**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one (#75) of two out of 39 sample residents. Resident #75 admitted to the facility with a left hip fracture, required extensive staff assistance for toileting, transfers and bed mobility. The resident was identified as being at moderate risk for developing pressure ulcers at admission. Subsequently, Resident #75 acquired an unstageable deep tissue injury to the left buttock (9/30/21), an unstageable deep tissue injury to the right buttock (9/30/21) and an unstageable deep tissue injury to the sacrum (9/30/21). The facility failed to implement an air mattress (10/14/21) as an intervention, until after 10/14/21, when she had developed three pressure ulcers. Furthermore, after the air mattress was in place, the resident acquired an unstageable deep tissue injury to the left distal posterior calf (10/21/21) and an unstageable deep tissue injury to the left posterior lateral heel (10/21/21). Findings include: 1. 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 (11/11/21): 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 and procedures The Pressure Injury Prevention and Management policy, copyright 2020, was provided by the nursing home administration (NHA) on 11/2/21 at 12:50 a.m. The policy revealed the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The term pressure ulcer/injury referred to localized damage to the skin and/or underlying soft tissue over a bony prominence or related to a medical or other device. The facility should establish and utilize a systematic approach for pressure injury prevention and management. This included prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions and modifying the interventions as appropriate. After the completion of a thorough assessment/evaluation, the interdisciplinary team would develop a relevant care plan that included measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions would be based on specific factors identified in the risk assessment, skin assessment and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging and wound characteristics). Evidence based interventions for prevention would be implemented for all residents who were assessed at risk or who have a pressure injury present. Basic or routine care interventions included, but were not limited to: redistribution of pressure (such as repositioning, protecting and/or off-loading of heels, etc.); minimize exposure to moisture and keep the skin clean, especially of fecal contamination; provide the appropriate pressure-redistributing support surfaces; and maintain or improve nutrition and hydration status where feasible II. Resident status Resident #75, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included fracture part of the neck of the left femur, dementia, anemia, depression, atrial fibrillation, difficulty in walking, muscle weakness and atrophy. The 10/14/21 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident did not have any behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was at risk for the development of pressure ulcers. The resident had one or more unhealed pressure ulcers/injuries. The resident had three unstageable deep tissue injuries. III. Record review The admission Data Collection note dated 9/22/21 at 5:06 p.m., revealed the resident did not have any pressure ulcers. The resident did have a non-pressure ulcer surgical skin incision at the left trochanteric hip. The admission Note dated 9/22/21 at 5:41 p.m., by a licensed practical nurse (LPN) revealed the resident arrived in the facility at 3:00 p.m., by an in-house transport. The resident had a status post left hip fracture with no signs or symptoms of distress. Active ranges of motion were performed on all extremities; except for the left lower extremity. Quarantine procedures were explained and the resident verbalized understanding. The Braden Scale for Predicting Pressure Sore Risk dated 9/22/21 at 2:17 p.m., revealed a score of 13 or moderate risk. The resident was very limited and responded only to painful stimuli. The resident could not communicate discomfort except by moaning or restlessness and/or the resident had sensory impairment which limited the ability to feel pain or discomfort over half of the body. The resident had occasionally moist skin and required an extra linen change approximately once a day. The resident was chair fast and the ability to walk was severely limited or non-existent. The resident was unable to support her own weight and/or must be assisted into a chair or wheelchair. The resident was limited and made occasional slight changes in her body or extremity position but was unable to make frequent or significant changes independently. The resident rarely ate a complete meal and generally ate only about half of the food offered to her. One of the potential problems was during movement her skin probably slid to some extent against the sheets, chair or other devices. A Behavior Note dated 9/23/21 at 1:50 a.m., by a registered nurse (RN) revealed the resident woke up this night confused and angry. This nurse explained that she came from the hospital with a hip repair and she would be staying at the facility for rehabilitation. The Head to Toe Skin Check dated 9/23/21 at 2:17 p.m., revealed the resident had a surgical incision to the left trochanter with a clean/dry/intact dressing. A Nursing Daily Skilled Charting note dated 9/24/21 at 1:20 p.m., revealed the resident had a surgical incision site to the left hip. The Baseline Care Plan dated 9/24/21 at 2:00 p.m., revealed the resident did not have any pressure ulcers. A Nursing Daily Skilled Charting note dated 9/25/21 at 12:45 p.m., revealed the resident had a surgical incision site to the left hip. The Bowel and Bladder assessment dated [DATE] at 2:17 p.m., by an LPN revealed the resident was incontinent of urine at all times. The resident had a bowel movement every three or four days. A Nursing Daily Skilled Charting note dated 9/26/21 at 1:36 p.m., revealed the resident had a surgical incision site to the left hip. A Care Conference Note dated 9/27/21 at 2:44 p.m., revealed the resident was already showing improvement in her mobility. The resident was willing to work with therapy and seemed motivated to meet her goals and return home. The resident would continue to receive physical therapy and occupational therapy. The care plan, created on 9/27/21, revealed the resident had the potential for impairment of the skin integrity related to the use of aspirin therapy, anticoagulant therapy, incontinence and limited mobility. Some of the interventions included for the resident to avoid scratching, keep the resident's fingernails short, keep hands and body parts from excessive moisture. Staff were to keep the resident's skin clean and dry: use lotion on dry skin. Encourage good nutrition and hydration to promote healthier skin. Staff were to follow facility protocols for treatments of injury. Interdisciplinary team referrals as indicated for physical therapy services and for nutritional services. Resident to utilize a pressure reducing mattress. Staff were to provide incontinence care after each incontinent episode or according to the established toileting plan. Staff were to provide treatments as ordered. Staff were to perform and document weekly skin checks. The care plan, created on 9/27/21, revealed the resident was at risk for pressure ulcer development related to slightly limited sensory perception, occasionally moist, chair fast, limited mobility, and the potential for friction/shear. The resident did not call for staff assistance for positioning or care when in bed. The resident rejected care from staff at times with repositioning and ordered treatments for skin. Some of the interventions were: To administer medications as ordered and observe for effectiveness. Complete a weekly full body check and document. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Interdisciplinary team referrals as indicated to registered dietitian, physical therapy and occupational therapy. Encourage and offer frequent repositioning and turning. Offload the resident's bilateral heels at all times while in bed initiated on 10/2/21. Application of an air mattress initiated on 10/14/21. Despite staff education, the resident often refused and/or would accept repositioning by staff and then turn herself back to the original position initiated on 10/27/21. Physician order dated 9/30/21 revealed to provide house supplement shake orally twice a day. The care plan created on 10/2/21, revealed the resident had the potential of pressure ulcer development related to immobility. Some of the interventions were to administer medications as ordered and observe for effectiveness. Complete a weekly full body check and document. Provide incontinence care after each incontinence episode, or according to the established toileting plan. Interdisciplinary team referrals as indicated to registered dietitian, physical therapy and occupational therapy. The care plan, created on 10/2/21, revealed the resident had an unstageable deep tissue injury of the left buttock on 10/14/21, an unstageable deep tissue injury of the right buttock on 10/14/21, an unstageable deep tissue injury of the left buttock now extending into the sacral region on 10/21/21, and an unstageable deep tissue injury of the left buttock now split and categorized into three separate wounds: (1) left buttock, (2) right buttock and (3) sacrum. Some of the interventions were to daily monitor the wound and surrounding tissues for any negative changes and/or abnormalities. Wound physician to routinely follow. Encourage and offer frequent repositioning and turning. Follow facility policies/protocols for the prevention/treatment of skin breakdown on. Staff were to observe/document location, size, treatment of pressure ulcer and report any changes to the physician or the wound team. Provide incontinence care to the resident after each incontinence episode, or per established toileting plan. Application of an air mattress and gel chair cushion initiated on 10/14/21. Despite staff education, the resident often refused and/or would accept repositioning by staff and then turn herself back to the original position initiated on 10/27/21. The care plan, created on 10/2/21, revealed the resident had an unstageable deep tissue injury of right heel. The resident had an unstageable deep tissue injury of the left distal posterior calf on 10/21/21 and an unstageable deep tissue injury of the left posterior lateral heel on 10/21/21. Some of the interventions were for daily monitoring of wound and surrounding tissues for any negative changes and/or abnormalities, wound physician to routinely follow, encourage and offer frequent repositioning and turning. Staff were to offload the resident's bilateral heels at all times while in bed. Observe/document location, size, treatment of pressure ulcer and report changes to physician or wound team. Provide wound care per physician orders. Obtain and observe lab/diagnostic work as ordered, report results to physician and follow up as indicated. Encourage good nutrition and hydration in order to promote healthier skin. Despite education, the resident often refused and/or will accept repositioning and then turn herself back to her previous position. Staff were to follow facility policies/protocols for the prevention/treatment of skin breakdown. Staff were to provide wound care as the physician ordered. The Physical Therapy progress note for services from 9/23/21 to 10/6/21 revealed the resident received skilled services for bed mobility. This was electronically signed by a doctor of physical therapy on 10/6/21 at 3:31 p.m. The Physical Therapy encounter note electronically signed by a physical therapy assistant on 9/27/21 at 1:46 p.m., revealed the resident received therapy for transfer training with emphasis on bed mobility with resident at total dependence on supine to side lying. The Physical Therapy encounter note electronically signed by a doctor of physical therapy dated 9/28/21 at 2:42 p.m., revealed therapy services to facilitate upright sitting at the edge of the bed for improved activity tolerance and core strength. The resident maintained position with intermittent upper extremity support for 15 minutes. The Physical Therapy encounter note dated 9/29/21 was electronically signed by a doctor of physical therapy dated 9/30/21 at 8:28 a.m., revealed therapy provided bed mobility training which included rolling in bilateral directions. The resident required maximum assistance to complete the activity and complained of pain in the left hip. The resident tolerated multiple repetitions and demonstrated increased participation throughout trials. The resident received sit to supine training with elevated head of the bed and the resident demonstrated improved initiation and participation with hip abduction/adduction and continued to require maximum assistance to complete the activity. The Physical Therapy encounter note dated 9/30/21 was electronically signed by a doctor of physical therapy dated 9/30/21 at 3:45 p.m., revealed the resident received instructions on seated lower extremity strengthening in all planes. The resident received bed mobility training and the resident continued to exhibit improved performance with hip abduction/adduction. The admission Nutrition Data Collection dated 9/30/21 at 10:09 a.m., revealed the resident was alert and verbal. The resident had a surgical wound of the left hip and no history of pressure ulcers and no current pressure ulcers. The resident utilized a regular diet and texture with a 25 to 75% meal intake. Recommendation for a house supplement shake twice a day for added nutrition for her variable intakes. A Physician order dated 9/30/21 revealed to provide a house supplement shake twice a day. A Physical Therapy encounter note dated was electronically signed by a doctor of physical therapy dated 10/2/21 at 4:09 p.m., revealed the resident received bed mobility training. A Physical Therapy encounter note dated was electronically signed by a doctor of physical therapy dated 10/2/21 at 4:09 p.m., revealed the resident was