**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#28) of three residents out of 37 sample residents. Resident #28, who was at risk for falls, was admitted on [DATE] with diagnoses of dementia, history of falling, abnormalities of gait and mobility, weakness and insomnia. On 5/1/25 the physician recommended the resident transition to a walker without wheels for safety and have a physical therapy (PT) evaluation. However, Resident #28 continued to use her four-wheel walker and a PT evaluation was not conducted until 5/13/25. Resident #28 fell three times in less than a week (on 5/6/25, 5/9/25 and 5/10/25). She was identified to have high blood pressure after the falls and was discovered to have a urinary tract infection (UTI) after the last fall on 5/10/25, increasing her risk for falls. All three of the falls occurred in the early morning hours when Resident #28 got out of bed independently. However, the facility failed to identify a pattern with the falls. Two of the three falls resulted in injuries, including facial injuries. The 5/10/25 fall resulted in the resident going to the hospital for stitches to her head. Specifically, the facility failed to identify and implement timely interventions for Resident #28 to help decrease her risk for patterned falls and risk of falls with injury. Findings include: I. Facility policy and procedure The Falls-Clinical Protocol policy, revised September 2012, was provided by the nursing home administrator (NHA) on 5/22/25 at 6:00 p.m. The policy read in pertinent part, For an individual who has fallen, staff will attempt to find possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in the fall. Often multiple factors in varying degrees contribute to a fall problem. The staff and the physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals are often at a greater risk for serious adverse consequences of the fall. Risk of serious adverse consequences can sometimes be minimized if falls can not be prevented. If interventions have been successful in preventing falls, the staff will continue the current approaches or reconsider whether the measures are still needed if the problem that required the intervention has been resolved. If the individual continues to fall, the staff and the physician will reevaluate the situation and consider other possible reasons for the resident falling and will reevaluate the continued relevance of current interventions. II. Resident #28 A. Resident status Resident #28, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, unspecified dementia, without behavioral disturbance, history of falling, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits (stoke), other abnormalities of gait and mobility, weakness and insomnia. The 2/8/25 minimum data set (MDS) assessment documented Resident #28 had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. According to the MDS assessment, Resident #28 needed partial to moderate assistance with dressing, including putting on and taking off footwear, toileting and personal hygiene. She needed touching or supervision with a sit to stand position. She used a walker for mobility. B. Resident observation and interview On 5/19/25 Resident #28 was observed throughout the day in the memory care unit. The resident had red, purple and green bruising on her face. The bruising was primarily under her left eye, on her left cheek and on her forehead. Resident #28 used a four-wheel walker for ambulation. Resident #28 was interviewed on 5/19/25 at 2:45 p.m. Resident #28 said she did not know what happened to cause the bruising on her face but she was happy the bruises were getting better. C. Record review The fall care plan, initiated 8/2/24 and revised 5/6/25, identified Resident #28 was at risk for falls. Interventions included reminding the resident to use her walker (initiated 8/22/24), ensuring the resident was wearing appropriate footwear and/or non-skid socks when she was ambulating (initiated 8/22/24 and revised 5/6/25), providing a therapy screen as needed (initiated 5/6/25), the resident was participating in a restorative program (initiated 5/7/25), a medication review was conducted with Resident #28's physician (initiated 5/9/25), placing the resident on a toileting schedule (initiated 5/12/25), keeping the resident's bed in the lowest position (initiated 5/11/25 and revised 5/21/25, during the survey), encouraging the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility (initiated 5/21/25, during the survey) and reviewing information on past falls and attempting to determine the cause of falls, recording possible root causes, altering or removing any potential causes if possible and educating the resident/family/caregivers and the interdisciplinary team (IDT) of the fall causes (initiated 5/21/25, during the survey). The 5/1/25 history and physical physician's note documented Resident #28's blood pressure was 140/82 millimeters of mercury (mmHg). The note identified Resident #28's blood pressure was well-controlled during the visit and the resident would continue on her current medications of amlodipine and lisinopril (high blood pressure/hypertension medications). The physician's note indicated Resident #28 had mobility issues and recommended the resident transition to a walker without wheels for safety, have a PT evaluation and have fall preventive measures in place. -However, the resident continued to use the four-wheel walker (see observations above and progress notes below). The 5/6/25 general progress note documented Resident #28 was found sitting on the floor at 4:45 a.m. She was putting her shoes on and her four-wheeled walker was beside her. Resident #28 was not able to identify if she fell or not but asked if it was time to get up. According to the note, the nurse who observed the resident on the floor felt the resident was possibly trying to get her shoes on while sitting on her four-wheel walker and the walker slid back, causing her to sit on the floor. The note identified the resident did not have skin trauma or shearing and was able to walk from the bed to the toilet without difficulty. The 5/6/25 fall risk data collection evaluation identified Resident #28 scored a 12, indicating she was a fall risk. According to the fall risk data collection evaluation instructions, interventions should promptly be put in place when a resident's score was 10 or more. The change of condition evaluation identified Resident #28 had a blood pressure of 148/76 mmHg on 5/6/25 at 5:12 a.m., indicating a high blood pressure. The 5/7/25 health status note documented Resident #28 was reminded not to sit on her walker for safety, but she was forgetful about the reminder and sat down her walker multiple times without locking her walker brakes. The 5/7/25 IDT at-risk note documented Resident #28's current fall intervention was to ensure she was wearing appropriate footwear and non-skid socks when she was ambulating and to remind her to use her walker. The at-risk note documented occupational therapy (OT) would evaluate and treat the resident for lower body dressing and the resident would participate in the restorative nursing program. The 5/9/25 at 4:45 a.m. nursing progress note documented Resident #28 came out of her room scooting on her buttocks and said she fell. The nursing assessment identified Resident #28 had a bruise forming to her left eye and cheek area and superficial cuts above her eyebrow. The area was cleaned and a bandage was applied. According to the progress note, the resident said she fell and hit her cheek on the floor when she got out of bed. The 5/9/25 at 5:40 a.m. health status note documented Resident #28 was being monitored for a fall on 5/6/25. She complained of left leg discomfort prior to going to bed this shift (5/8/25 into 5/9/25). According to the note, Resident #28 was sleeping in her bed prior to her 5/9/25 fall. The 5/9/25 IDT post-fall investigation documented Resident #28 had an unwitnessed fall at 2:45 a.m. The investigation identified the resident was last checked on by staff at 12:00 a.m. According to the fall investigation, the resident's current fall risk was high. The fall investigation indicated the fall factors included an unsteady gait, getting out of bed and poor lighting. The determining cause of the fall was weakness while ambulating without assistance. The resident was wearing socks at the time of the fall. The investigation indicated the resident was last toileted (on 5/8/25) at 9:00 p.m. The fall investigation documented there was not a noted pattern of falls. -However, the resident previously fell on 5/6/25 in the early morning hours after getting out of bed without assistance. -The note identified Resident #28 was last checked on by staff two hours and 45 minutes before the resident fell and scooted out of her room on her buttocks. The 5/9/25 fall risk data collection evaluation identified Resident #28's fall risk increased from a score of 12 to a 23 after her second fall. The resident's mobility was unsteady with problems and with devices. The 5/9/25 change of condition evaluation identified Resident #28's blood pressure was 182/88 mmHg at the time of the 2:45 a.m. fall, indicating a high blood pressure. According to the evaluation, she was having some discomfort to the left side of her face. The 5/9/25 fall incident report identified Resident #28 was not using her walker and had only regular socks on her feet while attempting to get out of bed to ambulate when she fell. According to the blood pressure log, the resident's blood pressure was trending upward and the medical director would elevate and perform a medication review. The 5/10/25 at 6:05 a.m. nursing progress note documented a certified nurse aide (CNA) was rounding in Resident #28's room and found the resident on the floor, bleeding from her head. According to the note, Resident #28 told the CNA that she fell and hit her head on the floor. The note identified the resident