**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#6) of one resident reviewed for pressure injuries out of 20 sample residents received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #6 was admitted on [DATE] for long term care. At the time of admission, the resident was identified for being at risk for developing pressure injuries. Upon admission, the resident had a surgical incision on her right leg and her skin was otherwise intact. Resident #6 attended dialysis three times a week. On 8/2/24, a primary care physician documented Resident #6 developed a blister on her left heel that had thick white drainage which may have represented some early infection. Preventative measures to protect the resident's heels were not implemented until after the development of the blister on 8/2/24. On 9/6/24, a physician's progress note documented the resident's left heel had developed eschar (dead tissue). On 11/7/24, when the wound care physician took over care (three months after the blister was initially identified), the wound was classified as an unstageable ulcer to the left heel. Due to the facility's failure to implement effective pressure injury interventions in a timely manner, Resident #6 developed a facility-acquired unstageable pressure injury to her left heel. 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 on 11/24/24 from https://www.internationalguideline.com/guideline, 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 procedure The Pressure Injury Prevention and Management policy and procedure, revised November 2022, was received from the nursing home administrator (NHA) on 11/21/24 at 2:46 p.m. It documented in pertinent part, The purpose of the policy is to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries. Preventative interventions can be, but are not limited to, frequent position changing and support of pressure points, adequate hydration and nutrition, appropriate exercise and movement, frequent perineal care, proper lifting techniques, correct application of pressure relieving devices and frequent inspection and assessment of skin integrity. Compliance with interventions will be documented in the medical record. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. A key implementation to pressure ulcer management will be interdisciplinary team (IDT) involvement and review and comprehensive care planning. III. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included diabetes mellitus (high blood sugar), end stage kidney disease (kidneys can no longer support body's needs) with hemodialysis (process where a machine filters and cleans the body's blood), right below the knee amputation and peripheral vascular disease (narrow blood vessels). According to the 10/19/24 minimum data set (MDS) assessment, Resident #6 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial/maximal assistance for showering/bathing, dressing and transferring. She was independent with wheeling in her motorized wheelchair. The MDS assessment documented that the resident was at risk of developing pressure ulcers and had one unstageable pressure ulcer due to the coverage of the wound bed by slough (soft, dead tissue, usually cream or yellow in color) and/or eschar. B. Resident interview Resident #6 was interviewed on 11/18/24 at 2:53 p.m. Resident #6 said the wound to her left heel developed at the facility and the facility staff were not floating the heel or using the blue botties prior to it developing. She said the heel wound started as a blister. C. Wound observation and interview On 11/20/24 at 2:10 p.m., a wound observation was completed with the assistant director of nursing (ADON). Resident #6 was positioned in her motorized wheelchair. The resident was wearing a soft blue bootie on her left foot. With consent from the resident, the ADON removed the dressing to the resident's left heel. Moderate light brown drainage was observed on the dressing. The wound on the resident's heel was round in shape, covering the entire heel. The wound was covered in black tissue (eschar), obstructing the wound. The periwound (skin surrounding the wound) was red. The ADON said there was stable eschar covering the wound. She said the periwound was red. She said there was little to no drainage. She said she had been tracking the wound since it started as a blister. She said at first it was cellulitis and the resident was started on an antibiotic. D. Record review The admission Braden scale for predicting pressure sore risk was completed on 7/15/24. It documented Resident #6 had a score of 18 which indicated she was at risk for developing pressure ulcers due to being chairfast, having slightly limited mobility, not having adequate nutrition and a potential problem for friction and shear. The skin integrity care plan, initiated 6/12/24 and revised 8/30/24, identified the resident had actual impairment to skin integrity with a right below the knee amputation and a left heel open blister. The care plan documented Resident #6 chose to remain in her wheelchair for long periods of time despite the potential risk of skin breakdown attributed to prolonged