provided seated balance training with the resident tolerating edge of bed position with intermittent upper extremity assist for 15-minutes. The resident was provided mobility training with rolling right and left. The resident did not tolerate a complete roll to the right due to pain. A Physical Therapy encounter note dated was electronically signed by a doctor of physical therapy dated 10/7/21 at 8:37 a.m., revealed staff facilitated bed mobility training with emphasis on rolling to increase resident participation in caregiving activities. The resident required maximum assistance and was resistant to complete left side lying due to pain. The resident received bed mobility training and required maximum assistance to complete supine to sitting with the head of the bed elevated. A Physical Therapy encounter note dated was electronically signed by a doctor of physical therapy dated 10/7/21 at 5:19 p.m., revealed therapy for supine ranges of motion to bilateral lower extremities in order to improve joint and muscular integrity. Also, therapy for bed mobility training for rolling with moderate assistance; supine to sitting with moderate assistance of two staff with additional time required. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/8/21 at 4:08 p.m., revealed the resident was provided therapy for bed mobility from sit to supine with maximum assistance for guiding trunk and for bringing lower extremities onto the bed. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/11/21 at 5:28 p.m., revealed the resident received therapy for bed mobility with moderate assistance of two staff scooting to the edge of the bed. The resident was also a moderate assist with proper positioning and scooting back for improved comfort and safety in a wheelchair. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/12/21 at 4:45 p.m., revealed the resident had an open wound to the right lateral heel; nursing staff was notified and would attend to the wound. The encounter was for bed mobility and positioning with maximum assistance; the resident tended to resist, which was likely due to pain. The nursing staff were educated to utilize a mechanical lift at this time for safe transfers. Also, provided instructions that the resident should be up in a wheelchair daily, to optimize healing and reduce the risk of decline. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/13/21 at 4:06 p.m., revealed the resident was positioned in bed with heels floated. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/14/21 at 3:48 p.m., revealed the resident provided bed mobility training for rolling with moderate assist. Positioning strategies were provided for improving comfort and safety in a wheelchair with bilateral feet supported to reduce the risk of falling forward. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/15/21 at 3:14 p.m., revealed the resident was assessed for the current seating system for appropriate modifications. A Physical Therapy encounter note electronically signed by a doctor of physical therapy on 10/19/21 at 3:35 p.m., revealed bed mobility training was provided with the resident requiring maximum assistance to complete rolling right and left. The resident expressed pain with the activity. There was no pain at sitting on the edge of the bed with supervision assistance. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/20/21 at 2:55 p.m., revealed diathermy applied to the right heel for 30-minutes in order to facilitate circulation, increase blood flow/circulation and minimize negative effects of immobility with intensity/setting at variable. The Occupational Therapy encounter note dated 10/19/21 electronically signed by an occupational therapist dated 10/25/21 at 3:31 p.m., revealed diathermy applied to the left heel for 30-minutes in order to increase blood flow/circulation and facilitate circulation with intensity level/setting at variable. The resident was provided with safety training during functional mobility. The resident was also provided with facilitation of neuromuscular functional synergy patterns to improve mobility, postural control, techniques to facilitate proprioception and techniques to facilitate motor control in order to facilitate motor control. The resident was further provided safety training during functional mobility. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/21/21 at 3:31 p.m., revealed therapeutic activities were provided for positioning related to skin integrity, modification to seating for skin integrity (including application of biomorphic equagel cushion). A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/21/21 at 4:54 p.m., revealed the resident received bed mobility training for improvement of the resident's position with a maximum assistance of two staff for rolling and scooting up to the head of the bed. Positioning strategies were also provided to reduce the risk for impaired skin integrity. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/21/21 at 5:08 p.m., revealed the resident was provided short wave diathermy to bilateral heels for increased circulation, edema, skin integrity and pain modulation. The resident also received modification to her seating surface for improved skin integrity while seated. The resident now has a 20-inch (tall) thickness equagel with sacral depression affixed for consistency of placement. A Physical Therapy encounter note electronically signed by a physical therapist assistant on 10/22/21 at 4:56 p.m., revealed the resident received bilateral ankle ranges of motion for improvement of joint flexibility and edema reduction. The resident was positioned for comfort with heels suspended to avoid pressure. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/22/21 at 2:48 p.m., revealed diathermy was applied to the right heel for 30-minutes to facilitate circulation and increased circulation for wound healing with intensity level/setting at variable. The resident received therapy for postural control techniques to facilitate motor control, facilitation of patterned movements and techniques to facilitate proprioception in order to facilitate neuromuscular functional synergy patterns to improve mobility and facilitate neuromuscular functional synergy patterns to improve self-care. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/25/21 at 4:03 p.m., revealed short wave diathermy to bilateral heels for increased circulation, edema and pain modulation on variable setting. Also, analysis/adjustment of wheelchair seating/positioning, facilitation of position in space, postural control and proper body alignment while sitting and supine. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/26/21 at 4:46 p.m., revealed short wave diathermy to bilateral heels for increased circulation, pain modulation at variable setting. The resident provided an anticipatory reaction challenge: weight shifter lateral, weight shifted anterior and trunk rotation in sitting unsupported for one repetition. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/28/21 at 3:48 p.m., revealed the resident participated in lower extremity ranges of motion for improving joint flexibility and circulation to musculature in order to improve the resident's tolerance for moving lower extremities during functional tasks. The resident also participated in positioning strategies in a wheelchair for improving comfort and safety. Also, lower extremity positioning on leg rest for improved alignment and reduced pressure to both heels. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/29/21 at 1:30 p.m., revealed provided facilitation of neuromuscular functional synergy patterns to improve self-care tasks, techniques to facilitate motor control, proprioceptive techniques to improve safety, decrease fall risk in order to have increased movement and safety with self-care tasks. A Physician order dated 10/27/21, revealed to provide a house supplement shake orally three times a day. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 11/1/21 at 5:08 p.m., revealed the resident was provided standing balance with assistance of two staff to optimize ability to stand and transfer for opportunity to return home. A. Pressure injury of right posterior heel A Head to Toe Skin Check dated 9/29/21 at 11:49 a.m., revealed a facility acquired blister/deep tissue injury to the right heel measuring 5.5 centimeters (cm) x 4.0 cm x 00. This was a fluid filled blister. The Head to Toe Skin Check dated 9/29/21 at 11:49 a.m., revealed a facility acquired blister/deep tissue injury to the right heel measuring 5.5 cm, 4.0 cm x 00 with an intact fluid filled blister. The eInteract Situation, Background, Assessment and Recommendation (SBAR) for Providers dated 9/29/21 at 11:49 a.m., revealed a change in condition was reported, related to a skin wound or ulcer. The skin status evaluation revealed a blister. The nursing observations, evaluation and recommendations revealed a pressure related deep tissue injury. The primary care provider feedback recommendations were for a wound care consultation, and the resident's physician would evaluate the resident tomorrow. The Interdisciplinary Team (IDT) note dated 9/29/21 at 12:30 p.m., by an LPN revealed the resident had a left hip surgical site skin impairment and scored a 15 on the Braden Scale, indicating the resident was at risk for development of a pressure ulcer. A Physician order dated 9/29/21 at 3:41 p.m., revealed to monitor the right heel and the surrounding tissues for changing or emerging wounds and pain until resolved. Document + or -. (+) = no observed abnormalities or changes to the dressing, skin, or pain associated with the wound. Document (-) = abnormalities or changes to the dressing, skin, or pain associated with the wound are present. If any abnormalities were observed, document in progress note every shift. every shift for monitoring. The Skin Weekly Pressure Ulcer Record dated 9/30/21 at 2:28 p.m., revealed an unstageable deep tissue injury to the right posterior heel measuring 4.5 cm x 5.5 cm x nm (no measurement). The surface area was 24.75 cm (squared) with a wound bed that was a purplish blister. Provider to evaluate and treat; wound care treatment and continue monitoring. The Initial Wound Evaluation and Management Summary dated 9/30/21 by the wound physician revealed unstageable deep tissue injury of the right posterior heel with partial thickness. The wound measured 4.5 cm x 5.5 cm x nm. The surface area measured 24.75 cm (squared). There was no exudate. The plan of care was to off load the wound. The treatment plan was for skin preparation twice a day for 30 days. The Wound Evaluation and Management Summary dated 10/7/21 by the wound physician revealed unstageable deep tissue injury of the right posterior heel with partial thickness. The wound measured 4.5 cm x 5.5 cm x nm with no exudate. The surface area measured 24.75 cm (squared). The plan of care was to off load the wound. The treatment plan was to apply skin preparation twice daily for 23 days. The Skin Weekly Pressure Ulcer Record dated 10/14/21 at 1:30 p.m., revealed an unstageable deep tissue injury to the right posterior heel measuring 4.5 cm x 5.5 cm x nm with an onset date of 9/29/21. The surface area measured 24.75 cm (squared): blister. Provide pillows, wedges and wound care treatment with monitoring. Discontinue the current order. Apply Betadine (antiseptic) twice a day, cover with an ABD (highly absorbent dressing) and secure with Kerlix (bandage roll). The Wound Evaluation and Management Summary dated 10/14/21 by the wound physician revealed an unstageable deep tissue wound of the right posterior heel with partial thickness. The wound measured 4.5 cm x 5.5 cm x nm with no exudate. The surface area was 24.74 cm (squared). The plan of care was to off load the wound. The treatment plan was for the primary dressing to use Betadine and apply twice daily for 30 days. The secondary dressing was an ABD pad applied twice daily for 30 days and a gauze roll (Kerlix) 2.25 inches: apply twice daily for 30 days. A Physician note with an encounter date of 10/15/21 was electronically signed by the resident's physician on 10/29/21 at 10:59 a.m. The necessi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #33 A. Resident status Resident #33, age [AGE], was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included repeated falls, muscle weakness, muscle wasting and atrophy, vascular parkinsonism, and unspecified dementia without behavioral disturbance. The 8/26/21 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of three out of 15. He required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. He had had two or more falls with no injury since the prior MDS assessment, and he had had two or more falls with injury since the prior MDS assessment. B. Record review The 9/24/21 Fall Risk Assessment documented Resident #33 was at high risk for falls. Review of the comprehensive care plan, initiated 7/16/19 and last revised 10/19/21, revealed Resident #33 was at risk for falls related to dementia without behavioral disturbances, muscle wasting/weakness and a history of repeated falls. Pertinent interventions included performing activities one to one with the resident in his room, helping the resident with putting on shoes, socks or non-skid socks, and keeping his wheelchair at the bedside when he was asleep for safety, educating staff to anticipate his needs, encouraging the resident to stay in commons areas for visual observation, utilizing a fall mat at bedside, installing non-skid strips on the floor next to his bed, and consulting with neurology and pharmacy for medication reviews and changes. The Post Fall Review assessment dated [DATE] documented Resident #33 had an unwitnessed fall in his room at 10:45 p.m. and first aid was provided to the resident. The fall assessment further documented Resident found on the floor, opposite the fall mat, on his hands and knees with blood coming from both nares. It appeared that he fell while standing on the fall mat and possibly struck his nose on the floor. There was no redness to his face or forehead and no swelling except to the bridge of his nose. Review of Resident #33's electronic medical record (EMR) revealed the following progress notes: 6/16/21 at 11:24 p.m: Appears that resident fell to ground and hit the floor with his face. He continues to be restless at bedtime (HS) and night (NOC) shift.When found, his nose was actively bleeding and there was swelling to the bridge of his nose. Resident confirms that his nose hurts and not his forehead or any other areas. 