**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to implement interventions and provide appropriate treatments to prevent the development of pressure injuries for two (#38 and #14) of six residents reviewed for pressure injuries out of 24 sample residents. Resident #38, was admitted on [DATE] for a long term care due to traumatic brain injury and continuous care needs. The resident was admitted to the facility with no open areas to her sacrum as documented on initial skin assessment on 12/9/21. On 12/15/21 (six days later) resident developed stage 3 pressure injury to her sacrum. Upon admission, the facility identified Resident #38 was at risk for developing pressure injuries, however no interventions were put in place to prevent the development of pressure injury. Due to the facility's failure to put interventions in place upon admission, Resident #38 developed an avoidable facility acquired Stage 3 pressure injury to the sacrum. Resident #14 was at high risk for development of pressure injuries with the initial Braden Scale on 11/30/21 revealed a score of 12 or high risk for the development of a pressure ulcer. The facility was unable to provide skin observation assessments from 11/31/21 through 12/13/21 a period of 14 days that described the resident's skin condition. The facility ordered a bed bolster to help elevate the resident's ankles/feet off the mattress on 12/13/21. The bolster was not received until 12/28/21 and placed on his bed, which was 15 days later. Due to the facility's failures, the resident developed a facility acquired unstageable deep tissue injury to his left lateral ankle. Findings include: I. Facility policy and procedure The Pressure Ulcer/Injury Risk Assessment policy and procedure, revised July 2017, was provided by the director of nursing (DON) on 1/5/22. In pertinent part, it read: The purpose of this procedure is to provide guidelines for the structures assessment and identification of residents at risk of developing pressure injury. Once the assessment is conducted and risk factors are identified and characterized, a resident centered care plan can be created to address the modifiable risks for pressure injury. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. If a new skin altercation is noted, initiate a form related to the type of altercation in skin. Develop the resident centered care plan and interventions based on the risk factors identified in the assessment, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. The effects of the interventions must be evaluated. II. Resident #38 A. Resident #38 status Resident #38, age [AGE], was admitted to the facility 12/9/21. According to the January 2022 computerized physician orders (CPO), diagnoses included epilepsy, history of falling, personal history of traumatic brain injury. The 12/15/21 minimum data set (MDS) assessment that was completed six days after the admission, revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no behavioral problems, psychosis, or rejection of care. She required extensive assistance of two staff members with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident was receiving hospice care. She was at risk of developing pressure injuries and had one stage three pressure injury as of 12/15/21 (six days after admission). She had pressure reducing devices for her chair and bed, and received treatments for pressure injury. B. Resident interview Resident #38 was interviewed on 1/4/22 at 12:20 p.m. The resident was in bed in a sitting position leaning to her right side. She said she did not recall how the wound on her bottom started, she said probably from sitting for too long in the same position. She said she needed help repositioning herself and staff help her reposition two to three times a day. She said she was not able to reposition independently. The resident did not have an air mattress in bed. On 1/6/22 at 10:30 a.m. the resident's mattress was replaced with an air mattress (which was during the survey). C. Wound care observation Wound care observations were conducted on 1/5/22 at 10:52 a.m. The dressing change was completed by a wound care nurse (WCN) #1. Resident was positioned on her right side on the bed. There was no dressing present on her coccyx. Certified nurse aide (CNA) #7 stated that the resident just took a shower and the dressing fell off in the shower. Resident had a small, about 1 centimeter (cm) long pressure ulcer on her coccyx that was visible when skin folds (intergluteal cleft) were separated. Wound bed was clean, bright pink in color with no drainage, no signs of inflammation and no odor. Wound edges were well defined and moist. WCN #1 cleaned the wound with wound cleanser and gauze, packed a small piece of collagen to the wound and applied island dressing on top. The resident did not complain of pain with the procedure. C. Record review The Braden Scale Observation/Assessment (for predicting pressure sore risk), dated 12/9/21, revealed a score of 16, which indicated the resident was at moderate risk for the development of pressure injuries. -No specific interventions were noted in the assessment. According to the physician orders, the resident was admitted to hospice care on 12/10/21 for progressive neurological condition. The comprehensive care plan for activities of daily living (ADLs), initiated on 12/9/21 and revised 12/13/21 revealed the resident required assistance with ADLs due to decreased mobility, increased weakness, history of falls, and history of brain injury. Interventions included to provide assistance with bathing, dressing, and incontinence care. The care plan for skin integrity was initiated on 12/9/21 and revised on 1/4/22 revealed the resident was at risk for skin breakdown related to impaired mobility, weakness, and bowel incontinence. -The care plan did not mention any existing skin problems on admission. On 12/13/21 the care plan was updated with following interventions: to apply creams and ointments as ordered and as needed, check and change resident upon awakening, before and after meals, at bedtime and as needed; complete weekly skin observations, education to resident on importance of compliance of incontinence care, provide incontinence care and keep skin clean and dry. On 1/3/22 (at the time of the survey) the care plan was updated with interventions to provide pressure ulcer treatments as ordered by physician, refer to dietitian as needed, turn and reposition resident as tolerated and weekly wound assessments. On 1/4/22 (at the time of the survey) the care plan was updated with intervention to follow with wound care clinic until wound resolved. -The care plan did not include specific interventions that were recommended by the wound care physician, such as offload the wound and limit sitting to 60 minutes. (See wound care notes below). -The care plan did not mention the need or use of an air mattress that was requested from hospice on 