had a round dollar-size area noted to the middle top of her forehead/head, a bruise on her left knee, a bruise and a skin tear to her right knee and a bruise and a skin tear to her right elbow. The injured areas were cleaned and dressed. The 5/10/25 at 8:00 a.m. nursing progress note documented Resident #28 complained of left hip and knee pain and was sent to the hospital for Xrays. The 5/10/25 at 11:00 a.m. nursing progress note identified Resident #28 returned from the hospital with two staples in her forehead. The 5/10/25 post-fall investigation documented Resident #28 fell at 5:25 a.m. when she got out of bed and was walking. The investigation identified the resident was last checked on by staff at 2:00 a.m. The investigation identified she self-toileted herself at times throughout the night and was last known to toilet at 4:00 a.m. The investigation indicated the resident had an increased need for assistance with noted weakness and a positive UA. The new interventions after the 5/10/25 fall included a PT evaluation and placing the resident on a toileting program. According to the post fall investigation, Resident #28 did not have a pattern associated with her falls. -However, each of the falls on 5/6/25, 5/9/25 and 5/10/25 were unwitnessed, occurred on the overnight shift in the early morning hours and happened when the resident got herself out of bed. -Additionally, the physician recommended a PT evaluation on 5/1/25, prior to the three falls on 5/6/25, 5/9/25 and 5/10/25 (see physician's note above). The 5/10/25 incident report documented Resident #28 was ambulating in her room without her walker in the dark room with only a night light on. The 5/10/25 at 5:37 p.m. nursing progress note identified the hospital did not complete the requested Xrays of the resident's left hip and knee and the resident had to return to the hospital. A 5/10/25 at 10:00 p.m. encounter note identified a nurse requested a physician's order for urine analysis (UA) laboratory (lab) work due to Resident #28's increased confusion and frequency and difficulty with urinating. The 5/11/25 at 4:31 a.m. health status note documented Resident #28 returned from the hospital at 9:35 p.m. (on 5/10/25) with no fractures. A second health status note on 5/11/25 at 4:33 a.m. documented Resident #28 was being monitored for her multiple falls, multiple bruises to her bilateral arms and knees, skin tears to her left knee and right elbow, a laceration with staples to her head and bruising to her face and both eyes. According to the note, Resident #28 complained of pain and discomfort. The note identified the resident continued to be a high fall risk and she almost fell again when she was observed to walk from her bed to the bathroom. The note indicated the nurse conducted multiple checks on the resident and kept her bedroom door open so the resident could be monitored. Resident #28 was dressed with non-skid socks on her feet for safety. The 5/11/25 at 8:45 a.m. electronic medical administration (eMAR) general note identified Resident #28 received oxycodone pain medication for 8 out of 10 pain and was limping. The 5/11/25 at 5:27 p.m. eMAR general note identified Resident #28 received oxycodone pain medication for 9 out of 10 pain to her left leg and face when she got up for dinner. The 5/12/25 physician's progress note identified Resident #28 had a UTI and was prescribed antibiotics. According to the note, the resident would continue to remain on amlodipine and lisinopril for high blood pressure. The 5/12/25 health status note identified Resident #28 was monitored every hour and offered toileting to prevent her from falling. The 5/13/25 health status note documented Resident #28 was administered oxycodone twice due to her complaints of generalized pain. According to the note, the pain medication was only a temporary relief because she complained again when she was toileted. The 5/13/25 PT evaluation and plan of treatment and three PT skilled service notes, dated 5/13/25, 5/14/25 and 5/19/25, were provided by the NHA on 5/22/25 at 1:05 p.m. The PT evaluation and plan of treatment identified Resident #28 was evaluated on 5/13/25. -The resident was not evaluated by PT until 12 days after the physician recommended a PT evaluation (on 5/1/25) and after the resident had three falls on 5/6/25, 5/9/25 and 5/10/25 (see above). The provided PT notes identified Resident #28 needed reminders and cueing for safety. The 5/14/25 PT skilled services note revealed Resident #28's four-wheel walker brakes were significantly loose and ineffective. The note identified PT replaced the walker with a different four-wheel walker from the facility's storage and adjusted it for the resident. The 5/21 at-risk meeting minutes documented Resident #28 completed her round of antibiotics for her UTI and fall interventions remained in place and were effective because she had had no further falls. -However, the facility failed to identify the resident had a UTI, ensure effective interventions were in place and obtain a PT evaluation until after Resident #28 sustained three consecutive falls in four days, one of which resulted in the resident being transferred to the hospital where she received two staples for a head laceration (see record review above). D. Staff interviews The NHA, the director of nursing (DON) and the corporate consultant (CC) were interviewed together on 5/22/25 at 12:12 p.m. The NHA said falls were reviewed the next business day at the at-risk meeting. He said the IDT reviewed current fall interventions, the root cause of the fall and what new intervention would be implemented. The NHA said over the last review months, the facility had implemented a fall reduction staff incentive plan to help reduce the occurrence of falls. The DON said the staff was trained to watch for clutter on the floor, conduct frequent rounding and make sure the residents' basic needs were met. The NHA said all new fall interventions were communicated through the facility's online communication board, verbal communication and the residents' care plans. The NHA said the former DON used to lead the facility's fall review and oversight. The NHA said the current DON was new to her position and would be trained to take over the fall program. The NHA said Resident #28 was found on the floor on 5/6/25 putting on her shoes. He said the IDT determined a shoe rack by her bed within her reach could help reduce a similar fall. He said he believed the shoe rack was in place. The DON said a shoe rack was not ordered yet. The CC said the shoe rack would be ordered today (5/22/25). The NHA reviewed the 5/6/25 progress note identifying the nurse thought Resident #28's fall was possibly contributed to the resident's walker sliding back, resulting in the resident on the floor. The NHA said he would look into Resident #28's walker. He said the resident was currently on the therapy caseload. He said he was not sure what the PT's fall interventions were at this time. The CC said all of Resident #28's falls were in the early morning. She said she did not see interventions specific to fall risks in the early morning hours. The CC said the resident was identified to have high blood pressure and a UTI after the falls. The CC said she did not see the staff identified what footwear Resident #28 was wearing when she fell on 5/6/25. The CC said Resident #28 did not have the right socks on when she fell on 5/9/25. The NHA said he was not sure if socks were identified as a concern or if staff was educated on the need for non-skid socks after the 5/9/25 fall. The NHA said the IDT discussed providing Resident #28 more assistance in the early mornings. The DON said staff should be checking on residents during rounding every hour making sure needs were met and checking for safety. She said Resident #28 should have been checked on more frequently on the nights before she fell. The DON said Resident #28 would need staff assistance to get dressed. The DON said after the 5/10/25 fall, Resident #28 was placed on a toileting program. She said the resident would be offered toileting when she woke up, before and after meals and at bed time. She said the staff would offer the resident toileting assistance if she woke up in the middle of the night. The NHA said red lights were installed in resident rooms to help residents see at night a couple of years ago. He said he did not know if the red lights were on at the time of Resident #28's falls. The CC and the NHA said they would look at the lighting in Resident #28's room, the status of her shoe shelf and her walker. The NHA and the CC said staff would be educated on non-skid sock use and rounding hourly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure one resident (#83) of five sample residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable, and to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the facility failed to ensure timely interventions were put in place to prevent the development of pressure injuries to Resident #83's heels which resulted in two unstageable pressure injuries. Resident #83 was admitted to the facility after a fall resulting in her impaired mobility. The resident was at risk for pressure injuries and had a current pressure injury to her sacrum on admission. The resident developed a stage II pressure injury to her right heel and a deep tissue pressure injury to her left heel in less than a week after her admission. The pressure injuries were not identified as unavoidable. Both pressure injuries were identified as healable. The stage II pressure injury to the right heel and the deep tissue pressure injury to the resident's left heel worsened to unstageable pressure injuries a month later. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 11/29/23, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedures The Prevention of Pressure Injuries policy, revised April 2020, was provided by the director of nursing (DON) on 11/16/23 at 8:25 p.m. The policy read in part: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the residents care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes of condition. Use a standardized pressure injury screening tool to determine and document risk factors. Supplement the use of a risk assessment tool with assessment of additional risk factors. Conduct a comprehensive assessment upon or soon after admission, with each risk assessment as indicated according to the resident's risk factors, and prior to discharge. During a skin assessment, inspect the presence of erythema, temperature of the skin and soft tissue and edema. Inspect the skin on a daily basis when performing or assisting with personal care ADLs (activities of daily living). Identify any signs of developing pressure injuries. For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, and ischium, trochanter). Use facility-approved protective dressings for at risk individuals. III. Resident #83 status Resident #83, age greater than 90, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for fracture with routine healing, unspecified abnormalities of gait and mobility, weakness, other reduced mobility, muscle weakness, other lack of coordination, osteoarthritis, chronic kidney disease and need for assistance with personal care. The 10/23/23 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a staff assessment for mental status. According to the 10/23/23 MDS assessment, the resident had one or more unhealed pressure ulcers. The resident had two stage II pressure ulcers, one of which was facility acquired. It read the resident had an unstageable pressure injury. The 9/25/23 MDS assessment identified the resident required substantial to maximal assistance for bed mobility and transfers. IV. Record review The 9/18/23 admission data collection with care plan assessment identified Resident #83 had a stage II pressure ulcer to her sacrum on admission. The admission assessment indicated the resident did not have pressure ulcers/deep tissue injuries or any skin issues to the heels of her feet on admission to the facility. The 9/25/23 Braden scale for predicting pressure sore risk identified Resident #83 was at risk for developing pressure sores. According to the Braden scale, the resident sensory perception was slightly limited. She responded to verbal commands but could not always communicate discomfort or the need to be turned or had some sensory impairment which limits ability to feel pain or discomfort in one or two extremities. Her skin was occasionally moist requiring extra linen changes. Her ability to change and control body position was very limited. The resident was able to make occasional slight changes in her body or extremity position but unable to make frequent or significant changes independently. Resident #83 had a friction and sheer potential problem. The resident had the probability that during a move the resident's skin slid down to some extent against sheets, chairs or other devices. The pressure skin care plan, initiated on 9/19/23, read Resident #83 had an actual impairment to her skin integrity. The care plan goal was for the resident to be free from skin breakdown. Interventions included staff to identify and document potential causative factors and eliminate/resolve where possible. The pressure injury care plan, initiated on 9/29/23, read Resident #83 had a stage II pressure ulcer to her sacrum and right heel and a deep tissue injury to her left heel related to a history of ulcers and impaired mobility due to pelvic fractures. The stage II pressure ulcer to the sacrum resolved on 10/5/23. Interventions initiated on 9/29/23 included to avoid positioning the resident's heels flat on the bed and laying flat on her heels for an extended period of time. A letter from the registered nurse (RN) #2 was provided by the nursing home administrator (NHA) via email on 11/20/23. According to the letter, RN #2 covered the wound rounds the week of 9/17/23 to 9/23/23. The letter read the resident had interventions put in place on the day of her admission [DATE]) related to stage II pressure injury (sacrum), comorbidities and pressure injury risk. The interventions were identified as turning and repositioning every two hours, air mattress, the registered dietitian to evaluate nutritional needs, protect bony prominences, elevate legs to minimize swelling, pressure relieving cushion to her wheelchair and physical and occupational therapy to increase functional mobility. -The letter did not identify specific interventions to prevent the development of pressure injuries to her heels. A. Right heel unstageable pressure injury The pressure wound log for the week of 9/24/23 and 9/30/23 read Resident #83 had a stage II pressure injury to her right heel. A foam heel protector and heel protective boots were put in place. The 9/25/23 CPO directed staff to float heels at all times while the resident was in bed using a wedge or boots as tolerated. The 9/25/23 CPO directed staff to provide daily wound review to her right heel. The 9/27/23 wound care physician assistant (PA) progress note read Resident #84 developed two new pressure wounds on her heels on 9/27/23 (9/24/23). According to the progress note, the initial wound encounter measurement of the resident's right heel stage II pressure injury was 5 centimeters (cm) in length by 5 cm in width with a serum filled blister. The PA recommended the staff to implement pressure relieving measures and offloading as tolerated to include a speciality device of a heel protector. The 9/27/23 skin and wound assessment read Resident #83 had a new stage II pressure injury/ulcer to her right heel. The pressure injury was facility acquired on 9/24/23. The stage II pressure injury to her right heel measured 3.9 cm in length by 2 cm in width. According to the assessment, the stage II pressure injury was healable. Interventions included heel suspension/protection device, a mattress with a pump, nutritional supplementation, reposition devices and turning/repositioning program. The assessment read Resident #83 was admitted to the facility due to a fall with left pubic fracture with a history of pressure ulcers. Her mobility was impaired and the resident required assistance with repositioning/loading heels. The resident was noted to have a stage II pressure injury presenting as a serum filled blister. Staff continue to offload heels. No dressing would be applied until the blister ruptured. The staff educated the resident on the importance of offloading pressure to bony prominences frequently. The resident verbalized understanding but would require assistance due to her limited mobility. The 10/11/23 skin and wound assessment identified Resident #83's stage II pressure injury/ulcer to her right heel measured 2.4 cm in length by 2 cm in width. The assessment read Resident #83's blister to the right heel ruptured and there was 60% eschar (necrotic) tissue present. The wound physician assistant (PA) assessed and diagnosed the wound as an unstageable pressure ulcer. New orders were placed for Santyl ointment applied daily to break down eschar tissue. The 10/18/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury had improved as evidenced by most of the eschar had broken down to slough (thick, yellow nonviable tissue). The skilled evaluations between 10/26/23 and 11/15/23 were provided by the facility on 11/15/23 at 2:25 p.m. The skilled evaluations all identified the right heel needed to be reviewed. The skilled evaluations between 10/26/23 and 11/15/23 all identified the wound to the right heel was a stage II pressure injury with slough on the wound bed, thin, watery, pale, red/pink drainage with moderate dressing saturation of 26-75%. There was partial thickness skin loss with exposed dermis. The skin tissue was boggy (mushy to the touch) and the resident had episodic pain. -However, the stage II pressure injury was identified as an unstageable pressure injury beginning on 10/11/23. The skin evaluation documentation did not change between 10/26/23 and 11/15/23, indicating the resident's right heel was not reviewed daily as ordered (refer to the 9/25/23 CPO above). The 11/1/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury had 40% of wound filled eschar. The resident returned from the hospital with new orders for Triad cream and a foam dressing applied three times a week and as needed. The 11/7/23 skin and wound assessment read Resident #83's right heel unstageable pressure injury was showing improvement. According to the assessment, the resident continued with heel protective boots to float heels while in bed. Her legs were elevated when the resident was in her chair to aid with pressure reduction and fluid. B. Left heel unstageable pressure injury The pressure wound log for the week of 9/24/23 and 9/30/23 read Resident #83 had a deep tissue injury to her left heel. The resident was treated with betadine qd (daily) and heel protective boots were put in place. The 9/27/23 wound care physician assistant (PA) progress note described the left heel deep tissue pressure injury as a persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer measuring 2 cm by 1.7 cm. The PA recommended applying betadine and floating heels. The 9/27/23 skin and wound assessment read Resident #83 had a new dark purple discoloration to the left heel consistent with a deep tissue injury (DTI) from pressure which was facility acquired on 9/24/23. The left heel DTI measured 2.1 cm in length by 1.5 cm in width. The DTI was identified as healable. Interventions included heel suspension/protection device, a mattress with a pump, nutritional supplementation, reposition devices and turning/repositioning program and a daily treatment of betadine. The staff educated the resident on the importance of offloading pressure to bony prominences frequently. The resident verbalized understanding but would require assistance due to