6/16/21 at 11:31 p.m: Resident found on his hands and knees by the side of his bed with bloody nose. Resident confirms that he fell and his nose hurts. Nurse practitioner (NP) contacted, order received to obtain an immediate (STAT) three view x-ray of facial bones. Will continue to monitor. 6/16/21 at 11:33 p.m: STAT three view x-ray of facial bones ordered at this time related to fall. 6/18/21 at 12:51 p.m: Notified NP about facial x-rays. No abnormal findings. No orders at this time. The facial bone x-ray report for Resident #33 dated 6/17/21 documented the following: Findings: No fracture. The osseous (bone) structures appear intact. The sinuses are clear. Soft tissues appear unremarkable. Old fracture. Conclusion: Normal facial series. Radiographs are insensitive for subtle abnormalities. If clinical concern or symptoms continue to exist, further workup with computed tomography (CT) should be considered. Review of the facility's Neurological Record documentation form revealed neurological checks were to be performed and documented following a resident fall. A resident was to be assessed with each neurological check for: vital signs (including blood pressure, pulse, respirations, and temperature), level of consciousness, pupil size and reaction, eye opening response, motor reflex response of all extremities, and verbal speech response. Per the facility's Neurological Record form, neurological checks were to be completed utilizing the following frequency: -Every 15 minutes times four checks; -Every 30 minutes times four checks; -Every hour times four checks; -Every four hours times two checks; and, -Every eight hours times two checks. Review of Resident #33's Neurological Record form which was initiated on 6/16/21 at 10:45 p.m. revealed the following: -10:45 p.m: all sections on the form were completed; -11:00 p.m: all sections on the form were completed; -11:15 p.m: all sections on the form were completed; -11:30 p.m: all sections on the form were completed; -12:00 a.m: all sections on the form were completed; -12:30 a.m: vital signs section was completed, all other assessment sections were left blank; -1:00 a.m: vital signs section was completed, all other assessment sections were left blank; -1:30 a.m: vital signs section was completed, all other assessment sections were left blank; -2:30 a.m: vital signs section was completed, all other assessment sections were left blank; -3:30 a.m: vital signs section was completed, all other assessment sections were left blank; -4:30 a.m: vital signs section was completed, all other assessment sections were left blank; -5:30 a.m: vital signs section was completed, all other assessment sections were left blank; and -9:30 a.m: documentation on the form revealed the resident sustained another fall at 6:15 a.m. on 6/17/21 and a new Neurological Record form was initiated at that time. Review of the Neurological Record form dated 6/17/21 revealed that all neurological checks had been completed for Resident #33's fall which occurred at 6:15 a.m. C. Unit manager (UM) #2 interview UM #2 was interviewed on 11/3/21 at 9:10 a.m. UM #2 confirmed that the neurological check form for Resident #33's fall on 6/16/21 had not been completed. She said the neurological checks between 12:30 a.m. and 9:30 a.m. did not include the assessment documentation for the resident's level of consciousness, pupil size and reaction, eye opening response, motor reflex response of all extremities, and verbal speech response. UM #2 said neurological checks were to be performed for every unwitnessed fall, or a fall in which the resident was known to have hit their head. She said neurological checks were to be performed per the facility's frequency protocol (see frequency above) and all assessment areas were to be documented thoroughly on the form. UM #2 said it was important to assess residents frequently following a fall in order to ensure that the resident had not sustained a head injury. She said the facility was working on a better process to ensure that staff thoroughly assessed and documented neurological checks after resident falls. IV. Additional interviews Licensed practical nurse (LPN) #4 was interviewed on 11/2/21 at 1:48 p.m. LPN #4 said neurological checks were to be performed for every resident after an unwitnessed fall. She said neurological checks would also be completed if the resident was known to have hit their head. She said nurses were to document the complete assessment on the Neurological Record form, per the facility frequency protocol. The NHA, director of nursing (DON), unit manager (UM) #1, UM #2, regional vice-president of operations (RVPO), and the regional nurse consultant (RNO) were interviewed together on 11/2/21 at 4:30 p.m. The NHA said neurological checks should be completed for the entire monitoring period following a resident fall according to the facility's frequency protocol. She said all sections of the Neurological Record form should be monitored with every neurological check, and documented on the form accurately and timely. LPN #6 was interviewed on 11/3/21 at 8:51 a.m. LPN #6 said neurological checks should be performed if a resident fall was unwitnessed or staff witnessed them hitting their head. She said neurological checks should be initiated immediately after the fall. She said nurses were to check vital signs, hand grasps, eye responsiveness, mentation, pupil reaction, and speech. LPN #6 said the neurological checks should be completed entirely for each assessment and documented for the entire period of the neurological check frequency protocol. Registered nurse (RN) #2 was interviewed on 11/3/21 at 9:20 a.m. RN #2 said neurological checks were initiated immediately after a fall for all unwitnessed falls or a fall in which the resident was witnessed hitting their head. He said the neurological check frequency was listed on the Neurological Record form. RN #2 said nurses should complete a full neurological assessment following the frequency protocol and document all findings on the neurological check form each time. LPN #5 was interviewed on 11/3/21 at 9:43 a.m. LPN #5 said neurological checks included assessing a resident's pupil reaction, hand grasps, vital signs, level of consciousness, and speech. She said neurological checks were to be initiated immediately following an unwitnessed fall or a fall where the resident was known to have hit their head. LPN #5 said it was important to monitor residents for signs of a head injury following an unwitnessed fall. She said neurological checks were performed per the facility's frequency protocol and all information was to be documented in its entirety on the Neurological Record form for each fall. Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#84 and #33) of six residents out of 39 total sample residents. Resident #84 with diagnosis of Alzheimer's disease was admitted to the facility with a known fall risk. The resident had an unwitnessed fall on 9/20/21 in which he sustained a skin tear and had left hip pain. The intervention for the fall was to move the resident closer to the nurse's station for better visual observation. The resident was not moved closer to the nurse's station due to COVID-19 isolation protocols. However, the facility did not implement increased supervision after the fall that occurred on 9/20/21. Due to the facility's failures, the resident had an unwitnessed fall on 9/23/21, where he sustained a fractured right hip and a fractured right elbow. In addition, the facility failed to ensure thorough neurological assessments were completed for Resident #33 after an unwitnessed fall in which he sustained a bloody nose and an x-ray was obtained. Findings include: I. Facility policy and procedure A. The Fall Prevention Program policy, dated 2020, was provided by the nursing home administrator (NHA) on 11/2/21 at 12:50 p.m. It read in pertinent part, When any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, notify the physician and family, and document all assessments and actions. B. The Head Injury policy, dated 2021, was provided by the NHA on 11/3/21 at 10:35 a.m. It read in pertinent part, It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury. Assess residents following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: vital signs, general condition and appearance, and a neurological evaluation for changes in physical functioning, behavior, cognition, level of consciousness, dizziness, nausea, irritability, and slurred speech/slowness to answer questions. Notify the physician and follow orders for care. Perform neurological checks as indicated or as specified by the physician. Notify family and document all assessments, actions, and notifications. II. Resident #84 A. Resident status Resident #84, age [AGE], was admitted on [DATE] and readmitted on [DATE]. The resident was discharged from the facility on 9/28/21. According to the September 2021 computerized physician orders (CPO), diagnoses included non-displaced fracture of the greater trochanter of the right femur (added 9/23/21), Alzehimer's disease, anxiety, chronic respiratory failure with hypoxia, dependence on supplemental oxygen, muscle weakness, muscle wasting/atrophy, and other signs/symptoms involving cognitive functions and awareness. The 9/9/21 minimum data set (MDS) assessment, revealed the resident was severely cognitively impacted with a brief interview for mental status (BIMS) score of 99. The resident had both short and long term memory problems. The resident had difficulty focusing his attention and was easily distracted or had difficulty keeping track of what was said. This behavior was present and fluctuated. The resident's thinking was disorganized or incoherent. This behavior was present and fluctuated. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review The care plan for falls related to confusion, incontinence, new admission to facility, unaware of safety needs and wandering was initiated on 9/12/21. Some of the interventions were to anticipate and meet the resident's needs, encourage non-skid footwear of the resident's choice while ambulating or when in wheelchair, maintain a safe environment (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items within reach) and follow the facility fall protocol. The admission data collection fall risk assessment dated [DATE] at 3:14 p.m., revealed a score of five, which indicated at risk. The resident was disoriented times-three at all times. The resident had one to two falls in the past three months. The resident had a balance problem while standing and walking. The resident had decreased muscular coordination and had a gait pattern change when walking through a doorway. The resident exhibited jerking motions and was unstable when making turns. The occupational therapy note dated 9/14/21 at 6:47 p.m., revealed the reason for therapy was the resident had impairments in balance, mobility, attention, planning, follow through, problem solving, self-modification, interpersonal interactions, and use of environmental modification strategies resulting in limitations and/or participation restrictions in the areas of interpersonal interactions and relationships, mobility and self-care which required skilled therapy services to assess and modify environmental barriers, assess safety and independence with activities of daily living, assess the need for adaptations/assistive devices, develop and instruct on compensatory strategies, facilitate dynamic standing balance, increase functional activity tolerance and maximize independence with activities of daily living in order to facilitate ability to live in environment with least amount of supervision and assistance. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient was at risk for: behavioral outbursts, decreased ability to return to prior level of supervision, falls and decreased participation with functional tasks. A nurse note dated 9/19/21 at 12:29 a.m., by a registered nurse (RN) revealed the resident was agitated and more resistive to care this evening. This nurse tried to administer medications three times without success. On the third attempt the resident smacked the nurse's hand away during the explanation of the medications. An attempt was made to assist the resident to the bathroom and the resident refused to walk or sit in his wheelchair. The resident refused to wear his oxygen cannula and would not allow it to be placed on him. Will continue to try to provide care. C. Fall 9/20/21 A situation, background, assessment and recommendation (SBAR) dated 9/20/21 at 6:08 p.m., by the director of nursing (DON) revealed the resident had an unwitnessed fall at 5:30 p.m., this date. The resident was found on his left side. He had a skin tear to his left elbow and bilateral first knuckles. The resident was unable to lay on his back to fully assess for signs of any fractures or dislocations. The resident reported pain on his left hip with pressure and manipulation. A call was placed to his power of attorney and she wanted the resident sent to the emergency department for a hip x-ray to rule out a fracture or dislocation. The 911 call was made and he was sent out at 6:06 p.m. The neurological assessment record was started on 9/20/21 at 5:30 p.m. The assessment columns for 5:30 p.m. and 5:45 p.m. (every 15 minutes for four checks per facility protocol), contained no assessment documentation. There were no assessments for vital signs, level of consciousness (alert, drowsy, stuporous, comatose), pupil reaction, eye signs, eye motor, eye movement, or verbal ability. The fall risk assessment dated [DATE] at 6:16 p.m. revealed a score of 10 or high risk. The resident was disoriented times-three at all times. The resident had one to two falls in the past three