**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 (#1) of three residents out of three sample residents. Resident #1, who was known to be at risk for falls, fell seven times between 12/8/24 and 2/1/25. The resident suffered a hip fracture as a result of one of the falls. The facility could not determine which fall resulted in the hip fracture. Resident #1 had one fall because his bed moved and six falls were because he attempted to self-transfer in or out of bed. Most of his falls were before or after meals and the resident was often incontinent at the time. According to staff, Resident #1 was very routine and would want to go to meals early, return to his room, use the urinal on the edge of his bed and lay down. He would self propel in his wheelchair to and from the dining room. Staff identified difficulty arriving to his room before he self-transferred to and from his bed. Resident #1 had a significant memory deficit and would be frequently reminded to use the call light as an immediate intervention. The facility failed to identify and implement timely interventions for Resident #1 in order to prevent multiple falls of similar occurrence that resulted in a hip fracture, a decrease in ability and a decision to place the resident on hospice services. Additionally, observations and record review during the survey revealed facility staff failed to consistently implement care planned fall interventions when Resident #1 was in bed (see observations below). Findings include: I. Facility policy and procedure The Fall Prevention and Management policy, revised 7/29/24, was provided by the nursing home administrator (NHA) on 2/27/25 via email. The policy's purpose read in pertinent part, To promote resident well-being by developing and implementing a fall prevention and management program; to identify risk factors and implement interventions before a fall occurs; to give prompt treatment after a fall occurs; and, to provide guidance for documentation. The policy identified the facility should review and update the care plan with any changes/new interventions and continue to monitor the condition and the effectiveness of the interventions. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included other sequelae of cerebral infarction (long term complications that can occur following a stroke), unspecified dementia without behavioral disturbance, cognitive communication deficit, fracture of unspecified part of the neck of right femur, subsequent encounter for a closed fracture with routine healing, difficulty walking, unsteadiness on feet, muscle weakness, lack in coordination, need for assistance with personal care and urgency of urination. According to the February 2025 CPO, the resident had repeated falls. The 1/31/25 minimum data set (MDS) assessment documented Resident #1 had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. According to the MDS assessment, there was not evidence of an acute change in mental status from the resident's baseline. The resident was dependent on staff for most of his activities of daily living (ADL), including transferring from surface to surface. He used a wheelchair for mobility. The MDS assessment indicated Resident #1 did not have rejections of care, physical or verbal behaviors directed to others or other behaviors or other behavioral symptoms not directed at others. The MDS assessment identified Resident #1 had a history of falls in the past six months and one fall without injury since his last assessment. Resident #1 had a life expectancy of six months or less. B. Resident observation and interview On 2/25/25 at 12:46 p.m. Resident #1 was lying in his bed. The bed was flush against the wall, his bed wheels were locked and his call light was within reach. -Resident #1 did not have his bed in the low position, as identified as a fall intervention in the resident's care plan (see care plan below) or a pool noodle under the fitted sheet between his body as recommended by the occupational therapist (OT) (see progress notes below). Resident #1 said he did know the details of his falls or why he fell. He said he only knew that he had a fall. He said he was not currently in pain. On 2/26/25 at 1:04 p.m. Resident #1 was lying in bed. His bed was in a low position and a pool noodle was between his body and the wall. -However, the pool noodle was on top of the blanket and sheets and not under the fitted sheet, as identified in the occupational therapy recommendation (see OT notes below). C. Visitor interview A visitor for Resident #1 was interviewed on 2/26/25 at 1:06 p.m. The visitor said he had visited with the resident everyday for the past couple of years. He said the pool noodle was placed on the bed so Resident #1 would not fall between the bed and the wall. D. Record review 1. Care plan Resident #1's fall care plans for an actual fall, initiated 5/3/23 and revised 2/18/25, and the resident's at risk for falls care plan, initiated 3/7/24, indicated the resident was at risk for falls related to deconditioning, cognitive deficits, confusion, gait imbalance and decreased safety awareness. The resident had a history of falls, poor communication/comprehension and was unaware of his safety needs. The fall care plan for actual falls indicated other fall factors included cerebral infarction, fracture of the left femur, fall history and anger issues. According to the actual fall care plan, Resident #1 sustained the following falls: a fall on 5/2/23 without injury; a fall on 5/6/23 without injury; a fall on 5/11/23 without injury; a fall on 4/13/24 without injury; a fall on 4/27/24 with a minor injury; a fall on 8/8/24 without injury; a fall on 12/8/24 with a head injury requiring stitches; a fall on 12/9/24 without injury; a fall on 12/13/24 without injury; a fall on 12/19/24 without injury; a fall on 12/30/24 without injury; a fall on 1/2/25 without injury; a fall on 1/24/25 with laceration to the forehead and complaints of hip pain, and the resident was sent to the hospital; and, a fall on 2/1/25 with a minor injury of a skin tear to his left elbow. The following interventions were added to the resident's care plan on 3/7/24, after the facility determined Resident #1 was at risk for falls: Remind the resident not to bend over to pick up dropped items, encourage him to use a grabber/reaching device or to ask for assistance, ensure the resident was wearing appropriate footwear of fully enclosed slip resistant shoes or gripper socks when ambulating or mobilizing in wheelchair, monitor the resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function, monitor visual and auditory impairments, ensure correct bed height by having bed in lowest position when resident was in room alone and reviewing as indicated for significant changes in cognition, safety awareness and decision-making capacity. The fall intervention initiated on 5/1/23 and revised on 5/1/23 documented the staff was to remove the resident's foot pedals from the wheelchair when staff was not pushing him. The fall interventions initiated on 5/3/23 and revised on 5/9/23 documented the staff should review Resident #1's history of recent or recurrent falls, ensure correct bed height by keeping in low position. According to the intervention, most of the resident's falls occurred at the bottom of the bed related to himself ambulating to the bathroom. The intervention indicated the resident had urinals available. Another fall intervention initiated on 5/3/23 and revised on 5/9/23 documented staff should ensure the resident was wearing appropriate footwear. According to the care plan, the resident would refuse gripper socks and non-slip shoes and liked being barefoot. According to the care plan intervention, the resident's fall on 5/6/23 identified the resident had gripper socks on but the gripper side was on top of his foot. The staff was educated and directed to monitor for proper placement of the socks with grips on the bottom of foot. The fall intervention initiated on 5/3/23 and revised on 4/16/24 documented that on 4/15/24, staff added Dycem (non-slip material) to the resident's recliner to help prevent the resident from sliding and falling. The fall intervention initiated on 12/11/24 and revised on 2/6/25 documented staff requested a physical therapy (PT) consult for strength and mobility and OT on 12/13/24 for transfers, PT, OT and activities to assess weakness, room safety, falls and boredom on 1/8/25 and on 2/1/25, the resident's bed was placed in low position and OT was to assess for noa (positioning) bars and bed positioning. The fall intervention initiated on 5/6/23 and revised on 1/31/25 directed staff to educate the resident not to bend over to pick up dropped items and encourage the resident to use a grabber or to ask for assistance. The care plan intervention documented the resident refused to allow staff to standby for assistance to the toilet. The 5/6/23 intervention directed staff to make sure the resident's call light was always visible and continue to encourage him to use it. According to the intervention, staff was educated on 12/19/24 to frequently monitor the resident, offer to transfer from bed to wheelchair before and after meals as well as in the morning and at night to prevent falls. The fall intervention initiated on 5/6/23 and revised on 1/31/25, documented that on 2/1/25 the resident needed his environment to be modified for maximum safety. The fall intervention initiated on 2/1/25 and revised on 2/3/25 directed staff to ensure Resident #1's bed was locked and against the wall in a low position. The fall intervention initiated on 5/3/23 and revised on 2/6/25 directed staff to review the resident as indicated for significant changes in cognition, safety awareness and decision-making capacity. According to the intervention, staff obtained laboratory work (labs) to rule out infections on 2/1/25. The fall intervention initiated on 5/3/23 and revised on 2/18/25 directed staff to provide activities that promoted exercise and strength building where possible, round before and after meals to stand/assist with transfers on 12/8/24 and add an art volunteer for social interaction. According to the care plan intervention, on 12/30/24 the resident's friend returned from vacation and the resident was no longer attempting to self-transfer. The friend would speak to the resident about safety and remind him to use the call light. The care plan intervention directed staff to encourage activities and offer one-to-one activities in the resident's room to fill the void while the friend was out of town to help prevent falls. -However, Resident #1 self-transferred on 1/2/25 and fell again. The end of life care plan, initiated on 1/30/25, documented Resident #1 had a terminal prognosis related to non-operative management of a right femoral fracture. Hospice services were put into place. The care plan directed staff to adjust the provision of ADLs to compensate for the resident's changing abilities and encourage participation to the extent the resident wished to participate. Resident #1's activities of daily living (ADL) care plan, identified the resident had an ADL performance deficit. The ADL transfer between surfaces intervention, revised 1/28/25, directed staff to use a two-person total lift transfer. 