2. The clinical record for Resident 47 was reviewed on 3/9/22 at 10:00 a.m. The diagnoses included, but were not limited to, Parkinson's disease, neurocognitive disorder with Lewy bodies (problems with thinking, movement, behavior, and mood), unspecified intellectual disabilities, moderate protein-calorie malnutrition, ESBL (extended beta-lactamase) resistance, osteomyelitis, and pressure ulcer of sacral region Stage IV(full skin loss extends below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments). The care plan, dated 3/31/21 and last revised 3/7/23, indicated the resident had impaired skin integrity including a pressure area to her coccyx. She was at risk for further skin breakdown due to sensory perception being slightly limited; skin was very moist; she was chairfast; had very limited mobility; her nutrition was probably inadequate; and friction and shear was a problem. She preferred to lay flat on her back most of the day, she would occasionally turn slightly for very short periods of time, despite education. She frequently refused to turn, and often refused to have dressings changed as scheduled. When she was up in her chair, the resident often refused to follow the recommendation of being up in 1 hour intervals and would refuse to lay back down. The interventions included, but were not limited to, gel cushion in chair, treatment as ordered, no brief, limit time up in wheelchair to 1 hours intervals to promote wound healing (initiated on 3/9/22), Wound NP to evaluate and treat, pressure relief boots at all times (initiated on 5/13/21), skin prep to bilateral heels for prevention, wound location to the coccyx, assess for pain and treat as ordered, notify the physician of unrelieved or worsening pain, assess the wound weekly, document measurements and description, house barrier cream at bedside to use as needed, incontinent care as needed with perineal wash and moisture barrier, lab work as ordered, low air loss mattress to bed, adjust per resident preference, notify the physician of changes in the wound such as worsening or signs of infection, observe for signs of infection, turn and reposition every 2 hours. The Wound Management Detail report indicated upon admission, on 3/28/21, the resident had an unstageable pressure ulcer which was identified on 3/28/21. The wound measured 9 cm (centimeters) in length, 6 cm in width, and was 2 cm in depth. There was light serosanguineous drainage, and the wound was 100% slough (necrotic tissue). On 8/11/21, the resident's wound progressed to a Stage IV and measured 5.4 cm in length cm in length, 3.5 cm in width, and had a depth of 2 cm. There was 1 cm of undermining at 12 o'clock and the wound was 100% granulation tissue. The nurse's note, dated 3/12/22 at 12:23 a.m., indicated the resident refused to have her dressing changed. She was normally compliant but refused. She was willing to turn on her side for offloading. The Wound Management Detail report indicated, on 3/31/22, the wound was improving and measured 3 cm in length, 3.5 cm in width, and was 100% granulation tissue. The wound was stable. The April 2022 TAR (Treatment Administration Record) indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing between 7:00 a.m. and 7:00 p.m. was not administered due to the resident's refusal on 4/6/22 at 5:45 p.m., 4/17/22 at 5:31 p.m., and 4/18/22 at 5:32. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 4/28/22, the resident's wound measured 4.5 cm in length, 2.5 cm in width, and was 1.8 cm in depth with 100% granulation. The May 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing, between 7:00 a.m. and 7:00 p.m., was not administered due to the resident's refusal on 5/2/22 at 5:15 p.m., 5/4/22 at 6:21 p.m., and 5/16/22 at 5:03 p.m. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance except for education on 5/4/22. The nurse's note, dated 5/4/22 at 6:26 p.m., indicated the resident continued antibiotics for osteomyelitis. She was up in her chair and refusing to lie back down. She was educated on issues related to skin breakdown. She also refused to have her dressing changed secondary to refusing to lay back down. The resident was educated on issues related to missing treatments but still refused. The nurse's note, dated 5/19/22 at 9:21 a.m., indicated a wound culture was obtained by the wound care NP. The nurse's note, dated 5/23/22 1:10 a.m., indicated the resident's culture showed a heavy growth of pseudomonas aeruginosa. The nurse's note, dated 5/23/22 at 3:57 p.m., indicated the Wound Care NP gave orders for the resident to have Ciprofloxacin in 5% (percent) dextrose 400 mg (milligrams) IV (intravenously) daily for 7 days. On 5/26/22, the resident's wound was 3.5 cm in length, 2.5 cm in width, and 1 cm in depth and was 100% granulation tissue. The nurse's note, dated 5/31/22 at 5:36 p.m., indicated the resident had been up in her chair and was refusing to lay down. The only intervention documented was education. The June 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing between 7:00 a.m. and 7:00 p.m. was not administered due to refusal on 6/25/22 at 6:48 p.m. and on 6/26/22 at 5:44 p.m. There was no documentation of the treatment being completed on either day or night shift on 6/23/22. The