immobility (added 8/30/24). Interventions included cellulitis identified with pitting edema causing a blister. Treatment initiated. Prevelon boot (soft blue boot) ordered for offloading therapy (initiated 8/2/24), avoiding scratching and keeping hands moist and keeping fingernails short, educating caregivers and the resident of causative factors and measures to prevent skin injury (initiated 6/21/24), following facility protocols for treatment (initiated 8/13/24), using booties at night for skin integrity (initiated 8/6/24), providing a pressure-redistributing bed with a pump to prevent pressure ulcers due to her immobility (initiated 8/30/24) and monitoring/documenting location, size and treatment of skin injury and reporting abnormalities, failure to heal, signs and symptoms of infection or maceration to the physician (initiated 6/21/24). Review of Resident #6's November 2024 CPO revealed a physician's order to float the resident's heel when in bed, ordered 8/2/24. -However, review of the resident's August 2024 treatment administration record (TAR) revealed there was no documentation of the left heel being offloaded until 8/6/24, four days after the wound was identified and the above physician's order was obtained. A note from the vascular surgeon on 9/30/24 documented a follow up appointment Resident #6's left heel wound. The note documented the resident had adequate blood flow to her left lower leg. The wound care physician's (WCP) progress note from 11/21/24 documented Resident #6's left heel wound was an unstageable pressure wound due to necrosis (dead tissue). It was documented that there was moderate serous exudate (clear to light yellow fluid leaking from the wound) with 90% thick adherent devitalized necrotic tissue and 10% slough (shedding). IV. Staff interviews Certified nurse assistant (CNA) #4 was interviewed on 11/20/24 at 2:30 p.m. CNA #4 said Resident #6 had a wound to her left heel. She said she required one staff member's assistance for dressing, bathing and transferring with a slide board. She said on the days the resident went to dialysis, she required two people for assistance because staff used the hoyer lift so she had a sling under her body for transferring at dialysis. CNA #4 said Resident #6 never refused care. The director of nursing (DON), the ADON and the NHA were interviewed on 11/20/24 at 3:00 p.m. The DON said Resident #6 was readmitted on [DATE] after a right below the knee amputation. She said the resident was weight-bearing as tolerated and working with therapy. She said the resident scored a mild risk for pressure injury development on her admission Braden scale, so additional interventions were not put into place. She said on the Braden scale from 7/29/24, she scored a moderate risk so an intervention for a wheelchair cushion was added to help prevent pressure injury to her bottom. The DON said Resident #6's left heel blister was identified on 8/2/24 and a Prevelon boot (protective boot) was ordered. She said there was an order to offload the resident's heel until the boot came in on 8/6/24. She said the boot was not appropriate for the resident prior to the development of the wound because she was working with therapy and was weight-bearing as tolerated. She said she was wearing a regular shoe prior to the development of the heel blister. The DON said once the eschar formed on the wound and it was deteriorating, a pressure-reducing mattress was ordered on 8/30/24. The DON said Resident #6's vascular surgeon and the resident's primary care physician were managing the left heel wound initially. She said the WCP began to manage the wound on 11/7/24 (three months after the development of the wound). The WCP was interviewed on 11/21/24 at 12:00 p.m. The WCP said Resident #6's left heel wound was an unstageable ulcer with 100% necrotic eschar that had been stable for the past three weeks, since she had taken over her wound care management. She said the first week, on 11/7/24, when she saw Resident #6, there was no drainage to the wound. She said on 11/21/24 there was moderate serous drainage. The WCP said since the wound had deteriorated, she did a small debridement on 11/21/24 and talked to Resident #6 about ordering a different style of boot that would offer more protection to the heel. She said the wound was caused by pressure between the foot and the bed or chair. She said the resident had multiple comorbid factors which included diabetes type two, peripheral vascular disease and neuropathy that were likely all contributing factors to the development of the wound. She said offloading the heel was always a beneficial intervention for pressure injury prevention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #20 A. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, chronic kidney disease, polyneuropathy (malfunction of small vessels throughout the body), hypotension (low blood pressure), and complete atrioventricular block (electrical signals cannot pass to the chambers of the heart to allow proper blood flow). The 6/15/23 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) score was 13 out of 15 indicating the resident was cognitively intact. The resident required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and physical help, in part, with bathing/showering. The resident was unsteady on his feet and was not able to stabilize with staff assistance. The resident was occasionally incontinent of both bowel and bladder. The resident used a walker for ambulatory support and/or a wheelchair. B. Observations 7/24/23 -At 11:40 a.m. the resident was seated in a wheelchair sitting in the dining room with an older adult female.The resident stood up from his wheelchair and attempted to back away from the table. A CNA assisted the resident to sit down. -At 4:10 p.m. the resident was sitting in the dining room at the same table. A CNA sits and speaks with the resident about his need for assistance with his meal and reminded the resident to not get up from the table 7/25/23 -At 12:43 p.m. the resident was seated in a recliner in the activities room with his feet elevated and a neck pillow atop his shoulders. The resident was squirming in his seat, trying to sit up, moaning, and moving his hands back and forth under his thighs. 7/26/23 -At 10:19 a.m. to 10:43 a.m. the resident was seated in the activities room in a wheelchair among 4 other residents; he asked a staff member to put his feet down because he felt trapped. -At 12:40 pm the resident was moved from the dining room to the activities room and transferred from wheelchair to recliner by a male staff member. The resident declined to have his feet elevated saying he felt trapped. 7/31/23 -At 11:05 a.m. the resident was sitting in the dining room drinking a cup of coffee, looking into the cup, and attempted to rise from the chair. A male CNA comes toward the resident and eases the resident down to the chair. The CNA sits with the resident for 2 minutes. C. Record review The fall prevention care plan, initiated on 3/17/23, read Resident #16 was at a high risk for falling due to activities of daily living self care performance deficit, bowel/bladder incontinence, acute/chronic pain, and limited physical mobility. The fall interventions read, physical therapy evaluate and treat as ordered or as needed, review information on past falls and attempt to determine cause of falls. Alter or remove any potential causes if possible, and educate the resident, the family, and caregivers/interdisciplinary team as to the cause. The fall prevention plan of care was not revised until 3/30/23 after three separate fall events occurred. The resident was evaluated and treated with physical therapy beginning 6/8/23 (one day after three separate falls) for gait training therapy. Therapeutic approaches focused on remediation targeted at joint pain and stiffness, flexibility, adaptability, and efficiency of performance. Fall on 3/18/23 The 3/18/23 at 12:43 a.m. nursing investigative fall report read a CNA heard a voice and entered the resident's room and found the resident on the floor face down partly under the bed with both under garment and gown removed both of which were at the end of the bed. The resident said he needed the bathroom and took a step or two and could not walk. The resident was rolled onto a draw sheet and assisted to a wheelchair. Vital signs were stable and neurological checks were at baseline. A skin assessment revealed the resident sustained an abrasion to the left knee and a bruise to the left side of his forehead. The resident said he may have hit his head. The on-call provider was notified and advised the nurse to monitor the resident closely and to send the resident to the emergency room if there were changes to the resident's vital signs. The resident's oxygen saturation was at 80% and the nurse placed the resident on 5 liters of oxygen via a non-rebreather mask that increased the residents' oxygen saturation to 100% over 10 minutes. Predisposing physiological (normal function) factors included bowel/bladder urgency/frequency, gait imbalance, impaired memory, weakness, and confusion. Responsible parties are notified, spouse was not called. -The facility failed to reinforce the resident's use of the call light to request assistance with ambulation based upon the resident's inability to remember to use the call light. -Furthermore the facility failed to identify the resident's poor balance and incontinence as a potential culprit to the resident's falling. Fall on 3/20/23 The 3/20/23 at 12:30 a.m. nursing investigative fall report read a CNA went into the resident's room and found him on the floor on his right side next to his bed. The resident said he did not know what happened. The resident was incontinent of urine. The resident was lifted by two staff members and assisted back to bed to be cleaned and changed into dry clothing. Skin assessment revealed no new injuries, no reports of pain by resident. Floor mat was placed beside the bed on both sides, and the bed was placed in the lowest position. The resident was alert and talking and denied pain. Predisposing physiological factors included bowel/bladder urgency/frequency, gait imbalance, impaired memory, weakness, confusion, and incontinence. Predisposing