2. Pattern of falls Review of Resident #1's electronic medical record (EMR) from 12/1/24 through 2/25/25 revealed Resident #1 sustained seven falls during that time frame, including falls with injury. The falls were as follows: a. Fall with injury on 12/8/24 The 12/8/24 incident note documented someone was heard yelling for help down the hall. The certified nurse aide (CNA) reported Resident #1 was found on the floor. The resident was sitting on his bottom on the floor with his back to the dresser. The resident's wheelchair laid in a folded position on the floor at his feet. The resident had gripper socks on and his pants were slightly pulled down. According to the note, the resident had significant bleeding from a scalp wound. The note identified the wound as a quarter-sized skin tear with a two inch indentation to his scalp that continued to bleed when paramedics arrived. The incident note documented there was dried blood on the floor and it was undetermined how long the resident was on the floor. The registered nurse (RN) assessed for other injuries and no other injuries were identified. The 12/8/24 hospital emergency department notes identified Resident #1 had a laceration on his forehead requiring sutures and a hematoma (a localized collection of blood under the skin and outside the blood vessels). The 12/8/24 fall scene huddle worksheet was provided by the director of nursing (DON) on 2/25/25 at 10:20 a.m. The fall huddle worksheet documented Resident #1 was found on the floor incontinent of urine at 8:45 a.m., 45 minutes from when he last had contact with staff. The worksheet identified the resident was sitting in front of his dresser with his wheelchair on one side of him and blood on the floor on the other side of him. The 12/8/24 incident report was provided by the DON on 2/25/25 at 9:35 a.m. The incident report identified the fall occurred at 9:35 a.m. According to the incident report, predisposing physiological factors of the fall included impaired memory, confusion and incontinence. -The incident report documented the fall occurred at a different time than was identified on the fall huddle worksheet. The 12/8/24 hospital emergency department notes documented Resident #1 fell on [DATE] and was sent to the hospital. He had a laceration on his forehead requiring sutures and a hematoma. A 12/8/24 progress note identified the resident returned back to the facility from the emergency room on [DATE] with stitches applied to the artery that he opened during the fall. b. Fall on 12/9/24 The 12/9/24 fall tool identified Resident #1 was at high risk for falls. The 12/9/24 incident note identified Resident #1 had a total lift assist from the floor and was placed in his wheelchair. The note documented the resident denied hitting his head and would not allow a skin assessment because he was agitated and impatient. He had no pain with range of motion but he had slight pain with palpation to the right hip. According to the note, the resident fell on his right side the day before (12/8/24). The resident was assessed by the nurse practitioner (NP). The incident note identified the immediate intervention was education to the resident on the importance of using the call light for assistance before trying to get himself out of bed. The 12/9/24 fall huddle worksheet documented Resident #1 fell when he was attempting to self-transfer. He was last seen 20 minutes prior to the CNA finding him on the floor. The drawing on the fall huddle worksheet indicated the resident was found on the floor next to his bed. The resident was incontinent of urine and bowel. According to the fall huddle worksheet, the root cause of the fall was the resident's cognition and not using his call light. The 12/9/24 fall incident report identified the fall happened at 11:00 a.m. The report indicated the resident did not have injuries observed at the time of the incident. According to the report, the factors of the fall were weakness, gait imbalance, impaired memory, incontinence and not using his call light. The incident report identified the resident said he was trying to get out of bed to go to lunch. The 12/9/24 NP note identified the resident was seen for follow-up after multiple falls with a temporal artery laceration requiring sutures. The NP note documented Resident #1 was seen on 12/9/24, self-propelling his wheelchair to the dining room. The note indicated he was alert and oriented per his baseline and was calm and pleasant. He denied chest pain, palpitations or shortness of breath. The resident denied headache or dizziness. The note documented he had a recent fall (12/8/24) where he struck his head and sustained a laceration to the temporal artery which required an emergency department evaluation and multiple sutures. A CT (computed tomography) scan was conducted and he was negative for further acute process or brain bleed. Resident #1 denied pain and appeared comfortable on the exam since returning from the hospital. The resident had had another unwitnessed fall on 12/9/24 without injury. According to the note, Resident #1 had a memory impairment with dementia. The note identified he was impulsive and needed to be monitored for acute changes in his cognition and behaviors. The 12/10/24 communication visit with the physician note documented PT orders were requested for weakness, transfers and falls. According to the note, Resident #1 had changes of weakness as well as refusal of oral care and dental care. The resident had severe halitosis that could indicate an infection, a request for evaluation and orders were made. The 12/11/24 falls/interdisciplinary team (IDT) note documented the IDT met on 12/11/24 to review the 12/9/24 fall. Resident #1's medications, mobility status, room arrangement and interests and preferences were reviewed. According to the note, the intervention was for PT to evaluate and treat and staff would continue to monitor through the next evaluation date. The 12/31/24 PT note documented Resident #1 would benefit from continued assistance with all transfers due to his cognitive impairment. According to the note, he responded well to gentle guidance on proper set up. c. Fall on 12/13/24 The 12/12/24 at 3:52 a.m. (the day prior to the 12/13/24) fall) health status note revealed an increase in Resident #1's behaviors after the resident had a recent two falls. The note documented Resident #1 was very agitated on the 12/12/24 overnight shift and tried to get out of bed several times, yelling for help instead of using his call light and was able to communicate incontinence. Resident #1 told the staff that he had not slept in three days. The note identified lab work and a urine analysis would be obtained on the morning of 12/13/24 due to the resident's increase in behaviors. -The note did not identify if the resident was asked if he was in pain. The 12/13/24 incident note identified the resident had another unwitnessed fall. According to the note, the resident was found on the floor by a CNA. The resident was assessed and no injuries were identified. The note documented Resident #1 said he was trying to get into bed when he fell. The 12/13/24 fall huddle worksheet documented Resident #1 was found in his room on the floor next to his bed at 8:30 a.m. The resident was attempting to self-transfer when he fell. According to the worksheet, he was last seen at 7:00 a.m., one hour and 30 minutes prior to the fall. The worksheet identified the resident was wearing regular socks and not the gripper non-skid socks. The resident was incontinent of urine when he was found. The worksheet did not identify when the resident was last toileted. According to the fall huddle worksheet, the root cause of the fall was he was self-transferring. The 12/13/24 fall incident report documented Resident #1 was trying to get into bed. According to the report, there were no injuries observed at the time of the incident, the resident's range of motion was at baseline and he had weakness and a noted decline over the past few weeks. The fall incident report identified confusion as a factor to the fall. The 12/13/24 communication to the physician note identified the resident's lab results did not identify an infection. According to the note, the decline appeared to be a disease progression. The 12/16/24 physical therapy (PT) evaluation and plan of treatment was provided by the NHA on 2/26/25 at approximately 4:30 p.m. The PT goal was to improve ease of transfers to decrease Resident #1's risk for falls. According to the evaluation, the resident's 12/16/24 baseline for transfers was partial to moderate staff assistance needed for bed mobility, toilet transfers, sit-to-stand and chair-to-bed-to-chair transfers. The PT evaluation identified the resident had decreased functional capacity, decreased safety awareness, pain, strength impairments and procedural memory limitations. The 12/16/24 PT treatment encounter note revealed Resident #1 required total setup of his wheelchair in front of his bed with moderate assistance for a stand-pivot transfer and moderate assistance of bilateral leg management to move from a sitting position to laying down. The 12/18/24 care plan change note documented the IDT met and reviewed his fall on 12/13/24. According to the note, the intervention was for staff to round before and after meals to assist with transfers. The note indicated OT continued to work with him and a volunteer was requested to visit with him. d. Fall on 12/19/24 The 12/19/24 incident note identified Resident #1 had another unwitnessed fall in his room. The note documented Resident #1 fell on [DATE] at 7:15 p.m. He was observed sitting on the floor with bilateral hands grabbing the transfer bar on his bed to sit upright. His range of motion was at his baseline with all of his extremities but he had a slight redness on his left lateral back near his spine. According to the incident note, the resident was incontinent of bowel and bladder when he was found. The resident was assisted from the floor to his bed by use of a mechanical lift. The staff provided incontinent care and his bed was placed in a low position and his call light was placed within reach. The resident was reminded to use the call light for staff assistance. -Review of the progress notes did not identify Resident #1's 12/19/24 fall was reviewed by the IDT. -The 12/19/24 fall huddle worksheet did not identify when the resident was last seen by staff or when he was last toileted. The fall huddle worksheet did not identify the root cause of the fall. The 12/19/24 fall incident report documented Resident #1 was found sideways on the floor, parallel to the bed, facing towards the head of the bed and sitting on his bilateral buttock and his feet extending away from the bed and his bilateral hands gripping the transfer bar to keep himself upright. According to the incident report, Resident #1 said he didn't do anything. According to the incident report, factors of the fall included confusion, impaired memory and incontinence. The 12/19/24 physician note documented Resident #1's orientation level was stable but globally worsening over time. The note indicated the resident refused care intermittently and was agitated but was never aggressive. According to the note, the resident had functional impairments, bowel or bladder complications, new or worsening wounds, and significant cognitive deficits with high risk for falls with injury that required frequent monitoring. e. Fall on 12/30/24 The 12/30/24 incident note identified Resident #1 had another unwitnessed fall in his room while self-transferring. The note documented the resident was found on the floor by his family member. According