resident's order to limit time in the wheelchair to 1-hour intervals to promote wound healing was refused on day shift on 6/3/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. The nurse's note, dated 6/2/22 at 1:36 p.m., indicated the resident received orders to extend her antibiotics through 6/9/22. On 6/30/22, the resident's wound was 3.5 cm in length, 2 cm in width, and 1 cm in depth and was 100% granulation tissue. The July 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing twice daily was not administered on the 7:00 a.m. and 7:00 p.m. shift due to refusal on 7/24/22 at 5:19 p.m., and was not administered on the 7:00 p.m. to 7:00 a.m. shift due to refusal on 7/5/22 at 5:39 a.m. and 7/7/22 at 4:58 a.m. On the 7:00 p.m. to 7:00 a.m. shift on 7/18/22 at 5:14 a.m. The nurse documented the treatment as not administered with a reason being nurse did not have time. The resident's order to limit time in the wheelchair to 1 hour intervals to promote wound healing was refused on night shift on 7/23/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. The nurse's note, dated 7/25/22 at 12:34 a.m., indicated the resident refused her dressing change three times, related to pain. On 7/28/22, the resident's wound was 3.4 cm in length, 2 cm in width, and 1 cm in depth and was 75% granulation tissue and had 25% slough. The Significant change MDS (Minimum Data Set) assessment, dated 7/29/22, indicated the resident was severely cognitively impaired, had no rejection of care behaviors, was totally dependent of two or more staff for bed mobility, and had a Stage IV pressure ulcer which was present on admission. The August 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing twice daily was not administered on the 7:00 a.m. and 7:00 p.m. shift due to refusal on 8/7/22 at 6:00 p.m., 8/20/22 at 3:28 p.m., and 8/24/22 at 10:58 a.m., and was not administered on the 7:00 p.m. to 7:00 a.m. shift due to refusal on 8/6/22 at 7:21 a.m. The treatment was not documented as completed on the 7:00 a.m. to 7:00 p.m. shift on 8/21/22 and the 7:00 p.m. to 7:00 a.m. shift on 8/11/22, 8/21/22, and 8/18/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 8/25/22, the resident's wound measured 3 cm in length, 2 cm in width, and 1 cm in depth and was 75% granulation with 25% slough. There was a foul odor and moderate drainage. The nurse's note, dated 8/25/22 at 9:35 a.m., indicated the resident received new orders for a wound culture and cefdinir 300 mg every 12 hours for seven days related to odor to her wound. The NP's note, dated 8/29/22 at 12:19 p.m., indicated the wound culture showed the resident had growth of pseudomonas aeuroginosa and proteus mirabilis ESBL (extended spectrum beta lactamase). Her antibiotic was changed to Cipro for seven days. The nurse's note, dated 8/29/22 at 2:30 p.m., indicated the resident received new orders for Cipro 500 mg every 12 hours for 7 days. The September 2022 TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing twice daily was not administered on the 7:00 a.m. and 7:00 p.m. shift due to refusal on 9/12/22 at 4:57 p.m., and was not administered on the 7:00 p.m. to 7:00 a.m. shift due to refusal on 9/2/22 at 8:30 a.m., 9/5/22 at 5:12 a.m., and 9/25/22 at 2:18 a.m. The treatment was not documented as completed on 7:00 p.m. to 7:00 a.m. shift on 9/13/22 and 9/15/22. The resident's order to limit time in the wheelchair to 1 hour intervals to promote wound healing was refused on day shift on 9/19/22 and 9/25/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 9/1/22, the resident's wound was 3 cm in length by 2 cm in width, 1 cm in depth, and had 75% granulation with 25% slough. There was no odor. On 9/29/22, the resident's wound was 2.6 cm in length, 1.5 cm in width, 1 cm in depth, and was 100% granulation. The October TAR indicated the resident's treatment order to cleanse the wound with Dakin's, pat dry, apply a Dakin's wet to dry dressing and cover with a dry dressing twice daily was not administered on the 7:00 a.m. and 7:00 p.m. shift due to refusal on 10/2/22 at 5:39 p.m., 10/17/22 at 4:39 p.m., 10/18/22 at 9:20 a.m., 10/29/22 at 6:29 p.m., and 10/30/22 at 3:20 p.m., and was not administered on the 7:00 p.m. to 7:00 a.m. shift due to refusal on 10/16/22 at 1:34 a.m., 10/22/22 at 10:39 p.m., 10/29/22 at 10:26 p.m., and 10/30/22 at 2:22 a.m. The treatment was not documented as completed on 7:00 p.m. to 7:00 a.m. shift on 10/4/22, 10/11/22, 10/18/22, and 10/25/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. The nurse's note, dated 10/17/22 at 8:57 a.m., indicated the resident was started on meropenem 500 mg every 12 hours IV for ESBL in her wound. The nurse's note, dated 10/31/22 at 2:23 a.m., indicated the resident's treatment had come off and she refused to allow another to be applied. The November TAR indicated the resident's treatment order to cleanse the wound with normal saline, pat dry, apply collagen and cover with a dry dressing once daily from 7:00 a.m. to 7:00 p.m. The resident's order to limit time in the wheelchair to 1 hour intervals to promote wound healing was refused on day shift on 11/11/22, 11/14/22, 11/18/22, and 11/19/22. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 11/3/22, the resident's wound was 2.5 cm in length, 1.5 cm in width, 0.8 cm in depth, with light purulent drainage and a slight odor. The wound was 100% granulation tissue. The December TAR indicated the order to cleanse the coccyx with normal saline, pat dry, apply collagen, followed by betadine gauze and a dry dressing daily from 7:00 a.m. to 7:00 p.m., was documented as not administered due to the resident's refusal or her being up in her chair on 12/5/22 at 1:44 p.m., 12/15/22 at 4:51 p.m., and 12/25/22 at 9:06 a.m. The resident's order to limit time in the wheelchair to 1 hours intervals to promote wound healing was refused on day shift on 12/5/22 at 1:44 p.m. The clinical record lacked documentation of interventions attempted or implemented to address the resident's non-compliance. On 12/1/22, the resident's wound was 2 cm in length, 1 cm in width, 0.5 cm in depth, with no exudate, no odor, and 100% granulation tissue. On 1/5/23, the resident's wound was 2 cm in length, 1 cm in width, 0.5 cm in depth, with no exudate or odor and 100% granulation tissue. The January 2023 TAR indicated the order to cleanse the coccyx with normal saline, pat dry, apply collagen, followed by betadine gauze and a dry dressing daily from 7:00 a.m. to 7:00 p.m., was documented as not administered due to the resident being unavailable and up in her chair on 1/16/23 at 6:05 p.m. and 1/21/23 at 4:17 p.m. The resident's order to limit time in the wheelchair to 1 hour intervals to promote wound healing was refused on day shift on 12/5/22 at 1:44 p.m. On 2/2/23, the resident's wound was 1.8 cm in length, 1 cm in width, 0.4 cm in depth, there was no odor, light exudate, and 100% granulation tissue. The nurse's note, dated 2/11/23 at 5:43 p.m., indicated the resident was refusing to lie down once up in her wheelchair and was noncompliant with turning and repositioning. The nurse's note, dated 2/21/23 at 6:41 p.m., indicated the resident had refused her dressing changes for the past two nights. She was educated on the importance of dressing changes to prevent infections and promote wound healing. The resident verbalized understanding. No further interventions were documented. On 3/9/23, the resident's wound was 1.2 cm in length, 0.6 cm in width, 0.4 cm in depth, with light drainage, no odor, and 100% granulation tissue. The resident's care plan and clinical record lacked documentation of any interventions to address the resident's refusal of care or non-compliance, or alternative interventions for when the resident refused treatments, to lie down, or reposition. During an interview on 3/9/23 at 8:58 a.m., Resident 47's family member indicated the resident had the pressure ulcer since before she got to the facility. When she first came in you could see her backbone and now it was down to almost nothing. During an observation on 3/9/23 at 9:03 a.m., PTA (Physical Therapy Assistant) 7 entered the resident's room to conduct a saline mist treatment. The resident's heels were resting directly on the bed mattress. She did not have any pressure relieving treatments in place. PTA 7 removed the resident's dressing. There was a nickel sized open area to the resident's coccyx which was approximately 80% granulation and 20% slough (yellow, necrotic tissue). There was no odor and observed and minimal serosanguineous drainage was on the dressing. During an observation on 3/13/23 at 3:11 p.m., Resident 47 was sitting in her wheelchair by the nurse's station. During an interview on 3/13/23 at 3:13 p.m., CNA 19 indicated he was caring for Resident 47 that day. He was aware of her pressure injury, but it was his first time on the hall in a little while and he was not up to date on her interventions. He knew they turned her every 2 hours, and when she was in her chair, they made sure she was repositioned often and that she was off her bottom. He had cared for her in the past. He had been aware of her refusing care and repositioning quite often. When she refused, he notified the nurse. The nurse would talk to her and try to get her to cooperate with them and then they would often be able to reposition her. During an interview on 3/13/23 at 3:16 p.m., LPN 20 indicated she was the nurse on the hall and CNA 19 was her only aide. She did not know why the resident did not like to get back in the bed. She cried, and they would try to explain it to her. They had pillows and try to offload each side every 2 hours and lay her down as soon as possible. She had tried to encourage her to lay down that same day, but it did not go over too well, she cried. She would take her back to her room and would use pillows to switch the sides, and the resident would allow her to do that. She thought it was because the resident had not wanted to lay down. The resident was adamant if she was not going to do it, she was not going to do it. She did not have any pillows in place. The LPN had helped get the resident up just before lunch at 11:30 a.m., and it was time to put the pillows back in place. She wasn't sure if the resident had those interventions on her care plan. During an observation on 3/14/2 at 8:52 a.m., CNA 21 and CNA 22 assisted Resident 47 from the bed into her chair via a Hoyer lift transfer. The resident did not have any pressure relieving boots in place, and the