**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and the facility policy review the facility failed to implement interventions to prevent worsening of a Stage II pressure ulcer on the right heel for 1 of 3 residents reviewed for pressure ulcers (Resident #17). The facility reported a census of 38. Findings include: The Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #17 with diagnoses of medically complex conditions and multiple sclerosis; three Stage 4 pressure ulcers present on admission and no unstageable pressure ulcers present. The Annual MDS assessment dated [DATE] revealed Resident #17 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the resident required extensive assistance of 2 plus person physical assist with bed mobility and transfers. The MDS revealed diagnosis of progressive neurological condition and multiple sclerosis. The MDS revealed the resident had two Stage 4 pressure ulcers present on admission and one Unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. not present on admission. The MDS revealed the resident received an opioid 2 out of 7 days. The Admission/readmission Evaluation for Skin and Wound Initial Care Plan dated 2/15/23 at 1:15 PM revealed Resident # 17 had a history of pressure related injuries including a Stage 2 on right heel. The Care Plan revealed a focus area of self care deficit related to multiple sclerosis dated 7/19/21. The interventions dated 7/4/2018 revealed a rotating air mattress in place for assistance with pressure relief, but may need staff to assist with devices for my comfort with position changes; resident had minimal active movement with my BLE's (bilateral lower extremities), so please assure they are positioned comfortably and no pressure to areas; and pressure relieving boots on my bilateral feet to assist with pressure relief of my heels. The Care Plan revealed a focus area for Stage 4 pressure ulcers on resident's left buttock, right buttock, sacrum, and an unstageable pressure on the right heel initiated on 7/20/21 and revised on 5/3/23. The interventions dated 10/13/21 documented adjustment of the treatment plan if wound didn't heal within 2-4 weeks; weekly evaluation of wound healing; and monitored changes in skin status that indicated worsening of the pressure ulcer and notification to physician. The interventions dated 5/3/23 revealed assessment, recorded, and monitored wound healing (specific frequency) with measurement of length, width, and depth when possible and assessment of wound perimeter, wound bed, and healing progress with reported improvements/declines to physician. The interventions dated 9/18/23 revealed pressure relieving boots on bilateral feet. Braden Scale for Predicting Pressure Sore Risk dated 2/16/23 at 6:07 AM revealed a score of 15. A score of 15-18 indicated resident at risk for pressure sores. The Wound Evaluation dated 2/28/23 revealed a new in house acquired unstageable pressure ulcer due to slough and/or eschar to the right heel with the following measurements: a. area: 9.26 cm 2 (a unit of area measurement equal to a square measuring one centimeter on each side) b. length: 3.99 cm (centimeter) c. width: 3.08 cm The Wound Evaluation and Management Summary notes dated 3/1/23 revealed the following information: a. Unstageable DTI (deep tissue injury) of the right heel partial thickness b. Etiology (quality): Pressure c. MDS 3.0 Stage: Unstageable DTI with intact skin d. Duration: > 1 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 4.0 x 5.0 x Not Measurable cm g. Surface Area: 20.00 cm² h. Exudate: None i. Blister: Dry j. Expanded evaluation performed: The development of this wound and the context surrounding the development were considered in greater depth today. k. Dressing treatment plan: Primary Dressing(s); Skin prep apply once daily for 30 days l. Plan of Care reviewed and addressed: 1. Recommendations: Off-load wound Braden Scale for Predicting Pressure Sore Risk dated 3/2/23 at 9:02 AM revealed a score of 12. A score of 12 indicated resident high risk for pressure sores. The Wound Evaluation and Management Summary dated 3/8/23 revealed the following: a. Unstageable DTI of the right heel partial thickness b. Etiology (quality): Pressure c. MDS 3.0 Stage: Unstageable DTI with intact skin d. Duration: > 7 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 1.2 x 0.9 x Not Measurable cm g. Surface Area: 1.08 cm² h. Exudate: None i. Blister: Dry j. Wound progress: Improved k: Dressing treatment plan: 1. Primary Dressing(s) with Skin prep apply once daily for 23 days l: Plan of Care reviewed and addressed with the following recommendations: 1. Off-load wound The Wound Evaluation and Management Summary notes dated 3/15/23 revealed the following information: a. Unstageable DTI of the right heel partial thickness b. Etiology (quality): Pressure c. MDS 3.0 Stage: Unstageable DTI with intact skin d. Duration: > 13 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 4.0 x 3.0 x Not Measurable cm g. Surface Area: 12.00 cm² h. Exudate: None i. Blister: Fluid Filled j. Wound progress: No Change k. Additional wound detail: resident wore shoes when in his wheelchair l. Dressing treatment plan: 1. Primary Dressing(s) with Skin prep apply once daily for 16 days m. Plan of Care reviewed and addressed n. Recommendations: Off-load wound; Wear Prevalon boot on both feet. Wear boots when in wheelchair for protection Review of the March 2023 MAR/TAR (Medication Administration Record/Treatment Administration Record) lacked documentation for administration of skin prep on the right heel. The Wound Evaluation and Management Summary notes dated 3/22/23 revealed the following information: a. Unstageable DTI of the right heel full thickness b. Etiology (quality): Pressure c. MDS 3.0 Stage: Unstageable DTI within and around wound d. Duration: > 20 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 5.0 x 5.0 x Not Measurable cm g. Surface Area: 25.00 cm² h. Exudate: Moderate serosanguineous with thick adherent devitalized necrotic tissue: 50 % and other viable tissues: 50 % (Dermis) i. Wound progress: No Change j. Additional Wound Detail: blister erupted. Non viable skin debrided and a clean wound bed revealed with no non viable tissue left k. Dressing treatment plan: 1. Primary Dressing(s) with Alginate calcium with silver apply once daily for 30 days: or Iodosorb to the wound bed once daily 2. Secondary Dressing(s): Gauze island with border applied once daily for 30 days l. Plan of Care reviewed and addressed: 1. Recommendations: Off-load wound; Wear Prevalon boot on both feet. Wear