to the note, the nurse had given the resident his medication on 12/30/24 at 12:06 p.m. The nurse then told the resident to wait for someone to help him go to bed and not transfer himself to bed. The note read the resident said he would wait. The note documented there were nine minutes between the time the resident was told to wait for help and when the resident's family member found him on the floor. The resident refused the skin assessment after the fall. Range of motion was conducted and the resident denied pain. The note indicated there were no new obvious injuries observed and the resident was assisted to bed per his request. The 12/30/24 fall huddle worksheet identified the 12/30/24 fall occurred at 12:15 p.m. The worksheet documented he was incontinent of bowel and bladder at the time of his fall. The brakes to his wheelchair were not locked and the resident was found sitting next to his bed. The fall huddle worksheet documented the root cause/intervention was because the resident did not wait for help like he was told to do and transferred anyway. -However, according to the resident's fall care plan, staff was educated after the resident's 12/19/24 fall to offer to transfer the resident to bed, not direct him to wait (see care plan above). The 12/30/24 fall incident report documented Resident #1 was educated again to wait for help before attempting to self-transfer. The incident report indicated the factors of the fall were gait imbalance, weakness, impaired memory and incontinence. According to the incident report, there were no injuries observed at the time of the fall. Review of the progress notes did not identify Resident #1's 12/30/24 fall was reviewed by the IDT. The 12/31/24 PT note documented Resident #1 would benefit from continued assistance with all transfers due to his cognitive impairment. According to the note, he responded well to gentle guidance on proper set up. f. Fall on 1/2/25 The 1/2/25 incident note identified Resident #1 had another unwitnessed fall in his room while self-transferring. The note documented the nurse was walking to another room when the nurse heard Resident #1 yelling help me. The nurse entered Resident #1's room and observed the resident sitting on the floor on the side of his bed. According to the note, the resident said he was trying to go to bed and slipped. The nurse assessed the resident and there were no concerns with his range of motion and the resident denied pain with palpation. The resident was lifted to his bed after he was assessed. The note documented the staff stressed the need for Resident #1 to listen when asked to wait for help and not to self-transfer. -The incident note documented the resident did not listen or wait for assistance, however, review of the resident's EMR and staff interviews identified he had a significant memory deficit and was impulsive (see record review above and staff interviews below). The 1/2/25 fall huddle worksheet documented Resident #1 fell on 1/2/25 at 8:45 a.m. According to the worksheet, the resident used a walker but was not using it at the time of the fall. The worksheet identified the resident was last toileted at 7:50 a.m. He was found incontinent of bowel and bladder at the time of the fall. The root cause/intervention documented Resident #1 did not listen, was impulsive and had a poor memory. -However, staff interviews identified the resident did not use a walker (see interviews below). The 1/2/25 fall incident report documented Resident #1 did not have injuries observed at the time of the incident. According to the incident report, gait imbalance, weakness, poor safety awareness and impaired memory and incontinence were factors of the fall. -The incident report did not include new interventions put in place after the unwitnessed fall. The 1/8/25 care plan change progress note documented the IDT met on 1/8/25 and reviewed Resident #1's 1/2/25 fall. The note identified Resident #1 was probably going to be discharged from PT because he did not want to participate. The note identified the facility attempted to have Resident #1 visit with a volunteer but he was not receptive to the volunteer. The note indicated the resident's friend was going to begin visiting again. -The care plan change note did not identify what new interventions the facility was going to put into place to prevent repeated falls of a similar nature. g. Incident of unknown source on 1/24/25 with major injury The 1/24/25 incident note identified that on 1/24/25 Resident #1 complained of pain to his right leg. The nursing assessment identified his right foot was pointing laterally outward. The resident denied pain but was moaning in pain. His leg was not able to go back to a neutral position, identifying a possible issue. The note documented the fall on 12/8/24 identified the resident was found on his right side and was sent to the hospital to repair a skin tear. The resident did not express right leg or hip pain as a result of the 12/8/24 fall. The note identified out of 33 pain ratings between 12/8/24 and 1/24/25, five of the pain ratings were identified at a pain level of 3 out 10,two of the pain ratings were identified at a pain level of 2 out 10, two of the pain ratings were identified at a pain level of 1 out 10 and 24 of the pain ratings were identified at pain level of zero out 10. The incident note indicated the resident often denied pain. The incident note documented Resident #1 continued to get out of bed and into his wheelchair. According to the note, the facility was unsure if that was the cause of the fracture or if any of the other falls were a result of the injury. Resident #1 denied any new fall or injury on 1/24/25 other than some pain in his hip and needed to be encouraged to go to the hospital for an assessment. Review of Resident #1's level of pain log between 12/8/24 and 1/24/25 revealed the resident's pain rating was logged everyday at least once a day, except between 1/11/25 and 1/22/25. The pain log on 1/23/25 identified the resident complained of pain at a rating of 7 out 10 at 1:52 p.m. He had a pain level of 3 out 10 on 1/23/25 at 5:06 p.m. Resident #1's pain level was 7 out of 10 on 1/24/25 at 11:25 a.m. and again at 2:07 p.m. The 1/24/25 nurse practitioner note revealed Resident #1 told the NP on 1/24/25 that his pain was primarily in his right leg and had been increasing over the last week. The NP note indicated an x-ray, conducted on 1/24/25, identified an acute femoral neck fracture and the resident would be sent to the emergency room (ER) for further evaluation. The 1/24/25 injury of unknown source incident report documented Resident #1 had a very close friend who visited often and the resident was very calm and happy during these visits. He would listen to the advice of his friend and the friend could also often get the resident to be compliant. The friend went on a long vacation and the resident was upset and lonely. The facility attempted different people to try to visit with the resident, including the resident's family. The report indicated the resident had several falls while the friend was absent from the facility. The incident report identified the falls on 12/8/24, 12/9/24, 12/13/24, 12/19/24, 12/30/24 and 1/2/25. The incident report identified one of the falls resulted in a laceration to Resident #1's forehead and he was sent to the hospital to evaluate his head injury. -The review of the falls identified the resident would continue to self-transfer in and out of bed and was frequently incontinent when the falls occurred. The falls would often occur after meals (see interviews below). The 1/26/25 admission/readmission note revealed Resident #1 returned to the facility on 1/26/25 from the hospital with a right femoral neck fracture. The resident and his family had chosen not to do surgical intervention of the fracture. According to the note, the resident was returning to the facility on hospice services. The 1/29/25 care conference note identified members of the IDT, hospice and the resident's family attended the conference. The members of hospice explained their role and how often they would be visiting Resident #1. The care conference note indicated the resident had a fall that resulted in a broken hip which could not be repaired so he returned to the facility on hospice services. The note documented Resident #1 had his own routine and was able to self propel his wheelchair. The 1/31/25 OT evaluation and treatment plan, beginning on 1/31/25, indicated OT was to help the resident with pain management with positioni[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#58) of six residents reviewed for accidents out of 39 sample residents remained free from accidents. Resident #58, who was known to be a fall risk and had care planned fall interventions in place, sustained a fall on 4/20/24 which resulted in a fracture of her left femur (upper leg). During the facility's investigation of the fall, it was discovered the floor alarm, which was care planned as an effective fall intervention for the resident, had been in the off position at the time of the resident's fall and did not sound, therefore staff had not been alerted to the resident's movements in her room. Staff was aware that in order to reset the alarm after it had been triggered, it was necessary to reset the alarm by switching it to the off position and returning it to the on position. However, staff failed to ensure the alarm was in the on position at the time of the resident's fall. Due to the facility's failure to ensure staff reset the alarm appropriately after it had been triggered, Resident #58 sustained a fall on 4/20/24 which resulted in a fracture of her left femur. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/1/24 to 5/7/24, resulting in the deficiency being cited as past noncompliance with a correction date of 5/4/24. I. Incident on 4/20/24 The facility failed to ensure staff reset Resident #58's floor alarm, which had been implemented as an effective fall intervention for the resident, appropriately to the on position after the alarm triggered. Due to the facility's failure, Resident #58 sustained a fall on 4/20/24 which resulted in a fracture of the resident's left femur. Record review and interviews during the onsite investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the survey from 5/1/24 to 5/7/24. II. Facility plan of correction A. Immediate action to correct the deficient practice for Resident #58 The corrective action plan implemented by the facility in response to Resident #58's fall on 4/20/24 was provided by the director of nursing on 5/6/2024 at 10:00 a.m. On 4/20/24, the facility conducted an investigation of Resident #58's fall. The facility interviewed all staff on duty who were involved in care for the resident on the day of fall and a few days prior to the fall. Inspection of the floor alarm device determined the alarm device was in an off position at the time of the fall and therefore did not alert the staff about the resident's movement in the room. All interviewed staff reported that the alarm was functioning well and they heard the sound of it during their shift. Staff was aware that in order to reset the alarm after it was triggered, it was necessary to switch it to the off position and return it to an on position. It was unclear when the alarm was reset for the last time and why it was in the off position at the time of the fall. The last interaction with the resident