her limited mobility. The 10/5/23 skin and wound assessment identified Resident #83's DTI had a slight increase in size. The DTI measured 2.5 cm in length by 2.1 cm in width. The pressure wound log for the week of 10/8/23 and 10/14/23 for Resident #83's left heel DTI identified the resident was COVID-19 positive and required more frequent repositioning. The 10/11/23 skin and wound assessment identified the resident's left heel DTI had an intact blister. The 10/11/23 CPO directed staff to provide daily wound review to her left heel. The 10/18/23 skin and wound assessment identified Resident #83's DTI measured 2.7 cm in length by 1.8 cm in width. The 10/23/23 health status note read Resident #83 was sent to the hospital. The 10/26/23 evaluation summary note read the resident had pressure ulcers to her bilateral heels. The skilled evaluations between 10/26/23 and 11/15/23 were provided by the facility on 11/15/23 at 2:25 p.m. The skilled evaluations all identified the left heel needed to be reviewed. The skilled evaluations between 10/26/23 and 11/15/23 all identified the left heel was a DTI with episodic pain and minimal saturation. According to the skilled evaluations a pressure ulcer staging was not applicable. -However, the DTI was identified as an unstageable pressure injury beginning on 10/11/23. The skin evaluation documentation did not change between 10/26/23 and 11/15/23, indicating the resident's left heel was not reviewed daily as ordered (refer to the 10/11/23 CPO above). The 10/27/23 CPO directed staff to apply a thick layer of Triad Hydrophilic barrier cream to the resident's bilateral heels and cover with foam dressing three times a week and as needed. The 11/1/23 skin and wound assessment identified Resident #83's the facility acquired DTI was now an unstageable pressure injury/ulcer to her left heel. She had 60% wound filled eschar. The 11/7/23 skin and wound assessment read the wound was improving with no eschar present. V. Staff interview The assistant director of nursing (ADON) was interviewed on 11/15/23 at 1:21 p.m. The ADON identified she was the facility wound nurse. The ADON said Resident #83 was admitted on [DATE]. The resident was admitted with stage II pressure ulcer to her sacrum. The ADON said she was on leave at the time of the resident's admission. She said staff initiated interventions related to the sacrum pressure ulcer but preventive measures directly to prevent pressure ulcers to the resident's heels were not in place. The ADON said the resident was at risk for pressure injuries to her heels because of her history of pressure ulcers, her impaired mobility after a recent fall prior to her admission and her need for more assistance. She said she would have added heel protective boots to protect the heels on admission and a wedge to lift the heels off of the surface of the bed. She said proper interventions were not put in place to prevent the development of pressure injuries to the resident's heels. The ADON said the weekend nurse identified the right heel stage II pressure injury and the left heel DTI on 9/24/23. The ADON said the resident's heels were off loaded starting on 9/25/23. The ADON said both wounds had decreased in size but currently both of the heels had unstageable pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#1) of three residents reviewed for falls out of eight sample residents. Specifically, the facility: -Failed to ensure certified nurse aide (CNA) #4 followed proper procedure while providing cares to Resident #1 and ensure the resident was safe; -Failed to implement two-person assistance when providing cares to Resident #1, which was identified as a resident need on their minimum data set (MDS) assessment, and, -Failed to implement a care-planned intervention to provide two-person assistance when providing cares to Resident #1. On the morning of 12/30/22, CNA #4 was preparing to assist Resident #1 with personal cares while she was in bed. The resident required two-person extensive assistance with activities of daily living (ADL). However, the CNA assisted the resident independently, without a second person, and the resident suffered a fall from the bed that resulted in pain, transportation to the emergency department, bilateral femur fractures and a hematoma (solid swelling of clotted blood) on her thigh. Findings include: I. Facility policy and procedure The Managing Falls and Fall Risk policy and procedure, dated March 2018, was provided by the assistant director of nurses (ADON) on 3/22/23 at 3:22 p.m. It included in pertinent part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors included delirium or other cognitive impairment, pain, lower extremity weakness, medication side effects, functional impairments, visual deficits, incontinence, heart failure, neurological disorders and balance and gait disorders. A resident-centered fall prevention plan would be implemented to reduce the specific risk factors for falls for each resident. II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2023 computerized physician orders, diagnoses included severe morbid obesity, generalized muscle weakness, difficulty in walking, and fractures of right and left femurs. The 10/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance with two plus person's physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. She had no rejection of care. B. Record review The care plan, initiated 11/27/2020 and revised 3/17/23, identified the resident preferred to have only female caregivers provide personal cares. Interventions included she would let female caregivers provide all personal cares, if possible provide female staff from other units to provide care, and staff would provide cares in teams of two for safety. The care plan, initiated 7/4/17 and revised 3/17/23, identified the resident required assistance with ADLs related to obesity, decreased mobility, and the aging process. Interventions included she was totally dependent on two-plus staff for repositioning and turning in bed, required extensive assistance by two staff to dress her, and was totally dependent on at least two staff to check and change her incontinence brief. The CNA [NAME] Report dated 12/30/22, included the following categories and interventions: she was totally dependent on two-plus staff for repositioning and turning in bed, she was totally dependent on at least two staff to check and change her incontinence brief, she required extensive assistance by two staff members to dress her The Nursing Quarterly Data Collection for Fall Risk, dated 10/10/22, identified the resident's score was 0.0, which indicated she was not at risk to fall. A progress note, dated 12/30/22 at 6:27 a.m., was written by a registered nurse (RN) and documented she was called to assess Resident #1 after a fall out of the bed. The resident was being turned when she rolled out of the left side of the bed onto her anterior surface. The RN assessed all of the resident's joints with pain noted in the anterior right knee. She was turned to her back with the assistance of four staff members with splinting provided to the lower extremities. A mechanical lift was used to transfer the resident into the bed. The resident had a large discoloration to her right knee that extended to the proximal lower leg and discoloration to the anterior right foot with swelling in both areas. There was a discoloration to her left knee and a small area on the mid anterior lower leg with swelling. Any assessment attempted by the RN of the right knee resulted in extreme pain. The resident was being changed by only one CNA at the time, which resulted in her rolling out of the bed. The medical doctor was contacted to obtain an order to transfer the resident to the hospital. The progress note included, Future intervention would be to always have two staff for all cares. The facility's investigation was reviewed and included the following: A CNA assigned to Resident #1's hall stated that he and CNA #4 began their check and changes and had completed changing all of the residents on the hall, with Resident #1 being their last resident. He stated CNA #4 went in on her own to speak to the resident due to him recently being kicked out because he was a male, which was the resident's preference to not have male caregivers. CNA #4 voiced that it was okay for her to change Resident #1 alone, due to trust amongst one another. The investigation documented CNA #4 was interviewed and reported during the care the resident rolled out of bed and experienced a witnessed fall. The resident stated, I rolled out of the bed. The CNA verbalized that Resident #1 fell while she was attempting to adjust/reach for a personal item, causing her momentum to shift without the ability to stop herself, which resulted in the fall. Interviews conducted indicated that the resident had a history of kicking other staff members out and declining cares. The resident's preference is not to have males change her. CNA #4 stated that the resident verbalized okay to being changed alone. The hospital emergency department admission history and physical, dated 12/30/23, was reviewed and documented the x-ray results of her bilateral legs included pain after a fall which resulted in severely comminuted (multiple bone splinters or fragments) impacted distal femur fracture with some posterior displacement. The patella (knee cap) was displaced laterally (to the side). The resident experienced low blood pressure and heart rate after she was given pain medication and required resuscitation with fluids. She was admitted to the hospital and did not return to the facility until 1/13/23 (14 days later). III. Staff interviews The director of nurses (DON), ADON and nursing home administrator (NHA) were interviewed on 3/21/23 at approximately 3:30 p.m. and explained the facility did not currently have an MDS coordinator who could be interviewed. The MDS assessment dated [DATE] was reviewed