**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed perform assessments, failed to continue to monitor a resident's change of condition, failed to communicate changes in a resident's condition, and failed to provide treatment of a fracture in a timely manner for 1 of 3 residents (R1) reviewed for quality of care in the sample of 7. These failures resulted in experiencing continued pain after a fall on 8/23/24 and a delay in her being sent to the hospital for evaluation and treatment. R1 was transferred to the hospital on 9/5/24 (2 weeks after she fell) and had surgery for a right hip fracture. The findings include: On 11/6/24 at 10:44 AM, R1 was lying in bed. R1 said there were two CNAs (Certified Nursing Aides) putting her back to bed, after lunch (on 8/23/24). R1 said the wheelchair was parked, facing the bed, near the middle of the bed. R1 said the CNAs applied the sling under her arm, she held onto the grab bar, and they used the lift to stand her up. R1 stated, I don't know what the problem was, but they were taking too long, and I told them I couldn't stand anymore. They pushed the lift over near the bed, but my legs weren't against the bed. They were trying to take of my pants, so I could lay down. It was taking too long, and I told them. Then my legs just gave out. I was hanging there, by my arms. The sling was pulling under my armpits and shoulder, and I was hanging on to the handles. They tried to sit me on the edge of the bed, but I was slipping. I landed on my butt on the floor. My right arm was sore right away and later on my right hip stated to really hurt. R1 said a nurse did not complete a head to toe assessment after she fell. R1 said the CNAs used the total lift to get her back in bed without the nurse checking her first. R1 said the facility did X-rays a couple days after she fell, but they told her there wasn't a fracture. R1 said she was having hip pain for two weeks before she was sent to the hospital. R1 said she had to have her hip repaired surgically. R1 said she wasn't able to do her regular therapy because her right hip was hurting too bad. R1 said she tried the sit to stand one more time, but it hurt so bad, and they had to stop. R1 said after that, she only did therapy in her bed, and it hurt when she did the leg exercises. R1 stated, I think someone made a mistake. I don't like to think about the fall. It was such an awful experience. I was just hanging from that sit to stand lift, by my arms for a long time and then I fell on my butt. R1's Facesheet dated 11/6/24 showed diagnoses to include, but not limited to: right hip fracture and orthopedic aftercare (9/9/24); CHF (Congestive Heart Failure); COPD (Chronic Obstructive Pulmonary Disease); peripheral venous insufficiency; stroke with right sided weakness; major depressive disorder; morbid obesity; lymphedema; GERD (Gastro-Esophageal Reflux Disease); chronic pain syndrome; pain in right shoulder and right hip (9/9/24); reduced mobility; unsteadiness on feet; generalized muscle weakness; lack of coordination; and need for assistance with personal care. R1's facility assessment dated [DATE] showed she was cognitively intact; and was dependent on staff for toileting, shower/bathing, and transfers. R1's Progress Notes and Assessments were reviewed for 8/23/24. There were no notes or assessments (vital signs, neuro checks, ROM, pain, skin check) completed by R1's nurse (V18 - Agency RN). There were late entries created on 8/30/24 by V2 (DON - Director of Nursing) and V30 (MDS Coordinator). R1's Post Fall Evaluation dated 8/23/24 showed R1 had a witnessed fall in her room when she was being transferred to bed with a sit to stand mechanical lift, by V19 and V20 (CNAs). R1's Progress Note dated 8/25/24 showed, Resident complained of pain with ROM (Range of Motion) to right shoulder, right hip, and right lower extremity . The doctor was notified and orders for X-rays were obtained. (This note was 2 days after R1's fall). R1's portable Right hip X-ray report 8/25/24 showed there was no fracture or dislocation seen and she had moderate degenerative changes. R1's Health Status Note dated 9/5/24 showed R1 continued to complain of right hip pain after a fall on 8/23/24. The doctor was notified, and orders were received to send R1 to the hospital. R1's progress notes do not show continued assessments of R1 after her fall. R1's notes do not reflect that she was unable to bear weight in therapy, could no longer use the sit to stand lift, had pain with ROM/exercises with right leg, and was complaining of right hip pain from 8/25/24 until 9/5/24 (when she was sent to the hospital for continued right hip pain after a fall on 8/23/24.) R1's August and September 2024 MARs showed R1 took Norco (opioid pain medication) 5-325 mg 1 tablet 2-4 times a day for pain rated 3-9 on a 1-10 scale. R1's Occupation Therapy Notes dated 8/23/24 (before she fell) showed R1 was currently using the sit to stand machine for lifts and was completing tasks to increase her upper arm strength. On 8/26/24 R1's notes showed the therapist discussed attempting to get R1 up with a sit to stand lift tomorrow and R1 said she would try and wanted to work towards using the sit to stand again. R1's note on 8/27/24 showed she was a total lift transfer. R1's Physical Therapy Discharge summary dated [DATE] to 9/6/24 showed R1's prior equipment was a sit to stand lift and wheelchair. This summary showed R1 was discharged to the hospital. This note showed, .Progress & Response to Treatment: The patient had been demonstrating good stability on the sit to stand lift for functional transfers but had fallen off the lift when transferring with the CNAs in her room. Patient had been complaining of RLE (right lower extremity) pain, was admitted to the hospital . R1's Physical Therapy Recertification, Progress Report and Updated Therapy Plan dated 8/20/24 to 9/29/24 showed R1 was able to perform bed to wheelchair transfers with sit to stand lift with good stability but required more skilled therapy to ensure safety on sit to stand lift and to trial toilet transfers with sit to stand lift for safety. R1's Physical Therapy Progress notes dated 8/22/24 (before she fell) showed she performed a sit to stand from the bed to the wheelchair and the wheelchair to the bathroom. R1's Physical Therapy notes do not include R1's sit to stand performance after the fall on 8/23/24. R1's Orthopedic Pre-operative Report dated 9/8/24 showed R1 had a surgical nailing of her right hip to repair the fracture. This note showed R1 fell at the nursing home 2 weeks ago and continues to have pain in her right hip and inability to perform ADLs (Activities of daily living) including sitting to stand and stand to sit. The document showed, . The X-rays at the time of the nursing home showed a minimally displaced greater trochanteric hip fracture. The patient was then admitted to the hospital for continued right hip pain in order to get an MRI of the right hip. MRI of the right hip was done yesterday (9/7/24) which showed a greater trochanteric hip fracture with intertrochanteric extension to greater than 50% of the intertrochanteric region. The fracture