was reported around 6:30 p.m., about 30 minutes prior to the fall, when a staff member assisted the resident with care. On 4/20/24 all direct care staff who were involved in Resident #58's care and had access to the alarm device were educated on how to reset it and to make sure it was turned on. The device was to be checked at the beginning of every shift and on an as needed basis. Staff were to ensure it was in the on position after the reset. A log was initiated to ensure every shift checked the alarm. On 4/24/24 the interdisciplinary team (IDT) met to review the fall for the Resident #58. Medications, care routines, non-pharmacological interventions and resident preferences were reviewed. The IDT recommended adding the following interventions and continuing to monitor: Bariatric bed for extended sleep surface, improve lighting in the room, and add an air mattress. B. Identification of other residents The facility completed an audit and identified other residents in the building who were at risk for falls. Thirteen identified residents were reviewed for appropriate fall interventions and care plans were updated to ensure the accuracy of the interventions. The audit review was completed by 5/3/24. C. Systemic changes Nursing leadership re-educated the nursing staff in regards to reviewing the care plan and [NAME] (tool utilized by staff to provide comprehensive care of the residents) as well as the importance of following and implementing interventions outlined in these documents in an effort to reduce the risk of falls for facility residents. The training of all staff was completed on 5/3/24. On 4/21/24 audits were initiated to verify fall prevention interventions outlined in the care plans for residents identified to be at risk of falls were in place accordingly via direct observations when rounding as well as via interviews with staff. D. Monitoring The director of nursing (DON) was responsible for completing the audits weekly for the next four weeks, one a month for the next two months and quarterly for the next three quarters. A monthly Report Out, summarizing the findings of the audits, was to be completed and provided to the Quality Assurance Performance Improvement (QAPI) Committee. The QAPI Report Out was to be reviewed by the QAPI Committee for compliance and trends and to make additional recommendations as needed for continued improvement. The facility would be in substantial compliance by 5/4/24. Interviews and record review during the investigation revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place. III. Facility policy The Fall Prevention And Management- Rehab/Skilled, Therapy & Rehab (rehabilitation) policy, revised on 4/2/24, was provided by the nursing home administrator (NHA) on 5/7/24 at 2:10 p.m. It read in pertinent part, The policy's purpose is to promote resident well-being by developing and implementing a fall prevention and management program, to identify risk factors and implement interventions before a fall occurs, to give prompt treatment after a fall occurs and to provide guidance for documentation. On admission or readmission, review the applicable documents ( discharge summary from transferring agency, transfer record, history and physical, lab values, nursing admit/readmit data collection) and any additional admit information documentation for fall risk factors. IV. Resident #58 A. Resident status Resident #58, age [AGE], was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included muscle weakness, dementia with behaviors and history of falls. The 1/19/24 minimum data set (MDS) assessment revealed, resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #58 did not have any physical limitations and she used a manual wheelchair. The resident required the assistance of one person for most activities of daily living (ADL). She had at least two falls since she was admitted with no major injury. B. Record review Resident #58's fall care plan, initiated 8/25/2020 and revised 5/1/24, revealed the resident was at risk for falls and had had actual falls related to diagnosis of dementia, failure to thrive, poor safety awareness, weakness and poor balance. The resident was legally blind. Interventions included reminding the resident and encouraging her to use grab bars to prevent falls, using a padded floor alarm with the alarming device in the nurses station where the alarm alerted staff but did not sound in the resident's room to avoid scaring the resident (initiated 11/22/21), Adding anti-slip strips to the total length of the bedside area and by the sink to prevent slips leading to falls (initiated 6/28/23), adding padding to the sink to prevent injury, adding a bedside commode (without the bucket insert), with handles, over the toilet to help guide the resident to know when she had reached the toilet to sit down safely, adding a grab bar in the room to allow safety when the resident was getting out of bed and returning to bed (initiated 7/12/23) and extending the sleep surface on the opposite side of the bed to allow the resident to move and sleep sideways and help prevent falls (initiated 4/24/24). According to the fall incident report, on 4/20/24 around 7:00 p.m., Resident #58 sustained a fall. Staff found the resident sitting on the floor in no acute distress, between her bed and the sink area, scooting backwards on her bottom towards the sink wall. Resident #58 stated she was just walking toward her door and fell. Resident #58 initially denied pain or injury. The physician was notified on 4/20/24 and x-rays were ordered due to increased discomfort in the resident's left leg. On 4/21/24 the results of the x-ray revealed Resident #58 had sustained a left femur fracture and the resident was transferred to the emergency room for further evaluation. According to the hospital Discharge summary, dated [DATE], Resident #58 was admitted to the hospital on [DATE] after she had a mechanical fall at the long-term care facility. She was diagnosed with a left femur fracture. The resident's family chose not to pursue surgical repair of the femur fracture and the resident returned to the facility with a palliative care consultation on 4/23/24. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/6/24 at 1:15 p.m. LPN #1 said Resident #58 was currently bed bound after she had a fall in April 2024. She said the resident had a special floor alarm that alerted the staff at the nurses station about the resident's activity in the room. She said Resident #58 had the alarm for a long time and it was very effective at preventing falls. She said she had not worked on the day when Resident #58's fall occurred. LPN #1 said she was re-educated about alarm monitoring and its functioning a few weeks ago (April 2024). She said her responsibility was to check the alarm when she started her shift, every time it was reset and as needed to ensure the alarm was on. She said she usually checked it every time she was at the nurses station or at least every 20 minutes. Certified nurse aide (CNA) #1 was interviewed on 5/6/24 at 1:35 p.m. CNA #1 said Resident #58 required extensive assistance of two people with all cares. She said the resident was a risk for falls and her responsibility was to ensure the floor mattress that had an alarm was appropriately positioned, plugged in and turned on. She said the resident currently was not able to ambulate but she was still at risk of sliding off the bed. She said the floor alarm's sounding device was at the nurses station and she was familiar with its sound and knew how to reset it after it was triggered. She said the most recent education about the alarm was a few weeks ago (April 2024). The DON and the NHA were interviewed together on 5/7/24 at 11:00 a.m. The DON said Resident #58 was the only resident in the building who was using the type of alarm she had. He said it proved to be effective in preventing falls for the resident and the resident had been using it for a while. The DON said, on 4/20/24 when Resident #58 had the fall, the alarm was found to be in the off position. He said it was inconclusive at what point the alarm was switched off and the most probable cause was that the last person who reset the alarm did not switch it all the way to the on position. He said since the incident occurred, he had completed the investigation and re-educated staff on checking the alarm prior to the shift and on an as needed basis. The DON provided copies of the audits the facility had implemented on to ensure the alarm was being monitored to make sure it was in the on position. The NHA said she believed the facility had completed a thorough investigation and ensured that all residents at risk for falls had appropriate and effective fall interventions in place. She said the facility had taken appropriate actions following Resident #58's fall and ensured the safety of all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #47 A. Professional reference Reference for safe use of the sit to stand the resident must be able to stand on his feet to ensure proper placement of the sit to stand seat halves. https://safetyucsf.edu/sites/g/files/tkssra256/f/Arjo%20Sara%20Stedy%20Instructions%20for%20Use.pdf accessed 2/6/23 read in pertinent part, the sit to stand lift is intended to transfer a resident to and from a chair, a wheelchair, a bed and a toilet. Instructions for safe use of a sit to stand are -Position resident near the sit to stand; -Ask the resident to stand up; -Pivot the two seat halves on the sit to stand upward; -Ask the resident to sit down back down on the chair while holding the sit to stand crossbar. B. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO) diagnoses included Parkinson's disease, Alzheimer's disease, depression, syncope (loss of consciousness) and collapse, urinary incontinence, and malaise (general discomfort). On 11/30/22 he was admitted to hospice care at the facility. The 11/28/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of four out 15. The resident required extensive assistance from two or more persons for bed mobility, transfers, toileting, and extensive assistance of one person for dressing and personal hygiene. The MDS assessment documented the resident had a fall history upon admission; with at least one fall in the previous month, and additional falls in the previous two to six months. On 11/22/22 the resident scored a 20 of 20, high risk, on the facility fall risk assessment. C. Observations On 1/1/23 at 10:30 the resident was observed sitting in the facility common area recliner and was assisted to a wheelchair by facility staff of one person using a sit-stand transfer device so that he could use the toilet in his room. The resident was able to use his arms to grasp the sit-to stand and he did not place his feet on the floor during the transfer (see professional reference). The resident's room contained an electric bed and personal items. There was a call light cord clipped to the bed linens. The cord length was too short to allow the resident to use it from the floor. D. Resident representative interview The resident's spouse was interviewed on 2/6/23 at 11:55 a.m. She stated her husband was admitted to the facility because he had several falls at home and she was unable to care for him alone. She was aware her husband had fallen since he was admitted to the facility but did not recall how many times. She was aware the resident had once crawled from his room to the common area and had sustained a