boots when in wheelchair for protection m. Surgical excisional debridement procedure: Indication for procedure: 1. remove necrotic tissue and establish the margins of viable tissue The Physician Orders included the following medication orders: a. ordered 3/22/23 and discontinued on 8/1/23: Iodosorb External Gel 0.9 % (Cadexomer Iodine)- apply to right heel topically every day shift for open area and apply to wound bed and cover with an island dressing. The Mini Nutritional assessment dated [DATE] at 3:10 PM revealed a score of 12 which indicated normal nutritional status. The Progress note: Dietitian Nutritional Assessment revealed the multiple pressure wounds and no new recommendations and the Registered Dietician (RD) will continue to monitor and reassess as needed. The Wound Evaluation and Management Summary notes dated 4/19/23 revealed the following: a. Stage 4 pressure wound of the right heel full thickness b. Etiology (quality): Pressure c. MDS 3.0: Stage 4 d. Duration: > 47 days e. Objective Healing, sustained in hospital f. Wound Size (L x W x D): 2.5 x 4.0 x 0.1 cm g. Surface Area: 10.00 cm² h. Exudate: Heavy Serous i. Thick adherent devitalized necrotic tissue: 30 % j. Granulation tissue: 70 % k. Wound progress: Improved l. Dressing treatment plan: 1. Primary Dressing(s): Alginate calcium with silver apply once daily for 30 days: or Iodosorb to the wound bed once daily 2. Secondary Dressing(s): Gauze island with border apply once daily for 30 days m. Plan of Care reviewed and addressed with recommendations: 1. Off-load wound; Wear Prevalon boot on both feet. Wear boots when in wheelchair for protection The Wound Evaluation dated 4/21/23 revealed the following measurements for the right heel: a. area: 8.96 cm 2 b. length: 3.66 cm c. width 3.44 cm The Wound Evaluation dated 4/29/23 revealed the following measurements for the right heel: a. area: 64.15 cm2 b. length: 11.52 cm c. width: 7.08 cm The Physician Orders revealed the following orders: a. ordered 9/18/23 and discontinued on 9/18/23- Prafo boots to bilateral feet while in bed every shift b. ordered 9/18/23- Heel pressure relieving boots to bilateral feet while in bed During an interview on 9/11/23 at 1:37 PM, Resident #17 stated he developed new wounds on his heel and his bottom. Resident wore a sock on his right foot and sat in his wheelchair. During an observation on 9/13/23 at 2:34 PM, Resident #17 sat in his wheelchair in the common area. His right foot had a thickened bandage under the right heel under his sock. During an interview on 9/13/23 at 3:28 PM, Resident #17 stated he wore pressure boots at bedtime. During an observation on 9/14/23 at 3:59 PM, Resident #17 laid in bed and his heel pressure relieving boots laid on the bed next to him. During an interview on 9/14/23 at 11:58 AM, the Staff E, Wound Doctor queried on Resident #17 wounds and she spoke of his chronic wounds and stated the wounds in stable condition and she used to see him weekly for his wounds but that recently changed to monthly due to the stability of the wounds. Staff E asked when the resident needed to wear the Prevalon boots and she stated all the time even when he sat in the wheelchair. She stated they needed to be on all the time. During an interview on 9/14/23 at 1:10 PM, Staff A, Registered Nurse (RN) queried on the skin assessments and she stated if the resident develops a new wound the nurse got the IPAD and took a picture and conducted a risk management assessment. She stated the Nurse Practitioner (NP) did the staging for wounds. During an interview on 9/14/23 at 1:28 PM, Staff A queried about the pressure ulcer on Resident #17 right heel and she stated he wore moon boots when he laid in bed. She stated he didn't wear them when he sat in his wheelchair. She stated he didn't have a care plan for the boots to be worn in his chair and he sat in his chair 2 to 3 hours a day. Staff A asked if the Resident #17 had an order for Prevalon boots and she stated she didn't know but didn't think so. During an observation on 9/18/23 at 9:50 AM, Staff A, RN performed wound care on Resident #17 right heel. She removed a rolled gauze from the heel and cleaned the heel. The heel beefy red with necrotic tissue on the lateral side of the foot. Dressing completed as ordered. During an observation on 9/18/23 at 1:27 PM, Resident # 17 sat in his electric wheelchair sat in the hallway. His right foot crossed over his left foot. Resident # 17 stated his heel hurt and he stated he was making his way up to the nurse's station to get something stronger than acetaminophen for the pain. During an interview on 9/19/23 at 12:31 PM, Staff D, Certified Nurse Aide (CNA) queried on the interventions they used for Resident #17 heel and she stated they put boots on him when he laid in bed and he needed to wear them in the chair but didn't always wear them. She stated he used to wear a thin heel protector but didn't like it on and only wore the moon boots in his bed. Staff D asked if he wore boots in his chair prior to the wound and she stated she didn't remember. She stated when the wound developed they tried to get him to wear the boots in the chair and he didn't but she didn't remember any other interventions they tried and that would be the nurse's responsibility on what bandages they used to save the heel. During an interview on 9/19/23 at 12:59 PM, Staff C, CNA queried on the interventions used for Resident #17 heel and she stated he wore the moon boots when in bed and got up into his chair from 9:30 AM to around 1 PM. During an interview on 9/19/23 at 3:58 PM, Staff B, RN queried on Resident #17 right heel and she stated he had a wound since she been here and she believed it got worse. She states he wore the moon boots while in bed and he wore socks in the wheelchair and might wear shoes when he went into the public. Staff B asked if the resident used a pillow for a pressure reducing device for the right heel when he sat in the wheelchair and she stated not that she knew of and she stated she guessed she could of thought of that. During an interview on 9/18/23 at 10:08 AM, the Director of Nursing (DON) queried about Resident #17 right heel and she stated they found it after he came back from the hospital and it started out like a purple spot and deteriorated at the facility and now they got it back on track. She stated when he came back from the hospital they watched it and then it broke open and she thought the wound doctor staged it and marked it unstageable. The DON asked about interventions for the heel and she stated the resident wore Prafo