12/16/21. (See progress notes below). The nursing admission note on 12/9/21 by LPN #1 read Resident awake and alert, oriented to time and place. Skin assessment completed, bruise noted to left abdomen, bruise to left thigh, scratch to left thigh, scattered scabs to left shin, scab to left ankle, and bruise to left buttock. Resident was seen by a wound care clinic physician (WCP) #1 for the first time on 12/14/21 (five days after admission). The note documented the resident had a full thickness stage 3 pressure wound on the sacrum, measuring 1 centimeter (cm) by 0.3 cm. The wound was healing. Recommendations included to offload and limit sitting to 60 minutes. -Resident's care plan was not updated with the physician's recommendations. The wound was assessed by the WCP as healing, which indicated it had the potential to heal and was avoidable. The late entry note by WCN #1 on 12/15/21 revealed resident was assessed by a wound care physician (WCP) #1 Wound care physician was in to see resident for an open area to sacrum. Floor nurse will continue with wound care orders. WCN #1 and WCP #1 will continue weekly rounds until resolved. The progress note on 12/16/21 by WCN #1 documented hospice was contacted with a request for an air mattress. She said she would pass it along to the resident's nurse. On 12/21/21 WCP #1 documented that the wound improved, and had the same recommendations. The wound measurements were the same as before, 1 cm by 0.3 cm. The late entry progress note created on 12/23/21 for 12/21/21 by WCN #1 read WCP #1 was in to see the resident for an open area to sacrum. Resident is a patient of hospice. Resident has a diagnosis of epilepsy, history of falls and TBI (traumatic brain injury). Resident is incontinent to the bowel and bladder. New orders received for med honey dressing daily. Floor nurse will continue with wound care orders. WCN #1 and WCP #1 will continue weekly rounds until resolved. On 12/28/21 WCP #1 documented there were no changes in the wound size or progression, with the same recommendations. In addition, house barrier cream should be applied to the buttock twice daily for moisture associated skin damage (MASD). The progress note by WCN #1 on 12/28/21 was identical to the note above except for the treatment orders: New orders received for collagen packing every two days and island dressing daily. -There were no additional notes if an air mattress was placed for the resident. The treatment administration record (TAR) for January 2022 revealed resident was receiving following wound care treatment: Cleanse wound to sacrum with wound cleanser and pat dry. Cut and pack collagen sheet into wound and change packing every two days or if soiled. Cover with island dressing daily. The order to be completed every day shift starting on 12/29/21. -The TAR did not include physician recommendations for offloading the weight and limit sitting to 60 minutes. E. Staff interviews CNA #4 was interviewed on 1/4/22 at 2:44 p.m. She said the resident was a two person assistance for transfers, bed mobility and personal hygiene. She said the resident was able to do many things for herself. She said the resident was alert and able to communicate her needs. She said the resident did have an open area on her sacrum that nurses applied dressing to. She said for the resident she was offering her to reposition and the resident was receptive to care. Licensed practical nurse (LPN) #2 was interviewed on 1/4/22 at 2:44 p.m. She said the resident had a wound since admission, but she talked to the admitting nurse and she said she did not see anything on her coccyx at the time of admission. She said the resident could do more for herself than she was doing and sometimes was not cooperative with turning and repositioning. She said it was the resident's right to refuse care and there is nothing we can do about it. LPN #1 was interviewed on 1/6/22 at 2:40 p.m. She said when residents were admitted Braden scale was completed on admission. Based on the score that they received, nursing staff would start interventions such as turning and repositioning, assessment by registered dietitian for nutritional needs, air mattress and bunny boots if necessary. She said all these interventions should be implemented on admission for residents who are at risk for pressure ulcers and interventions should be based on their individual needs. For Resident #38, she said she did not know why it took so long to obtain a mattress for this resident. She said the facility has air mattresses available in the storage room that could be given to anyone who needs it. Regarding care plans, she said care plans could be updated by WCN, herself and the DON. WCN #1 was interviewed on 1/6/22 at 3:30 p.m. She said all skin assessments were completed on admission and documented under the initial skin assessment. She said she reviewed skin assessment for Resident #38 and there were no documented pressure injuries on admission. She said there was a potential that the area was missed on skin assessment. She said treatments were initiated on 12/15/21 when the area was discovered. She said all recommendations from the wound care physician or hospice care teams should be on the resident's care plan. She did not know why the delivery for an air mattress was delayed. She said she was new to the position and was still learning things. She said the hospice should have been contacted the next day to clarify the delivery for an air mattress. The DON was interviewed on 1/6/22 at 3:55 p.m. She said all residents in the building who had wounds were followed by a wound care physician. She said upon admission skin assessments were completed for all residents in addition to a Braden scale. Residents who were identified as at risk for pressure ulcers, receive special interventions such as turning and repositioning, elevating heels, weekly skin assessment and air mattress if needed. She said all of the above interventions were implemented as preventive measures and did not require physician order. She said any additional recommendations from the physician should be documented on the care plan, TAR and [NAME] to make sure nurses and CNA have access to the care needs and preferences of the residents. Regarding the wound, she said the wound was potentially missed on admission. She said it would be better to complete skin assessments on admission by two nurses to minimize the chance of missing skin problems. WCP #1 was contacted during the survey. He did not return the call. III. Resident #14 A. Resident status Resident, #14, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included cerebral palsy, epilepsy, muscle wasting, impulse disorder, intervertebral disc degeneration lumbar region, wedge compression fracture of T9-T10 vertebra, and acute respiratory failure with hypoxia. The 11/8/21 minimum data set (MDS) assessment revealed the resident was severely impaired in cognition with a brief interview of mental status (BIMS) score of four out of 15. The resident had inattention with difficulty focusing his attention (distractible or having difficulty keeping track of what was said). This behavior was continuously present and did not fluctuate. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was at risk for the development of pressure ulcers/injuries. The resident did not have any pressure ulcers during the assessment period. B. Resident observations On 1/4/22 at 8:30 a.m., the resident was lying on his back in a low bed with covers pulled to his chest. He had a regular mattress on the bed and a fall mat on the floor beside his bed. His feet were slightly exposed and he wore yellow non-skid socks with blue foam boots on both feet. On 1/6/22 at 8:59 a.m., the resident was lying on his back in a low bed with covers pulled to chest. He had a regular mattress and a bed bolster was on the bed. There was a fall mat on the floor by the bed. His feet were floated and wore yellow non-skid socks and blue foam boots on both feet. C. Wound observation On 1/4/22 at 11:12 a.m., wound care observations were conducted with the wound certified nurse (WCN). The resident was lying on his back in bed. Both of his legs were elevated on the bolster pillow to float the ankles and heels. The resident wore blue foam boots on both of his ankles. The dressing on the left ankle was dated 1/4/22. There was a moderate amount of bright pink and yellow discharge observed on the dressing. The wound bed appeared about 1.0 centimeter (cm) in diameter, bright red to pink in color, with no clearly defined edges. There were three to four small scattered red spots around the wound. The WCN cleaned the wound with wound cleanser and gauze, applied meta-honey to the wound bed and covered it with island dressing. The resident stated he did not feel pain or discomfort during the procedure. D. Record review The care plan for skin, initiated on 11/3/21, revealed the resident was at risk for skin breakdown due to a left ankle deep tissue injury. Provide pressure ulcer treatment as ordered. Some of the interventions were to apply creams and ointments as physician ordered and as needed. Resident skin should be kept clean and dry. Turn and reposition the resident as tolerated. Perform weekly wound evaluations. Float the resident's heels while in bed as tolerated and apply bunny boots. Apply heel float bolster to the resident's bed was initiated on 1/3/22. A skin observation note dated 11/16/21 at 1:52 p.m., revealed the resident was at risk for the development of skin integrity issues. -The note did not reveal the resident had a deep tissue injury to the left ankle. A skin observation note dated 11/30/21 at 12:22 p.m., revealed the resident was at risk for the development of skin integrity issues. -The note did not reveal the resident had a deep tissue injury to the left ankle. The Braden Scale for Predicting pressure sore risk dated 11/30/21 at 12:20 p.m., revealed a score of 12 or high risk. The resident responded to verbal commands, but could not always communicate the need to be turned and/or the resident had some sensory impairment which limited the ability to feel pain/discomfort in one or two extremities. The resident made occasional slight changes in his body or extremity positioning but was unable to make frequent or significant changes independently. The resident required moderate to maximum staff assistance in moving. Complete lifting without sliding against bed sheets was impossible. The resident frequently slid down in bed that required frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction. -The facility was unable to provide skin observation assessments from 11/31/21 through 12/13/21 a period of 14 days that described the resident's skin condition. The wound physician progress note dated 12/14/21 revealed the resident had an unstageable deep tissue injury to the left lateral ankle with partial thickness with intact skin. The etiology was pressure and the duration was greater than five days. The wound measured 1.5 cm by 0.5 cm with no depth. The measurable surface area was 0.75 cm squared. There was no exudate. The treatment plan was to apply [NAME]/castor oil twice daily for 30 days. The recommendations were to float the heels while in bed; EZ boots (eliminates pressure on heels) to be worn in bed and in a chair to off load the wound. A skin observation tool note dated 12/14/21 at 11:21 a.m., revealed the resident had skin issues and was at risk for the development of skin integrity issues. The resident had an outer left ankle deep tissue injury. The injury measured 1.5 cm by 0.5 cm. The Braden Scale for Predicting pressure sore risk dated 12/16/21 at 11:24 a.m., revealed a score of 12 or high risk. The resident responded to verbal commands, but could not always communicate the need to be turned and/or the resident had some sensory impairment which limited the ability to feel pain/discomfort in one or two extremities. The resident made occasional slight changes in his body or extremity positioning but was unable to make frequent or significant changes independently. The resident required moderate to maximum staff assistance in moving. Complete lifting without sliding against bed sheets was impossible. The resident frequently slid down in bed that required frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction. A weekly wound tool dated 12/16/21 at 11:37 a.m., revealed to use bunny boots. The bolster leg rise for the bed was ordered. The left lateral ankle wound started as a suspected deep tissue injury on 12/13/21. The wound now measured 1.5 cm x 0.5 cm. There were new orders for Venelex ([NAME]/castor oil) twice a day for 30 days. The wound physician progress note dated 12/21/21 revealed the resident had an unstageable deep tissue injury to the left lateral ankle with partial thickness with intact skin. The etiology was pressure and the duration was greater than 11 days. The wound measured 1.0 cm by 0.5 cm with no depth. The measurable surface area was 0.50 cm squared. There was no exudate. The treatment plan was to apply Venelex [NAME]/castor oil twice daily for 23 days. The recommendations were to float the heels while in bed; EZ boots to be worn in bed and in a chair to off load the wound. A weekly wound tool dated 12/21/21 at 12:09 p.m., revealed to use bunny boots. The bolster leg rise for the bed was ordered. The left lateral ankle wound started as a suspected deep tissue injury on 12/13/21. The wound had no odor or drainage. The wound measured 1.5 cm x 0.5 cm. No changes to orders for Venelex twice a day for 30 days. A skin observation tool note dated 12/21/21 at 12:11 a.m., revealed the resident had skin issues and was at risk for the development of skin integrity issues. The resident had an outer left ankle deep tissue injury. The injury measured 1.5 cm by 0.5 cm. The Braden Scale for Predicting pressure sore risk