skin abrasion on his foot. She said they will never know what happened with that. The resident's spouse said she thought the resident had multiple falls because his legs were weak. She did not recall facility staff speaking to her about a plan of care for occupational therapy or physical therapy, although she recalled one meeting after admission before the falls occurred. She also stated she liked to take the resident home sometimes and wished someone would help her understand how to use a transport style wheelchair so that she could do that more often. The resident's spouse was unsure if the resident would be able to consistently use his call bell light because he likely would not remember because of his anxiety. E. Record review A review of the resident's medical record revealed he had sustained 12 falls from 11/24/22 to 2/7/23. A hospice care plan was provided by the DON on 2/7/23 and identified the care area of mobility/safety/falls. The goals identified for the falls care area were for the resident to maintain a level of mobility and decreased risk of falls. Interventions for the achievement included: -Assess resident need for supportive devices; -Assess for impaired physical limitations; -Train resident/caregiver on reporting falls/safety issues to hospice; -Train resident/caregiver on safe use of equipment; -Wheelchair for transfers; -Train patient/caregiver on methods to reduce falls to use a gait belt, minimum to moderate assist of 2 people present was preferred; -Train patient/caregiver on mechanical lift; -Assess risk vs benefits for bed rails; -Hospital bed with bed rails elected by patient and primary caregiver; -Train the patient/caregiver to move and function safely within the patient's limitations; -Use an electric recliner modified 1-2 persons with supervision and use a toileting schedule; -Encourage appropriate use of durable medical equipment; -Use a sit to stand aid used in the facility with 1-2 persons; -Remove hazards and reduce injury; -Keep bed in low position/fall pad next to bed while in bed. A review of the February 2023 CPO indicated the facility failed to obtain physician orders for those fall prevention interventions recommended by the hospice provider, durable medical equipment, fall risk assessments, to notify the physician with resident changes in conditions, to complete frequent safety checks, and document transfer status. On 11/25/22 the facility and hospice physician initiated an order for an occupational therapy evaluation. Fall #1 The nurse progress note dated 11/24/22 at 7:15 p.m. documented the resident had an unwitnessed fall and was found on the floor in front of his recliner. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented the director of nursing (DON) nursing home administrator (NHA), wife, and nurse practitioner were notified of the resident's fall. -The documentation failed to include documentation of how those notified responded and did not indicate the hospice provider was notified of the fall. Fall #2 The nurse progress note dated 11/27/22 at 2:30 p.m. documented the certified nurse aide (CNA) heard the resident's wheelchair bump into a heater. The resident was found by the CNA sitting on the floor between his wheelchair and bed. -The nurse did not document that a post-fall assessment was completed. The nurse note failed to reveal notification to the family, physician, hospice provider, DON, or NHA. Fall #3 A nurse progress note dated 11/29/22 at 5:30 p.m. documented the resident had an unwitnessed fall and was found on the floor in front of his wheelchair. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented the resident's call light was in his reach and frequent safety checks were in place. -There was no documentation that indicated the resident had the ability to understand and use a call light system. Results of the results of the safety checks were not found in the record. The note revealed the DON, NHA, wife, and nurse practitioner were notified of the fall. The documentation failed to include how those notified responded or any if any recommendations were made. The documentation failed to reveal the hospice provider was notified. The facility's residents care plan was updated on 11/30/22 and initiated a focus for fall prevention. The facility care plan added the following and interventions: -Monitor/document/report as needed x 72 hours (after a fall) to health care provider for signs and symptoms, pain, bruises, changes in mental status, new onset, confusion, sleepiness, inability to maintain posture, agitation; -Ensure the resident wears appropriate non-slip footwear when mobilizing in wheelchair; -Monitor resident for significant changes in gait, mobility, positioning devices, standing/sitting balance and lower extremity joint function. Fall #4 A nurse progress note dated 12/5/22 at 11:38 a.m. documented the resident was found on the floor, on his back. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented responsible parties notified; the DON, NHA, wife, and physician. -The documentation failed to include responses or recommendations from those notified. There was no documentation the hospice provider was notified of the resident's fall. On 12/8/22 the facility updated the resident's care plan with the following intervention: -Cognitive: encourage participation and plan diversional activities that are of resident interest. There was no documentation of assessment or interdisciplinary team review for consideration of effectiveness or failure of previous interventions and why and how the resident's cognition contributed to his falls prevention. Fall #5 A nurse progress note dated 12/9/22 at 6:49 p.m. documented a fall that was reported by another resident who noticed the resident was on the floor by his recliner. The nurse completed a post-fall assessment and determined the resident was not injured. After the fall the nurse placed a fall mat next to the resident's bed and put the resident's bed in the lowest position. The nurse documented the DON, NHA, wife, and after-hours provider were notified about the fall. -The documentation failed to include responses or recommendations from those notified. After the two new interventions were initiated, the facility did not update the residents care plan and did not document that communication with the hospice provider occurred. The hospice nurse completed a nurse visit on 12/22/22. It documented on the Missouri Alliance for Home Care (MAHC) 10-Fall Risk Assessment the resident had a score of 10 with a score of four or more was considered a risk for falling. -The hospice nurse did not include documentation of an awareness of the resident's falls. Falls #6 and #7 The nurse progress note dated 12/20/22 at 4:16 a.m. documented the resident had two falls during the shift. The nurse note revealed the resident was found on the floor next to his bed on the fall mat. -The documentation failed to include a post-fall nursing assessment for each fall and did not document whether or not injuries were present. The nurse determined the resident required anti-anxiety medication. The documentation did not reveal if notifications to family, facility staff, physician,or the hospice provider we completed. Fall #8 A nurse progress note dated 1/2/23 at 4:15 p.m. documented the resident was found on the floor in his room between the recliner and bed. The nurse documented the resident said he was getting up and out of his recliner. The nurse documented the resident's vital signs and neurological assessment was all normal and did not indicate whether or not any injuries occurred. -The nurse documented all notifications were made, but did not include who was notified of the fall, or whether or not those notified had responses or recommendations. There was no note the hospice provider was notified of the resident's fall. On 1/4/23 the facility edited the resident's care plan and listed some of the dates the resident had falls: 11/24/22, 11/17/22, 11/29/22, 12/5/22, 12/9/22, 1/2/23. The care plan edits failed to include changes to the fall prevention interventions and there was no documentation the facility or hospice provider interdisciplinary teams had reviewed the residents fall status. Fall #9, #10 and #11 The nurse progress note dated 1/17/23 at 6:48 a.m. was a nurse summary note for three separate falls during the shift. The nurse documented the resident was found out of bed on the fall mat next to his bed after each fall. -The nurses documentation failed to include a post-fall nursing assessment after each fall and did not document whether or not the resident was injured. The documentation did not reveal if notifications to family, facility staff, physician,or the hospice provider we completed. On 1/19/23 the facility physician discontinued the order for occupational therapy evaluation and treatment. On 2/7/23 the facility produced a copy of a handwritten sticky note which indicated the resident had refused the occupational therapy evaluation. There was no documentation why the resident refused or if therapy benefits were reviewed with the resident and family. Fall #12 The facility physician documented on 1/25/23 the resident was found on the floor on a previous day. The physician documented the resident had crawled out of his room, across a common area to where he was found by the facility staff. The physician documented as a result of crawling on the floor, the resident sustained an abrasion to his right foot which required wound care evaluations and physician orders for treatment. The facility physician documented the resident had a problem with falls and all interventions were in place. The nurse progress notes dated 1/21/23 documented the resident had a new wound on his right foot. The nurse progress note failed to document if the family or hospice physician was notified of the resident's change in condition. F. Staff interviews Registered nurse (RN) #1 was interviewed on 2/6/23 at 11:30 a.m She stated the staff keep a close eye on the resident to prevent falls. She said the resident sits in a recliner in the common area and his wife visits him to help calm his anxiety. She stated the resident has impulsive behaviors and did not use his call light for staff assistance when he was in his room. The RN was unable to locate a hospice care or communication binder. She stated at times communication with the hospice nurse occurred when the hospice nurse visited the resident. The RN was unable to identify when the hospice nurse visited the resident and could not locate documentation that revealed the hospice had been notified of the resident's falls. The RN stated she was unaware how the hospice and facility reviewed and collaborated with the resident's care and believed it was up to the hospice company to complete nurse assessments and communicate with the providers regarding resident status. She was unaware of fall prevention interventions recommended by the hospice provider. The restorative nurse aide (RNA) was interviewed on 2/7/22 at 2:15 p.m. She stated she was unaware the resident had fallen numerous times. She stated she could evaluate the resident and spouse's request for assistance with wheelchair use and training. The director of nursing (DON) was interviewed on 2/7/22 at 2:33 p.m. The DON stated when a resident had a fall the nurse was to complete an assessment form and a facility incident report form. He stated he was unaware of the numerous falls the resident had and that the facility