situational factors include admitted within the last 72 hours. -The facility failed to address the resident's unsteady gait, impaired balance, poor memory, weakness and confusion as a culprit to the resident's falls. -The facility failed to implement fall prevention initiatives like floor mats immediately on admission based on the resident's fall history. Fall on 3/24/23 The 3/24/23 at 1:49 a.m. nursing investigative fall report read the resident was found on the bedside kneeling on the floor mat with upper body partially on the bed. The resident stated he slid off of the bed and he was confused. The resident denied hitting his head, no injuries noted, and the resident was alert and oriented. The resident's blood pressure was 77/46 (normal blood pressure 120/80). Provider was notified and recommended the resident be sent to the hospital for evaluation. The resident was given intravenous fluids and returned to the facility in stable condition, blood pressure 128/68. Predisposing physiological (normal function) factors included impaired memory, weakness, confusion, hypotensive, and incontinence. Predisposing situational factors include call light/pendant not used. -The facility failed to acknowledge the resident's hypotension (low blood pressure) may have precipitated the resident experiencing a fall. -The facility failed to address the resident's need for assistance with scheduled toileting, toileting behaviors, including the time of the resident's toileting needs. Fall on 4/2/23 The 4/2/32 at 3:50 a.m. nursing investigative fall report read the resident was found with his knees on the floor mat and upper body on bed. There were no apparent injuries upon assessment, no complaints of pain, did not hit head, neurological assessment within normal limits. Vital signs stable, blood pressure 128/72. No predisposing physiological or situational factors noted. Wife and medical provider notified. -The facility failed to address the resident's need for assistance with scheduled toileting, toileting behaviors, including the time of the resident's toileting needs. - The facility failed to include assigning the resident's care to the same nursing personnel to promote continuity of care. Fall on 4/5/23 The 4/5/23 at 4:15 a.m. nursing investigative fall report read the resident was found nude laying on the floor mat next to his bed. The resident said he crawled out of bed because staff were not monitoring him. The resident further stated I tried staying in bed but couldn't, you should've been watching me. The resident denied hitting his head and denied pain. Skin assessment revealed no bruising or skin tears. Blood pressure at 144/73, neurological assessment within normal limits. The resident was assisted back to bed with two person assist, the resident was incontinent of urine, new brief applied, pajamas replaced. Predisposing physiological (normal function) factors included incontinence. -The facility failed to include the use of a sit-to-stand lift to support pivot transfers and to assist the resident with toileting. -Furthermore, the facility failed to add consistent and close observation into the plan of care based on the residents ambulating unassisted in his room. D. Resident interview The resident was interviewed on 7/31/23 at 11:13 a.m. The resident said he was seated in the activities room because he did bad things and he needed to be watched. The resident said he was here because he fell at home and fractured his left leg. The resident said he plans to go home after he healed up because he did not necessarily like this place and no one looks in on him when he needs the bathroom. The resident said he forgets to use the call light and needs to be reminded. The resident said the staff are good to him and some are really good but he would rather be at home. The resident said all he needs is a little help to get to the bathroom. E. Staff interviews CNA #2 was interviewed on 7/27/23 at 11:34 a.m. CNA #2 said the resident needs help with everything, including, walking, transferring, toileting, etc. CNA #2 said when the resident was admitted in March 2023, the resident could walk with a walker but now he was unable to walk with a walker. CNA #2 said the resident often awakened at night, removed his clothing and was incontinent of urine. As a result the resident was often tired and fatigued the next morning. CNA #2 said the resident was awakened by 6:15 a.m and staff needed to assist him to the bathroom, help him shower, brush his teeth, dress him and get him ready for the day. RN #2 was interviewed on 7/27/23 at 4:00 p.m. RN #2 said the resident was always within sight to prevent him from falling. RN #2 said the resident was not left in his room alone because he has very poor balance and sometimes low blood pressure that caused him to fall. RN #2 said the resident eats all his meals in the dining room, he sits at the same table, among the same people that allows for close observation. RN #2 said the routine was productive for the resident due to his Parkinson's. RN #2 said the staff moved the resident's personal recliner in the activities room to give