was due to a combination of trauma from a fall and pathologic bone due to osteoporosis . On 11/7/24 at 12:01 PM, V18 (Agency RN) said she was R1's nurse on 8/23/24 but she had no idea R1 fell. V18 said the CNAs didn't tell her R1 fell. V18 said she was charting at the nurses' station, and she was approached by therapy. V18 said therapy reported that R1 had a rough transfer. V18 said she went to R1's room about 30 minutes later. V18 said the CNAs were in R1's room and she asked if there was an incident. They said it was a rough transfer. V18 said no one reported a fall to her, she didn't complete an assessment of R1 after the fall, and there wasn't any documentation because she wasn't aware R1 fell. V18 stated, If I knew about a fall, then I would have started the assessments and paperwork immediately. If you're going to have a fall, a witnessed fall is the easier one to have. It's less paperwork. All R1 said was she didn't want to use the sit to stand anymore, she stated, I don't want to do that again. Then I heard a few days later she told someone else she fell, and she was sent out to the hospital. V18 said she didn't take care of R1 again until she returned from the hospital after she had surgery on her broken hip. On 11/7/24 at 9:55 AM, V23 (PTA - Physical Therapy Assistant) said prior to R1 falling, they had been working training with the sit to stand. V23 said a sit to stand lift was performed in the therapy gym successfully and he had completed in room training with the CNAs on sit to stand transfers for R1. V23 said R1 was doing well with the training and could bear weight for several minutes during the transfer. V23 said he was surprised when he heard there was a rough transfer on 8/23/24 (Friday). V23 said he saw R1 the following Monday or Tuesday and attempted the sit to stand lift and R1 could not bear weight. V23 said R1 complained of right hip pain and demanded to stop. V23 said he should have documented that in his notes. V23 said he didn't attempt the sit to stand lift with R1 again and after that her therapy consisted of exercises in the bed or wheelchair and the staff used a total lift for transfers. V23 said R1 often had pain with ROM and exercises with her right leg. V23 said he did not communicate R1's complaints of right hip pain with ROM/exercises and inability to bear weight to the nursing staff. V23 stated, I thought since the X-ray didn't show a fracture that her pain would eventually go away. I was under the assumption that the nurses' knew about her right hip pain. That's my fault. I thought they knew, but I should have told them. She was doing pretty good with the sit to stand transfers before the incident, but after the failed sit to stand attempt, her therapy consisted of more seated or in the bed exercises due to her pain in the right leg. On 11/7/24 at 11:03 AM, V26 (RN - Registered Nurse) said she was familiar with R1 and verified that she had worked R1's hallway between 8/23/24 (R1's fall) and 9/5/24 (R1's transfer to hospital - 2 weeks later). V26 said R1 was alert and oriented. V26 said R1 had chronic issues of pain and had complained of hip pain occasionally. V26 said she gave R1 Norco and tried to stay on top of her pain. V26 said she was not aware that R1 was not able to bear weight in therapy and was having right hip pain with movement of her right leg. V26 stated, They don't always tell us stuff. If I knew R1 fell and she was having those problems, I'd assume her hip was broken and call the doctor to send her to the hospital as soon as possible. But no one told me that. On 11/7/24 at 8:54 AM, V22 (RN) said she was working 9/5/24 (when R1 was sent to the hospital). V22 said she was not assigned to R1 but was the supervisor working that day. V22 said V25 (R1's nurse) came to her because she didn't know what to do. V22 said V25 reported R1 had a fall on 8/23/24 and was complaining of right hip pain rated at a 10 on a 1-10 scale. V22 said she told her to call the nurse and helped call 911. V22 said that's why she entered a note on 9/5/24. V22 said if a resident had a fall and is complaining of severe hip pain, they need to be sent out as soon as possible because there may be a fracture. On 11/7/24 at 1:02 PM, V2 (DON) said she was at the facility on 8/23/24. V2 said she didn't witness R1's fall, was not in R1's room after the fall and didn't not complete an assessment on R1 on 8/23/24. V2 said the CNAs did not report a fall. V2 said she was in the hall and overheard V19 talking. V2 said V19 reported a rough transfer, but not a fall. V2 said she didn't ask any other questions and went to deal with another issue. V2 said on 8/25/24 she got a call from V1 (Administrator). V2 said she was told R1 was having pain all over, and was asked if there had been an incident. V2 stated, I told her that I heard there was a rough transfer but wasn't aware of an incident. She (V1) said [R1] did go on the floor and that's considered a fall. They got orders for X-rays. I didn't come in that day or do an assessment. The nurses should be documenting a fall and their assessment in the progress notes. The purpose is to ensure there is continuity of care and communicate with other staff what has been happening with the resident. On 8/30/24 we had a fall meeting and were reviewed R1's documentation and realized there was no charting on 8/23/24 about the fall. V2 said, If a resident is complaining of pain with ROM after falling, then the resident shouldn't be moved and sent out 911 to the hospital. I don't have X-ray vision. I can't tell if there is a fracture by looking at them. The nurses should have charted all of that information, but the CNAs didn't report a fall. V2 said the nurses should have performed and documented continued assessments of R1 after she fell to ensure there wasn't an injury. V2 said she was not aware that R1 was having pain with movement of the right leg and was no longer able to bear weight. V2 said therapy did not report that to her. V2 said if she had known, then she would have sent R1 out to the hospital sooner for further evaluation. V2 said R1's progress notes and assessments should reflect a timeline of R1's injuries and complaints. V2 said R1's progress notes did not contain the pertinent nursing assessments to demonstrate a thorough assessment. V2 said the purpose of continued assessments, documentation of findings, and interdisciplinary communication of resident's change of condition is to ensure the resident is receiving proper care and continuity of care can be maintained. On 11/7/24 at 11:26 PM, V27 (NP - Nurse Practitioner) said she is familiar with R1 and took care of her before she was admitted to the facility. V27 said she would expect the staff to complete a head to toe assessment after a fall, continued assessments of the resident, and to document their assessments. V27 said the nurses will notify her or the physician of falls. V27 said if there is an injury then they call right away, but if not, injury they may send a message. V27 said she wasn't sure when she was notified of R1's fall. V27 said she doesn't document her phone communication with the facility. V27 stated, The facility