and the DON said Resident #1 was assessed to require extensive assistance of two people for bed mobility. The ADON clarified the staff were providing more than 50 percent of the assistance but the resident was able to participate some, less than 50 percent. The ADON said the two people would mean there was one person on each side of the bed so one would help roll and the other would help hold the resident during turning and bed mobility. The NHA was interviewed on 3/21/23 at 4:04 p.m., and he said on the day Resident #1 fell out of bed, two CNAs working on that floor; a male and a female CNA (CNA #4) were conducting rounds. He said CNA #4 made the decision to go in and ask Resident #1 if it was okay to provide cares to her without the assistance of a second staff member, and that CNA #4 admitted to not asking anyone for help. The NHA said staffing was not low and there was an extra staff member working that morning until 10:00 a.m. He said CNA #4 had initiated cares with the resident by herself, when the resident reached for a personal item and then fell out of bed. He said there was a time prior when Resident #1 would accuse the staff of stealing things from her, so they initiated cares in pairs for mechanical lift use as well as for behavioral reasons. Restorative certified nurse aide (RCNA) #1 was interviewed on 3/21/23 at 4:20 p.m., and she said she routinely worked with Resident #1. She said the facility had multiple ways to communicate to staff which residents required two-person cares and assistance. A sign was posted on the wall in each resident's room above their bed to indicate whether the person required a mechanical lift for transfers as well as how many staff were required to provide assistance for cares. In addition, she said a CNA Book was located at each of the nurses' stations with a list of which residents required a mechanical lift, the sling size, their room number and their name. She said all clinical staff were trained prior to starting work on the floors about this. The RCNA showed the list that was posted in the CNA book in December 2022, and it revealed Resident #1 required transfers with a Hoyer mechanical lift with a green sling. The RCNA said she also checked the residents' care plans to ensure the interventions were care-planned approaches. The RCNA said Resident #1 was supposed to have two-person assistance for personal cares as well, which included bed mobility, which was for both the resident's and the staff's safety. The RCNA said Resident #1 was able to make safe decisions about her care sometimes, but not always, and at times the resident would grab the straps on the mechanical lift during transfers, and that was not safe. She said Resident #1 had a history of falsely accusing staff of mistreating her, so the facility began providing care to her in pairs, with two staff members present. The RCNA said the resident was particular about which CNAs provided her with care, and she did not like male caregivers. CNA #3 was interviewed on 3/21/23 at 4:55 p.m., and she said she routinely worked with Resident #1. She said Resident #1 could brush her hair, wash her face, and brush her teeth if she was provided with set up assistance. She said when the resident was turned in bed, they were always supposed to provide assistance with two people because the resident was very large and could roll off. The CNA said Resident #1 had days where she was alert and could make good safety decisions about her care, and she had days where she was confused, and was not consistently alert and oriented. CNA #3 said the facility had provided clinical staff with additional training on how to safely provide care for Resident #1 after her fall, but said she did not receive the training. Instead, she said she was told by nurses what they were doing now to provide care for the resident. RN #3 was interviewed on 3/21/23 at 5:07 p.m., and she said she routinely worked with Resident #1. She said the resident could not provide much care for herself and before the accident, she required two-person assistance for ADL care, transfers, changing her, and rolling her in bed because she was very large. She said Resident #1 was confused at times and would accuse staff of random things that were not true, and did not like men in her room. She had a cognitive communication deficit with garbled speech and was difficult to understand at times. RN #3 said it was not a normal behavior of Resident #1 that she would accept care assistance from a single staff person because she was always scared she was going to roll off the bed, and knew it was in her best interest for safety to have the assistance of two staff members at a time. RN #3 stated, She didn't really have good safety awareness and had a fear of falling. RN #3 said one staff member would go in and help her at times because there was not enough staff. She said as recently as last night, she was aware of a single staff member providing care and assistance to a resident who required two-person assistance. RN #3 said after Resident #1 fell on [DATE] and returned to the facility from the hospital, a change was made that required her to receive the assistance of four staff members during cares and transfers, and there was never a time after that she did not have four people assist her. The RN stated, Everyone felt really bad. We did that to her. The medical director (MD) was interviewed on 3/21/23 at 3:08 p.m., and she said since Resident #1 was assessed by the facility to need two-person assistance for bed mobility and cares, then she should have been provided with that assistance. The MD said the resident's history with making her own reasonable, safe decisions was not reliable and she did not make appropriate decisions at times. The DON, ADON and NHA were interviewed on 3/21/23 at 5:29 p.m. The ADON said staff knew which residents required two-person cares because it was listed on the CNA [NAME], which could be accessed by CNAs and nurses. She said each residents' room also had laminated signs above the bed that indicated how much assistance they required. If a resident who required two-person assistance told a staff member it was acceptable to provide one-person assistance to them, they should still provide assistance of two staff members because it was for resident and staff safety. IV. Facility follow-up The NHA provided the following documentation on 3/22/23 at 4:11 p.m., which included the facility's response to Resident #1's fall on 12/30/22. The NHA said the audits were done recently and not during the time, the performance improvement plan was put in place, and included the following: An Ad Hoc Quality Assurance Performance Improvement/Four Point Plan of Correction Agenda and Summary, which was dated 1/3/23. The meeting was attended by 11 interdisciplinary team (IDT) members and identified an opportunity for improvement that included verifying that residents who required two-person cares was reflected on both the resident care plans and [NAME]. Audits were to be completed by 1/6/23. All direct care staff would be educated on residents who required two-person cares and educated to check the [NAME] when cares were provided, which was to be completed by 1/20/23. In addition, the DON or designee would complete the audits twice a week for four weeks to ensure that staff were following the plan of care. A Staff In-Service Summary, dated 1/12/23, included a review by the ADON that explained what the [NAME] was and where it was located. There was no attendance record included. An undated, untitled Attendance record was provided, which included the signatures of 25 staff members. Four staff (two CNAs, one licensed practical nurse, and one RN) audits were included, which were undated to know when they were completed, and each included the following three questions: 1.When you are unsure of how a resident transfers, where can you find this information? 2. Do you know how to access the [NAME]/Care Plan to find this information? 3. Ask for demonstration on where to find how a specific resident transfers. One of the four staff members audited did not know how to access the [NAME]/Care Plan, and required a demonstration of the process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure effective and timely fall prevention practices to prevent falls for two (#19 and #49) of 12 residents out of 30 sample residents. Specifically, the facility failed to: -Conduct timely post fall investigations or at all; -Review residents' falls with the interdisciplinary team (IDT); -Update residents' care plans to reflect interventions to prevent falls; -Educate new staff on fall preventions for residents; and, -Follow care planned interventions to prevent falls. These failures led Resident #19 to experience six falls since admission from 2/2/22 through 7/18/22, the date of last fall, which resulted in the resident being treated at the emergency room for excessive bleeding of a head wound sustained during the fall requiring the resident to receive six staples to his head to close the wound. These failure also led Resident #49 to experience eight falls since admission from 3/7/22 through 7/9/22, the date of last fall. Early failures for the resident contributed to the resident experiencing a fall which resulted in a fracture to his leg, causing the resident pain and decreased mobility. Findings include: I. Facility policy and procedure The Fall Management and Investigation policy, effective 9/1/18, provided by the nursing home administrator (NHA) on 3/11/22 at 3:00 p.m., read in pertinent part, the facility utilized all reasonable efforts to provide a system to review residents' potential risk for falls and provide a proactive program of supervision, assistive devices and interventions to manage and minimize fall and identify residents continued needs. Post fall management and plan of care procedure included: -Fall interventions were reviewed for continued effectiveness