**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify the direct root causes of falls for implementation of individualized interventions and update resident care plans with the individualized interventions related to fall safety for 4 (#s 11, 16, 17, and 18) of 6 sampled residents; and failed to ensure staff had the necessary training to provide fall prevention interventions for 1 (#18) of 6 sampled residents. Findings include: 1. Review of a facility reported incident, dated 1/10/23, showed resident #11 had been assisted to the toilet following an episode of incontinence. While the CNA was getting clean clothing, resident #11 self-transferred off the toilet and fell when exiting the bathroom. The facility investigation showed, Fall occurred due to resident being incontinent prior to ambulating to bathroom and resident #11's care plan interventions (were) current. Review of a facility reported incident, dated 1/14/23, showed resident #11 fell when transferring from the resident's recliner to a standing position. Resident #11's legs became weak, and she dropped back to the recliner. Slid from recliner to the floor landing on buttocks. Resident #11 was transported to the emergency room for evaluation of low back pain and weakness. Resident #11 sustained no injuries but was found to have a urinary tract infection and cystitis. The facility investigation showed, Care plan updated.Requiring moderate amount of assist with ADL's d/t recent fall. Care plan current. Review of a facility reported incident, dated 3/2/23, showed resident #11 . was found lying on floor next to wheelchair and bedside table face first with blood coming from head. The nursing assessment showed resident #11 had a 4 cm laceration to her forehead with hematoma formation. Resident #11 was transported to the emergency room for evaluation of her head injury. The facility investigation showed, Resident [#11] was assisted up in wheelchair for scheduled hair appointment and was left in wheelchair unsupervised, fell asleep and fell forward out of chair on to bedside table striking head on edge of bottom stand of bedside table. Care plan updated for staff to not leave resident unsupervised in room in wheelchair all other fall interventions remain current. Review of resident #11's EMR, Hospice Note, effective date 3/6/23, showed: .SNF reported patient had fallen out of her recliner on 3/3/23. Patient was taken to ER for evaluation, sutures placed in forehead laceration. No other concerns noted.Hoyer lifts for transfers . During an interview on 3/28/23 at 2:19 p.m., staff member C said the CNAs referred to the [NAME] (communication tool for nursing staff showing resident's needs, current status, resident information, and interventions). Staff member C said resident #11 had a decline and was no longer walking in her room with her walker. Resident #11 required full assist with transferring, and the staff was using the Hoyer lift (mechanical lift) for all of resident #11's transfers. Staff member C said he was told resident #11 was no longer allowed to be left in her wheelchair, unattended, after her fall on 3/2/23. Resident #11 fell asleep in her wheelchair, and fell forward, out of her chair. Review or resident #11's MDS, dated [DATE], showed resident #11 had a BIMS (Brief Interview Mental Status) score of 13; cognitively intact. Record review of a facility [NAME] document for resident #11, dated 3/28/23, showed: Safety [Resident #11] needs a safe environment .Be sure [Resident #11's] call light is within reach .Encourage [Resident #11] to use bell to call for assistance Ensure [Resident #11] has unobstructed path to the bathroom Ensure [Resident #11] is wearing appropriate footwear when ambulating to mobilizing in w/c .Fall mat at bedside Follow facility fall protocol Frequent visual checks every shift HIGH FALL RISK .Toilet Use: 1 person extensive assist. .Mobility: [Resident #11] is able to walk with one person assistance and use of FWW .Transferring: Limited 1 person assist. Use walker with all transfers Transfers: [Resident #11] requires extensive one person assist with transferring. The [NAME] for resident #11 failed to show intervention changes with resident #11's change in mobility, increased need for assistance when transferring, and need for supervision when in her room and seated in her wheelchair. Record review of resident #11's care plan, dated 1/20/23, showed: Focus: [Resident #11] is at high risk or falls. Fall risk is increased d/t poor mobility, medication use (psychotropic /narcotic), O2 use, Arthritis, HX of past falls prior to admit. Date Initiated: 01/20/2023 .Revision on: 01/23/2023 .Goal: Side effects of: psychoactive drugs, anti-hypertensives etc.; contributing to: gait disturbance, balance disturbance and increasing [Resident #11's] fall risk will be reduced by the review date. Date Initiated: 01/10/2023 .Revision on: 02/02/2023 . Interventions: [Resident #11] needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; bed canes as ordered and personal items within reach. Date Initiated: 01/20/2023 .Revision on: 01/23/23 .[Resident #11] needs to be evaluated for, and supplied appropriate adaptive equipment or devices as needed.Walker used with transfers. Date Initiated: 01/20/2023 .Revision on: 01/23/2023 .[Resident #11] may not be left alone in her room when in wheelchair due to increased fall risk. Date Initiated: 03/02/2023 .Be sure [Resident #11's] call light is within reach and encourage [Resident #11] to use it for assistance as needed. [Resident #11] needs prompt response to all requests for assistance. Date Initiated: 01/20/2023 .Revision on: 01/23/2023 .Ensure [Resident #11] is wearing appropriate footwear when ambulating or mobilizing in w/c.Date Initiated: 01/20/2023 .Revision on: 01/23/23 .Follow facility fall protocol. Date Initiated: 01/20/2023 .Revision on: 01/23/2023 .Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible.Date Initiated: 01/20/2023 .Revision on: 01/23/2023 . Resident #11's care plan did not show individualized interventions that reflected the direct root cause determined for each fall, from the resident's transfers when toileting, and from the recliner. 