is responsible for maintaining that documentation. V27 said she had not done an assessment on R1 between 8/23/24 - 9/5/24. V27 said she expects the staff to perform and assessment and notify her of any changes in the resident condition. V27 said she isn't an orthopedic doctor, but inability to bear weight, increased pain upon palpation of the right hip area, or increased pain with movement of the right leg could be indications of a fracture. V27 said she would expect the staff to notify her immediately with these symptoms, so the resident can be transferred to the hospital for further evaluation. V27 said it's possible that R1's fall on 8/23/24 contributed to her right hip fracture, but she was not an orthopedic doctor. On 11/7/24 at 3:08 PM, V28 (Orthopedic Surgeon) said it's very likely that the initial portable X-ray completed on 8/25/24 did not capture the fracture due to R1's body size and positioning with portable X-ray machines. V28 said an MRI would be needed for more sensitive results. V28 said inability to bear weight, pain in the hip area, or pain with ROM/movement of the affected limb are signs of a fracture. V28 said the facility should report these concerns to the physician and obtain an order to send the resident to the hospital for further evaluation. V28 said he wasn't clear how R1 fell. The surveyor explained the fall from the sit to stand lift. V28 replied, It's very likely that caused her fracture, and the original X-ray missed it. If she was complaining of continued pain and hadn't returned to baseline physical functioning, they should have sent her to the hospital. She ended up having surgery to repair her hip. The pain she was having was likely from the fracture and she needed stabilization (surgery) on her hip to reduce the pain. The facility's undated Safe Resident Handling/Transfers Policy showed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . The facility's undated Fall Prevention Program showed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. The facility's undated Fall Checklist showed, #1. Complete assessment/VS, initial neuro checks as indicated. If any injury noted or suspected keep resident still and do not transfer to bed or chair. Contact 911 and send to ED for evaluation and treat .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to safely perform a mechanical lift transfer and failed to follow their policy and procedure after a fall for 1 of 3 residents (R1) reviewed for safe transfers in the sample of 7. This failure resulted in R1 falling to the floor, sustaining a right hip fracture, and requiring surgical repair of the fracture. The findings include: On 11/6/24 at 10:44 AM, R1 was lying in bed. R1 said there were two CNAs (Certified Nursing Aides) putting her back to bed, after lunch (on 8/23/24). R1 said the wheelchair was parked, facing the bed, near the middle of the bed. R1 said the CNAs applied the sling under her arm, she held onto the grab bar, and they used the lift to stand her up. R1 stated, I don't know what the problem was, but they were taking too long, and I told them I couldn't stand anymore. They pushed the lift over near the bed, but my legs weren't against the bed. They were trying to take of my pants, so I could lay down. It was taking too long, and I told them. Then my legs just gave out. I was hanging there, by my arms. The sling was pulling under my armpits and shoulder, and I was hanging on to the handles. They tried to sit me on the edge of the bed, but I was slipping. I landed on my butt on the floor. My right arm was sore right away and later on my right hip stated to really hurt. R1 said a nurse did not complete a head to toe assessment after she fell. R1 said the CNAs used the total lift to get her back in bed without the nurse checking her first. R1 said the facility did X-rays a couple days after she fell, but they told her there wasn't a fracture. R1 said she was having hip pain for two weeks before she was sent to the hospital. R1 said she had to have her hip repaired surgically. R1 said she wasn't able to do her regular therapy because her right hip was hurting too bad. R1 said she tried the sit to stand one more time, but it hurt so bad, and they had to stop. R1 said after that, she only did therapy in her bed, and it hurt when she did the leg exercises. R1 stated, I think someone made a mistake. I don't like to think about the fall. It was such an awful experience. I was just hanging from that sit to stand lift, by my arms for a long time and then I fell on my butt. R1's Facesheet dated 11/6/24 showed diagnoses to include, but not limited to: right hip fracture and orthopedic aftercare (9/9/24); CHF (Congestive Heart Failure); COPD (Chronic Obstructive Pulmonary Disease); peripheral venous insufficiency; stroke with right sided weakness; major depressive disorder; morbid obesity; lymphedema; GERD (Gastro-Esophageal Reflux Disease); chronic pain syndrome; pain in right shoulder and right hip (9/9/24); reduced mobility; unsteadiness on feet; generalized muscle weakness; lack of coordination; and need for assistance with personal care. R1's facility assessment dated [DATE] showed she was cognitively intact; and was dependent on staff for toileting, shower/bathing, and transfers. R1's Progress Notes and Assessments were reviewed for 8/23/24. There were no notes or assessments (vital signs, neuro checks, ROM, pain, skin check) completed by R1's nurse (V18 - Agency RN). There were late entries created on 8/30/24 by V2 (DON - Director of Nursing) and V30 (MDS Coordinator). R1's Post Fall Evaluation dated 8/23/24 showed R1 had a witnessed fall in her room when she was being transferred to bed with a sit to stand mechanical lift, by V19 and V20 (CNAs). R1's Progress Note dated 8/25/24 showed, Resident complained of pain with ROM (Range of Motion) to right shoulder, right hip, and right lower extremity . The doctor was notified and orders for X-rays were obtained. (This note was 2 days after R1's fall). R1's portable Right hip X-ray report 8/25/24 showed there was no fracture or dislocation seen and she had moderate degenerative changes. R1's Health Status Note dated 9/5/24 showed R1 continued to complain of right hip pain after a fall on 8/23/24. The doctor was notified, and orders were received to send R1 to the hospital. R1's Orthopedic Pre-operative Report dated 9/8/24 showed R1 had a surgical nailing of her right hip to repair the fracture. This note showed R1 fell at the nursing home 2 weeks ago and continues to have pain in her right hip and inability to perform ADLs (Activities of daily living) including sitting to stand and stand to sit. The document showed, . The X-rays at the time of the nursing home showed a minimally displaced greater trochanteric hip fracture. The patient was then admitted to the hospital for continued right hip pain in order to get an MRI of the right hip. MRI of the right hip was done yesterday (9/7/24) which showed a greater trochanteric hip fracture with intertrochanteric extension to greater than 50% of the intertrochanteric region. The fracture was due to a combination of trauma from a fall and pathologic bone due to osteoporosis . On 11/6/24 at 2:59 PM, V20 (CNA) said R1 was in the wheelchair, and we were trying to get her back to bed, after lunch. V20 said V19 (CNA) was helping her. V20 said R1 was seated in the wheelchair, the sling was placed under her arms, and they started to use the sit to stand lift to raise R1's bottom out of the wheelchair. V20 said they were having difficulty with R1's wheelchair being in the way and the transfer was taking a little longer than usual. V20 said R1 can't stand on the sit to stand platform very long. V20 said they moved R1 toward the bed as fast as they could, but R1's right side gave out. V20 said R1 is a large lady and part of her bottom was on the bed. V20 said she was managing the lift and from where she was standing, she thought R1 was on the edge of the bed. V20 said V19 told her that she was trying to hold the resident in place with her knee and she needed to get help. V20 said she ran to the hall for help. V20 stated, It was chaos. Everyone was busy V20 said R1 was hanging from the sit to stand lift by her arms, with her hands still holding on to the hand grips, and her arm stretched over her head. V20 said R1 was hanging like that for a couple of minutes. V20 said V21 (CNA) came to help. V20 said V19 (CNA) was on R1's right side, using her knee to wedge R1 into the bed and keep her from slipping, but it was getting too hard, and they had to lower her to the floor. V20 said R1 just slipped to the floor. V20 said R1 still was holding onto the handles, the sling was still attached to the lift, and R1's bottom was on the floor. V20 said they didn't think it was a fall because she slipped from the bed to the floor. V20 said they removed R1's sit to stand sling and used a sling to lift R1 off the floor and back into bed. V20 did not report the fall to the nurse immediately and the nurse did not assess R1 before she was removed from the floor. V20 said she didn't work for a couple weeks after R1's fall. On 11/6/24 at 3:46 PM, V19 (CNA) said she was the CNA helping V20 transfer R1 to bed on 8/23/24. V19 said they were transferring R1 from her wheelchair to bed and tried to change her incontinence brief before sitting her down on the edge of the bed. V19 said R1 said she couldn't hold herself up any longer, her legs went week, and she collapsed. V19 said she placed her knee behind R1 to try to keep her from sliding off the bed. V19 said some of her bottom was on the bed, but not all of it. V19 said she told V20 to get help because she couldn't hold R1 for long, her knee was starting to hurt. V19 said V20 thought we could push R1 into the bed, but I told her that wouldn't work, and we needed help. V19 stated, [V20] left the room to go get help. I don't how long she was gone but felt like a long time. I told [R1] we were going to have to lower her to the floor because my knee was hurting. We lowered her to a seated position on the floor. One of her legs was in an awkward position. It was a little twisted. I don't remember which one. She seemed scared because we got scared. She was complaining of pain, but I don't remember exactly what she said. She was hanging from the lift for quite a while. All of it was so sudden. She said, I can't, my feet. By the time [V20 and V21 (CNAs)] came back in the room, I was already lowering R1 to the floor. [V20] and I got the total lift, and we got her back to bed. The nurse didn't come in and assess her before we got her back to bed. [V20] and we got write ups for this. I was surprised the nurse didn't come. [V20] said the nurse isn't coming because she's pregnant. I know we shouldn't have gotten her up until the nurse assessed her. On 11/7/24 at 8:38 AM, V21 (CNA) said she was providing care to another resident when V20 said they needed help in R1's room. V21 said when she went in the room, V19 had her knee underneath R1 and R1 was hanging from the sit to stand lift. V21 stated, There's no way [V19] could have held R1 for long. V21 said she and V20 help lower R1 to the floor. V21 said she left R1's room after that. V21 said when a resident falls the nurse should be notified right away. V21 said the nurse does an assessment and tells us if it's safe to transfer the resident. V21 said we don't want to hurt the resident if they have injuries already. On 11/7/24 at 12:01 PM, V18 (Agency RN) said she was R1's nurse on 8/23/24 but she had no idea R1 fell. V18 said the CNAs didn't tell her R1 fell. V18 said she was charting at the nurses' station, and she was approached by therapy. V18 said therapy reported that R1 had a rough transfer. V18 said she went to R1's room about 30 minutes later. V18 said the CNAs were in R1's room and she asked if there was an incident. They said it was a rough transfer. V18 said no one reported a fall to her, she didn't complete an assessment of R1 after the fall, and there wasn't any documentation because she wasn't aware R1 fell. V18 stated, If I knew about a fall, then I would have started the assessments and paperwork immediately. If you're going to have a fall, a witnessed fall is the easier one to have. It's less paperwork. All R1 said was she didn't want to use the sit to stand anymore, she stated, I don't want to do that again. Then I heard a few days later she told someone else she fell, and she was sent out to the hospital. V18 said she didn't take care of R1 again until she returned from the hospital after she had surgery on her broken hip. On 11/7/24 at 9:55 AM, V23 (PTA - Physical Therapy Assistant) said prior to R1 falling, they had been working training with the sit to stand. V23 said a sit to stand lift was performed in the therapy gym successfully and he had completed in room training with the CNAs on sit to stand transfers for R1. V23 said R1 was doing well with the training and could bear weight for several minutes during the transfer. V23 said he was surprised when he heard there was a rough transfer on 8/23/24 (Friday). V23 said he saw R1 the following Monday or Tuesday and attempted the sit to stand lift and R1 could not bear weight. V23 said R1 complained of right hip pain and demanded to stop. V23 said he didn't attempt the sit to stand lift with R1 again and after that her therapy consisted of exercises in the bed or wheelchair and the staff used a total lift for transfers. V23 said R1 often had pain with ROM and exercises with her right leg. On 11/7/24 at 12:42 PM, V30 (MDS Coordinator) said she did not witness R1's fall, nor did she assess R1 on 8/23/24. On 11/7/24 at 1:02 PM, V2 (DON) said she was at the facility on 8/23/24. V2 said she didn't witness R1's fall, was not in R1's room after the fall and didn't not complete an assessment on R1 on 8/23/24. V2 said the CNAs did not report a fall. V2 said she was in the hall and overheard V19 talking. V2 said V19 reported a rough transfer, but not a fall. V2 said she didn't ask any other questions and went to deal with another issue. V2 said on 8/25/24 she got a call from V1 (Administrator). V2 said she was told R1 was having pain all over, and was asked if there had been an incident. V2 stated, I told her that I heard there was a rough transfer but wasn't aware of an incident. She (V1) said [R1] did go on the floor and that's considered a fall. They got orders for X-rays. I didn't come in that day or do an assessment. The nurses should be documenting a fall and their assessment in the progress notes. The purpose is to ensure there is continuity of care and communicate with other staff what has been happening with the resident. On 8/30/24 we had a fall meeting and were reviewed R1's documentation and realized there was no charting on 8/23/24 about the fall. V2 said after a fall she expects the CNAs to report the fall immediately, the nurse to perform a full head to toe assessment of the resident and determine if it is safe to transfer the resident from the floor. If a resident is complaining of pain with ROM after falling, then the resident shouldn't be moved and sent out 911 to the hospital. I don't have X-ray vision. I can't tell if there is a fracture by looking at them. The nurses should have charted all of that information, but the CNAs didn't report a fall. On 11/7/24 at 3:08 PM, V28 (Orthopedic Surgeon) said it's very likely that the initial portable X-ray completed on 8/25/24 did not capture the fracture due to R1's body size and positioning with portable X-ray machines. V28 said an MRI would be needed for more sensitive results. V28 said inability to bear weight, pain in the hip area, or pain with ROM/movement of the affected limb are signs of a fracture. V28 said the facility should report these concerns to the physician and obtain an order to send the resident to the hospital for further evaluation. V28 said he wasn't clear how R1 fell. The surveyor explained the fall from the sit to stand lift. V28 replied, It's very likely that caused her fracture, and the original X-ray missed it. If she was complaining of continued pain and hadn't returned to baseline physical functioning, they should have sent her to the hospital. She ended up having surgery to repair her hip. The pain she was having was likely from the fracture and she needed stabilization (surgery) on her hip to reduce the pain. V19 and V20's Employee Disciplinary Forms dated 8/29/24 showed R1's fall was not reported to the nurse. They were provided education and in-servicing. The facility's undated Safe Resident Handling/Transfers Policy showed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . The facility's undated Fall Prevention Program showed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. The facility's undated Fall Checklist showed, #1. Complete assessment/VS, initial neuro checks as indicated. If any injury noted or suspected keep resident still and do not transfer to bed or chair. Contact 911 and send to ED for evaluation and treat .

Based on observation, interview, and record review the facility failed to ensure safe resident transfers for two (R1 and R2) of three residents reviewed for falls with transfers in a sample of three. This failure resulted in R1 and R2 being sent out to the hospital. R1 suffered from pain and a left hip fracture requiring surgery. R2 suffered from pain and a left hip sprain and sacral contusion. Findings include: The facility's undated Safe Resident Handling/Transfers policy documents, Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident/s needs to prevent manual lifting except in medical emergencies. 4. Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts (add any others that may apply). 5. Handling aids may include gait belts, transfer boards, and other devices (specify as applies). The facility's undated Use of Gait Belt policy documents, Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Policy Explanation and Compliance Guidelines: 1. Each nursing department employee will be given a gait belt during orientation .3. It will be the responsibility of each employee to ensure they have it available for use at all times when at work. The facility's undated Fall Prevention Program policy documents, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 1. R1's current Face Sheet documents diagnoses including, but not limited to: Fracture of Unspecified part of neck of left femur; Diabetes Mellitus Type II; Unspecified Dementia, Unspecified severity with other behavioral disturbance; Weakness; History of falling; and Unsteadiness on feet. R1's Fall Risk Evaluation, dated 7/30/24, documents R1 is a high risk for falls. R1's Minimum Data Set/MDS Assessment, dated 7/30/24, documents R1 is cognitively intact and is dependent on staff for toilet transfers. R1's current Care Plan includes but is not limited to (R1) requires extensive assist of 1 (one) with toileting and ileostomy cares and (R1) is at risk for falls related to Confusion, Gait/balance problems, and Unaware of safety needs . R1's Fall Nursing Progress note, dated 8/31/24 at 10:30am by V7 Licensed Practical Nurse/LPN, documents, Fall occurred on 8/31 at 9:45am in the resident's bathroom. Resident (R1) was transferring from toilet to sink with gb (grab bar) and walker. While transferring, (R1's) left leg gave out and (V6 Certified Nursing Assistant/CNA) caught resident's head from hitting the floor. Resident landed on L (left) hip. When nurse (V7) walked in the room, resident (R1) was sitting on her bottom laying against the bathroom wall. Full assessment initiated. Full range of motion in upper and lower extremities. Resident able to move both legs up and down along with her arms. Slight pain noted in L (left) hip. (V6 CNA) and nurse (V7) helped resident (R1) up to walker, no complaints of pain during that time. Resident (R1) walked back to her bed from bathroom. VS (vital signs) WNL (within normal limits). (V6) CNA denies resident hitting her head. No visible injuries noted at the time. Assisted resident back to bed. R1's Progress note, dated 8/31/24 at 3:00pm by V7 LPN, documents, Reassessed resident's pain and rates 8/10 pain. Noted pain in L (left) groin area. Notified V12 R1's Nurse Practitioner/NP and new order to obtain STAT (immediate) x-ray of L (left) hip/femur and Tramadol 50mg (milligrams) TID (three times per day) x (times) 3 days. R1's Progress note, dated 8/31/24, at 7:40pm by V7 LPN, documents, X-ray results came back and noted L (left) femoral neck fracture. Notified (V12) NP. Administered Tramadol 50mg for pain. New order to send resident to ER (Emergency Room) for evaluation and treatment. R1's Progress note, dated 9/5/24, documents, Resident arrived to facility via ambulance from (named hospital) at 5:45pm, primary diagnosis closed left hip fracture, WBAT (weight bearing as tolerated) to LLE (left lower extremity). C/o (complains of) pain 8/10, received PRN (as needed) Tramadol at 6:30pm. Resident received a Norco prior to arrival at 4:25pm. Colostomy changed today at hospital. Surgical incision to left lateral thigh with 9 staples, dry blood on dressing . The facility's Reportable for R1's fall on 8/31/24, documents V6 CNA's statement as, (V6) states resident was transferring from toilet to sink with grab bar and walker. While transferring (R1's) left leg gave out and I caught her head from hitting the floor. (R1) landed on her left hip/leg. (V6) states the nurse did a full ROM (range of motion) assessment and resident c/o (complained