CNAs did not make any attempts to apply boots. During an interview on 3/14/23 at 9:03 a.m., CNA 22 indicated the resident did have pressure relieving boots, but she did not wear them anymore. CNA 21 indicated the resident did not wear the boots anymore. She had not worn them in a couple of weeks, maybe a couple of months. She didn't have them on in the mornings when they got her up. During an interview on 3/14/23 at 9:32 a.m., LPN 4 indicated the resident had the wound for a long time. She was not aware of the resident refusing any treatments unless she was up in her chair already. She believed she had done it a while back, but she tried to make sure, and do the dressing before she got up as she did not like to lay back down. She was to be laid down after an hour, but she refused, she didn't want to lay down. She wanted to be up during the day. She didn't know what they were doing additionally. She would allow staff to reposition her in the chair. Repositioning her in the chair would be an appropriate intervention. She did not know if the care plan had any interventions to address the resident's refusal of care. She did not see any specific interventions to address what to do when she refused care. She would say the resident was not able to be educated, as she was not cognitively intact. Her wound had improved. They had not discontinued the heel boots, she just put them on the resident. She didn't know why some staff didn't put them on, she did kick them off a lot, but she didn't know why they wouldn't apply them. There had been no determination to discontinue them. During an interview on 3/14/23 at 9:47 a.m., the DON indicated usually when the resident refused care they would step away and reapproach her, then notify the family. She liked being up in her chair and being social. When a resident refused, they would try to get to the root cause of why they were refusing. They would see if it was because she was in pain or if she wanted to stay up, or if she was not wanting the treatment done because she wanted to get up. The intervention of limiting time in her wheelchair would not be an appropriate intervention because she liked to get up. She would agree the resident needed alternative interventions. The boots on her heels were still an intervention.Based on record review, interview and observation, the facility failed to ensure residents' Weekly Skin Assessments were completed and accurate, interventions were implemented, and treatment and monitoring was completed to identify and prevent the development or worsening of a pressure ulcer resulting in an unstageable pressure ulcer worsening to a Stage IV pressure ulcer for 3 of 6 residents reviewed for pressure ulcers. (Residents 62, 47 and 56) . Findings include: 1. The clinical record for Resident 62 was reviewed on 3/8/23 at 11:55 a.m. The diagnoses included, but were not limited to, difficulty in walking, unsteadiness on his feet, and a displaced intertrochanteric fracture of right femur. The weekly skin assessment, dated 1/10/23, indicated the resident had no pressure wounds observed. The weekly skin assessment, dated 1/16/23, indicated the resident had no pressure wounds observed. The current care plan, dated 1/20/23, indicated the resident had impaired skin integrity of a pressure ulcer to right heel. The resident was at risk for skin breakdown or further skin breakdown. The interventions included, but were not limited to, encourage the resident to wear heel lift boot to RLE (right lower extremity) while up in a wheelchair, encourage the resident to float his bilateral heels on a heel riser while abed, turn and reposition every 2 hours, assess wound weekly documenting measurements and description, assess for pain, and treat as ordered. Notify the physician of unrelieved or worsening pain, a pressure reducing and redistribution cushion in the chair, and Promat Plus Mattress with bolsters. The Physical Therapist (PT) note, dated 1/20/23, indicated the resident complained of right foot pain. PT 17 assessed the area and skin. Upon assessment she observed a black necrotic area on the right heel and reported it to the nursing staff for further follow-up. The current physician's order, dated 1/24/23, indicated to apply skin prep to the right heel as preventative, encourage the resident to float the bilateral heels on a heel riser while abed, encourage the resident to turn and reposition every 2 hours and PRN (as needed), with a start date 1/6/23. The wound care NP (Nurse Practitioner) to evaluate and treat, with a start date of 1/26/23. A heel lift boot to the right foot while up in a chair, if the resident was noncompliant with the heel riser encourage the resident was to use a wedge to elevate the right heel while abed, with a start date of 2/16/23. The clinical record lacked documentation indicating the resident's pressure wound was identified before it was observed to be unstageable (full thickness tissue loss obscured by slough or eschar in wound bed). The weekly skin assessment, dated 1/24/23, indicated the resident's bilateral lower extremities were observed to have edema and an open area to the right heel. The wound care note, dated 1/26/23, indicated the resident's wound status was open. The wound was currently