staff had not been communicating with the hospice provider. The DON provided several printed hospice nurse visit notes but was unable to locate documentation the facility had communicated the resident's problem with falls with the hospice provider. The DON stated the facility did not currently have an interdisciplinary team that reviewed resident falls or a fall prevention team. The DON stated the facility was aware improvement was necessary and planned to start a quality improvement project for falls prevention in February 2023. Based on record review, and interviews, the facility failed to provide supervision, assistance, services, and implement timely interventions to prevent falls with injuries for two (#66 and #47) of four residents reviewed for accidents/hazards out of 24 sample residents. Resident #66 had a history of falls upon admission, was cognitively intact, used a walker and wheelchair, and needed supervision with ambulation and transfers. Between 11/29/22 and 1/12/23, Resident #66 experienced eight falls: six unwitnessed and two witnessed. After the 12/20/22 fall, the resident sustained a fractured femur (thigh bone). After the femur fracture the resident became dependent for ambulation in a wheelchair. The facility failed to conduct an interdisciplinary team (IDT) review of Resident #66's repeated falls and implement effective interventions. Additionally, the facility failed to: -Implement effective fall interventions, conduct IDT review of falls and communicate with hospice provider for Resident #47; and, -Ensure the Resident #47's feet were secured during a transfer with a mechanical lift. Findings include: I. Facility policy The Fall Prevention and Management policy, revised 3/30/22, was provided by the nursing home administrator (NHA) on 2/6/23 at 2:35 p.m. It read in pertinent part: The purpose was to promote resident well-being by developing and implementing a fall prevention and management program, identify risk factors and implement interventions before a fall occurs, give prompt treatment after a fall occurs, and prevent further injury. A fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. Upon admission the facility will review the applicable documents, discharge summary from the transferring agency, transfer record, history and physical, lab values, and any additional admit information documentation for fall risk factors. Complete the Falls Tools UDA (user defined assessment) for fall screening and identifying fall risk factors. Care plan the appropriate interventions, including personalizing all areas. Communicate fall risks and interventions to prevent a fall before it occurs per the 24 hour report, care plan, kardex, daily stand up meeting, and/or fall committee meetings. Communicate any identified environmental changes and /or referral needs (maintenance, dietary, therapy). After a fall, the facility will: a. Assess the resident. b. Notify the physician and resident representative. c. Complete the Fall Scene Huddle worksheet. d. Document the physician's comments in the medical record. e. Complete the Falls Tool UDA. f. If appropriate, contact the physician for a referral to therapy. g. Communicate that a fall has occurred during shift change and daily stand-up meeting. h. Give completed fall scene huddle worksheet to the fall committee chair. i. Report to the state regulatory agency when appropriate. j. Continue to monitor condition and the effectiveness of the interventions. k. The investigation documentation is completed in the notes tab within the Risk Management module. II. Resident #66 A. Resident status Resident #66, age [AGE], was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnoses included fracture of the right femur, unspecified dementia, anxiety disorder, severe protein-calorie malnutrition, depressive episode, muscle weakness, unsteadiness on feet, need for assistance with personal care, legal blindness, wedge compression fracture of T7-T8 (bones in the spine), difficulty in walking, and repeated falls. The 1/10/23 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief mental status score (BIMS) of 14 out of 15. She required limited assistance with bed mobility, transfers, and walking in the room and corridor. She used a wheelchair and had a fracture related to a fall. She had falls prior to admission. B. Record review Care plans The fall care plan, initiated 8/25/2020 and revised 1/12/23, revealed the resident was at risk for falls and had actual falls related to dementia, failure to thrive, poor safety awareness, weakness, poor balance, legally blind, and atrial flutter. The goal was for the resident to resume usual activities without further incident. The interventions included: -Monitor/document/ report pain and bruises-Initiated 2/20/22. -Provide activities that promote exercise and strength building where possible-Initiated 8/25/2020. -Contact physical therapy for strength and mobility as needed-Initiated 2/20/2022 and revised on 3/16/22. -Ensure the resident was wearing footwear when standing that has a gripping bottom and secure back such as slippers, shoes, or grip socks-Initiated 8/25/2020 and revised on 5/9/22. -Encourage the use of a wheelchair or walker when leaving the room-Initiated 8/25/2020 and revised on 5/9/22. -Frequent monitoring upon waking, before bed, before and after meals, and routinely through the night-Initiated 8/26/2020 and revised on 9/23/2020. -Monitor visual and auditory impairments-Initiated 8/25/2020. -Review as indicated for significant changes in cognition, safety, awareness, and decision making-Initiated 8/25/2020. -Review bowel and bladder continence status and establish and/or review toileting plan based on residents needs-Initiated 8/25/2020 and revised 3/16/22. -Ensure/provide a safe environment, monitor and remove tripping hazards - Initiated 9/23/2020 and revised 7/19/22. -Maintain a clear path in the corridor for ease of ambulation when the resident leaves the room-Initiated 9/23/2020 and revised 7/19/22. -Assist with maintaining a clear area around the bed to allow room to stand safely-Initiated 9/23/2020 and revised 7/19/22. -Purposeful proactive rounding every two hours for safety and assessing needs and comfort-Initiated 2/20/22 and revised on 1/10/23. The visible impairment care plan, initiated 9/14/2020 and revised 11/2/22, revealed the resident had impaired vision related to artificial left eye. She had prophylactic antibiotics for right eye health. The goal was for the resident to maintain optimal quality of life within limitations imposed by visual function left eye blindness. The interventions included: -Maintain room arrangement to promote independence. -Arrange consultation with an eye care practitioner as required. -Monitor/document/report change in ability to perform Activities of daily living (ADLS), decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaint of halos around lights, double vision, tunnel vision, and blurred or hazy vision. -Tell resident where her items are being placed and be consistent with placement of personal items. -Approach the resident from her right side as she has a prosthetic left eye. According to the fall report, nursing progress notes and fall investigations dated 11/29/22 through 1/12/23, the resident had eight falls within three months. 1. According to the 11/29/22 risk management, at 5:30 p.m., the resident was walking down the hallway and did not see another resident in a wheelchair, causing her to lose her balance. She landed in the Indian style (crossed legs) sitting position. The nurse assessed her and walked her back to her room, where she sat on the bed. She was not injured and said she did not see the other resident and lost her balance. Predisposing factor was impaired vision. The fall was witnessed. The risk management note revealed the resident would continue working with restorative and encouraged to use her front wheeled walker when ambulating. A physician order was obtained for a PT evaluation. 2. According to the 12/9/22 risk management, at 12:35 p.m., the nurse found the resident in her room leaning with her back on her bed and her feet up against the closet and her behind up in the air. The nurse assessed the resident and assisted her to her bed. She was not injured and said she sat on the floor and was trying to get up. Predisposing factor was impaired vision. The fall was unwitnessed. The risk management note revealed the resident would continue working with restorative nursing. No new interventions were implemented since the resident was already working with restorative nursing from her previous fall (11/29/22). 3. According to the12/14/22 risk management, at 10:00 a.m., certified nurse aides witnessed the resident trip over her bedside table landing on her bottom. She was sitting on her bottom between the bed and the table. The nurse assessed the resident and assisted her to her bed. She was not injured and said she was going to the bathroom and tripped on the table. Predisposing factor was impaired vision. The risk management note revealed the resident would continue working with restorative. An electrocardiogram (EKG), labs, and urine sample was ordered related to dizziness and nausea. Staff were to ensure the room was free of clutter so the resident had a clear pathway to the bathroom and the room exit. No new interventions were implemented since the resident was already working with restorative and the room should have already been cleared of clutter from her previous two falls (11/29/22 and 12/9/22). 4. According to the 12/20/22 risk management, at 8:30 p.m., the resident was heard yelling out and was found sitting on her left buttocks with her legs to her right. She was holding onto the grab bars facing the toilet. She was wearing tennis shoes. The nurse assessed the resident as she was attempting to get up off the floor on her own. She refused to wait for the staff to use the lift to get her up. The resident was able to bear weight however she walked with a limp and complained of right outer thigh pain. She said, Ow with each movement. The resident said she tripped over her roommate who was at the sink and landed on the floor. She said she then scooted herself to the bathroom to try and stand up. A stat x-ray was ordered for the right hip pain. Predisposing factor was impaired vision and impaired memory. This was an unwitnessed fall. The resident was subsequently transferred to the emergency department for evaluation and treatment. She was found to have a right femur neck fracture which required surgical intervention. The risk management note revealed the resident had an increase of falls related to tripping over other residents. The resident appeared to be having difficulty adjusting to increasing impairment to good eye and loss of physical independence. The resident was hospitalized on [DATE] and readmitted to the facility on [DATE]. 5. According to the 1/5/23 risk management, at 3:30 p.m., the nurse was called to the resident's room by the floor certified nurse aide (CNA), and found the resident on the floor beside her bed wrapped up in her covers. The nurse assessed the resident and two CNAs used the hoyer lift to help her back into bed. She was not injured and said she was looking for her sock and slid off of the bed. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident was wearing socks. She was encouraged not to reach for items and to use the call light for assistance. The resident would continue working with restorative nursing for safe ambulation. 