boots, air mattress, and whatever the treatments the wound doctor ordered. She stated he didn't like wearing the boots in the wheelchair and he used to wear shoes but she convinced him not to wear shoes. The DON asked if she documented his refusal for the boots and she stated she needed to look. The DON asked if the wound was preventable and she stated yes. She stated the resident liked the thinner boots and she told him he needed a bigger boot and she thought the thin boot caused the wound because they didn't have cushion or a lift to keep the pressure off. During an interview on 9/18/23 at 11:04 AM, the Regional Director of Clinical Services stated Resident #17 never wore Prafo boots and he wore Prevalon boots since admission until the hospital gave a different pressure cushion boot that the resident prefers. She stated he didn't have an order for them but the boots placed on the care plan and the [NAME]. The Facility Pressure Ulcers/Skin Breakdown - Clinical Protocol dated April 2018 revealed the following information: a. Assessment and Recognition: The staff will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. b. Treatment/Management: The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. c. Monitoring: As needed, the physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. 1. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. 2. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, were affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review the facility failed to transport a Resident safely in the shower chair and failed to determine the root cause analysis for two recent falls for 2 of 3 residents reviewed for accidents. (Resident #13 and Resident #34). The deficient practice resulted in a fractured fibula, increased pain and hospitalization. The facility reported a census of 38. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #13 dated 08/18/2023 documented Resident #13 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS assessment documented Resident #13 completely dependent on staff when transported. The Care Plan Initiated 07/20/2023 documented; I am unable to transfer independently. The Care Plan initiated 03/11/2023 with a target date of 11/16/2023 documented the resident had a fractured left fibula. Per the Care Plan the following goals and interventions were initiated on 03/16/2023 and revealed: 1. I will not develop complications or permanent loss of mobility related to fracture through review date. 2. I will be free from signs and symptoms of pain, or will express/exhibit relief of pain after administration of ordered meds, alt comfort measures. 3. Encourage use of affected limb as much as tolerated, to help maintain range of motion. 4. Give pain, anti-inflammatory medications as ordered. Monitor/document side effects and effectiveness. 5. If orthopedic fixation device or traction is present, follow physician's orders for monitoring, maintaining device, and providing skin care. 6. Monitor, document, and report as needed edema, bruising/discoloration of skin, skin temperature changes, loss of sensation distal to fracture, presence/absence of pulses distal to fracture. If cast is present, skin breakdown or trauma at cast edges and pad as recommended 5. PT, OT evaluate and treat as indicated. 7. Support injured area with pillows and immobilize part as appropriate. An Incident, Accident, Unusual Occurrence Note dated 3/2/2023 at 2:14 PM documented by the facility included; CNA was transporting resident in the shower chair from shower to her room. As they came around the corner, residents foot slipped under chair causing pain and bruising. Resident states My foot went under the shower chair Review of Nurse Progress Note documentation dated 3/2/2023 Incident, Accident, Unusual Occurrence; CNA transported Resident in the shower chair from shower to her room. As they came around the corner, residents foot slipped under chair causing pain and bruising. Resident states My foot went under the shower chair elevate foot, Ice pack administered, order for x-ray obtained and no fracture was determined. Will continue to elevate and ice as needed. Review of nursing note dated 3/6/23 revealed x-ray results no evidence of acute fracture or dislocation and No acute fracture dislocation seen. Osteoarthritis and Osteopenia Per Primary Care Physician (PCP) no acute fracture. No new orders. Power of Attorney (POA) notified and resident aware. Review of nursing note dated 3/6/23 advised the nurse called the Primary Care Provider (PCP) for concerns of residents left leg and foot. Calf and foot were swollen, red and had slight warmth to the touch. Resident stated some pain was present to the arch of the foot. Family was present in the room and also requested she be sent to Emergency Department (ED) and family all notified of transfer. The Nurses Note dated 3/11/23 at 11:54 AM documented, this nurse called PCP for concerns of residents left leg and foot. Calf and foot were swollen, red and had slight warmth to the touch. Resident stated some pain was present to the arch of the foot. Family was present in the room and also requested she be sent to ED. Review of nursing note dated 3/11/23 revealed Resident returned from ED with new orders. Minimal weight bearing for 2 weeks. Repeat left ankle x-ray in 2 weeks. Document dated 3/11/23 by the hospital reported; Ankle run over by shower chair now red and swollen possibly infection. X-rays completed, 3 views. Impression indicated a subacute oblique mildly fracture of the distal fibula with large amount of soft tissue swelling of the ankle. The Major Injury Determination Form dated 03/13/2923 reported the following; X-rays done on 3/1/23 showed no fracture. X-rays done 3/11/23 shows fibula fracture. Resident was transported in shower chair when foot caught under chair. Document narrated by the Physician and dated 4/8/23 advised the fibular fracture is healing, but the radiologist noticed a possible subtle fracture on the other side of the ankle. She had diffuse osteoporosis of her bones from being immobile. An interview with Resident #13 on 09/11/23 revealed Resident had broken her ankle earlier this year while at the facility. Resident was in the shower chair and was being transported to the shower room by a male staff member when her foot slid off the peddle and she scrapped her big toe and it hurt. Resident thought foot would be alright but it started swelling. The nurse on duty looked at the foot/ankle at the time of incident. On 09/13/23 at 10:51 AM Resident #13 was interviewed again and reported the morning of the