classified as an unstageable or unclassified wound with etiology of pressure ulcer located on the right calcaneus. The wound measures 4.5 cm (centimeters) long by 4.5 cm wide. There was no drainage observed. There was no granulation within the wound bed. There was a large (67 to 100%) amount of necrotic (dead) tissue within the wound bed including eschar. The peri wound skin appearance had no abnormalities observed for color. The peri wound skin appearance exhibited: callus, scarring, dry and scaly. Peri wound temperature was observed as no abnormality. The peri wound had tenderness on palpation. The nurse's note, dated 1/29/23 at 3:25 a.m., indicated the resident's right heel continued with necrotic skin related to a pressure injury. The resident had complained of increased pain and that it was unbearable, and he wanted to cry. The nurse had continued with non-pharmacological and pharmacological interventions with no relief expressed from the resident. The physician was notified related to the infection. The Significant Change MDS (Minimum Data Set) assessment, dated 2/2/23, indicated the resident was cognitively intact. The resident had one unstageable pressure ulcer due to coverage of the wound bed by slough or eschar. The nurse's note, dated 2/9/23 at 10:15 p.m., indicated the wound NP assessed the resident and ordered a CMP (Comprehensive Metabolic Panel), CBC (Complete Blood Count), ESR (Erythrocyte Sedimentation Rate), CRP (C-Reactive Protein), and an x-ray of the right heel. The nurse's note, dated 2/11/23 at 4:41 p.m., indicated the physician wrote an order to schedule an appointment with the hospital wound care. The nurse's note, dated 2/14/23 at 5:26 p.m., indicated the laboratory and x-ray results were reviewed by the wound NP with an order to schedule an MRI (magnetic resonance imaging) of the resident's right heel to rule out osteomyelitis. The hospital MRI report, dated 2/23/23, indicated the resident had moderate marrow edema in the posterior calcaneus tuberosity without evidence of significant marrow replacement. This was nonspecific and may represent reactive marrow changes. Osteomyelitis was considered less likely at that time, but not completely excluded. The Wound Care NP note, dated 3/2/23, indicated the resident's wound status was open. The wound had been in treatment for 5 weeks. The wound was currently classified as a unstageable or unclassified wound with etiology of pressure ulcer located on the right calcaneus. The wound measured 3.4 cm (centimeters) long by 3.4 cm wide. There was no drainage observed and no granulation within the wound bed. There was a large (67 to 100%) amount of necrotic tissue within the wound bed including eschar. The peri wound skin appearance had no abnormalities observed for color. The peri wound skin appearance exhibited callus, scarring, and was dry and scaly. The temperature was observed as no abnormalities. The peri wound had tenderness on palpation. The treatment included cleanse the wound with normal saline. pat dry, paint the wound base with betadine and cover with a bordered gauze daily and PRN (as needed) for soilage or dislodgement. During an interview on 3/10/23 at 8:35 a.m., Physical Therapist 17 indicated the resident came to them for therapy due to a right hip fracture. She found the resident's pressure wound to his right heel and it was necrotic. She informed the nursing staff. Resident 61 was blaming the physical therapy department for his pressure wound. She educated the resident on using his feet. He had no restrictions at that time. She would never tell a resident to use the footboard for strengthening exercises. Push and pull exercise using the foot board would not cause a pressure wound. Friction from the bed had caused the pressure wound. During an interview on 3/10/23 at 9:20 a.m., the DON (Director of Nursing) indicated the resident was admitted for rehab due to the surgical repair of a right hip fracture. They used skin prep and educated the resident on turning and repositioning at least every 2 hours, heel risers, and a wedge. She indicated RN 18 found the resident's pressure wound on 1/24/23 and filled out a skin event. It was an unstageable wound. He was followed by a wound management company. He had an MRI and it was negative for osteomyelitis. The resident was blaming physical therapy for his pressure wound. His wound was stable and had no decline. During an observation on 3/10/23 at 10:10 a.m., the Wound Care Nurse explained to Resident 62, that she was going to provide wound care. He indicated he was in pain and requested Tylenol. She indicated the pressure wound was facility acquired. She was not sure who found the pressure wound. She cleansed the wound with wound cleanser and there was no drainage or odor. The pressure wound was unstageable, and the wound was approximately the size of a silver dollar. The wound was covered with 100% eschar tissue. The treatment included betadine and cover with a dressing. During an interview on 3/10/23 10:10 a.m., the resident indicated he would slide his heel up and down the bed sheet and mattress to get traction so he could exercise his right leg. The physical therapist told him to move his leg for strength. The therapist found the wound and told the nurse. During an interview on 3/10/23 at 11:25 a.m., RN 18 indicated she would fill in sometimes and do the weekly skin assessments. On 1/24/23 she observed a pressure wound on the resident's right heel. The wound had large black eschar and was 3.4 cm x 3.4 cm. No drainage was observed. The pressure wound should have been found on the weekly skin assessment before it got to that stage. It should have been found when the heel was red then skin preventions should have been implemented. The resident was supposed to have skin prep every shift to his heels. 