at the weekly at risk meeting, -Revised interventions are routinely reviewed and updated to ensure effectiveness at the weekly at risk meeting, -Person Centered interventions were reviewed with the staff, family and resident for safety awareness and the risk and benefits of fall prevention. Post fall investigation procedures included: -Falls were investigated, reported, and documented using root cause analysis concepts. The administrator was responsible for instituting/commencing the investigation process. -A careful review and analysis of the possible contributing factors to the fall with or without injuries was completed using the QAPI (quality assurance process improvement )Post Fall Investigation Form. -The director of nursing (DON), or designee, analyzed results for trends and patterns in the resident falls to use as the basis for implementation of process improvement. II. Resident #19 A. Resident status Resident #19, age [AGE], was admitted on [DATE]. The August 2022 computerized physician orders (CPO) included diagnosis of Parkinson's disease, dementia with lewy bodies, and difficulty in walking. According to the 5/13/22 minimum data set (MDS) assessment, the resident scored a nine out of 15 on the brief interview for mental status (BIMS) assessment indicating the resident was moderately cognitively impaired. The resident required two person physical assistance with bed mobility, toileting, and transfers. The resident was not steady and only able to stabilize with human assistance with moving from a seated to standing position and surface-to-surface transfers. The resident used a wheelchair for mobility. The resident was noted to have a history of falls after admission and was identified on the 2/11/22 admission MDS to have fallen prior to admission. The resident was not identified on either the admission MDS or the 5/13/22 MDS for being on hospice. A social services note on 2/3/22 at 11:27 a.m. showed the resident was admitted for end of life care with no plans for discharge. B. Fall #1 The situation, background, assessment, and recommendations (SBAR) form dated 2/5/22 at 6:15 p.m. showed new interventions for frequent checks (no time frame). A nursing progress note on 2/5/22 at 7:12 p.m. showed the resident was found lying on his back on the floor at the foot of his bed. His head was leaning against the leg of a chair in the corner of the room. No apparent injuries were noted, but the resident reported he was in pain in his left ribs where he stated he broke them two weeks prior to admission and his pain was a seven or eight out of 10 (with 10 being the worst pain on the scale). He also reported a dull headache about a level three out of 10. His wheelchair was noted to be several feet away from the resident and he reported he was getting up to put a book over by the door and tripped walking towards the TV (television). The resident was noted to report he broke his ribs falling while getting out of the car and had fallen many times prior to that as well. An interdisciplinary team (IDT) fall review note dated 2/8/22 at 2:11 p.m. read the resident was status post fall on 2/5/22 at 6:15 p.m. He was found on the floor next to his bed. The resident was new to the facility and his primary diagnosis was Parkinson's disease. He was mobile throughout the facility using his wheelchair. He was able to take one or two steps, but only with staff present and with a gait belt. He is pleasant and cooperative, but his wife says at times does not understand his limitations. He was still adjusting to the facility. At the time of the fall he was attempting to turn on his TV. Staff were reminded to ensure his bedside table with needed items (call light, bed remote, TV remote) were within reach. Would continue to monitor the resident and anticipate needs. -A quality assurance and performance improvement (QAPI) post fall investigation was not provided for this fall. A Fall Risk Data Collection form, dated 2/5/22 at 6:15 p.m. showed the resident scored a 14 (no numerical range given) and any score 10 or more indicated more interventions should promptly be put into place. The resident's care plan initiated on 2/5/22 identified the resident was at risk for falls related to Parkinson's disease, a history of falls, oxygen use, back pain, and psychotropic medications. -Although this fall was noted to be reviewed in the care plan, there were no new interventions or revisions to the care plan to prevent further falls. B. Fall #2 An SBAR form on 2/5/22 at 8:15 p.m, two hours after the first fall, showed the resident had fallen again. There were no new interventions or orders listed. The nursing progress note on 2/6/22 at 12:07 p.m. showed while doing a nurse report a loud noise was heard from the resident's room. When entering the room the resident was noted on the floor on his back by the foot of his bed. Upon assessment by the registered nurse (RN) there were no injuries noted. The resident stated he was trying to turn on the TV. The resident was assisted back to bed using a mechanical lift with no pain and was able to move all extremities. The director of nursing (DON) and hospice were notified, and the primary care provider (PCP) notified via fax. The staff were educated to monitor the resident more often. -There were no IDT notes or post fall investigation provided for this fall. -The care plan did not address this fall nor did it provide any new information or interventions to prevent further falls. C. Fall #3 A nursing note on 2/27/22 at 11:07 a.m. showed at approximately 9:55 a.m. Resident #19 was found by a staff member on the ground between the two beds in the room. The resident had not attempted to call staff to assist with transferring as the call light was not activated. A skin tear was noted to the left upper anterior forearm with scant exudate noted. The resident was noted to have footwear in place, non-skid strips present at the side of the bed, and the floor was free of clutter with adequate lighting. The resident was able to freely move all extremities with no complaints of pain. The resident was reminded to call for transfers. The resident was with minimal complaints of pain overall. -The SBAR summary note on 2/27/22 at 9:55 a.m. did not list any new orders or interventions. A follow up nursing note on 2/27/22 at 2:27 p.m. showed the resident fell trying to self ambulate from wheelchair to bed. The resident wanted to lie down in bed and did not use the call light. His wheelchair brakes were noted to be unlocked, and he was wearing shoes. The resident did have a skin tear on his left forearm from the fall and was well approximated with steri-strips. -There were no QAPI post fall investigations or IDT fall review notes provided for this fall. On 3/2/22 a health status note indicated the resident had bruising and swelling of his left ring finger and had no pain and was attending meals in the dining room. A faxed order from the PCP regarding the fall on 2/27/22 ordered physical therapy to evaluate, orthostatic blood pressures, and his cerumen (ear wax) to be checked. -Although there was noted to be a revised goal on 2/28/22 the resident would have decreased risk for injury associated with a fall through the next review date, there were no new interventions noted in the care plan to prevent further falls. D. Fall #4 A nursing note on 3/4/22 at 3:24 p.m. showed the resident had a witnessed fall in the bathroom. He stood up from the toilet and fell against the wall while sliding to the floor. He had a small abrasion to the back of his head. He denied pain and discomfort, and there was no bleeding or other injuries noted. The plan of action was noted to not leave him unattended while in the bathroom. The SBAR summary noted new interventions of monitoring the resident while in the restroom. An incident report dated 3/9/22, five days after the fall, read the care plan was updated to reflect the stipulation of toileting, the resident was not to be left alone while sitting on the toilet. A health status note on 3/4/22 at 5:56 p.m. showed the resident had some bruising to the inner left forearm and swelling to the outer aspect of the left forearm. Sensation to his fingers was intact, warm to touch and he could move his arm without difficulty. A health status note on 3/6/22 at 3:20 p.m. showed the resident was exhibining limited range of motion in the left arm and favoring it. He winced and guarded that arm when touched. The entire left forearm was swollen, bruised, and tender with capillary refill in less than five seconds. The facility spoke to the resident's spouse and explained that due to the resident's increased pain to the area and limited range of motion (ROM) an evaluation would be appropriate. The spouse agreed and an order was obtained by the on-call provider to send the resident to the emergency room for evaluation. The resident returned the same day with no fractures noted, and an order for an antibiotic topical bactroban ointment to be administered to his skin tear on his left forearm (from the previous fall). A QAPI post fall investigation dated 3/4/22 at 4:46 p.m. showed the resident was last checked on at 2:38 p.m. by a certified nurse aide (CNA). It was a witnessed fall in the bathroom getting up off the toilet although equipment involved was noted to be a low bed at the time of the fall. -Revisions to the care plan were noted to have been completed on 3/7/22, three days after the fall and time of the QAPI notes effective date. It did not specify the revisions to the care plan. An intervention in the resident's care plan initiated on 3/9/22 (five days after the fall) showed the resident was not to be left unattended while utilizing the toilet. E. Fall #5 An SBAR summary dated 3/7/22 at 6:00 p.m. indicated the resident experienced a fall. The note provided no detail to the nature of the fall. New interventions noted were increased observations. -There were no associated nursing notes