incident a staff member transported her to the shower room. On the way there, Resident's foot hit the edge of the floor where the carpet and laminate come together and her foot twisted to the left. The worker stopped and looked at it. Resident indicated she did not see a nurse at this time. Resident had pain when it first happened. Resident advised she told staff she had pain. Staff looked at her foot and it was scraped. Resident was given a as needed (PRN) Tylenol 3 Resident's foot was x-rayed later in the day after a portable x-ray machine was brought in to the facility. The x-ray did not reveal a fracture or dislocation. Resident reported her foot was swollen and the back of her heal was bruised. Resident advised she continued to have pain and swelling to the left foot and ankle and several days after the incident she was sent to the Emergency Department at the request of a family member. Her foot and ankle were x-rayed again and a fracture was revealed. On 09/13/2023 at 6:46 PM A family member was interviewed and provided the following information. The family member was notified of the incident by the resident and not the facility. Reportedly Resident's foot was ran over when transported to the shower room. The foot pedals were not on. The staff member needed the Resident to hold her leg up while they pushed her down to the shower room. Resident reported it really hurt. Complainant observed the injury several hours later and advised it was swollen and black and blue. Does not think they iced her foot but may have given her a Tylenol 3. Complainant spoke to Staff Member I, Licensed Practical Nurse (LPN), who advised the foot did not look like that earlier. The Nurse claimed they had checked on the foot throughout the day. The foot was x-rayed that day and no fractures were indicated. Several days later the foot was the x-rayed again and it was determined there was a fracture. Resident not able to wear a shoe on that foot since the fracture. On 09/19/23 03:56 PM an in-person interview conducted with Staff B, Registered Nurse (RN), who reported the following. The injury to Resident #13's foot occurred prior to the start of her shift. During her shift a portable x-ray machine was brought in to the facility to x-ray the Resident's foot. The initial x-ray did not indicate there was a fracture. Several days later Resident #13's foot was x-rayed again after she was taken to the hospital. This x-ray revealed a fractured fibula. Staff B does not know how the injury was assessed or watched after the first x-ray. Staff B advised the foot was not hot to the touch. Staff B does not remember that the foot or ankle was hot or swollen but remembers the Resident had some pain. Resident had already been on Tylenol 3 PRN and that was provided. On 09/20/23 11:50 AM the Director of Nursing (DON), advised she was not at the facility when the incident occurred. The DON was not notified at the time of the incident. The DON reported Staff I, RN described to her how the injury occurred. Staff I advised Staff H CNA, was bringing the Resident back from the shower and the Resident's foot got caught underneath the shower chair. The Nurse that worked that shift completed an assessment. Later that day the doctor was notified and ordered a portable x-ray. The original x-ray did not indicate a fracture. The DON advised she assessed the Resident's foot the following morning and there no was bruising, redness or swelling. Resident always has had some edema plus 2 in her foot but nothing out of the ordinary for her. Resident was treated for pain. Resident had a previous order for Tylenol 3 PRN. Staff elevated and iced the Resident's foot. Prior to the incident Resident was not able to no ambulate on her own and was weak and couldn't pull herself up. Resident had had issues with transfers for a while. Staff H CNA had transported the Resident when the incident occurred. On 09/20/23 at 5:35 PM Accompanied by the DON the shower chair was observed. The DON indicated the large shower chair was likely the one used with the Resident the day of the incident. The PVC chair had a padded seat with hole along with six locking wheels and a mesh back. There was a pull-out platform foot rest. See pictures in file. On 09/21/23 09:11 AM Staff H provided the following interview. Staff H transported the Resident to the shower room. During the transport the area near the nurses station was congested with other residents. Staff H advised he was pulling the Resident backwards and then spun her around to navigate past the other residents and as he spun the shower chair it went over the slight slope between the laminate and carpet near the cafeteria and the Resident's toes caught on the carpet and the chair slid more than expected. The Resident had her shoes on. The Resident stated, my foot and Staff H immediately backed up the nurse Staff H was there. Staff H reportedly did not observe any redness to the foot. Staff H proceeded with the shower as Resident did not have pain. Staff H checked on the Resident before breakfast. Later that morning Staff H again checked resident who advised there was a little tenderness. Staff H then notified Staff I who reported they would monitor the Resident. The next time Staff H returned to work Staff H was advised the Resident had x-rays and there was no fracture. Staff H could not recall if the shower chair utilized had a platform for the Resident's feet on it or not. Staff H advised he had pulled the Resident backwards in the shower chair because there was no place for her feet. When the incident occurred the shower chairs, were older and Staff H advised the DON they needed replaced and shortly after facility got a new. Had a small, medium and large shower chair at that time. Staff H used the medium chair as it was shorter to the ground. Staff H could not recall if the medium chair had a foot platform on it. On 09/21/23 10:00 AM Staff I Licensed Practical Nurse (LPN) recalled the incident and explained what she could remember. Staff H CNA, was transporting Resident #13 backwards in the shower chair and when they approached the area was congested and Staff H turned the Resident around to better maneuver and her foot came down and got underneath the plastic PVC. The top of her foot just above her toes was scrapped. Reportedly the foot did not bend backwards. The chair sits high. Her feet were not on the floor because they didn't reach the floor. As soon as he realized he stopped quickly. Doesn't remember if the chair had footings or platform. Staff I looked at and noticed a slight rug abrasion on the top of the foot. Resident did not report pain. Staff I checked on her throughout my shift but didn't put anything in notes and called her family. Staff I indicated I know we had a portable x-ray technician come in and x-ray her and then the daughter took her to the ED and there were conflicting reports. Her next shift we were ace wrapping her. Went from sit to stand to Hoyer lift because it was getting to difficult for us as 3 staff. Per Staff I If there is any chance a resident's feet would hit the floor and I would think it would be safer to pull them backwards. 