dated 12/21/21 at 12:14 p.m., revealed a score of 12 or high risk. The resident responded to verbal commands, but could not always communicate the need to be turned and/or the resident had some sensory impairment which limited the ability to feel pain/discomfort in one or two extremities. The resident made occasional slight changes in his body or extremity positioning but was unable to make frequent or significant changes independently. The resident required moderate to maximum staff assisting in moving. Complete lifting without sliding against bed sheets was impossible. The resident frequently slid down in bed that required frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction. The wound physician progress note dated 12/28/21 revealed the resident had an unstageable deep tissue injury to the left lateral ankle with full thickness within and around the wound. The etiology was pressure and the duration was greater than 17 days. The wound measured 1.0 cm by 0.5 cm x 0.1 cm. The measurable surface area was 0.50 cm squared. There was light serosanguinous exudate with 20% granulated tissue and 80% other viable tissues (dermis). The treatment was to apply Leptospermum honey once daily for 30 days with a secondary dressing of island gauze with borders applied daily for 30 days. The recommendations were to float the heels while in bed; EZ boots to be worn in bed and in a chair to off load the wound. The Braden Scale for Predicting pressure sore risk dated 12/28/21 at 12:04 p.m., revealed a score of 12 or high risk. The resident responded to verbal commands, but could not always communicate the need to be turned and/or the resident had some sensory impairment which limited the ability to feel pain/discomfort in one or two extremities. The resident made occasional slight changes in his body or extremity positioning but was unable to make frequent or significant changes independently. The resident required moderate to maximum staff assistance in moving. Complete lifting without sliding against bed sheets was impossible. The resident frequently slid down in bed that required frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction. A weekly wound tool dated 12/28/21 at 12:08 p.m., revealed to use bunny boots. The bolster leg rise for the bed was ordered. The left lateral ankle wound started as a suspected deep tissue injury on 12/13/21. There was granulated tissue (beefy red in color) with no odor. There was serosanguinous drainage. The wound measured 1.0 cm x 0.5 cm x 0.1 cm. New orders were received for med-honey daily and to cover with island dressing. A skin observation tool note dated 12/28/21 at 12:11 a.m., revealed the resident had skin issues and was at risk for the development of skin integrity issues. The resident had an outer left ankle deep tissue injury that measured 1.0 cm by 0.5 cm x 0.1 cm and was open. A physician's order dated 12/28/21 at 12:01 p.m., revealed to cleanse the wound to the left lateral ankle with wound cleanser and pat dry. Apply medi-honey and island dressing daily on each shift for wound care. laboratory results dated [DATE] at 10:09 a.m., revealed the resident had a low protein level that measured 5.7 grams/deciliter (g/dl). The protein range should be between 6.9 and 8.5 g/dl. The resident also had a low albumin level that measured 3.0 g/dl. The albumin range should be between 3.8 and 4.8 g/dl. A skin observation tool note dated 1/3/22 at 6:30 p.m., revealed the resident did have skin issues and was at risk for the development of skin integrity issues. The resident had an outer left ankle wound with wound care orders. The wound physician progress note dated 1/4/21 revealed the resident had an unstageable deep tissue injury to the left lateral ankle with full thickness within and around the wound. The etiology was pressure and the duration was greater than 23 days. The wound measured 0.8 cm by 1.0 cm x 0.1 cm. The measurable surface area was 0.80 cm squared. There was light serosanguinous exudate with 20% granulated tissue and 80% other viable tissues (dermis). The wound was in an inflammatory state and was unable to progress to a healing phase because of the presence of biofilm. Apply Leptospermum honey once daily for 23 days with a secondary dressing of island gauze with borders applied daily for 23 days. Recommendations were to float the heels while in bed; EZ boots to be worn in bed and in a chair to off load the wound. The note further indicated debridement was discussed with the primary physician on 12/28/21 and it's necessity was mutually agreed upon. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, a 15-blade was used to surgically excise biofilm from the entire wound surface. Removal of a margin of healthy subcutaneous fat and surrounding connective tissues along with the attached biofilm was accomplished and healthy bleeding was observed. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care were documented in the Assessment and Plan. E. Staff interviews The wound certified nurse (WCN) was interviewed on 1/4/22 at 11:12 a.m. She said the injury started as a deep tissue injury and had recently opened. She said she did not know the staging of this injury. She said when the resident was asleep in his bed, his ankles were positioned in such a way that they touched the surface of the bed. She said since the wound was identified, the resident was provided a bed bolster pillow that elevated his legs and floated his ankles. The WCN was interviewed again on 1/5/22 at 3:37 p.m. She said the resident had a wound on the lateral side of his left ankle. She said this was a facility acquired pressure ulcer that started on 12/13/21 as a deep tissue injury, according to the wound physician notes. She said the resident still had this pressure ulcer. She said this wound started because part of the left ankle came into contact with his mattress. She said when the resident was sleeping, he externally rotated his legs and this resulted in the lateral portion of his left ankle to contact the mattress. She said the facility used pillows under his calves to help raise (float) his ankles/feet off the mattress. The facility also placed bunny boots on both of the resident's feet. She said the facility started using the bunny boots prior to the wound, however when he externally rotated his feet, the boots would also rotate slightly. This caused the left ankle to touch the mattress. She said the bed bolster was ordered on 12/13/21 and arrived on 12/28/21 (15 days later). It was placed on his bed when it arrived. She said the bed bolster raised (floated) his legs up sufficiently so that his heels/feet did not touch the mattress. The WCN was interviewed again on 1/6/22 at 8:40 a.m. She said there was no actual physician order for the placement of the bunny boots and she did not know the date the bunny boots were first applied to the resident's feet. She said the bunny boots were in place prior to the