3. The clinical record for Resident 56 was reviewed on 3/9/23 at 2:37 p.m. The diagnoses included, but were not limited to, diabetes mellitus, moderate protein-calorie malnutrition, abnormalities of gait and mobility, and osteomyelitis of the right ankle and foot. The Quarterly MDS assessment, dated 1/31/23, indicated the resident was moderately cognitively impaired. The resident required extensive assistance of one staff for ADLs (Activities of Daily Living). The care plan, dated 4/21/22 and last revised on 2/6/23, indicated the resident was at risk for skin breakdown or further skin breakdown due to the pressure area to the right heel. The interventions indicated (initiated 5/20/22) to use a heel riser when in bed, (initiated 4/21/22) to assess and document the skin condition weekly and as needed. Encourage the resident to turn and reposition at least every 2 hours. The Wound Management note, dated 4/21/22 at 3:40 p.m., indicated the resident was admitted with a Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to the right heel. The wound measured 4 cm long by 3.5 cm wide. There was light bloody exudate and 100% granulation tissue. The Wound Management note, dated 5/5/22 at 10:09 a.m., indicated the wound was unstageable to the right heel. It measured 3.4 cm long by 1.8 cm wide. There was 100% eschar tissue. The wound had declined. The nurse's note, dated 9/15/22 at 12:57 p.m., indicated the wound nurse practitioner was in to see the resident with a new order for a wound culture of the right heel. The Wound Management note, dated 9/15/22 at 3:08 p.m., the wound was a Stage IV to the right heel. It measured 2.4 cm long by 1.5 cm wide by 0.3 cm deep. There was 50% granulation tissue and 50% slough. Necrotic tissue was present. The wound culture results, obtained on 9/16/22, indicated the wound to the right foot had a heavy growth of Escherichia coli ESBL, MRSA (Methicillin Resistant staphylococcus aureus), and diptheroid bacillus. The Wound Management note, dated 12/15/22 at 6:22 p.m., indicated the Stage IV wound to the right heel measured 0.8 cm long by 0.4 cm wide, by 0.3 cm deep. There was light serous exudate and 100% granulation tissue. The Wound Management note, dated 1/26/23 at 4:16 p.m., indicated the Stage IV wound to the right heel measured 0.5 cm long by 0.4 cm wide by 0.2 cm deep The Wound Management note, dated 3/2/23 at 5:00 p.m., indicated the Stage IV wound to the right heel measured 0.5 cm long by 0.5 cm wide by 0.2 cm deep with light serosanguineous exudate. The April 2022 TAR (Treatment Administration Record) lacked documentation, on 4/29/23, of the completion on the 7:00 a.m. to 7:00 p.m. shift of the following interventions: the removal of the heel lift boots to the bilateral lower extremities for skin check, the positioning device of 2 half side rails while the resident was in bed, the turning and repositioning every 2 hours and prn, and Zinc oxide ointment 20% (percent) applied topically to the coccyx. The IDT (Interdisciplinary team) note, dated 4/21/22 at 4:06 p.m., indicated the resident was admitted from the hospital on 4/20/22 with a Stage II wound to the right and left heel. The interventions were in place prior to the wound development to assess and document skin weekly and as needed, encourage the resident to turn and reposition at least every 2 hours; a pressure reducing/redistribution mattress on bed and in chair. The new interventions initiated were heel lift boots to the bilateral feet. The current treatment order was to cleanse the left and right heel with normal saline, pat dry, apply venalax, cover with ABD (army battle dressing) pad, and wrap in kerlix every day. The physician's order, dated 5/9/22, indicated to apply a Promat Plus Mattress. The physician's order, dated 5/20/[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure appropriate intervention to prevent a fall for 1 of 3 residents reviewed for falls, which resulted in the resident having broken bones, bruising, and skin tears. (Resident 35) Findings include: The clinical record for Resident 35 was reviewed on 3/9/23 at 2:18 p.m. The diagnoses included, but were not limited to, a fall slipping, tripping, and stumbling; muscle weakness; stiffness of the left ankle; pain in the right knee; stiffness of the right hip and right ankle; idiopathic peripheral autonomic neuropathy; contracture of the left and right ankle; mechanical complication of the internal fixation device of the right femur for a displaced supracondylar fracture; abnormal posture; and the need for assistance with personal care. The physician's order, dated 2/8/22, indicated the resident was to have two quarter side rails to enhance bed mobility