2. The Quarterly MDS assessment dated [DATE] revealed Resident #34 scored 2 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely cognitively impaired. The MDS revealed the resident need extensive assistance with one- person physical assist with bed mobility, dressing, and toilet use. The MDS revealed the resident needed extensive assistance with two plus person physical assist with transfers. The MDS revealed the resident fell once since admission with no injury. The Care Plan revealed a focus area dated 1/16/23 of risk for falls related to the need for assistance and Parkinson's. The interventions dated 1/15/23 documented encouraged use of call light for assistance. The Care Plan lacked documentation for actual falls and interventions after resident's falls on 5/18/23 and 8/22/23. The Fall Risk Evaluation completed on 4/25/23 at 9:52 AM revealed a score of 8. The Incident Report #1111 revealed an unwitnessed fall on 5/18/23 at 11:20 AM with the following information. a. resident's description: resident stated he tried to close his blinds in his room and he tripped over his TV stand and TV and fell onto the floor. b. type of injury: no injury observed at the time of incident. c. mental status- oriented to person, situation, place and time d. no predisposing environmental factors. e. predisposing physiological factors: gait imbalance f. predisposing situation factors: ambulating without assist The Progress Note dated 5/18/2023 at 12:33 PM revealed the nurse and Certified Nurse Aide (CNA) ran down to see what they could find after they heard the yelling and found the resident laying on the floor face down. Resident stated he was not seriously hurt but did have some pain to his Left hip. This nurse did a head to toe assessment and found no major injuries. Vitals were taken and resident placed back into his wheelchair safely. The facility doctor in the building and also evaluated him. Resident stated he hit his head. This nurse called 911 and resident was sent to Emergency Department (ED) at the local hospital. The family, Primary Care Provider (PCP) and facility manger notified of incident. The Fall Risk Evaluation completed on 5/22/23 at 10:28 AM revealed Resident # 34 scored a 10 which indicated high risk for falls. The Fall Risk Evaluation completed on 7/19/23 at 3:33 PM revealed Resident # 34 scored a 8. The Incident report #1135 dated 8/22/23 at 3:00 AM revealed an unwitnessed fall with the following information: a. resident description: See what you did, where's my God Damn blanket? b. assist of 3 to get resident off of floor into WHEELCHAIR and then into bed. c. no injuries observed at time of incident. mental status: orient to person, situation, place and time. d. no predisposing environmental factors e. other predisposing physiological factors (resident agitated when tried to get out of bed by himself) f. predisposing situation factors: ambulating without assist The Progress Note dated 8/22/2023 at 3:43 AM revealed resident put self on floor due to not getting sheet fast enough. Resident laid on right side on floor beside bed. Assist of 3 to get resident off of floor into wheelchair and then into bed. No injuries noted. Resident denies pain/discomfort. Neuros Within normal limits (WNL). The Fall Risk Evaluation completed on 8/22/23 at 3:46 AM revealed Resident # 34 scored a 6. During an observation 09/14/23 10:27 AM Resident # 34 sat in his wheelchair in the dining room and played Bingo with other residents. During an interview on 9/14/23 at 1:10 PM, Staff A, Registered Nurse (RN) queried on the interventions after a fall and she stated most falls were unwitnessed and she went and got vital signs, a head to toe assessment, seen if resident hit their head, did neuros, and got them laid back in bed. She stated they did a risk management, notified the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) and informed the doctor and family and if the resident injured themselves, they went to the hospital and if the resident on a blood thinner they automatically went to the Emergency Department (ED) for a scan. During an interview on 9/20/23 at 10:10 AM, the ADON queried on how management found out about falls and he stated in the morning meeting they discussed risk management and if any falls happened since previous day meeting and what happened and the cause. The ADON asked if they looked at the root analysis for falls and he stated yeah, we discussed the circumstances of the fall and what went on and what time of day and the contributing factors. The ADON asked if they filled out a form or paperwork and he state they didn't use a form. The ADON asked if they looked at interventions and he stated yes, they looked at different interventions. The ADON asked how the staff knew of the new interventions and he stated they were usually done in the meeting and if the interventions would have been put in, they linked to the [NAME] for staff to know them. During an interview on 9/20/23 at 11:25 AM, the DON queried on how she found out about a fall and she stated she staff notified her or the ADON and then every morning they looked at the risk management and seen if they got notified. The DON asked if they did root cause analysis with falls and she stated yeah, they just started doing them and a received a training on them. She stated they did a little investigation and found out what the resident did when they fell and the interventions in place when they fell. During an interview on 9/20/23 at 3:30 PM, the DON queried if a root cause analysis completed and documented for Resident #34 and she stated she would look. No documentation submitted for a root cause analysis for Resident #34 for falls. The Facility Falls - Clinical Protocol Policy dated March 2018 revealed the following information: a. The staff and practitioner will review each resident ' s risk factors for falling and document in the medical record. 1. Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment. b. The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness or hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant). 