6. According to the 1/8/23 risk management, at 4:45 a.m., the nurse was walking down the hall, making rounds, and noticed the resident sitting on the floor in the doorway of her bathroom. She was not injured and said she rolled out of the bed and scooted to the bathroom. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident continues working with restorative nursing on safe ambulation. She will continue working with PT related to repeated falls. No new interventions were implemented since the resident was already working with restorative and PT from her previous five falls. 7. According to the 1/10/23 risk management, at 11:16 p.m., the resident was found in front of her dresser going through her clothes. She was not injured and said she put herself on the floor and was sorting her clothes. The nurse assessed her for any injuries. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident would continue working with PT related to repeated falls. The resident was reminded to use the call light and wait for assistance. No new interventions were implemented since the resident was already working with PT from her previous six falls (11/29/22 and 12/9/22), and the resident was reminded to use the call light from her previous two falls. 8. According to the 1/12/23 risk management, at 5:00 a.m., the resident's roommate went to the nurses station to report that Resident #66 was on the floor. The nurse found the resident on the toilet. She was not injured and said she was reaching for the grab bar and slid down onto the floor. Predisposing factor was impaired vision, impaired memory and gait imbalance. This was an unwitnessed fall. The risk management note revealed education was provided to the resident to use the call light and wait for assistance with transfers. No new interventions were implemented since the resident had already been educated to use her call light and wait for assistance from previous multiple falls. There were no IDT review notes for any of the above falls, the risk management notes were completed by the floor nurse. C. Staff interviews CNA #1 was interviewed on 2/7/23 at 10:08 a.m. She said the Resident #66 could not see well and was very independent. She said the facility discontinued her air mattress because it was slippery. She said the staff put her shoes at her bedside so she can put them on before ambulating. She said she was sure there were other interventions in place, but she could not think of them at the time of the interview. Licensed practical nurse (LPN) #1 was interviewed on 2/7/23 at 10:11 a.m. She said the interventions for Resident #66's repeated falls were to keep the call light within reach, frequent checks, and working with therapy. She said the resident ambulated with a front wheel walker to the bathroom. She said she was not sure if the resident was supposed to ambulate independently or not. She looked in the resident's medical record which revealed the resident was a limited assist to and from the bathroom. The restorative nurse aide (RNA) was interviewed on 2/7/23 at 2:18 p.m. She said Resident #66 was discharged from PT on 2/3/23 and she had not started working with her, however she was on her list to start a restorative nursing program. She said Resident #66 was previously on a restorative program for ambulation but was ambulating independently and discontinued the program. She said the resident was one assist with cuing. She said there had not been a fall committee since COVID-19 began. She said she had not been involved with the fall committee. The director of nursing (DON) was interviewed on 2/7/23 at 2:33 p.m. He said himself and the NHA were new to the facility. He said they were aware there was no fall committee in place and planned on starting one. He said the NHA, himself, the two new unit managers, therapy, dietary, and the facility director had morning huddles in which they discussed resident changes, occurrences, and incidents. He said a resident with repeated falls was to have a fall committee in place to look at the root cause of the falls and put a plan in place for that individual resident. He said the unit managers were responsible for updating the care plans with recent falls and new interventions. He said a fall committee would help with follow up of interventions and would include the physician. The NHA was interviewed on 2/7/23 at 3:43 p.m. She said currently the fall committee was the morning clinical stand up. She said the DON and herself were currently working on updating care plans and reviewing interventions. She said the facility recently hired two new unit managers who would be responsible for fall management investigations and care plan updates as well as the minimum data set coordinator (MDSC). She said the facility completed a fall audit in December 2022 and identified documentation missing from the neurological assessment. She said she had put together a plan to bring back the fall committee to identify residents with repeated and high fall risks and trends. She said the facility had areas that needed improvement such as neurological assessments, use of the fall huddle worksheet, interventions, and updating/revision of the care plans. She acknowledged the facility triggered high for falls. She said she would put a performa[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to ensure two (#2 and #32) of four out of 28 sample residents received care consistent with professional standards of practice to promote prevention and healing of pressure injuries. The facility failed to ensure Resident #2 who was severely cognitively impaired with diagnoses of encephalopathy, type 2 diabetes mellitus with diabetic polyneuropathy, chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbance, unsteadiness on feet and muscle weakness, did not sustain a facility acquired pressure injury (pressure ulcer). The facility's failures to implement timely person centered interventions, follow up on the initial observation of the wounds and implement new interventions created a delay in care indicated the facility did not do everything to promote prevention of pressure ulcers. The facility's failures to implement an air mattress for Resident #2 who was dependent on staff for off loading, prevented Resident #2 the ability to retain healthy skin integrity and Resident #2 sustained a Stage 3 pressure ulcer. Resident #2 had the ability to heal, therefore the pressure ulcer was avoidable. Additionally, the facility failed to timely implement treatment orders for Resident #32's pressure injury. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, from http://www.npuap.org (11/22/21): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). II. Facility policy The Wound Care Pressure Ulcer policy, revised on 5/25/21, was provided by the nursing home administrator (NHA) on 11/17/21 at 2:36 p.m. It documented in pertinent part, to include mobility support and positioning, documentation, and pressure ulcer prevention and treatment. The policy noted the facility must ensure a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. III. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included encephalopathy, type 2 diabetes mellitus with diabetic polyneuropathy, chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbance, unsteadiness on feet and muscle weakness. The 10/27/21 minimum data set (MDS) assessment revealed Resident #2 was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. He required extensive one person assistance with all activities of daily (ADLs) and was always incontinent of bowel and bladder. Resident #2 had one stage 3 pressure injury. He had a pressure reducing device on his bed and on his chair. He was receiving pressure ulcer/injury care, he was on a hydration and nutrition program as well as a turning/repositioning program. He was a fall risk and was using a wheelchair for mobility. B. Record review The 7/28/21 MDS revealed Resident #2 did not have any pressure ulcers identified. The resident's pressure ulcer care plan, revised on 11/10/21, identified a pressure ulcer on his left ischium. The goal was to have the pressure ulcer healthed by the review date. The interventions included: -Monitor location, size and treatment of the skin injury; -Report abnormalities, failure to heal, infection, and maceration to the health care provider; -Identify potential causative factors and eliminate/resolve where possible; and, -Turn and reposition in bed and wheelchair as needed for maximum comfort and to minimize skin breakdown. The November 2021 CPO included: -Protein modular 30 milliliters (ml) liquacel mixed with 240 ml beverage of choice one time a day for wound healing with a start date of 11/16/21. (added during survey) -Protein modular 1 ounce (oz) liquacel mixed with 4 ounces beverage of choice one time a day for 14 days for wound healing with a start date of 10/25/21. -Vitamin C tablet (ascorbic acid) 500 milligrams (mg) two times a day for wound healing with a start date of 8/26/21. -Left ischium wound treatment cleanse, apply hydrocolloid dressing, may secure with transparent film three times a week every day shift on tuesday, thursday and saturday and as needed with a start date of 8/28/21. (This was not ordered for nine days after the first observation see, rehabilitation note below 8/19/21) -Offload buttocks turn resident on his side when he was in bed. Resident should not sit up for longer than 1 hour at a time every day and night shift for wound with a start date of 8/26/21. -Air mattress for wound care with a start date of 10/1/21. The quarterly care conference note dated 8/3/21 revealed the resident's skin was intact with no noted concerns. His weight was stable and he ate 80 percent of his meals. The rehabilitation note dated on 8/19/21 noted the resident had a quarter sized spot on his left buttock that was open and bleeding from bowel movement (BM) irritation. The wound was cleaned with wound cleaner, applied skin prep to edges and applied a foam dressing to protect the remainder of the night and offloaded buttocks. Documented reported to day staff to have physician determine the course of action. There was no follow-up documentation that indicated the day staff were notified after the observation on 8/19/21 until the nurses note on 8/23/21. This created a delay in care to address the residents' pressure related skin areas. The 8/22/21 Braden scale assessed Resident #2 was at mild risk for skin breakdown with a score of 16 out of 23. The intervention guide suggested frequent turning, manage nutrition, manage moisture and provide pressure reduction support surfaces if bed or chair bound. The nurses note dated 8/23/21 documented the registered nurse (RN) was called to the residents room while he was being cleaned. The resident had a moisture associated skin damage (MASD) open area on his left buttock. It was noted he had a pressure wound on his left ischium and a wound on his right ischium. The RN asked for orders for the resident to be seen by the wound doctor. The RN wound rounds note dated 8/26/21 noted the open area on the right ischium was resolved and the left ischium wound was debrided and orders given for wound treatment. The nurses note dated 8/26/21 noted new orders for occupational therapy (OT) to evaluate and treat for proper positioning in a wheelchair. The physician wound evaluation dated 9/2/21 revealed the resident had a stage 3 pressure wound of the