or IDT notes providing information about the nature of the fall. A QAPI post fall investigation dated 3/9/22 at 4:00 p.m, two business days after the fall, was provided. It showed the fall on 3/7/22 was unwitnessed and in the resident's room. The resident was found on the floor. The time the resident was last checked on was left blank. The resident was noted to have not sustained any injuries and was not transported to the hospital. The form asked if there was a pattern with falls including time, location, or activity and it was documented as no. Activity at the time of fall was indicated to be moving between surfaces and equipment involved showed the resident wheelchair. A revision to the care plan was noted to have been completed on 3/8/22, it did specify the changes made. -There was no mention of the 3/7/22 fall in the resident's care plan, nor were there updates or revisions specific to this fall. F. Fall #6 A nursing progress note on 7/18/22 at 4:36 p.m. showed the nurse was called to the resident's room around 3:45 p.m. and the resident was lying prone (on stomach) and parallel to the bed on the floor. The resident was fully dressed with non-skid socks on. Two CNAs and the floor nurse turned the resident to the supine position (on his back). The nurse noted she attended to the resident's injuries sustained to his head, which were lacerations to the right eyebrow, top of right scalp, and base of right scalp. Hematomas were noted on the top and base of the right scalp. The nurse applied pressure to the wounds and cleaned blood from the resident's face and around his head. The nurse asked the resident what happened and it was noted the resident replied he was answering the front door. The nurse reassured the resident that the paramedics were on the way. A nursing note the next day by another RN on 7/19/22 at 11:47 a.m. detailed the fall. It showed the RN heard yelling coming from the patient's room. The RN entered the room to find the resident prone next to his bed. A large pool of blood was underneath the resident and blood was pouring out of his head. The resident was fully dressed with non-skid socks on. It was noted the resident's bed was way higher than it normally was. The resident was noted to have a right eyebrow laceration and two large hematomas, one of which was bleeding heavily. The resident also sustained two large skin tears to the right arm. 911 was called and the resident was sent to the hospital. The SBAR summary dated 7/18/22 at 3:55 p.m. showed the resident was sent out to the hospital emergency room and received six staples to the head and a head CT (computed tomography) scan. The final transcription from the hospital record showed the resident arrived at the hospital at 4:10 p.m. and discharged back to the facility at 9:50 p.m. on 7/18/22. The emergency room physician's note showed the resident was brought to the emergency room from a skilled nursing facility after a fall. The resident sustained a laceration to his right scalp which was stapled (six staples). The imaging performed showed no acute traumatic injuries and the resident was deemed safe to return to the facility. An IDT note on 7/27/22 at 1:19 p.m. showed staff were educated on the appropriate level of where the resident bed should be. A lipped mattress was ordered to help prevent rolling out of bed for safety. No falls were noted since 7/18/22, the time of the note. The resident's staples were noted to be removed on 7/28/22 without difficulty or signs or symptoms of infections. A QAPI post fall investigation dated 7/20/22 at 12:19 a.m. (two business days after fall) showed the resident was last checked on by a CNA at 3:00 p.m. the day of the fall. The location of the fall was in the resident's room. Revision to the care plans were documented as being completed on 7/19/22 and other pertinent information was noted the resident would be within sight while toileting. -There was no indication the resident was using the toilet during the time of this fall, as well as this intervention was added to the care plan for a previous fall on 3/9/22. If the resident was using the toilet, the care plan was not followed. -The resident's care plan under a focus of The resident has had an actual fall with no injury (the care plan did not focus on falls with injury) showed an initiation date of 2/6/22 and a revision date of 7/19/22. Although listed as revised, there were no new interventions listed to prevent the resident from further falls. Revisions made to the care plan addressed monitoring for change in condition and neurological status checks for 72 hours. An intervention dated 4/12/22 showed staff needed to keep the resident's bed at an appropriate height to allow the resident to get up and down safely; it did not specify what height that was. G. Observations The resident was observed in his wheelchair on 8/10/22 at 3:19 p.m. next to his bed alone with no staff present. The resident was leaning forward grabbing at his socks. H. Interviews Licensed practical nurse (LPN) #2 was interviewed on 8/11/22 at 9:02 a.m. She said the fall interventions for Resident #19 were to keep him in line of sight and busy in activities. She said the staff would not put him in the wheelchair by his bed because he would try to transfer on his own and fall. She said he did fall out of bed recently which was new for him and now they have a bolster on his bed to prevent him from rolling out of bed. She said the main goal was to keep him within line of sight of the staff. -These interventions (bolster to bed and line of sight) were not listed in the resident's care plan. -The resident was observed parked in his wheelchair next to his bed the day prior despite the LPN saying this was a preventive fall measure. LPN #3 was interviewed on 8/10/22 at 3:26 p.m. She was Resident #19 was pleasant but oriented to himself only. She said he could not make his needs known and the staff anticipated his needs as he required total care by staff. She said she had only worked at the facility for a few months and the resident had a fall in that time when he rolled out of bed and lacerated his forehead and needed six staples. She said fall interventions for the resident included non-skid socks, a high back wheelchair, and the bolster which was added in July (2022). -However, there were no care plan updates to address the resident rolling out of bed or mention of the bolster to his bed in the care plan. The DON was interviewed on 8/11/22 at 5:41 p.m. She said when a resident had a fall the IDT team usually meets the next business day to review the information from the nurses and CNAs. She said she looked at what happened, what was the cause, and reviewed and updated the resident's care plan. She said Resident #19 required full assistance from staff due to his advanced Parkinson's disease. She said the IDT team would look at it from all perspectives because the interdisciplinary team has staff that were not nurses and maybe then could identify causes and interventions that she and the nurses did not see. She said the facility did an investigation form for each fall. She said she would have to look at the resident's information but she thought the resident's falls were under control. She was unaware of specific fall interventions for the resident but she said she would expect his bed to be in the low position because he was assessed and determined to be a fall risk. She was not familiar with the resident's falls and was unaware of interventions put in place since. -The resident's care plan did not specify the bed should be in the low position but at an appropriate height to allow the resident to get up and down from bed safely. -There was no further information provided by the DON after the survey by close of business the next day on 8/12/22. V. Resident #49 A. Resident status Resident #49, age [AGE], was admitted on [DATE]. The August 2022 CPO diagnoses included Alzhiemer's disease, muscle weakness, and type 2 diabetes mellitus. According to the 7/5/22 MDS assessment the resident scored a four out of 10 on the brief interview for mental status indicating severe cognitive impairment. The resident was a two person physical assist with bed mobility, transferring, and toileting. The resident was not steady and could only stabilize with human assistance with moving from a seated to standing position. The 3/18/22 admission MDS showed it was undetermined if the resident had any falls prior to admission but did show the resident had a fall since admission on [DATE]. B. Record review Fall risk The resident's admission fall risk assessment dated [DATE], day of admission, identified the resident was a fall risk. 1. Fall #1 A nursing note progress note on 3/10/22 at 6:36 p.m. showed the resident experienced an unwitnessed fall by his recliner. He was found on the floor on his left side. Non-skid socks were on and his walker was within reach. The resident's power of attorney (POA) was noted to have said the resident could not have his foot rest on his recliner up. -The SBAR summary dated 3/10/22 at 10:17 p.m. did not include any updates or new interventions -The IDT team note dated 3/15/22 at 11:34 a.m. did not address the resident's fall. There was noted to be some aggressive behavior, which was the focus of the note. -A QAPI post fall investigation was not completed. The resident's care plan did address the fall on 3/10/22. -However, interventions noted were to monitor the resident 72 hours post fall for change in condition. There were no interventions to prevent further falls. 