of) minimal soreness. (R1) was pulling and trying to get up so they assisted (R1) and (R1) said I have no pain and ambulated with no difficulty. R1's radiology report of left femur, dated 8/31/24, documents, Results: There is a fracture involving the left femoral neck with minimal to no displacement. The joint shows no dislocation. Pubic rami are intact. Osteopenia is present. R1's Witness Fall Investigation report, dated 8/31/24, documents, Resident was transferring from toilet to sink with gb (grab bar) and walker. While transferring, her left leg gave out and CNA caught resident's head from hitting the floor. Resident landed on L hip. When nurse walked in the room, resident was sitting on her bottom laying against the bathroom wall. Full assessment initiated. Full range of motion in upper and lower extremities. Resident able to move both legs up and down along with her arms. Slight soreness noted in L hip. CNA and nurse helped resident up to walker due to resident insisting on getting up and was pulling at that time we assisted to prevent further incident, no complaints of pain during that time. Resident walked back to her bed from bathroom. VS WNL. CNA denies resident hitting her head. No visible injuries noted at the time. Assisted resident back to bed. Administered PRN (as needed) Tylenol for pain. 'I turned too fast, and my leg gave out.' On 9/10/24 at 11:25am, R1 sat in a wheelchair in the therapy room. R1 stated the following occurred on 8/31/24: I went to the bathroom with (V6 Certified Nursing Assistant/CNA) and my walker. (V6) did not put a gait belt on me. There were none in my room and (V6) did not bring one with him. He stayed in the bathroom with me while I was on the toilet. I stood up holding the grab bars and (V6) pulled my pants up. I went to use hand sanitizer and he asked if I wanted to wash my hands. I turned around and did that. I shook my hands off. Then I think I turned too quickly to get paper towels and I hit the wall with my back. I slid down and couldn't grab the bar. I slid down the wall and hit the floor. (V6) caught my head as it was only about six inches from the stone floor. I couldn't get up and needed two people, so he (V6) and a nurse (V7 Licensed Practical Nurse/LPN) got me up and walked with me to the bed. Later, I went to the lobby, but by 4pm I couldn't take the pain. I went to the (local) hospital then they transferred me to (named) hospital for surgery for a left hip fracture. On 9/10/24 at 3:05pm, V6 CNA stated the following: She (R1) needed to use the restroom and empty her colostomy bag. She was in her wheelchair, and we went down to her room. (R1) was dumping out her stool into a measuring cup and I said, 'hey, let's wash our hands' and I got her up to the sink. I tried to reposition the wheelchair behind her while she washed her hands. I was in visual view of her but was hands off. She turned and then did a weird jerk and I said, 'oh snap'. (R1) fell on her left side. I was able to catch her head. The moment (R1) was on the floor I went to get my nurse (V7 LPN). (R1) insisted she could get up on her own and with a walker, so we helped her. I should not have let go of (R1) to get the wheelchair. I should have grabbed the (mechanical lift) instead of letting her walk to the wheelchair after the fall. Protocol is we (mechanical lift) after a fall. (R1) insisted and felt good to get up. V6 could not recall for sure if V6 used a gait belt for R1's transfer. On 9/10/24 at 3:19pm, V7 LPN stated the following, I did not witness (R1's) fall (on 8/31/24). I was doing med pass and (V6 CNA) came and grabbed me. (V6) explained that (R1) turned around to wash her hands too fast and went down. (V6) said he caught (R1's) head before hitting the floor. I went with him and assessed (R1). I should have used a (mechanical lift) to get (R1) up, but (R1) insisted on getting up with me and (V6's) help. V7 confirmed that gb in the progress note V7 wrote meant grab bar. V7 said, (R1) was not wearing a gait belt. After the fall we got her up without a gait belt by going under her arms to lift her up then walked her to her bed. A gait belt would be ideal, give resident more time to wash her hands, not let go of her or have her out of site. If I'd known she had that injury I would have used the (mechanical lift). (V1) told me we are a no lift facility which means everybody is a (mechanical lift) after a fall. I did know that, but in the heat of the moment we thought it was just easier to help her up. (R1's) transfer status was a stand-by one assist so a gait belt should be used. On 9/10/24 at 11:35am, V4 Physical Therapy Assistant/PTA stated that prior to (R1's) fall on 8/31/24, (R1) was receiving therapy and was a one assist with walker. (R1) was walking 75-100 feet. V4 confirmed that a gait belt is to be used for transfers and is the house-wide facility policy. On 9/11/24 at 9:25am, R1 was lying in bed with a mechanical lift sling under her. V5 and V11 CNAs prepared to transfer R1. V5 brought the mechanical lift into R1's room. V5 and V11 hooked the lift to the sling, V5 supported R1's left leg while they lifted her up then lowered her into her wheelchair. R1 grimaced and stated her left hip hurts right where the staples are. On 9/11/24, at 12:30pm, V1 Administrator confirmed a gait belt should have been used for R1's transfer. V1 stated that after a resident fall the staff are to use a mechanical lift to get the resident up. V1 confirmed that when V6 and V7 didn't use a mechanical lift they should have then used a gait belt to assist R1 to get off the floor. V1 stated, We are a no lift facility, and we train staff to use a mechanical lift and they understand that. 2. R2's current Facesheet documents diagnoses including, but not limited to Diabetes Mellitus Type II; Unspecified Dementia, Unspecified severity; Obesity; Unsteadiness on feet; and Muscle Weakness (generalized). R2's Fall Risk Evaluation, dated 7/3/24, documents R2 is a high risk for falls. R2's Minimum Data Set/MDS Assessment, dated 7/3/24, documents R2 is moderately cognitively impaired; uses a wheelchair and walker; requires substantial/maximal assistance for sit to lying - the ability to move from sitting on side of bed to lying flat on the bed; and partial/moderate assistance for chair/bed-to-chair transfer - the ability to transfer to and from a bed to a chair (or wheelchair). R2's current Care Plan documents R2 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility, confusion, multiple comorbidities and Dementia with interventions including but not limited to Transfer: Requires extensive assist of 1-2 with gait belt and wheeled walker for stand and pivot transfers and (R2) is at risk for falls related to Confusion and Gait/balance problems. R2's Progress note, dated 9/3/24 and signed by V8 Licensed Practical Nurse/LPN, documents, Summoned to the resident room on 9/2/24 at 7:10pm. (V9) CNA (Certified Nursing Assistant) was transferring resident stand and pivot from wheelchair. When CNA was moving wheelchair out of the way resident slid out of bed onto left side of the floor and did not hit head. This note states that V12 (R2's Nurse Practitioner) ordered