for falls and for falls with injury for three (#5, #26 and #54) of six out of 17 sample residents reviewed. Resident #5 had diagnoses of dementia, normal pressure hydrocephalus (a condition in which fluid accumulates in the brain) and history of repeated falls prior to admission 6/30/22. The facility failed to develop a person centered plan of care to promote safety and prevent repeated falls with injury. Resident #5 had falls on 8/15/22, 9/7/22 and 12/29/22, the resident suffered a skin tear, bruising and a head laceration (see record review). On 9/7/22 Resident #5 suffered a laceration to her head she was hospitalized and received five staples to her head. The facility failed to conduct an interdisciplinary team (IDT) review of Resident #5's repeated fall and implement further interventions. Additionally, the facility failed to develop person centered plans of care to prevent repeated falls for Resident #26 and #54. Findings include: I. Facility policy The Fall p[TRUNCATED]