development of the pressure ulcer to the left lateral ankle. She said as soon as he developed the deep tissue injury, pillows were immediately placed under his calves while he was in bed to help prevent the bunny boots from resting on his mattress. She said the pillows were used to keep his heels floated until the bed bolster arrived and was put on his bed on 12/28/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#39 and #14) of five residents reviewed for accidents out of 24 sample residents remained as free from accident hazards as possible. Resident #39 sustained three falls in the facility over a two-month period. The facility identified the resident's numerous fall risks (stroke affecting left non-dominant side, weakness with paralysis on the left side and history of falls) but failed to develop, communicate and implement effective interventions based on thorough investigations after each fall, in order to minimize her risks and keep her safe from injury. The resident's care plan was not updated with new interventions and resident's needs after the fall on 10/24/21, 12/3/21, and 12/21/21. Due to the facility's failures, the resident fell in her bedroom on 12/3/21, resulting in a right hip fracture (see hospital summary under record review). In addition, the facility failed to implement effective interventions to prevent Resident #14 from falling on 11/6/21. Furthermore for Resident #14's fall on 11/7/21 the facility failed to thoroughly investigate, ensure accurate documentation and review. Findings include: I. Facility policies and procedures The Falls and Fall Risk policy, dated 2001 and revised March 2018, was provided on 1/5/22 at 1:29 p.m. by the nursing home administrator (NHA). The policy read in pertinent part, the staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling and minimize complications from falling. If a resident continues to fall, staff will reevaluate the situation and whether the current interventions are appropriate. II. Resident #39 A. Resident status Resident #39, age [AGE], was admitted on [DATE], discharged to acute care hospital on [DATE], and readmitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnosis included: stress fracture of the right hip diagnosed on [DATE], history of stroke with weakness and paralysis to the left non-dominant side. The 12/14/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 14 out of 15. The resident required a two plus person assistance for bed mobility, transferring from bed to chair/wheelchair/walker, and activities of daily living (ADLs). The MDS further indicates the resident was not steady, only was able to stabilize with staff assistance to move on and off the toilet, or moving from a seated to standing position. She did not have any falls prior to admission. B. Resident interview and observations Resident #39 was interviewed on 1/4/22 at 8:32 a.m. The resident said she fell a couple of weeks ago trying to get up to go to the restroom, she stated her call light was on but no one came in to assist her. She said she was lying on the floor for what seemed like a while for someone to come in and help her. She said she broke her hip when she fell and had to go to the hospital and required surgery. The resident was observed at this time as well. She was seated in her wheelchair next to the bed. Her commode was behind her wheelchair and her television was in front of her. The room appeared to be very cluttered with adaptive equipment for both residents in a small room. The resident did have her call light next to her on the bed, the bed was in the lowest position with shoes on her feet, however, the call before you fall sign was not in the resident's room. The sign was a recommendation by the Interdisiplinary team (IDT) on 11/3/21 for the 10/24/21 fall, see record review below. The resident was observed and interviewed on 1/5/22 at 3:00 p.m. Resident #39 stated she was happy she had more room to move around without a roommate (her roommate had moved out of the room on 1/5/22). The room did appear to be less cluttered since the roommate was moved. The resident was in her wheelchair, call light was within reach and the call before you fall signage was not immediately visible. C. Record review 1. Resident fall assessments There was no fall assessment on the day the resident was admitted , 7/21/2020. A fall assessment on 11/20/2020 (four months later) indicated the resident was a moderate fall risk. -Facility record review revealed the facility knew Resident #39 was at risk for falls identifying a diagnosis of, history of falling, upon admission on [DATE]. The fall assessment completed on 11/1/2020 indicated the resident was a moderate fall risk and required the use of an assistive device and exhibited loss of balance while standing. The fall assessment on 1/24/21 indicated the resident was a moderate fall risk and required the use of an assistive device and exhibited loss of balance while standing. The fall assessment completed on 3/18/21 indicated the resident was a moderate fall risk and was unable to independently come to a standing position. The quarterly fall assessment on 10/11/21 indicated the resident was at a high risk for falls. The assessment revealed the resident was unable to stabilize her balance from a sitting to standing position without assistance. 2. Facility response to identified risks A fall care plan initiated on 7/20/2020 and revised on 11/16/2020, revealed the resident was at a risk for falls due to a history of falls. Interventions on the 7/20/2020 care plan included ensuring items are within reach, ensure call light is within reach and encourage use, provide appropriate footwear when transferring and ambulation, provide assistive devices as needed and review information on past falls. An ADL care plan initiated on 7/20/2020 and revised on 11/16/2020, revealed the resident required assistance for ADLs due to impaired mobility and weakness. The care plan indicated the resident required a one person assistance with bathing, bed mobility and dressing. The interventions included encouraging the resident to notify staff when assistance was needed. An ADL care plan initiated on 7/21/2020 and revised on 2/10/21, revealed the resident required an assistive device for mobility and positioning. The interventions included encouraging safety awareness with education on the use of anti-lock rollback brakes and encouraging use of adaptive equipment. -The resident's care plan was not updated with new interventions and resident's needs after the fall on 10/24/21, 12/3/21, and 12/21/21 (see below). 