1. Falls often have medical causes; they are not just a nursing issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS documented extensive assistance with two plus person physical assist. The MDS revealed an indwelling catheter. The MDS lacked documentation of a diagnosis of an indwelling catheter. The MDS revealed the resident received an antibiotic 3 out of 7 days. The Admission/readmission Evaluation dated 7/21/23 at 4:22 PM revealed a urinary catheter not present and Resident # 19 always incontinent. The Admission/readmission Evaluation dated 8/1/23 at 1:24 PM revealed Resident #19 continent of bladder with a 16 French catheter Foley catheter in place. The Care Plan revealed a focus area for a urinary catheter related to a neurogenic bladder dated 8/1/23. The interventions dated 8/1/23 documented catheter care every shift and evaluation for removal of the catheter. The interventions dated 9/11/23 revealed a catheter size 18 French, 10 cc (milliliter) indwelling catheter and position catheter bag and tubing below the bladder and way from the entrance door. The interventions dated 9/11/23 documented monitored, documented and reported signs or symptoms of urinary tract infection as needed such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, pulse, increased temp., urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and eating patterns. The Progress Notes dated 8/7/2023 at 8:23 PM documented resident's Foley found out of bladder at approximately 7:00 PM, disposable underwear soaked with urine, bladder not distended, resident denied any distress. On call Medical Doctor (MD) notified, will watch overnight and MD will see in the morning. The Skilled Progress Note (SPN) dated 8/8/2023 at 2:02 PM revealed resident incontinent and used disposable underwear, Foley catheter found and discontinued yesterday. The Progress Note dated 8/9/2023 at 1:30 PM revealed an 18 French catheter inserted with 5 cc balloon. No return of urine, this nurse flushed catheter with still no return of urine. Resident tolerated well. Advanced Registered Nurse Practitioner (ARNP) notified and continued to monitor and draw complete metabolic panel (CMP) lab. The SPN dated 8/9/2023 at 6:28 PM revealed resident monitored for (cerebral vascular accident (CVA) and left sided weakness. Resident with a poor appetite, didn't eat supper this evening, he wanted to stay in bed due to being tired. Plan of care ongoing. The Orders Noted dated 8/10/2023 at 4:18 AM revealed monitored urine output every shift. The SPN dated 8/10/2023 at 6:12 PM revealed reason for evaluation: Hot Charting (Not related to incident/accident/unusual occurrence)- Resident evaluated for the insertion of a new catheter. Resident with adequate urine outflow at this time, and denies any discomfort in his abdomen. The Progress Note dated 8/11/2023 at 9:44 AM revealed the physician called with new orders for antibiotic Cephalexin to be started and given 4 times a day for 5 days. The EMR (Electronic Medical Record) revealed a diagnosis of retention of urine, unspecified dated 8/1/23 and creation date of 9/11/23. The Physician Order revealed the following orders: a. ordered 8/11/23- Cephalexin Oral Capsule 500 MG (Cephalexin)- Give 500 mg by mouth four times a day for UTI (urinary tract infection) for 5 Days b. ordered 9/11/23- type of Catheter: indwelling; size of catheter: 18 French; Bulb Size: 10 cc; How often to change: Monthly c. ordered 8/11/23- monitor urine output every shift d. ordered 8/1/23- Foley catheter, 18 French, 10 ml. Change monthly and PRN (as needed)- every evening shift every 1 month(s) starting on the 1st for 1 day(s) e. Start Date-08/10/2023 1330 Check Vital Signs every shift for 24 hrs for 1 Day -Start Date- 08/10/2023 1330- Monitor urine output every shift The August TAR (Treatment Administration Record) revealed Resident # 19 produced 0 ml (milliliters of urinary output on the evening shift of 8/9/23 and 5 ml of urinary output on the night shift of 8/9/23. The day shift of 8/10/23 Resident # 19 produced 1700 ml of urinary output. During an observation on 9/11/23 at 1:55 PM, the urinary catheter hooked to the side of the bed and laid on the floor. During an observation on 9/13/23 at 3:24 PM, the catheter bag laid on the floor hooked to the side of the bed. During an observation on 9/14/23 at 3:56 PM, Resident #19 laid in bed and catheter bag laid on the floor, not attached to the bed. During an observation on 9/18/23 at 8:24 AM, Resident # 19 transferred with the sit to stand and during the transfer the urinary catheter bag drug on the floor. During an interview on 9/14/23 at 1:28 PM, Staff Registered Nurse (RN) queried where the catheter bag needed to be located for good drainage and she stated the bag needed hooked to the frame of the bed and when in a wheelchair they needed a dignity bag and hooked to the bottom of the seat lower than the bladder. Staff A asked if the catheter bag can touch the floor and she stated no. During an interview 9/19/23 at 12:31 PM, Staff D, Certified Nurse Aide (CNA) queried on where the catheter bag is placed for proper drainage and she stated normally it hung on the bed frame. Staff D asked if the catheter bag could touch the floor and she stated no, it shouldn't touch the floor. Staff D asked where she placed the catheter when transferring a resident in a sit to stand and she stated the sit to stand had a hook the catheter bag hung it on. Staff D asked how often catheter care completed and she stated she checked it every 2 hours. Staff D asked when she would be concerned with low urine output and she stated normally less than 200 milliliter (ml) wasn't really a lot especially when not emptied out of the catheter and pushed fluids. She stated she told the nurse to make sure everything was okay. During an interview on 9/19/23 at 12:59 PM, Staff C, CNA queried on where the catheter bag needed placed for good drainage and she stated on the bed frame. Staff C asked if the catheter bag could touch the floor and she stated no and she stated when the resident laid far down in bed she hung it on the foot of the bed up high enough but not pulling the tube tight to keep the bag off the floor. She stated she used a two person assist with Resident #19 when she used the sit to stand and had the other CNA hold the catheter bag so it didn't get pulled out. Staff C asked how often catheter care completed and she stated completed it at the beginning and end of every shift and drain the bag in the morning and when she put