related to weakness. The order was discontinued on 3/2/23. The care plan, dated 11/08/18 and last revised on 2/17/23, indicated the resident required assistance with ADLs (activities of daily living) including bed mobility, transfers, eating and toileting related to the resident having impaired mobility and decreased strength. The interventions, dated 11/8/18, indicated staff were to assist the resident with bathing as needed per resident preference; assist with bed mobility with two quarter side rails; assist with dressing, grooming, and hygiene as needed; assist with toileting or incontinent care; and assistance of two staff with the use of a Hoyer for transfers. The Quarterly MDS (Minimum Data Set) assessment, dated 7/22/22, indicated the resident was cognitively intact. The resident required the extensive assistance of two staff members for bed mobility, transfer, personal hygiene, and toileting. The physician's order, dated 8/12/22, indicated the resident was to have a low air loss mattress. The order was discontinued on 3/6/23. The Quarterly MDS assessment, dated 2/1/23, indicated the resident was cognitively intact. The resident required two plus staff assistance with bed mobility, transfer, and toileting. The nurse's note, dated 3/4/23 at 11:00 a.m., indicated CNA 12 alerted the nurse that the resident had fallen on the floor during incontinence care. The resident was found semi-prone on her right side between the wall and the bed. Resident's head was resting on the front left corner of her bed side table. A skin tear was observed to the right dorsal side of the hand. The resident was assisted by the nurse, a CNA (Certified Nurse Aide), and two additional nurses via Hoyer lift back into her bed. The resident complained of pain to her left ankle and left knee. Multiple skin tears were observed in addition to the left hand, including a laceration to the right side of the face, under the eyebrow, the dorsal side of left great toe, and right shin. The resident indicated she did not want to be sent to the hospital. The on-call NP (Nurse Practitioner) ordered x -rays of the areas indicated. The resident's family voiced concerns regarding the lack of a full-sized bed. The nurse's note, dated 3/4/23 at 6:18 p.m., indicated there was new swelling and bruising to the resident's medial side of the knee. The resident states extreme pain. The NP gave new orders for an x-ray of the right lower leg. The nurse's note, dated 3/5/23 at 10:01 a.m., indicated the resident continued to complain of severe pain in the BLE (bilateral lower extremity). The x-ray report concluded a possible subtle proximal tibial plateau fracture and an acute fracture of the proximal tibial metaphysis with mild impaction, but minimal displacement, other than a small anteriorly displaced fracture. The nurse's note, dated 3/5/23 at 12:16 p.m., indicated the resident was agreeable to being transferred to a local hospital. The hospital notes, dated 3/5/23 at 6:31 p.m., indicated the resident was being attended to by staff yesterday morning when she rolled out of bed striking her hip and bilateral knees. She had striked her head. She indicated a mild headache yesterday and was complaining of bilateral hip pain, bilateral knee pain and bilateral ankle pain. X-rays were obtained at the rehabilitation facility which indicated multiple fractures. The resident's history indicated two right hip fractures, right femur surgery, neck surgery and back surgery. The resident weighed 250 pounds and was 72 inches tall. The resident had diffused tenderness to the knee, a proximal left tibia, and the ankles were diffusely tender with chronic plantar flexion deformities. The x-ray results indicated a hairline fracture of the distal left tibia medial cortex just above the metaphysis. There was moderate swelling of the left ankle and moderate diffuse osteoporosis. The right knee x-ray revealed an acute fracture of the right proximal tibial metaphysis with minimal displacement of the tibia-fibula. The left tibia-fibula x-ray revealed a subtle proximal tibial plateau fracture. The resident was non-ambulatory, and the fractures were non operative. The plan indicated to place a right lower extremity knee immobilizer and left equalizer boot and to be worn at all times but may be removed for hygiene and sleep unless the device was in place for fracture. The IDT (Interdisciplinary team) Fall review note, dated 3/6/23 at 12:58 p.m., indicated a new intervention was put in place to address the root cause of the fall, for assistance of two staff at all times with bed mobility and incontinence care, to discontinue the low air loss mattress and to initiate the Promat Plus mattress. During an observation on 3/8/23 at 9:23 a.m., the resident had bruising to the right chin and a cut to the right eyebrow. During an interview on 3/9/23 at 2:47 p.m. a family member indicated the resident fell and this was her third fall. During the other two falls she slid out of bed with her head and torso first. A staff member was changing her with just one staff and she rolled out of bed. She may have been trying to hold onto the rail and she somehow fell out of the bed with this latest fall. She had bilateral tibial fractures, and she had a fibular fracture