3. Resident #39 sustained falls on 10/24/21, 12/3/21, and 12/21/21. a. Fall #1 on 10/24/21 According to the nurses ' progress note dated 10/24/21, the resident sustained an unwitnessed fall on 10/24/21 at 3:44 p.m. The note read, Resident was on her left side on the floor between her bed and wheelchair. Resident had shoes on and wheels locked to wheelchair. According to the physician note dated 10/28/21, resident is status post fall with left hip bruising without hematoma, left hand and left knee injury. An interdisciplinary team (IDT) review dated 11/3/21 (six days after the fall) contained the same note as above by the nurse. The root cause analysis of the fall was loss of balance during transfer. The IDT recommended intervention was call before you fall signage. The IDT review included an electronic signature from the NHA. A fall risk assessment was completed after the fall. The assessment revealed the resident was a moderate fall risk, required an assistive device and exhibited a loss of balance while standing. The assessment revealed over the past six months, the resident had one to two prior falls. The fall risk assessment was not mentioned in the IDT review on 11/3/21. -The call before you fall sign intervention was not documented on the resident's care plan. There was no evidence that this intervention was effective or resident specific. The IDT review did not document the details regarding the location of the call light, footwear the resident was wearing, the nature of the transfer, and other items present in the room that may have contributed to the resident's fall. -The facility's failure to develop interventions based on a comprehensive assessment of the residents ' specific fall risks (cerebrovascular disease affecting left non-dominant side, weakness and paralysis of the left side, and history of falls) and a comprehensive review of the 10/24/21 fall, contributed to the lack of effective interventions to prevent another fall and keep the resident safe from injury. b. Fall #2 on 12/3/21 According to the nurses ' note on 12/3/21, the resident sustained an unwitnessed fall on 12/3/21 at 3:37 a.m. The note read, certified nursing assistant (CNA) heard the resident calling out for help. Resident was lying on the floor on her left side between her night table and wheelchair. She stated that she fell on her right hip. She did not have her shoes on at the time, they were in her wheelchair where she usually keeps them. She does put them on before getting into her wheelchair. Resident states was getting up to go to the bathroom and fell. The resident did require assistance to transfer to the bedside commode or restroom. States that she fell before she could get into her wheelchair. The resident was transported to the hospital due to right hip pain. According to the hospital Discharge summary dated [DATE], the resident had an arthroplasty replacement partial hip. The surgical repair of the hip was due to a diagnosed pathologic osteoporotic right hip fracture from a low trauma fall. The IDT review dated 12/16/21, contains the same nurses ' note as above. The root cause analysis of the fall was that the resident did not have proper footwear on when ambulating. The recommended interventions were to educate the resident on proper footwear while transferring from bed to wheelchair (however, this intervention was already indicated on the care plan revised 11/16/2020, see above). The IDT review included an electronic signature from the NHA. -The IDT review did not document the details regarding the location of the call light and other items present in the room that may have contributed to the resident's fall. The IDT review did not document a new care plan or revised care plan to address the right hip fracture. A fall risk assessment completed on 12/3/21 revealed the resident was a low fall risk. The assessment did not indicate the resident used an assistive device or exhibited a loss of balance when walking. The assessment revealed the resident had one to two falls in the last six months. The fall risk assessment was not mentioned in the IDT review. -The facility's failure to develop interventions based on a comprehensive assessment of the residents ' specific fall risks and a comprehensive review of the 12/3/21 fall, contributed to the lack of effective interventions to prevent another fall. c. Fall #3 on 12/21/21 According to the nurses ' note on 12/21/21, resident sustained an unwitnessed fall on 12/21/21 at 2:40 p.m. The note read, resident was on her knees by her bedside commode. Call light within reach. Proper footwear. The physician's note dated 12/21/21 stated the resident slid onto her knees when attempting to self-transfer without assistance. The IDT review dated 12/22/21 contained the same nurses ' note. The root cause analysis of the fall was the resident thought she could transfer herself. The IDT recommended interventions were to have staff provide frequent additional education to call prior to getting out of bed. The IDT did include an electronic signature from the NHA. -The IDT did not indicate if a new care plan was implemented to address the multiple falls for resident-specific interventions. A fall risk assessment was completed on 12/21/21 and revealed the resident was a moderate fall risk. The assessment did indicate the resident used an assistive device while walking, exhibited a loss of balance while walking, had a decrease in muscle coordination and suffered multiple falls in the past six months. The fall risk assessment was not mentioned in the 12/22/21 IDT review. -The IDT review did not document other items present in the room that may have contributed to the resident's fall. The IDT review did not document a new care plan or revised care plan to address the right hip fracture, residents physical mobility status and most current needs. D. Staff interviews CNA #1 was interviewed on 1/5/22 at 1:02 p.m. He said the resident was a one person assistance with a gait belt, full weight bearing and he knew how to help assist with her transfers by the information on the care plan. He said the care plan was like a [NAME] and he could pull up to see transfer assistance. He demonstrated on a laptop where to find the transfer information under the special considerations section in the resident's chart. Licensed practical nurse (LPN) #1 was interviewed on 1/5/22 at 2:06 p.m. She stated the resident has had several falls. She said the interventions in place include appropriate footwear when transferring, call before you fall signage, assure call light was within reach and encourage use, educate the resident to call for help before attempting to get up and assure items are within reach. CNA #7 was interviewed on 1/5/22 at 2:19 p.m. She said she knew how each resident transfers because she worked with the residents a lot caring for them and transferring them. She said she could see on the resident's care plan and [NAME] what their transfer status was. She said if she did not know a resident's transfer status, she can ask therapy what their assistance level was. LPN #3 was interviewed on 1/6/22 at 10:26 a.m. She said fall assessments were to be completed upon admission, a few days after admission, and every three months. She said fall precautions depended