the resident comfort and familiarity. The director of nursing (DON) was interviewed on 7/31/23 at 1:00 p.m. The DON said the staff are finding new approaches to assure the resident's safety. The DON said the resident was situated in the activities room to allow staff to check on the resident every 15 minutes and to ask the resident what he needs, especially toileting. The DON said the resident's wife hired a private aide to stay with the resident during the night to assure the resident did not get up by himself and to assist the resident to the bathroom. The DON said we try to assign the resident with the same CNA for continuity of care and to build trust. The physical therapy assistant (PTA) was interviewed on 7/31/23 at 2:20 p.m. The PTA said the resident demonstrated poor rehab potential to achieve his goals due to a lack of motivation to actively participate in physical therapy. The PTA said she started inviting the resident's wife to physical therapy and that seemed to motivate the resident. The PTA said she recently facilitated the use of a sit-to-stand lift to support pivot transfers and to assist the resident with toileting. The PTA said one CNA in particular arrived to learn more about pivot transfers to make it easy on the CNA staff and the resident. IV. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), diagnoses included hypertensive heart disease with heart failure (chronic high blood pressure), acute-on-chronic heart failure (damage to the heart that develops over time), and diabetes mellitus (elevated glucose levels). The 6/19/23 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) score was 15 out of 15 indicating the resident was cognitively intact. The resident required extensive assistance with bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene, and physical help, in part, with bathing. The resident was unsteady and was not able to stabilize with staff assistance. The resident was occasionally incontinent of both bowel and bladder. The resident used a four wheeled walker for ambulatory support and had a history of falling. B. Observations 7/24/23 -3:26 p.m. the resident was sitting in a recliner facing the television. The resident had yellowish brown bilateral black eyes, a yellowish brown bruise above the right eye, a large yellowish brown bruise on the forehead and a yellowish brown bruise to the left side of her face. There were small scattered bruises on both arms and legs. 7/25/23 -At 10:00 a.m. the resident was in the recliner with a walker on the right side of the recliner, the resident pulled the walker to the front of her and used the arm rests of the recliner to raise to a standing position, the resident is unsteady on her feet and sits down. The resident attempted to stand again and lost her balance and sat down. The resident did not use her call light. -At 4:10 p.m. the resident remained seated in the recliner, the television volume was loud. The resident did not acknowledge a staff member entering her room. The nurse administered medication one-by-one by name. The nurse reminds the resident to use her call light. 7/26/23 -At 7:22 a.m. a CNA entered the resident's room and offered the resident assistance with hygiene. The resident and CNA moved out of sight toward the bathroom. The resident was unsteady on her feet while using a walker. -At 1:47 p.m. to 2:22 p.m. the resident had not left her room in the past three days and remained seated in the recliner in front of the television. The resident raised herself from sitting to standing on two separate occasions The resident was unsteady on her feet both times. The resident did not use her call light. 7/27/23 -At 11:05 a.m. the resident was escorted by one CNA to the shower in the resident's room, the resident was using the four wheeled walker. The resident was unsteady on her feet and sat down on the right side of her bed. The CNA uses the call light to request help with assisting the resident to the shower. C. Record review The falls care plan, initiated on 5/20/23, read Resident #16 was at a high risk for falling due to limited physical mobility, altered respiratory status, and difficulty with communicating basic needs. The fall interventions read, educate/remind the resident about safety, encourage participation in activities that promote exercise, physical activity for strengthening for improved mobility, ensure appropriate non-skid footwear when ambulating, evaluate and supply the resident with adaptive equipment as needed, re-evaluate for continued appropriateness to ensure least restrictive device or restraint. The resident was evaluated and treated with physical therapy beginning 6/8/23 (one day after three separate falls) for gait training therapy. Therapeutic approaches focused on remediation targeted at joint pain and stiffness, flexibility, adaptability, and efficiency of performance. Although the resident experienced five actual falls and the circumstances involved were not added to the care plan. Fall on 5/23/23, three days after admission The 5/23/23 at 1:36 a.m. nursing fall investigative report read the resident was found on the floor sitting