to send (R2) to ER (Emergency Room) to evaluate and treat .Resident was transferred with the assist of four to stretcher and left for ER at this time. R2's Progress note, dated 9/3/24 at 00:10am by V8 LPN, documents, Resident returned from (named ER) had left hip and lumbar spine (back) x-ray with DX (diagnoses): left hip sprain and contusion of sacrum. No complaints of pain or discomfort at this time. R2's Witness Fall Investigation report, dated 9/2/24, documents, Resident was transferring to bed and was sitting on the side of bed. CNA (V9) moved the wheelchair out of the way to help resident put legs in bed. When CNA was moving the wheelchair, resident slip out of the bed onto her left side. Complained of left hip pain .Resident unable to give description. This report documents V9's statement as, I was transferring resident to bed from the wheelchair stand and pivot. Resident was sitting on the side of the bed, and I moved the wheelchair out of the way so I could help resident get her legs in bed. As I was moving the wheelchair resident slid off bed and landed on her left side. Did not hit her head. On 9/10/24 at 3:48pm, V8 Licensed Practical Nurse/LPN stated the following, I was getting report and (V9 CNA) came up to me and said (R2) just fell. (V9) said she was transferring and (R2) was sitting on her bed. (V10 Registered Nurse/RN) and I went down there. (R2) complained of a lot of pain, back, hip and whole left side which she was laying on. (V9) did not use a gait belt and (V9) should have. (R2) is a stand and pivot. (V9) had (R2) on the bed and went to move the wheelchair to make room for (R2's) legs and as (V9) moved the wheelchair (R2) went down. (V9) should not have left (R2) to move the wheelchair. (V9) could have just pushed it out of the way. The wheelchair was over by the closet door when I walked in. (R2) had a sprain of the hip and a contusion to the sacrum. We had ordered her Tylenol 1000 mg every 6 hours as needed and I felt she needed something stronger, so we got an order for Norco. On 9/11/24 at 10:13am, V9 CNA stated the following: I had taken (R2) back to bed and had her on the bed sitting. (R2) usually has to scoot back a little bit when she sits on the bed. We hadn't got back to that part. I pulled the wheelchair away to the end of the bed. Maybe she was reaching for the remote or something. (R2) fell off the bed. I turned a little bit, but was right next to her, but the wheelchair was in front of me. I helped transfer (R2) from her wheelchair to her bed. I did not have a gait belt on her. I should have used it and usually do. I had left it in the resident's room prior. When I use a gait, I usually keep my hands on the gait belt. I could have kept the wheelchair there or given her the remote. (R2's) legs were bad that day and (R2) has a hard time standing. Possibly could have prevented (this fall) if I wouldn't have taken my eyes off her. I hadn't taken care of her for a long time either. V9 confirmed that the facility policy is to use gait belts on all transfers. V9 stated, (R2) self-transfers but needs one assist and that's where the use of the gait belt comes in. I don't trust her. I feel awful. I stayed with her until ambulance came and got her. She had pain at first in one of the hips. R2's hospital After Visit Summary, dated 9/2/24, documents, Reason for visit: fall. Diagnoses: Fall in elderly patient; Hip sprain, left, initial encounter; Contusion of sacrum, initial encounter. Imaging Tests: Left Hip X-ray, Lumbar Spine (Back) X-ray. R2's September 2024 Medication Administration Record/MAR documents R2 received Tylenol 650 mg (milligrams) on 9/3/24 at 5:49am for 10/10 pain and Tramadol HCl (Hydrochloride) 50 mg at 7:35pm for 9/10 hip pain. On 9/10/24, at 10:40am, R2 sat in a wheelchair in her room. R2 stated that she had fallen off the bed. R2 said, I must have wanted to get up to go to the bathroom or something. The ambulance came and took me away. I hurt my buns. It still hurts when I sit. On 9/11/24, at 12:30pm, V1 Administrator stated that a gait belt should have been used for R2's transfer; (V9 CNA) got written up for not using a gait belt. The facility's Employee Disciplinary Form, dated 9/2/24, documents that V9 CNA received a verbal warning for Transferred a stand a pivot resident without the use of a gait belt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions for a resident identified at risk of skin breakdown and failed to complete weekly skin assessments for one of one resident (R8) reviewed for pressure ulcers in the sample of 24. This failure resulted in R8 developing unstageable pressure ulcers to R8's bilateral heels. Findings include: The facility's undated Pressure Injury Prevention and Management Policy documents, Policy - This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Avoidable is defined as, The resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. A section titled Policy Explanation and Compliance Guidelines documents, 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including 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. 3. Assessment of Pressure Injury Risk: a. Licensed nurses will conduct a pressure injury risk assessment, using the (Pressure Ulcer Risk Assessment) tool, on all residents upon admission/re-admission, weekly x (times) four weeks, then quarterly or whenever the residents' condition changes significantly. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will 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, wound characteristics). c. Evidenced based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Provide non-irritating surfaces; and v. Maintain or improve nutrition and hydration status, where feasible. f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting. 5. Monitoring: a. The RN (Registered Nurse) Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. The facility's undated Skin Assessment Policy documents, It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. This policy further documents Compliance Guidelines as, 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. R8's admission Record documents R8 was most recently admitted to the facility on [DATE] with diagnoses to include: Type 2 Diabetes Mellitus, Age-Related Osteoporosis, Need for Assistance with Personal Care, Unspecified Dementia, Chronic Kidney Disease Stage 3B, Heart Failure, Unspecified Urinary Incontinence and Weakness. R8's Minimum Data Set Assessment, dated 8/23/23 documents, R8 has moderately impaired cognition; is at risk of developing pressure ulcers/injuries; requires extensive assistance by two (plus) persons physical assist in the areas of bed mobility, transferring, dressing, toileting, and personal hygiene. R8's current Care Plan documents, R8 is at risk for skin breakdown due to limited mobility, incontinence, diagnosis of diabetes and chronic kidney disease; R8 has an ADL (Activities of Daily Living) self-care performance deficit related to Dementia, Impaired balance, Limited Mobility, Disc Degeneration, Osteoporosis and Osteoarthritis; Needs assist to turn and reposition at least every two hours and as needed; Requires extensive