left ischium. The wound size was 1.0 x 2.4 x 0.15 centimeters. The treatment plan was ordered to apply dressing three times a week for 23 days with offloading and repositioning per facility protocol. The RN wound rounds note dated 9/2/21 documented the wound on his left ischium was 80 percent better than it was last week. The physician wound evaluation dated 9/16/21 revealed the resident had a stage 3 pressure wound of the left ischium. The wound size was 0.7 x 2.2 x 0.15 centimeters. The treatment plan was ordered to apply dressing three times a week for 30 days with offloading and repositioning per facility protocol. Dietitian to review his protein intake. The physician wound evaluation dated 9/23/21 revealed the resident had a stage 3 pressure wound of the left ischium. The wound size was 0.9 x 2.0 x 0.15 centimeters (cm). The treatment plan was ordered to apply dressing three times a week for 23 days with offloading and repositioning per facility protocol as well as limiting his sitting to 60 minutes. The physician wound evaluation dated 9/30/21 revealed the resident had a stage 3 pressure wound of the left ischium. The wound size was 0.9 x 2.4 x 0.15 centimeters (cm). The treatment plan was ordered to apply dressing three times a week for 23 days with offloading and repositioning per facility protocol. Limit his sitting to 60 minutes. Gel cushion to his wheelchair. The RN wound rounds note dated 9/30/21 noted the wound on his left ischium was a little bigger than it was last week. The nurses note dated 10/3/21 revealed an order for an air mattress for the resident's bed. However, the skin breakdown was first discovered by the rehabilitation department on 8/19/21 and the resident was assessed by an RN on 8/23/21 for skin concerns with MASD and open area to left buttock (see rehabilitation note 8/19/21 and nurse note 8/23/21 above). The physician wound evaluation measurements read weekly: -10/7/21, 0.5 x 1.4 x not measurable; -10/14/21, 0.4 x 2.0 x not measurable; -10/21/21, 0.7 x 1.7 x 0.1 cm; and, -11/4/21 0.5 x 0.9 x 0.1 cm. The RN wound rounds note dated 11/4/21 noted the wound on the left ischium was smaller probably due to the air mattress he was using on his bed. -This indicated the resident had the ability to heal given proper person centered interventions and care. This also indicated the wound was avoidable. The physician wound evaluation dated 11/11/21 noted the resident had a stage 3 pressure wound of the left ischium for at least 81 days duration. The wound size was 0.7 x 2.2 x 0.15 centimeters. The treatment plan was ordered to apply dressing three times a week per 30 days with offloading and repositioning per facility protocol as well as limit sitting to 60 minutes. C. Observations and wound care observation On 11/15/21 at 11:25 a.m. a continuous observation was conducted. Resident #2 was observed in his wheelchair in the dining room. He was observed exiting the dining room and propelling himself down the hall. The resident was observed in his wheelchair for the duration of the observation period from 11:25 a.m. until 3:44 p.m. During the observation, he propelled up and down the hallway and staff would redirect him back towards his room. He did have a cushion on his wheelchair during observation. -Staff were observed redirecting him but did not offer for him to lay down or offload during the four hour observation. On 11/17/21 at 4:45 p.m. licensed practical nurse (LPN) #2 was observed providing wound care to Resident #2. LPN #2 performed hand hygiene and donned cleaned gloves before she provided wound care treatment. The wound on the left ischium was not measured at time of treatment but was approximately 1.5 inches long, 1 centimeter wide and 0.1 centimeters deep. There was serosanguinous drainage, no odor and no signs of infection. LPN #2 said the wound was facility acquired due to the resident sitting in his wheelchair for too long. She said he did not like to lay down and stayed in his wheelchair for long periods of time. D. Staff interview LPN #2 was interviewed on 11/17/21 at 12:45 p.m. She said there was a wound care nurse and a physician who completed a weekly wound care round for the residents with wounds. She said when a resident was admitted to the facility a registered nurse would assess residents for wounds and for skin integrity. She said Resident #2 did not have wounds when he was first admitted . She said he used to walk with a walker and was more independent. She said he had a history of falls and became unsafe to walk. She said the wounds were acquired once he was not walking and was spending all of his time in his wheelchair. She said he was incontinent of bowel and bladder which contributed to his skin breakdown. She said he did not like to lay down in bed and will yell to get back into his wheelchair. The director of nursing (DON) was interviewed on 11/18/21 at 9:49 a.m. She said the wound for Resident #2 was a facility acquired pressure ulcer. She said he was noncompliant with offloading and preferred to be in his chair. She said the staff encouraged repositioning and the care plan was updated. However the pressure ulcer care plan revised 11/10/21 did not indicate the resident was non-compliant with offloading and preffered to be in his chair. IV. Resident #32 A. Resident status Resident #32, age [AGE], was admitted [DATE]. According to the November 2021 computerized physician orders (CPO), the diagnoses included congestive heart failure (CHF) and right femur fracture. The 9/15/21 minimum data set (MDS) assessment indicated Resident #32 had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. She was totally dependent on two persons for transfers, and required extensive two person assistance with bed mobility, toileting, dressing, and personal hygiene. She had no pressure ulcers, but was at risk for pressure ulcers. She was incontinent of bowel and bladder. B. Record review The November 2021 CPO was reviewed and revealed Resident #32 had an order to apply moisture barrier cream to buttocks every shift start date 4/6/21, and pressure reducing mattress start date 3/30/21. The skin integrity care plan, dated 6/25/21, documented the resident has actual and potential for impairment to skin integrity related to Braden score of 13 and need for ADL assistance with bed mobility and transfers. Keep skin clean and dry. Use lotion on dry skin. Turn and reposition in bed as needed to maximize comfort and minimize skin breakdown. Resident uses incontinence products: brief. Check before and after meals and as needed. The skin observation tool written on 11/3/21 at 10:39 a.m. revealed redness to left and right buttock. The nurses notes, on 11/7/21 at 4:09 p.m., documented, CNA (certified nurse aide) reported to writer that resident has two small open areas on her tailbone/coccyx. Writer looked at area and applied barrier cream. Will notify nurse practitioner (NP) and see if there are any new orders. -There were no further orders or documentation regarding the wound or follow-up from the nurse practitioner (NP) until 11/15/21. The wound data toll collection sheet, on 11/7/21 at 4:13 p.m., documented there was an open ulcer, slightly red. The resident had a hard time repositioning, but it documented she had an air mattress. The data collection sheet documented the wound was not present on admission and the section for measurements was blank. The wound data collection sheet further documented will write note to the NP about open area and see if they would like to order anything. The nurses note, dated 11/9/21 at 4:50 p.m., documented communication with NP, resident open areas on buttocks/sacrum. Orders to consult wound care RN and to assist with weight shifting. -However, no orders were written until 11/15/21. The nursing skilled note, dated n 11/13/21 at 2:02 p.m., documented Resident #32 had wounds/ulcers, shallow open areas to coccyx and sacrum. -There was no measurement. An order was written on 11/15/21, during the survey, for the wound care MD to eval and treat the wounds. -However, this was seven days after the order was initially given on 11/9/21. The nurses notes, on 11/15/21 at 4:54 p.m., seven days later, documented Communication with NP related to resident open areas on buttocks/sacrum. Orders to consult wound care RN and to assist with weight shifting. The facility failed to follow up on the open wounds for seven days. -The NP ordered a wound care consult on 11/9/21. The nurses notes, on 11/16/21 at 1:52 p.m., documented, Resident has two open areas one on each side of her sacrum. They are both superficial and look like blisters that may have opened. The nursing skilled note, on 11/16/21 at 7:35 p.m., documented two superficial open areas to both sides of the sacrum. Area cleaned, barrier cream applied, Order to see wound care MD. It further documented, the resident was sent to the hospital at 3:45 p.m. with critical labs. The residents wounds could not be observed during the survey due to being transferred to the hospital, and she had not returned by the completion of the survey on 11/18/21. C. Interviews Registered nurse (RN) #1 was interviewed on 11/17/21 at 10:30 a.m. She said if a new or worsening skin condition occurred, the nurse should document a description of the wound, notify the MD for orders, and then notify the DON for further follow up. The DON was interviewed on 11/18/21 at 10:15 a.m. She said when a nurse finds a new wound or worsening wound, they should call the MD for orders and leave the facility wound care nurse (WCN) a message for follow-up. The wounds should be assessed and documented including the size, color, drainage and odor. The DON said the nurse notified the NP on 11/7/21 and the NP responded to the message sent to her on 11/9/21. The DON said the messages sent were not part of the medical record, but she could see them on her laptop. The DON said the NP gave instructions to get a wound care consult, and assist the resident with weight shifting. The DON said the wound care physician was at the facility on 11/11/21, but did not see the resident because no order was written until 11/15/21. The DON looked at the medical record on her laptop, and said she did not see an assessment from the wound care MD, or any follow up documented from the nurses. The DON said she reviewed the facilities WCN's wound log and did not see anything documented on her wound care log for Resident #32. She said the wounds should have been on the wound care log to be tracked and ensure follow up. The DON said the wound care log was used to track all wounds. The DON was interviewed again on 11/18/21 at 12:42 p.m. She said the WCN was not available at the facility for an interview. The DON said she had spoken to the WCN and the WCN said she had not seen any order until 11/15/21. The DON said Resident #32 had gone to the hospital on [DATE], and they would assess her wounds there. The DON said there was no further documentation regarding the wounds, or follow up, until the order was written on 11/15/21. The WCN was interviewed by phone on 11/22/21 at 4:45 p.m. She said Resident #32 was not seen by the wound care physician because the order was not written until 11/15/21. She said she did not know why there was a delay. The WCN nurse said she did not know if the wound was from pressure. -However, the wounds were over a bony prominence. The WCN said she had not seen the wounds because she had been pulled to work the floor frequently, and had not had a chance.