in the bathroom with the resident's walker beside her. The resident was barefoot. The resident sustained a small laceration to the left side at the back of the head which was actively bleeding. Range of motion to all extremities were normal. Laceration to the back of head cleaned with wound cleanser to stop the bleeding. Neurological checks were within normal limits and the resident was alert and oriented. No vital signs were documented. Predisposing physiological factors included gait imbalance. Responsible parties are notified. -The facility failed to monitor the resident's toileting patterns, reinforce the use of the call light and ensure the resident had non-skid footwear accessible and within reach. -The facility failed to document post fall vital signs following the resident striking her head. Fall on 6/1/23 The 6/1/23 at 8:03 p.m. nursing investigative fall report read the resident's call light was answered and the resident was observed getting up atop her bed. The resident said she was trying to get to the bathroom but urinated on herself and the bed sheet. The resident reported she bumped her nose on the walker but there was no deviation or bleeding. The staff member assisted the resident to the bathroom to change her clothing but the resident declined help. The staff member left the resident's side to change the bedding and while the resident was washing her hands, the resident fell again onto her left elbow. Neurological checks were at baseline, the resident was alert and oriented, and range of motion to the left upper extremity was at baseline. Staff member reminded the resident to use the call light and wait for assistance, and the resident agreed by nodding her head up and down. No vital signs were documented. Predisposing physiological factors included gait imbalance and incontinence. Responsible parties are notified. -The facility failed to respond to the residents' call light in a timely manner, toileting assistance. -The facility failed to ensure the resident was not left alone in the bathroom immediately after the initial fall, resulting in a secondary fall. Fall on 6/7/23 The 6/7/23 at 3:10 p.m. nursing investigative report read a staff member was assisting the resident with a transfer and the resident lost her balance causing the resident to fall onto her left side. The resident did not hit her head but assessment of the left upper extremity revealed the resident had three skin tears. The skin tears were cleaned with wound cleanser, patted dry, and dressed with a dry dressing. The skin tears to the resident's left arm were well approximated. Neurological checks were at baseline and the resident was alert and oriented, range of motion to left upper extremity at baseline. The resident's blood pressure was measured at 107/61 with no additional vital sign abnormalities. Predisposing physiological factors included gait imbalance and confusion. Responsible parties are notified. -Although the resident was injured during a staff-assisted transfer and therapy was initiated, the facility failed to develop a plan to ensure the resident had two person assistance in response to the resident's balance issues. -Furthermore, the facility failed to provide transfer training as part of the resident's therapy plan. -The care plan identified the resident experienced a fall on 6/26/23 (no time included) while under the care of a hospice nurse resulting in a bruise to the resident's face. There are no additional details related to the fall and there was an absence of a nursing fall investigative report related to the fall. Fall on 7/5/23 The 7/5/23 at 6:35 a.m. nursing investigative fall report read two CNAs (one off-going and the other on-coming) heard a loud noise coming from the resident's room. The CNAs entered the room and found the resident sitting on the floor facing the door entrance. The resident reported she lost her balance while trying to shut the door. The resident denied hitting her head. The nurse post fall assessment identified bruising to the resident's upper back and right forearm. The resident's blood pressure measured at 88/47 with no additional vital sign abnormalities. The resident was assisted from the floor by the CNAs using a gait belt. The resident was alert and oriented. Predisposing physiological factors included gait imbalance and weakness. Predisposing situational factors include call light/pendant not used. Responsible parties are notified. -The facility failed to respond to the resident's poor safety awareness, joint stiffness, weakness, and fatigue and educate the resident to avoid ambulating without assistance or use of her walker. -The facility failed to address the resident's hypotension (low blood pressure) nor identify the resident's low blood pressure as a precursor to her falling. D. Resident interview The resident was interviewed on 7/27/23 at 3:26 p.m. The resident said her facial bruising was a result of a fall that occurred prior to her admission to skilled nursing. The resident said she was using her walker at the time of the fall. The resident said she tripped between the carpet and the floor panel