months. The resident had a balance problem while standing and walking. The resident had decreased muscular coordination. The resident exhibited jerking motions and was unstable when making turns. The interdisciplinary team (IDT) post fall review dated 9/20/21 at 6:18 p.m., revealed the resident had an unwitnessed fall in his room at 5:30 p.m., this date. The resident had a skin tear to his left elbow and bilateral knuckles. The staff could not assess his left hip. The resident complained of pain in his left hip. He was sent to the emergency department for a hip x-ray (the right hip had an x-ray due to resident complaining of pain in right hip at the hospital, which was negative). After return to the facility and upon completion of isolation protocols; the resident would be moved closer to the nurse's station for better visual observations. A nurse note dated 9/20/21 at 10:20 p.m., by an RN revealed the resident returned to the facility by emergent hospital transport at this time. The resident was calm and cooperative with care. The resident did not complain of any discomfort and there were no non-verbal pain cues noted at this time. The resident had a skin tear to his left hand knuckle with a dressing in place and a skin tear to his right hand knuckle without a dressing. He had a skin tear to his left elbow with a dressing in place. The resident was in bed watching television with the bed in a low position. Discussion with the emergency department nurse occurred at 9:30 p.m., this date. The SBAR follow-up note dated 9/21/21 at 12:57 p.m., by a licensed practical nurse (LPN) revealed the continued on follow up with no deficits observed. The resident denied any pain or discomfort at this time. The IDT note dated 9/22/21 at 9:21 a.m., by the DON revealed the IDT met to review the resident's fall status. The resident had a fall on 9/20/21. The fall resulted in a skin tear to the left elbow and bilateral knuckles. The resident complained of hip pain and was sent to the emergency department for evaluation. The IDT investigated the fall on 9/20/21 and determined the cause of the unwitnessed fall. The new interventions were to send the resident to the emergency department for his x-rays and move the resident close to the nurse's station for better visual observation (when he came off isolation precautions). The resident's care plan was reviewed and updated. Staff would continue to monitor and make changes to the plan of care as needed. -However, the resident was not moved closer to the nurse's station for better visual observation (see NHA interview below). Subsequently the resident had another fall on 9/23/21 that caused major injury. Due to isolation for COVID-19, the resident was not moved for visual observation and the facility failed to implement measures to increase supervision after his fall on 9/20/21. D. Fall 9/23/21 The fall risk assessment dated [DATE] at 3:46 p.m., revealed a score of 13 or high risk. The resident was disorientated times-three at all times. The resident had one to two falls in the past three months. The resident had a balance problem while standing. The IDT post fall review note dated 9/23/21 at 3:48 p.m., revealed the resident had a fall at 3:30 p.m., this date. The resident had a (un)witnessed fall with a possible head injury. The resident was found on the floor by therapy. The resident was on his right side with his head leaning on an overside table. The resident wore non-skid socks. He complained of pain in the shoulder related to laying in an awkward position. He was able to move all extremities with purpose with no pain while in a chair. Three staff members transferred the resident to a wheelchair for safety. The resident had a skin tear to the right elbow. It was cleaned with a wound cleanser and a bandage was applied. A nurse note dated 9/23/21 at 3:55 p.m., by the minimum data set coordinator (MDSC) revealed the resident was found on the floor in his room by therapy staff. The resident was on his right side and his head on a table. He was wearing non-skid socks and his oxygen was not in place. The resident complained of pain related to the awkward position he was in. He had a skin tear to his right elbow and first aid was provided. The resident said he hit his head and the fall protocol was initiated. The resident moved all extremities with purpose and he had no complaint of pain. The resident was unable to recall what happened due to being a poor historian. The neurological assessment record was started on 9/23/21 at 3:50 p.m. The assessment columns for 4:05 p.m., 4:20 p.m., 4:35 p.m., 5:05 p.m., 5:35 p.m., and 6:05 p.m., contained no assessment documentation. There were no assessments for vital signs, level of consciousness (alert, drowsy, stuporous, comatose), pupil reaction, eye signs, eye motor, eye movement, or verbal ability. The pain evaluation form dated 9/23/21 at 4:00 p.m., revealed no pain in the past five days. The SBAR summary note dated 9/24/21 at 4:05 p.m., by the MDSC noted the resident had no safety awareness. The resident was found on the floor (in his room) by therapy staff. The resident was on his right side with his head on a table. He was wearing non-skid socks. The resident was not wearing oxygen. The resident complained of pain related to the awkward position he was in. He has a skin tear to his right elbow and first aid was provided. The resident said he hit his head and the fall protocol was initiated. The resident was able to move all extremities with purpose with no pain. The resident was unable to recall what happened due to being a poor historian. A nurse note dated 9/24/21 at 10:23 a.m., by an LPN revealed the nurse practitioner was advised the resident appeared visibly in pain upon waking, however due to his cognition, he was unable to express it verbally. Received a new order for Tylenol 1,000 mg orally three times a day. A nurse note dated 9/24/21 at 1:10 p.m., by an LPN revealed the resident's right hand was observed to be swollen and non-pitting. The resident was unable to open the hand completely. The nurse practitioner was advised and a new order was received to obtain an x-ray of his right hand. The SBAR follow up note dated 9/24/21 at 1:14 p.m., revealed the resident continued on follow up and no deficits were observed. The x-ray was ordered for right hand pain. Pain medications were administered as ordered. Will continue to monitor. A nurse note dated 9/24/21 at 5:03 p.m., by a licensed practical nurse (LPN) revealed the x-ray to the right hand was performed and awaiting results. A nurse note dated 9/24/21 at 5:34 p.m., by an LPN revealed when the resident was assisted back to bed, he was unable to stand on his own. The resident was observed to wince with movement of the right hip. The resident was placed carefully in bed with a pillow between his knees. The nurse practitioner was called and a new order for a STAT (immediate) anterior view x-ray of the resident's right hip. The radiology report dated 9/24/21 at 8:20 p.m., revealed a right hip greater trochanter fracture that was non-displaced. A nurse note dated 