on the resident. She said in general the staff kept beds in the lowest position for all residents and if a resident had multiple falls, a fall mat could be used. She said the CNAs were able to find the residents transfer status for each resident in the computer under the special considerations section. She said Resident #39 transferred with a gait belt, one-person assistance, and she used her walker with therapy. She said since her last fall on 12/21/21, the resident was doing better about calling for assistance prior to trying to get up. The director of nursing (DON) was interviewed on 1/6/22 at 1:55 p.m. She said the fall risk tool was used to determine fall risk along with medications the resident was on, any weaknesses and ability to use extremities. She said the fall risk tool should have been completed upon admission, quarterly and yearly, also with a fall or change in condition. The care plans were reviewed quarterly to determine effectiveness of interventions. She said after a resident fell, the staff would ensure a call before you fall sign was placed, call light was in reach, and provide education about proper footwear. (The sign was not in the room during the observations above) She said for Resident #39, a fall mat was used and tried, however, she received reports the resident was tripping on it and needed it moved out of the way. She said the fall mat was a risk to cause the resident more falls. III. Resident #14 A. Resident status Resident, #14, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included cerebral palsy, epilepsy, muscle wasting, impulse disorder, intervertebral disc degeneration lumbar region, wedge compression fracture of T9-T10 vertebra, and acute respiratory failure with hypoxia. The 11/8/21 minimum data set (MDS) assessment revealed the resident was severely impaired in cognition with a brief interview of mental status (BIMS) score of four out of 15. The resident had inattention with difficulty focusing his attention (distractible or having difficulty keeping track of what was said). This behavior was continuously present and did not fluctuate. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The assessment also revealed the resident had a fall within the last two to six months prior to admission and he had a fall in the last month prior to admission. B. Record review A physician's order dated 11/2/21 at 9:37 a.m., revealed to monitor the resident's pain each shift. Document as follows (0=No Pain; 1-3=Mild; 4-7=Moderate; 8-10=Severe). If as needed pain medication was administered, document non-pharmacological approach(es) attempted prior to administering the as needed pain medication. (1=Repositioning; 2=Calm Environment; 3=Distraction; 4=Music Therapy; 5=Other; 6=Refused; 7=PRN Not Offered this shift). Every shift for Pain Monitoring / PRN Non-Pharmacological Pain Monitoring AND PRN Non-pharmacological approach(es) required under supplemental documentation. Interventions: Non-Pharm Approach(es)#1-5. If refused enter #6. If medication was not offered this shift enter #7. The admission/readmission evaluation bundle dated 11/2/21 at 12:26 p.m., revealed the resident had a fall within the last month prior to admission and was a high fall risk. The resident required physical assistance from staff for bed mobility, transfers, ambulating and toileting. A physician's order dated 11/2/21 at 3:17 p.m., revealed that physical therapy would see the resident five times a week for four weeks. The plan of care would include bed mobility, transfer training, therapy exercise, wheelchair mobility training and endurance training. A care plan for being at risk for falls due to a history of falls was initiated on 11/3/21. Some of the interventions were to assist the resident to bed after meals. Place the resident's bed in the lowest position. Ensure the resident's call light was within reach and encourage the resident to use the call light. Provide the resident with appropriate footwear when transferring and ambulation. Move the resident closer to the nurses ' station initiated on 11/6/21. Place a safety mat on the floor next to the resident's bed initiated on 11/6/21. Therapy to evaluate for bed mobility and safe transfers initiated on 11/6/21. Review information on past falls and attempt to determine the cause of the falls initiated on 11/11/21. The physical therapy evaluation electronically signed on 11/3/21 at 12:17 p.m., revealed the reason for therapy was to assess the resident's functional abilities, minimize falls functional deficits, promote safety awareness, increase lower extremity ranges of motion, improve dynamic balance and decrease complaints of pain. The risk factors section revealed due to the documented physical impairments and associated functional deficits; without skilled therapeutic interventions, the resident was at risk for falls, further decline in function, depression, decreased ability to return to his prior level of assistance and limited out of bed activity. A physician's order dated 11/12/21 at 6:30 p.m., revealed to administer one Norco Tablet 5-325 milligrams (Hydrocodone-Acetaminophen) orally every six hours as needed for pain and do not exceed three grams in a day. A physician's order dated 11/13/21 at 1:06 p.m., revealed to administer one Acetaminophen Tablet 500 milligrams orally every six hours for back pain fracture C. Fall on 11/6/21 The risk management evaluation for incident #1106 was dated 11/6/21 at 11:30 a.m. The resident was found on the floor lying on his right side. He was awake and alert but was unable to get up. He complained of back pain. He was able to move all extremities and answer simple questions. No injuries were found. He denied hitting his head when he fell. Neurological assessments were started and the nursing home administrator (NHA) and his primary care physician were notified. The description of the action was to send the resident to the emergency room by an ambulance for further evaluation of his back pain. The interdisciplinary team review dated 11/6/21 at 11:30 a.m., revealed the resident was found lying on the floor on his right side. The resident was awake and alert but was unable to get up from the floor. The resident complained of back pain. He was able to move all extremities and answer simple questions. No injuries were found and he denied hitting his head when he fell. Neurological assessments were started. The nursing home administrator (NHA) and his primary care physician were notified. The root cause analysis of the fall revealed the resident had a previous L2 fracture that caused chronic pain and he needed to be laid down on his bed after meals. The recommendations were to have the resident laid down on his bed after every meal to relieve back pain. He was on the therapies caseload. The care plan was reviewed and updated. A fall risk assessment dated [DATE] at 11:30 a.m., revealed a score of 16 or high risk. The resident had