2. Fall #2 A nursing progress note on 3/11/22 at 11:00 p.m. showed the resident was found on the floor sitting next to his recliner. The foot of the recliner was still elevated. The resident was noted to say I just wanted to get up. The resident's walker was noted to be at his bedside and he was wearing regular socks. The room was well lit with no obstacles on the floor, and his shoes were next to the chair. There were no new injuries noted and future prevention was to have non-skid socks on and non-skid strips at the bedside and chair. -There was no mention of the recliner's footrest as the POA had already informed the facility staff the resident had issues with the footrest on his recliner. -The QAPI post fall investigation dated 3/12/22 at 6:27 p.m. indicated fall factors related to the resident's walker and shoes despite the nurses progress note stating the resident was not wearing shoes and the walker was at the resident's bedside. There was no mention of the recliners listed in the investigation form. -An IDT team note on 3/15/22 at 11:34 p.m. showed the team had discussed the resident's aggressive behaviors with other residents at the time. There was no mention of falls or a fall review noted. -The resident's care plan did not address the resident's fall on 3/11/22 nor were there any updates, revisions, or new interventions added to prevent further falls. There was no mention of the resident's reclining footrest. -The SBAR summary for the fall on 3/11/22 did not note any new orders or interventions. 3. Fall #3 with injury On 4/4/22 at 3:29 a.m. a nursing progress note showed staff heard a crashing noise come down the hall. The nurse and CNA on the hall went to find the noise and found Resident #49 on the floor in his bedroom with his shoes and brief on. The CNA was noted to have checked on the resident just 30 to 45 minutes previously and he was sleeping in his recliner with his shoes on. The resident's walker was noted to be beside the resident and as if he had pushed it away from himself. The resident had an abrasion to his left knee and skin tear to his left forearm. The staff used a mechanical lift to return the resident to his recliner as this was where he preferred to sleep. There were no other observable injuries noted at this time. A QAPI post fall investigation on 4/6/22 at 1:51 p.m. showed the resident fell at 3:15 a.m. and was last checked on by a CNA at 1:45 a.m. and a fall pattern was noted to be at night when he was more confused. A revision to the care plan was noted to have been completed on 4/5/22 and staff had been informed of the necessary changes. An alert note on 4/4/22 at 7:00 p.m. showed the staff had notified the resident's wife the resident was having pain and some swelling to his left leg which they were elevating and icing and would reevaluate in the morning. An IDT note on 4/5/22 at 4:30 p.m. showed the resident had fallen on 4/4/22 with immediate injuries noted to be an abrasion to left knee, left hand skin tear, and a blister to the left third toe. The resident was ambulatory but complained of pain to the left knee with weight bearing. A knee x-ray was ordered and performed which revealed a left tibial tip (shin bone) fracture. The PCP was notified and ordered non weight bearing status for 12 weeks and an immobilizer to the left knee. A full lift was to be used for transfers to prevent weight bearing. Restorative was to get a wheelchair with extended leg support to allow for elevation of the left leg. Pharmacy was noted to have reviewed medications and made no recommendations for changes. The IDT team was to follow up with further interventions as indicated. A health status note on 4/7/22 at 10:55 a.m. showed the resident had become combative during care if the left leg was touched. He would yell out for help, but became verbally abusive when helped. Tylenol was given for pain. Another IDT note on 4/7/22 at 1:11 p.m. showed the team reviewed the fall on 4/4/22. The resident continued to be non weight bearing due to a tibial tip fracture. An initial fall intervention to keep the walker close to the recliner was noted to be no longer appropriate as the resident was non weight bearing. A new intervention was noted: the resident had a wheelchair with an elevated leg to allow for improved mobility as well as a call don't fall sign placed in his room. Reminders to call for assistance were being offered to the resident, non-skid socks were in place, staff were offering to assist the resident outside for some time in the sunshine, staff retraining was done (did not specify what training was done), and skin tears and abrasions were being monitored. The family was noted to not have any further suggestions and staff would continue to implement any additional interventions as indicated. The resident's care plan showed updates (4/6/22) as: -Wheelchair with extended leg rest; -Knee immobilizer in place for 12 weeks, may be removed for bathing and skin care; and, -Pharmacy has reviewed medications. -There were no new interventions listed in the care plan to prevent further falls. 4. Fall #4 An SBAR summary note on 4/24/22 at 7:07 p.m. showed the resident experienced a fall with new intervention orders as increased observations overnight. A nursing progress note on 4/24/22 at 7:35 p.m. showed the resident was assessed by the RN for a fall and did not have any new injuries. His brace remained in proper position and he was assisted to bed using a lift and four staff members. The resident was incontinent of bowel at the time and did report a headache which was not new and was treated with non pharmacological methods. He was reported to have received a new wheelchair on 4/22/22 and the RN noted she would have therapy evaluate the wheelchair positioning and cushion to ensure they are appropriate for him. An IDT note on 4/25/22 at 11:19 for review of fall showed the resident fell out of his wheelchair the night previous after his evening meal. He was incontinent of bowel at the time of the fall and there were no new injuries. The resident was noted to be joking with staff following the fall, and the family was requesting a video monitor be placed and that was in process. The family and PCP were noted to have been notified and the care plan updated. A QAPI post fall investigation was completed on 4/25/22 at 11:07 a.m. and showed the resident fell on 4/24/22 at 7:10 p.m. in his room and was found on the floor, and was last checked on by staff at 6:30 p.m. The care plan was noted to be revised on 4/25/22. Care plan updates were noted on 4/25/22: -Urinal to be kept at bedside to assist with urinary incontinence and have a commode bedside to encourage fecal continence; -PT consult for strength and mobility; -Pharmacy consult to evaluate medications; and, -On 4/27/22 a video monitor was placed to allow for staff oversight without multiple interruptions. An IDT note on 4/27/22 at 2:43 p.m. showed for weekly fall review the resident fell out of his wheelchair on 4/24/22. There were no injuries from the fall and no latent injuries discovered. He was participating in therapy and a video monitor was in place to allow staff better oversight of the resident without agitating him. A call don't fall sign was placed and although the resident does not use the call light he did yell out I'm calling, not falling; this allowed the staff to respond. The room was being kept clean and clear of clutter and the resident was offered assistance to the recliner or bed often to increase comfort. The family was noted to be happy with the plan of care. 5. Fall #5 A nursing progress note on 5/14/22 at 3:59 p.m. showed the resident was found lying on the floor on his left side leaning his head and torso against his recliner. No injuries were reported. Another nursing note at 8:07 p.m. showed the resident fell unwitnessed and denied pain with no apparent injuries. The resident stated he was sleeping and does not remember falling. The SBAR summary on 5/14/22 at 3:38 p.m. summarized the resident was lying in his recliner when it tipped over causing him to slide to the ground. -The nursing notes did not indicate the recliner was tipped over. The QAPI post fall investigation dated 5/16/22 at 12:58 a.m. (two days after fall) did not indicate when the resident was last checked on prior to fall. A pattern was identified as the resident was often attempting to self transfer as he has dementia and does not recall his limitations. Other pertinent information documented was the resident was settling in more at the facility and was improving with therapies which may be contributing to his over estimation of his abilities. The care plan was noted to be revised 5/16/22. The care plan was revised on 5/16/22 with an intervention to keep the video monitor on the medication cart during high care times to ensure safety at all times. An IDT note on 5/16/22 at 1:56 p.m showed the resident had slid out of his recliner and stated he was just sleeping. There were no injuries and the area was checked and was free of trip hazards and spills. The resident was wearing his shoes and socks and he did not often use the call light and did have a sign to call don't fall, which had been helping him to remember to call out but he did not call out this time. He was noted to lack safety awareness and had been participating in therapies which may have him overestimating his abilities. The staff were to have the video monitor on their med cart now to allow visualization during higher care times when the staff was not readily at the station. 6. Fall #6 A nursing progress note on 5/18/22 at 4:09 p.m. showed the resident had an unwitnessed fall. The resident was lying on the floor on his right side. His shoes were on and the resident was able to move all extremities. He was heard yelling for help just prior to the fall and found by the CNA. The camera was noted to be in the proper position and within view of the nurse. He was standing prior to the fall and the wheelchair was to his left side. The floor was dry, and the call light was nearby. The family was notified and requested the resident not be left in his wheelchair alone. The SBAR summary on 5/18/22 at 4:33 p.m. showed the resident was able to stand and ambulate there were no new interventions ordered. The IDT note on 5/19/22 at 3:27 p.m. showed the resident had returned f[TRUNCATED]