on one leg. When she fell the first time, the family asked about bed rails and was told by the Social Worker that they couldn't have bed rails. After staff mentioned that she could go from a small enabler rail to a longer side rail she just about lost it. The resident was in horrible pain. She had several bruises and a laceration above her eye. Her bones were not in good shape. The facility only reacted to things after the fact. They didn't put best practices in place from the beginning. You can't get two CNAs to come to the room. The resident use to be transported in a Hoyer lift and sometimes she would be stuck in bed for hours, because they couldn't get two people to come and get here up. Now she's on a lot of pain medication. The family didn't trust the staff to care that she's safe. I know we will have a big reaction if something happens, I can't foresee everything that might happen. The surgeon said her bones are like lace. The pain she had gone through with this fall should never have happened. The nurse's note, dated 3/10/23 at 3:55 a.m., indicated fall precautions remained in place and the resident continued to have facial bruising and a steri strip to the right temple. She had swelling to bilateral feet. During an observation on 3/10/23 at 12:55 p.m., the resident's right cheek and jaw were slightly swollen. During an interview on 3/10/23 at 12:58 p.m., CNA 12 indicated the resident could move her legs up and down and could open them a bit. She could raise her upper torso up and down and reach her face with her arms. She controlled her bed most of the time. When she rolled, she would get started and would rock and eventually roll over. She was not concidered a total assist, but a partial assist. She put her light on when said she was wet. She changed the resident daily and the bed was stripped at the same time. The resident was turning toward the wall and had ahold of the side rail. She rocked herself and went over. She just had a hold of her gown, and she went over. She didn't put her leg over. She would just wiggle over. She rolled a little too far. Her torso was twisted. Her leg and bottom went over first. She hit the bedside table against the wall first. She had always been considered a one person assist until the recent fall. The resident would let the CNA know what she wanted to do or not do. She was laying straight on the mattress and turned onto her left side. She got her sheets together and got the rolled-up sheets under the resident. She was already on her side. She was laying on the middle of the mattress and rolled too far and just kept going. During an interview on 3/10/23 at 1:05 p.m., the Therapy Director indicated the resident had previously been able to roll with maximum assistance (75% plus assistance). She could grab the quarter side rails. She just now got the new bed in and therapy still needed to check the bed. She was not currently in therapy, but when she came back from the hospital, an assessment was planned to be completed. Prior to the fall she could not move her legs in bed and required assistance. She had received therapy and received range of motion. The resident had always required the assistance of two for pulling her up in bed. For nursing care, she required position devices, and maximum assistance of two dated 2/8/22. She could not [NAME] her legs over to roll on her side. She required assistance and had a minimal amount of her own assistance. She could grab her rails to assist with rolling, but she could not move her legs. At therapy discharge, the resident could lean to her left and reposition herself independently to midline. She had a low air loss mattress. It could have led to her falling out of bed, due to the decompression when getting close to the edge. It should be on the firm setting for bed mobility. During an interview on 3/18/23 at 10:50 a.m., the MDS Coordinator indicated the MDS assessments was a collaboration of the nurses, charting, hospital records, the resident, and the family. The Functional Status section was based on the gathered information from huddles, and the decline of the resident. It would be addressed during meetings. The MDS had changed since she took over the MDS assessments. The DON (Director of Nursing) conducted the assessments prior to her coming in December 2022. During an interview on 3/13/23 at 11:14 a.m., the resident indicated CNA 12 was providing incontinence care, and gave her a push to roll over. The CNA had been getting ready to change her and was getting the wet brief out from under her. Her legs eventually went over, out of the bed. She had been hanging onto the rail to get her balance. The CNA was short and couldn't grab her in time to prevent her from rolling out of bed. They sometimes called for 2 CNAs to change her because she couldn't roll well. She now had pain from the fall. Her left forearm had a large circular bruise, approximately 2 1/2 inches and her right forearm had a small circular eraser sized bruise. They made braces for her legs. The Fall Management policy, last revised on August 2022, was provided by the DON on 3/13/23 at 1:36 p.m. The policy included, but was not limited to, . Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls. 3.1-45(a)(1) 3.1-45(a)(2)