recent falls, required hands-on staff assistance to move from place to place and had decreased in his muscle coordination. The resident was administered antihypertensive and anti-seizure/antiepileptic medications. A physician's order dated 11/6/21 at 11:53 a.m., revealed status post unwitnessed fall. Send the resident to the emergency room for a complaint of back pain. A nurse note dated 11/6/21 at 12:15 p.m., by a licensed practical nurse revealed the resident was transported to the hospital at 12:10 p.m. A nurse note dated 11/6/21 at 2:05 p.m., by a registered nurse for the fall at 11:30 a.m., revealed the resident was found lying on his right side on the floor. The resident denied hitting his head and was able to answer questions. His eyes were equal and reactive. He was able to move all extremities. He complained of mid back pain and he refused to roll onto his back due to the back pain. No injuries were found. The ambulance service was called and the resident was sent to the emergency department. The NHA, director of nursing, unit manager and the resident's primary care physician were notified. The resident's pain scale on 11/6/21 on the day shift (6:00 a.m. to 6:00 p.m.) was three (mild) out of ten on the numerical pain scale. The pain scale for the night shift (6:00 p.m. to 6:00 a.m.,) was zero. A nurse note dated 11/6/21 at 3:37 p.m., by a registered nurse revealed the resident was at the emergency room for further evaluation. A nurse note dated 11/6/21 at 6:47 p.m. by a licensed practical nurse revealed the resident had returned from the hospital via a wheelchair with a certified nurse aide escort. He was alert and had no complaint of pain, was taken to his room and assisted into bed. A fall risk assessment dated [DATE] at 11:00 a.m., revealed a score of 18 or high risk. The resident had recent falls, required hands-on staff assistance to move from place to place and had decreased in his muscle coordination. The resident was administered diuretics, narcotic, psychotropic, antihypertensive and anti-seizure/antiepileptic medications. The resident's pain scale on 11/7/21 on the day shift (6:00 a.m. to 6:00 p.m.) was 3 (mild) out of 10 on the numerical pain scale. His pain scale was the same on the evening shift (6:00 p.m. to 6:00 a.m.). D. Fall 11/7/21 The resident's pain scale on 11/7/21 on the day shift (6:00 a.m. to 6:00 p.m.) was 10 (severe) out of ten on the numerical pain scale. The pain scale for the night shift (6:00 p.m. to 6:00 a.m.,) was zero. -The facility was unable to provide a nurse progress note that described the first initial encounter with the resident after the fall, if the resident was assessed by a registered nurse or how the resident was moved from the floor. A nurse note dated 11/7/21 at 11:28 a.m., by a registered nurse revealed the resident's primary care physician did not want the resident to be sent to the emergency room (after fall two). He wanted a fall mat put in place and to move the resident closer to the nurse's station. He also wanted the nursing staff to check on the resident every 15-minutes. The 15-minute checks were put in place and a charting page was placed in the resident's room and a fall mat was placed on the floor next to the bed. The resident would be moved to a new room tomorrow on 11/8/21. -The facility was unable to provide the risk management evaluation of the fall that included a recapitulation of the fall. -The facility was unable to provide the interdisciplinary team review of the fall that included a recapitulation of the fall, the root cause analysis or any recommendations to prevent future falls. A skilled progress note dated 11/8/21 at 6:43 a.m., by a registered nurse revealed the resident was alert and able to make his needs known. The resident said he was in a lot of pain but was unable to give a number on the pain scale. The resident was administered as needed Tylenol that was somewhat effective. The resident was being monitored for a fall on the previous shift. A room change notice dated 11/8/21 at 9:30 a.m., revealed to move the resident closer to the nurse's station as the physician ordered. The resident's case manager was in agreement. A nurse note on 11/8/21 at 11:00 a.m., by a licensed practical nurse revealed the resident was having a lot of pain this morning. He was administered Tylenol earlier and his Lidocaine patch was changed. The resident said his pain level was 10 out of 10 on the numerical pain scale. A call was placed and a message was left for his physician for any special instruction or different pain medication. A nurse called and said due to his seizure history, he had orders for Tylenol and a pain patch. This nurse will wait for any further instructions if any were provided. Will continue to monitor the resident. A social service note dated 11/8/21 at 7:08 p.m., by a charge nurse revealed the resident had a room change as physician ordered. The resident seemed to tolerate the move to the room well. The resident was being monitored for a fall and he was in pain. Tylenol was administered as ordered. The alert note dated 11/9/21 at 3:23 a.m., by a registered nurse revealed the resident had been moved closer to the nurse's station secondary to multiple falls. The resident tolerated the room change okay. The resident was on 15-minute checks throughout the shift. E. Staff interviews The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 1/6/22 at 7:51 a.m. The DON said there was no initial fall risk assessment upon his admission, however the admission/readmission evaluation bundle revealed he was high risk for fall due to a history of falls and a BIMS score of four out of 15. She said the fall interventions put in place after admission were to keep his bed in the low position, keep items within reach, ensure the call light was in reach, use appropriate footwear, use assistive devices as needed and to refer to therapies as needed. The DON said the root cause for the first fall on Saturday 11/6/21 was that the resident was trying to transfer himself from his wheelchair to his bed after lunch. The interventions put in place were to lay the resident down after meals to help relieve his back pain, place a fall mat on the floor by his bed and he was to be evaluated by therapies. The DON said the root cause of the second fall on Sunday 11/7/21 was that the resident rolled out of his low bed onto the fall mat on the floor and he had no injuries from this fall. The DON said the resident was moved closer to the nurses' station on 11/7/21 and the paperwork for the move was completed on 11/8/21. The DON was interviewed on 1/6/22 at 11:05 a.m. She said the resident rolled out of bed onto the fall mat for the second fall on 11/7/21. She said the resident did not receive any injuries from this fall. She agreed there were no specific progress notes that describe the second fall. She said the interdisciplinary team did meet to discuss the fall on 11/7/21.