9/24/21 at 10:50 p.m., by an RN revealed the results of the right hip x-ray returned with a closed fracture to the right greater trochanter. The hospital was contacted and an order received to send out to the emergency department for further evaluation. The resident was sent by non-emergent transport and left the facility at 10:45 p.m. The SBAR communication note dated 9/24/21 at 10:58 p.m., revealed the x-ray results of the right hip showed a non-dislocated fracture of the right greater trochanter from a fall on 9/24/21. The condition was made worse by movement, physical activities and repositioning. The condition was made better by lying still. The resident had a history of dementia, falls, and metabolic encephalopathy. The SBAR summary note dated 9/24/21 at 10:58 p.m., revealed the resident had pneumonia, weakness and dementia. He had a history of falls at home combined with new comorbidities. The resident was at a higher risk for falls and fractures. Contact was made with a nurse practitioner who requested the resident be sent to the emergency department for evaluation. The emergency department Discharge summary dated [DATE] at 4:45 p.m., revealed the resident had intractable pain, acute closed non-displaced fracture of the greater trochanter of the right femur and acute non-displaced fracture of the proximal right olecranon (elbow)with possible intra-articular extension. The admission note dated 9/26/21 at 2:41 p.m., by an LPN revealed the resident returned from the hospital to the facility by non-emergent transport at 12:15 p.m., this date. The resident was in visible pain and pain medications were administered. The resident was admitted with a right femur fracture and a right olecranon fracture. The resident had a cast on the right arm. The resident was confused at baseline and was unable to answer questions properly. The admission data collection for pain dated 9/26/21 at 1:46 p.m., revealed a level of 10 out of ten. The location was in the bone and joint of the right hip and right elbow. Repositioning and walking in the morning makes it worse. Rest reduces the pain. E. Staff interviews The NHA was interviewed on 11/1/21 at 11:10 a.m., and at 11:52 a.m. She acknowledged the times for the six missing neurological assessments for the fall with an injury on 9/23/21. She reviewed the neurological assessment form and agreed the frequency the staff should follow for an unwitnessed fall or a witnessed fall with a head injury was located in the upper right hand corner of the form. The frequency was every 15 minutes ' times four, every 30 minutes ' times four, every hour times four, every 4 hours ' times two and every 8 hours ' times two. She said the staff should complete the neurological assessments accurately and according to this frequency. She said neurological assessments should be completed to make sure there were no negative outcomes from a fall. She said some possible concerns from not completing the assessments might be a head injury, brain bleed, stroke or paralysis. Registered nurse #1 was interviewed on 11/1/21 at 11:20 a.m. She acknowledged the neurological assessment form for the fall on 9/23/21 had six missing neurological assessments. She said for an unwitnessed fall and for a suspected head injury the staff should follow the frequency of neurological assessments located in the upper right hand corner of the neurological assessment record. She said neurological assessments were performed to look for any changes in the resident's cognition or any deviation from the resident's established baseline (a starting point for comparison). She said not completing the neurological assessments might delay any treatments for a head injury or brain bleed. She said some possible concerns from not completing the assessments might be the possibility of missing any additional aberrant neurological findings. Unit manager #2 was interviewed on 11/1/21 at 11:39 a.m. She acknowledged the neurological assessment form for the fall on 9/23/21 had six missing neurological assessments. She said for an unwitnessed fall and for a suspected head injury the staff should follow the frequency of neurological assessments located in the upper right hand corner of the neurological assessment record. She said neurological assessments were performed to check for any changes from the resident's baseline assessments and to check the resident's mentality/cognition for any deviations from the resident's normal. She said some possible concerns from not completing the assessments might be neurological deficits, stroke or paralysis. She said the resident did sustain a fractured hip from the fall. The NHA and the DON were interviewed on 11/2/21 at 4:10 p.m. The NHA acknowledged the two missing neurological assessments for the fall on 9/20/21 and the six missing neurological assessments for the fall with an injury on 9/23/21. The NHA said the neurological assessments should be completed according to the frequency in the upper right hand corner of the neurological assessment record. The NHA said the resident did not sustain any fractures for the fall on 9/20/21. She said the resident went to the emergency department after this fall for an evaluation. She said when he returned to the facility, he had to return to a COVID-19 room on the isolation unit due to his evaluation at the hospital. The NHA said after the second fall on 9/23/21 the resident initially did not have any signs or symptoms of a hip fracture. The NHA said the resident was sent to the emergency department for evaluation and he did have a hip fracture. The NHA said was noted to be a fall risk and was found both times by staff in his room after the falls. She said the resident was confused, exit seeking, restless, had hallucinations, looked for his truck outside the facility and took his oxygen off. She said the resident did receive therapy services at the facility. She said one of the suggested interventions was to move the resident closer to the nurse's station once he came off isolation; however, this intervention was unable to be implemented. The NHA was interviewed on 11/3/21 at 8:32 a.m. She acknowledged the resident had two falls in the facility on 9/20 and 9/23. She said there were no fractures on the first fall, however he did sustain a fracture of the trochanter and olecranon on the second fall. She said the nursing staff did not complete the neurological assessments according to the frequency on the neurological assessment record. The NHA, director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 11/3/21 at 1:00 p.m. The NHA said resident falls were discussed in the 8/24/21 Quality Assurance and Improvement (QAPI) meeting. She said past deficiencies in falls were also discussed. She said nursing staff and medical records staff were educated to ensure the resident medical records were accurate and complete. She said Monday through Friday, resident falls were discussed in the morning meeting and the fall documentation was reviewed. She said they discussed the total number of falls, any injuries, and residents that had multiple falls.