in front of the door to her apartment. The resident said she did not recall the exact details of the fall except that she fell forward striking her face on the floor and the walker. The resident said after the fall she was hospitalized for bloody stools (unrelated to the fall) for a few days and released to skilled nursing for rehabilitation. The resident said she wanted to return to her apartment in assisted living in the near future. The resident said she fell a few times since her arrival to skilled nursing and feared the falls would keep her from returning to assisted living. The resident said she had a history of falling. E. Staff interviews CNA #1 was interviewed on 7/27/23 at 10:50 a.m CNA #1 said the resident sat in her recliner in view of staff as they passed her room. Each staff member knows the resident was at a high fall risk due to her history of falling. If the resident isn't sitting in her recliner we knock and enter to see what's going on. CNA #1 said the resident does not use her call light/pendant to ask for assistance. CNA #1 said the resident had fallen a few times already and the bruises on her face were already there before she came to skilled nursing. CNA #1 said he did not know what happened regarding the facial bruising. LPN #3 was interviewed on 7/27/23 at 11:10 a.m. LPN #3 said the resident came directly from the hospital to skilled nursing. LPN #3 said the resident fell while in assisted living that resulted in facial bruising. LPN #3 said the resident had poor safety awareness and the resident's falls were a result of her getting up to go to the bathroom unassisted. LPN #3 said the resident waited until she could not hold her urine or stool any longer and rushed to the bathroom. LPN #3 said the resident rarely used her call light despite reminders daily on every shift, plus, education on how and when to use the pendant to call for assistance. LPN #3 said the resident was confused at times but very clear by mid afternoon. The physical therapist (PT) was interviewed on 7/31/23 at 5h:05 p.m. The PT said interventions for the resident include strengthening to avoid repeat falls after two separate hospitalizations for heart failure and gastrointestinal bleed. The PT said the resident was independent with bed mobility and transfers with use of a walker but joint pain, stiffness, weakness and fatigue contributed to decreased independence and safety. The director of nursing (DON) was interviewed on 7/31/23 at 9:18 a.m. The DON said the interdisciplinary team (IDT) said the staff recognize the attention the resident needs to avoid future falls. The DON said she talks to the residents on a regular basis and got the resident's consent to change rooms to better serve the resident and avoid repeat falls. The DON confirmed the resident fell in assisted living and suffered facial bruising. V. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included muscular sclerosis (a disabling disease of the brain and spinal cord), orthostatic hypotension (an decrease in blood pressure upon assuming an upright position) and neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve problems). The 6/5/23 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) score was 15 out of 15 indicating the resident was cognitively intact. The resident required extensive assistance with bed mobility, transfers, dressing, and personal hygiene and was dependent on staff for bathing and toilet use. The resident was unable to walk, had a urinary catheter for a neurogenic bladder related to muscular sclerosis and was bowel incontinent. The resident was assessed to be at risk of falling due to balance problems and unsteadiness and was only able to stabilize with staff assistance. The resident used a motorized wheelchair for mobilization. B. Observations 7/25/23 -At 4:57 p.m. the resident was sitting upright in a motorized wheelchair; the resident had his back to the door reading the newspaper. Two staff members entered the resident's room with a hoyer lift and proceeded to transfer the resident to a shower chair. The resident was unable to assist with the transfer. -At 5:20 p.m. the resident was up in a motorized wheelchair with visitors in his room; the call light was on. One staff member responded and a second staff member entered the room with a hoyer lift to assist the resident with toileting. The resident was unable to assist with the transfer. 7/26/23 -At 7:20 a.m. the resident was assisted with hygiene and dressing while in bed. Two staff members used the lift to transfer the resident from bed to wheelchair. The resident's brows were creased and the resident appeared to be holding his breath. The resident was unable to assist with hygiene, dressing or transfer. 