them in bed and did catheter care as well. Staff C asked what she considered low urinary output and what she did and she stated actually they just had an incident and immediately told my charge nurse and the DON (Director of Nursing). She stated the incident happened with Resident #19 probably 3 or 4 weeks ago. She stated she went into his room and only had 25 ml in the catheter and she told the charge nurse and they called NP (Nurse Practitioner) and she came in and fixed it right up and drained the catheter. Staff C asked if she received report about the resident's urinary output and she stated she didn't get report he didn't have any urine. Staff C asked if urinary output should be reported and she stated yep it was something we should report. During an interview on 9/19/23 at 3:59 PM, Staff B, RN queried on what she considered a change of condition and she stated a major change in vitals, for example a pulse 60 normally and then today 110; a fever, any change in vital signs, pain, weight loss, fall, and look at people and see if something off were what she considered a change of condition. Staff B what she done for a change of condition and she stated if something not right she called the physician or called the ambulance. Staff B asked how nurses reported to each other on things like urinary catheter output and she stated she concerned about Resident #19 when he got here and monitored his urinary output. Staff B stated she informed all the nurse aides he needed 30 ml out an hour. She stated Resident #19 never produced less than 300 ml a shift for her and she gave him fluids every time she seen him. Staff B asked what interventions she did if a resident didn't produce any urinary output for a shift and she stated she would reposition the catheter and looked to see if draining, pushed fluids, palpated the bladder, and called the doctor for an order to flush the catheter or change the catheter. Staff B asked what interventions she did if a resident didn't produce urinary output for 2 shifts and she stated the same interventions and made sure the catheter tube not kinked. Staff B asked if she documented the interventions and she stated yes, she would and no urinary output would be a big concern. During an interview on 9/20/23 at 11:25 AM, the Director of Nursing (DON) queried on what she considered a change of condition and she stated it could be a cough or cold, decrease in Activities of Daily Living (ADL), and anything not in their normal baseline. The DON asked how nurses reported to each other on things like urinary catheter output and the CNA grabbed the amounts at the end of their shift and monitored it with cares and let them know when the resident had little to no output and even they didn't produce more than 300 ml. The DON asked she expected of the nursing staff if a resident didn't produce any urinary output in their catheter in a shift and she stated her as a nurse assessed the person, asked about pain, palpated bladder and advanced the catheter and seen output came out and called the on call or Primary Care Provider (PCP)and let them know the residents didn't produce output. She stated if no output for 8 hours, she called the doctor. Discussed the situation with documentation of Resident #19 of no production of urinary output for 2 shifts and then on the day shift produced 1700 ml and then the following day received orders for a UTI. The DON asked what she expected to happen in this situation and she stated she expected by the second shift for them to call the on call and the PCP to find out what to do next. The DON asked if this situation contributed to the UTI and she stated possibly. The DON stated the ARNP advanced the catheter that morning and informed them the catheter needed to go all the way to the split and then ordered a UA (urinalysis). During an interview on 9/20/23 at 12:38 PM, the DON queried asked if the catheter bag could touch the floor and she stated no, it shouldn't touch floor for any circumstance. The Catheter Care, Urinary Policy dated September 2014 revealed the following information: a. Input/Output 1. Observed the resident ' s urine level for noticeable increases or decreases. If the level stayed the same, or increased rapidly, report it to the physician or supervisor. b. Infection Control 1. Be sure the catheter tubing and drainage bag kept off the floor. c. Complications 1. Observed for other signs and symptoms of urinary tract infection or urinary retention. Reported findings to the physician or supervisor immediately. d. Managing Obstruction 1. If the catheter material contributed to obstruction, notified the physician and changed the catheter if instructed to do so. 2. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. Based on observation, interview, and record review, the facility failed to ensure prompt follow up on urinalysis and culture and sensitivity results, failed to document effectiveness of antibiotics, failed to ensure a catheter drainage bag remained positioned off of the floor, and failed to promptly address decreased urinary output for a resident who had a Foley catheter for three of four residents reviewed for catheter and/urinary tract infections (Resident #19, Resident #93, Resident #143). The facility reported a census of 38 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #143 dated 9/21/22 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Per this assessment, Resident #143 had an indwelling catheter. The Care Plan dated 10/1/22 documented, I have a chronic urinary tract infection which require prophylactic antibiotics. The Intervention dated 12/9/22 documented, give antibiotic therapy as ordered. Monitor for and document side effects and effectiveness. Another intervention also dated 12/9/22 documented, Monitor, document, and report to physician as needed any signs or symptoms of urinary tract infection: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. The Physician Order dated 11/7/22 to 11/9/22 documented, Urinalysis (UA) with Culture and Sensitivity (C& S) one time only for 2 Days. Review of a Bacteriology report from a urine culture, collection date 11/8/22 with final report verified date and time 11/13/22 at 11:43 AM, documented the following: 70-80,000 cfu/ml Escherichia coli Multi drug-resistant organism. Recommended isolation precautions. Extended spectrum Beta lactamase (ESBL) type organism. This organism should be considered resistant to all penicillin's, cephalosporins, and aztreonam. Organism is a Carbapenem-resistant Enterobacteriaceae. Consider using Contact Isolation precautions. Organism