assistance of one to reposition in recliner chair; R8 has cognitive impairment; and is malnourished. R8's Predicting Pressure Ulcer Risk Evaluation, dated 7/21/23, documents R8 is at risk for developing pressure ulcers. This same Pressure Ulcer Assessment contains Clinical Suggestions for pressure ulcer prevention interventions to be implemented. R8's clinical suggestions are all blank and not marked as implemented on this evaluation tool. R8's Predicting Pressure Ulcer Risk Evaluation, dated 8/22/23, documents R8 is at moderate risk for developing pressure ulcers. A section titled Activity documents R8 is Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. A section titled Mobility documents R8 is Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. A section titled Nutrition documents R8 Probably Inadequate: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. A section titled Friction and Shear documents Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. This Pressure Ulcer Assessment has Clinical Suggestions for pressure ulcer prevention interventions to be implemented. R8's clinical suggestions are all blank and not marked as implemented on this evaluation tool. R8's Mini Nutritional assessment dated [DATE] documents the following: R8 is bed/chair bound and R8 is with severe dementia or depression. R8's Progress Note dated 9/11/23 at 1:21 am documents, (R8) continues to receive (hospice) services for heart failure. Periods of lethargy. Dependent upon all aspects of care. Transfers per (two) staff assist and (mechanical) lift. Mobility and positioning per (geriatric)-chair propelled by staff. (Two) staff assist required with bathing, personal hygiene, dressing, toileting, and post-use hygiene cares. (Bowel and bladder) incontinence with brief worn. Staff assist of one with feeding. Intake varies. R8's Progress Note dated 10/16/23 and written by V14 (Registered Nurse) documents R8 continues with (local hospice) for CHF (Congestive Heart Failure); transfers with two assist and (mechanical lift); Uses (reclining chair with wheels) for mobility, assist of one to two with bathing, dressing, and grooming; Assist of two with toilet use and post-use hygiene; Incontinent of bowel and bladder with brief worn at all times. R8's Client Coordination Notes Report dated 10/17/23 and written by V12 (Hospice Aide) documents, During this (visit, I) found a very large blister on (R8's) left hill (heel), black in the middle . (Manager, V13) notified of changes. R8's Client Coordination Notes Report dated 10/18/23 and written by V13 (Hospice RN) documents, (R8) is a [AGE] year-old living (at present facility) with primary diagnosis of CHF (Congestive Heart Failure) with senile degeneration of the brain. This same note documents (R8) was asleep in her (mobility) chair; R8 would mumble occasionally; R8 is a total assist with her ADLs (Activities of Daily Living); R8 will not eat without being fed, and even then, only taking in 25% (percent). (V12) had called earlier and said (R8's) left heel had a blister on it from pressure. Heel protectors were ordered and new wound care order. It was covered with Hydrogel at this visit. R8's Progress note written by V14 (Registered Nurse) on 10/17/23 at 7:44 pm documents, Hospice CNA (V12) summoned this nurse to (R8's) room. Hospice CNA (V12) notified Hospice RN (V13) awaiting call back. (R8) presents with a left (heel) ulcer black colored noted to heal (heel). Treatment in place for foam boarder dressing M/W/F (Monday, Wednesday, Friday) and PRN (as needed) until healed. (Pressure Ulcer Preventative soft boots) in place for left foot. R8's Wound Observation Tool dated 10/17/23 documents, R8 has a (facility) acquired ulcer measuring four centimeter by three centimeter area to R8's left heel. R8's Care Plan was revised on 10/18/23 to include R8 had a wound to R8's left heel. There are no interventions added for pressure relieving device to R8's heel(s). R8's Physician Order Sheet dated October 2023 documents an order for (pressure relieving) boots at all times to left foot with an order start date of 10/17/23. R8's Progress Note dated 10/19/23 at 7:25 pm states, (Hospice) CNA/Certified Nursing Assistant noted a pressure sore starting to R8's right heel when giving (R8) a bath. Dark soft area (one centimeter in diameter) noted with surrounding skin red. Hospice to bring air mattress and (pressure relieving boot) applied with new order for skin prep. R8's Wound Observation Tool dated 10/19/23 documents R8 developed a (facility) acquired pressure area to R8's right heel discovered on 10/19/23. This same Tool documents R8's pressure ulcer as a dark circle measuring one centimeter by one centimeter. On 10/17/23 at 10:35 am, R8 was observed in R8's bedroom, sitting upright in a (wheeled mobility) chair with R8's knees bent and R8's feet flat, directly on the chair rest. No chair cushion was noted to R8's chair or pressure relieving interventions were noted to R8's bilateral heels. On 10/17/23 at 12:06 pm, R8 was observed in R8's (wheeled mobility) chair inside her room. R8 remained upright in her chair with her knees bent and feet resting directly on the footrest. R8 appeared asleep and did not respond when surveyor knocked on her open door. No chair cushion was noted to R8's chair or pressure relieving interventions were noted to R8's bilateral heels. On 10/17/23 at 2:30 pm, R8 was observed lying in bed on her back. R8's feet were not elevated off the bed and no pressure relieving devices were in place. On 10/18/23 at 10:30 am, R8 was noted to be in R8's (wheeled mobility) chair. R8 was sitting slightly reclined with her knees bent and feet flat on the footrest of her chair. No chair cushion was noted to R8's chair or pressure relieving interventions were noted to R8's bilateral heels. On 10/19/23 at 11:28 am, R8 was noted to be in bed with facility staff performing incontinence care. At this time, an approximate two centimeter by one centimeter open area was noted to R8's right heel. 10/19/23 at 1:23 pm V2 (Director of Nursing) confirmed R8 is at moderate risk for developing pressure ulcers; R8's left heel pressure ulcer was discovered on 10/17/23; R8 was ordered a heel protector for R8's left foot only; R8 developed a new pressure ulcer to R8's right heel on 10/19/23; pressure reducing interventions had not been implemented prior to R8's bilateral heel skin breakdown; and R8 did not have a chair cushion to offload pressure when R8 was out of bed. V2 stated V2 ordered offloading supplies today (10/19/23) and R8 now has bilateral heel protectors. At this time, V2 verified skin assessments should be performed by the nurses weekly. V2 verified V2 was only able to provide one Weekly Skin Assessment conducted by a licensed nurse which was dated 8/27/23. As of 10/20/23, R8's medical record did not contain documentation that weekly skin assessments were completed on R8 since R8's admission to the facility other than the one obtained on 8/27/23 and R8's medical record did not contain documentation that pressure ulcer prevention interventions were implemented for R8's bilateral heels prior to the development of R8's pressure ulcers.