7/31/23 -At 10:40 a.m. the resident was lifted into his wheelchair with a hoyer lift by the help of two male staff members. The resident complained he despised the lift because he felt vulnerable. C. Record review The falls care plan, initiated on 2/16/23 read Resident #3 was at high risk for falling due to activities of daily living (ADL) self performance deficit and limited physical mobility. The fall interventions initiated on 2/16/23 read, staff will educate/remind the resident about safety, encourage the resident to participate in physical activity for strengthening and improve mobility, minimize the potential for falls while providing diversion and distraction, evaluate and supply the resident with appropriate adaptive equipment or devices as needed, promote a safe environment free of spills and clutter, reachable call light, personal items in reach, and review past falls and attempt to determine root cause for falls and educate the resident and family members as to fall causes. The resident was evaluated and treated with physical therapy from 3/7/23 to 6/4/23 for repeated falls, muscle weakness, abnormal gait and impaired mobility. Therapeutic approaches focused on remediation targeted at body structure and function primarily walking with poor prognosis for improvement. Fall on 3/15/23 The 3/15/23 at 3:45 p.m. nursing fall investigative report read the resident was found on the floor in a supine (face up) position next to a recliner in the resident's room. The resident explained he attempted to self transfer from the recliner to the scooter and fell because he physically couldn't make it. The resident denied injury or hitting his head and an assessment of the resident confirmed the resident was uninjured. Neurological checks were negative and at baseline and the resident's vital signs were stable. The nurse provided the resident with education related to use of the call light. Predisposing physiological factors included gait imbalance. Predisposing situational factors included transfer. Both the resident's physician and family member were notified of the fall event. -Although the resident said he was having difficulty with transferring, the facility failed to offer further assistance, supervision or education on using his call light when he needed transfer assistance. Fall on 3/21/23 The 3/21/23 at 1:15 p.m. nursing fall investigative report read the resident was found on the floor on his back next to the left side of the recliner. The resident explained he attempted to self transfer from the scooter to the recliner (the scooter was facing the recliner) and pressed his call light but did not wait for staff assistance. The resident was not injured and he denied hitting his head. The resident's neurological assessment was within normal limits while the resident's blood pressure was measured at 106/66. All other vital signs were within normal limits. Predisposing physiological factors included impaired memory. Predisposing situational factors included transfer. Notification of fall event to MD, family member, and DON. -This was the resident's second fall involving self transferring to or from the scooter. He had used his call light as instructed. However, the facility failed to develop a plan to respond more timely to his call light, provide therapy for transfer training or provide additional education and reinforcement of call light use, although the facility was aware he could be impatient and impulsive. Fall on 4/12/23 The 4/12/23 at 1:46 a.m. the nursing fall investigative report read the resident was found on the floor with his motorized wheelchair behind him. The resident's left knee was wedged between the carpet and the right leg. The resident sustained bruises to both sides of the left knee which was cleansed with normal saline and dressed with a dry dressing, no additional injuries were noted. The resident denied pain or hitting his head. The resident said he pushed the call light after the fall. The resident's vital signs were normal and his neurological assessment was absent of mental/physical deficits. Predisposing physiological factors were marked other without specifying additional comments. Predisposing situational factors include transfer. Responsible parties were notified. -The facility failed to instruct and reinforce resident education on call light usage prior to leaning forward, reaching or transferring. -The facility failed to acknowledge the resident's vulnerability to falling based on the resident's decreased energy, poor activity tolerance and fatigue as identified by physical therapy. D. Resident interview Resident #3 was interviewed on 7/26/23 at 11:42 a.m. The resident said he was diagnosed with muscular sclerosis in 1988 and remained independent and active until 2005 when he began to decline physically. The resident said he had a history of falling while residing in independent living, assisted living and now in skilled nursing. The resident said he fell a few times before he entered the facility. The resident said the latest fall on 4/12/23 scared him because he did not realize he could slide out of his wheelchair as he reached for pen and paper. The resident said he stopped taking Rebif (medication for muscular sclerosis) in May 2023 and immediately became more weak and tired. E. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/27/23 at 10:36 a.m. CNA #1 said the resident came to skilled nursing with a history of falling. CNA #1 said the resident was very weak, could not stand upright or walk[TRUNCATED]