is not enzyme producing. > (greater than) 100,000 cfu/ml Pseudomonas aeruginosa. Review of documentation hand written on the bottom of the report revealed, please call me with current weight. Review of the resident's Progress Notes between 11/13/22 and 11/22/22 at 1:26 PM lacked documentation of follow up about the resident's weight, and lacked reference to further actions taken following the Bacteriology report results (dated 11/13/23). The Order Note dated 11/22/22 at 1:26 PM documented, Verbal order received to hold methenamine while on Bactrim and Cipro. Power of Attorney (POA) aware. Medication Administration Record (MAR) updated. The Physician Order, start date 11/23/22, documented, Cipro Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth two times a day for UTI for 7 Days. The Physician Order, start date 11/23/22, documented, Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI for 7 Days. On 9/20/23 during an interview with the Director of Nursing (DON), additional information was requested about what occurred for the resident between 11/13/22 until the antibiotics began. On 9/21/23 at 2:00 PM, the Director of Nursing explained the Nurse Practioner (NP) had been unable to find the culture and sensitivity. The eInteract Transfer Form dated 12/2/22 revealed the resident sent to [Hospital Name Redacted] on 12/2/22 per resident and family request. Blood pressure, pulse, respiration, temperature, and oxygen saturation vital signs for the resident were all dated 11/27/23. Review of an Infectious Disease Note from Hospital Records, date of service 12/3/22, documented, in part the following for Resident #143: presents with chief complaint (CC) of lower abdominal pain and lower back pain. Infectious Disease (ID) is consulted for Urinary Tract Infection (UTI) [Resident #143] was admitted to [Hospital Name Redacted] yesterday through the emergency department (ED) where she presented [illegible words] facility in [City Redacted] w/ (with)UTI concerns. She has been at [City Name]. CC of malodorous urine and abdominal pain worse over the past several days. The Assessment and Plan per Hospital Records documented, in part, the following: ID is consulted for UTI Isolated E faecalis from new Foley urine culture on 12/2 .She recently received treatment of cipro and tmp/smx for full duration for UTI that didn't improve likely because of current culture showing E faecalis. Recommend treatment of E faecalis with vancomycin until the susceptibilities come back, then can likely de-escalate. 2. The admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #93 revealed the resident scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The assessment revealed Resident #93 as frequently incontinent of urine. The MDS documented that the resident had diagnoses including Multiple Sclerosis (MS), and kidney disease. The Care Plan initiated 8/28/23 revised 9/11/23 documented, I have a urinary tract infection. The Intervention dated 9/11/23 documented, give antibiotic therapy as ordered. Monitor for and document side effects and effectiveness. The Nurses Note dated 8/31/23 at 3:36 PM documented, Resident holding arm up complaining of (c/o) starting to have an MS flare-up and asking for Solumedrol. This RN called [Nurse Practitioner Name Redacted] and discussed residents MS and request for solumedrol; [Name Redacted] states that resident needs to follow up with Neurology, [Name Redacted] re; MS and she will not order solumedrol at this time. UA (urinalysis) was ordered stating infections may cause flare up. The Physician Order dated 8/31/23 to 9/2/23 documented, UA with C&S one time only for 2 Days possible MS flare up r/t UTI. Review of Resident #93's Medication Administration Record (MAR) dated August 2023 revealed the following, start date 8/31/23: UA (urinalysis) with C&S (culture and sensitivity) one time only for 2 Days possible MS (multiple sclerosis) flare up r/t (related to) UTI (urinary tract infection). Review of the resident's MAR for September 2023 revealed the order signed as completed on 9/1/23. The Provider Note dated 9/5/23 at 12:00 AM documented, in part, the following for Resident #93: She states that she thinks she is having an MS flare .A UA was obtained and results are pending. The Nurses Note dated 9/7/23 at 10:16 AM documented, UA from 9/1 results received on 9/6, PCP notified. New order for antibiotic. The Provider Note dated 9/7/23 at 12:00 AM documented, in part, the following for Resident #93: seen today for follow-up of urinalysis and urine culture. She had felt that she was having symptoms related to an MS flare. Due to this, a urinalysis was obtained. Urinalysis and culture returned today. The urinalysis showed leukocyte Estrace, negative nitrates. She had 11-20 WBCs (white blood cells) per high-power field. Urine culture was faxed to me today and shows 2 different organisms, a multidrug-resistant E. coli and Streptococcus group . Due to resistance pattern and allergy to cephalosporins, we are limited in what we can use for treatment. Discussed that ertapenem would be a good option that would cover both E. coli and strep. Discussed that this would need to be given intramuscularly. The Physician Order dated 9/8/23 to 9/15/23 revealed, Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium)with directions to inject 1 gram intramuscularly one time a day for UTI for 7 Days. The MAR dated September 2023 for Resident #93 revealed Ertapenem administration daily from 9/8/23 through 9/14/23. Review of Progress Notes for Resident #93 lacked documentation of monitoring for antibiotic effectiveness or side effects. Review of Skilled Evaluation documentation dated 9/8/23 and 9/9/23 for Resident #93 lacked documentation the resident currently under treatment for a UTI, and lacked documentation of signs and symptoms of infection or antibiotic effectiveness. On 9/20/23 at 10:42 AM during an interview with the Assistant Director of Nursing (ADON), the ADON explained a UA would come back in 24 to 48 hours, and the C and S in 3 to 4 days sometimes. When queried if there was a certain timeframe when they would call, the ADON explained usually on labs they called the next day, and with the UA either the next day or the day after. On 9/20/23 at 12:26 PM, the Director of Nursing (DON) acknowledged issues with labs not faxed right away. The DON explained the nurse would need to follow up and make sure got results, then needed to notify the practitioner. The Facility Policy titled Antibiotic Stewardship dated 12/16 documented, 11. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.