2. Review of a facility reported incident, dated 8/21/22, showed resident #16 was found on the floor in front of her recliner. She had a lump on her forehead with slight bleeding present, and she had lost a tooth. Resident #16 was unable to give a description of the fall incident. Resident #16 was transferred to the emergency room for an evaluation due to the unwitnessed fall and head injury. Resident #16 received two staples to the laceration on her head, with no other injuries noted. The resident's family declined dental treatment for resident #16's tooth. The facility investigation showed, Suspected that resident was playing with the remote to her electric recliner chair at the time of the fall. The remote has since been removed from her reach .she is frequently encouraged to use call light for assistance. Review of resident #16's EMR Nursing Note, effective date 11/1/22, showed: Today and Sat. res. Hollering out when staff went in to see what res. Needed, she was found sitting on the edge of her recliner between the seat and the foot rest. Res. Demanding that she needed to go to the BR even though she was just taken to the toilet.[sic] Review of resident #16's EMR, Fall Note, effective date 11/9/22, showed: Resident was sitting on the floor by her recliner when the nurse entered her room to respond to the call light. Resident stated that she crawled out of bed to get her candy. Assessed for injuries and initiated neuro checks as this was unwitnessed. Resident slid out of bed to the fall mat positioned on left side and crawled over to her recliner looking for her candy. She then pressed her call light for help. Review of a facility reported incident, dated 11/12/22, showed resident #16 was found in her room lying on her left side, near her recliner. Resident #16 had a 2.5 cm x 4 cm skin tear on her left elbow. Resident #16 said, I fell. The facility investigation showed, No complaints noted from this reported fall, skin tear healing properly, neuro checks remain within normal limits. Staff continue to encourage resident to utilize call light system for assistance. Review of a facility reported incident, dated 11/13/22, showed resident #16 was found lying on her right side, beside her bed on her fall mat. Resident #16 was yelling, I did it again. Resident #16 said she was sitting on the side of her bed and slid off and onto the floor. Assessment did not identify any injury to resident #16. She was assisted back to bed and encouraged to use the call light for assistance. The facility investigation showed, No complaints or injuries reported from this fall, neuro checks remain within normal limits, resident is encouraged to utilize call light for assistance, fall mat continues to be in place. Review of resident #16's EMR, Nursing Note, effective date 11/13/22, showed: Resident was noted to be lying on her right side on top of her fall mat. She stated that she was trying to sit on the edge of her bed and slid off.Earlier in the evening, [resident #16] was very anxious, agitated and combative during cares. Administered Trazodone PRN. Review of a facility reported incident, dated 11/21/22, showed resident #16 stated she was trying to get out of her recliner and slid to the floor. Resident #16 is unable to stand/ambulate on her own. It was determined after assessment, resident #16 had no injuries. She was encouraged to use her call light when she needed assistance. The facility investigation showed, .UA and bloodwork ordered, findings within normal limits. Care plans states that resident is not to be left alone in wheelchair and/or bathroom. It is also care planned that she is not to have remote to her recliner due to increased confusion at times and doesn't utilize it correctly. Fall mat remains in place and resident is visually checked on frequently to ensure that needs are met in a timely manner. [sic] Review of resident #16's EMR, Nursing Note, effective date 11/21/22, showed: Resident was heard to be calling out, Help! When nurse entered resident's room, she was noted to be sitting on the floor between her recliner and bedside table. She was sitting in an upright position with her legs extended in front of her. Review of resident #16's EMR, Alert Charting, effective date 11/22/22, showed: Resident was very anxious most of the night and yelled out nonstop until 0100 (1:00 a.m.). Resident tried crawling out of bed numerous times and finally stopped when she fell asleep. Review of resident #16's EMR, Alert Charting, effective date 11/23/22, showed: Resident is agitated and yelling out. She has been observed trying to get out of bed multiple times this evening. Resident remains a high fall risk. [Resident #16 is impulsive and exhibits very poor safety awareness. Review or resident #16's MDS, dated [DATE], showed resident #16 had a BIMS score of nine; moderately impaired cognition. Review of resident #16's care plan, dated 10/3/22, showed: .Focus: [Resident #16] is at risk for falls r/t Gait/balance problems due to Parkinson's disease and psychotherapeutic drug use: Trazodone and Lexapro.Date Initiated: 10/03/2022 .Revision on: 12/23/2022 .Interventions: Anticipate and meet [resident #16's] needs. Keep call light within her reach. Respond asap. Round on her hourly. Date Initiated: 10/03/22 .Revision on: 12/23/22 Be sure [Resident#16's] call light is within reach and encourage [Resident #16] to use it for assistance as needed. [Resident #16] needs prompt response to all requests for assistance. Date Initiated: 10/3/2022 .Revision on 12/23/2022 .[Resident #16] is safe to ambulate to/from bathroom with FWW, gait belt and 2 person assist per PT eval. Staff to ambulate [Resident # 16] to bathroom as requested by [Resident #16]. Date Initiated: 10/03/2022 .Revision on 12/23/2023 .[Resident #16] needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; fall mat on floor beside bed. Date initiated: 10/03/2022 .Revision on: 12/23/2022 .Follow facility fall protocol. Date Initiated: 10/03/2022 .Revision on: 12/23/2022 .Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible.Date Initiated: 10/03/2022 .Revision on 12/23/2023 .When [Resident #16] is sitting in her recliner staff to unplug chair after placing in preferred position d/t history of fall with independent use of chair remote. Date Initiated: 10/03/2023 .Revision on: 12/23/2022 . Resident #16's care plan failed to show a progression in interventions related to resident #16's change in condition, limited cognition, anticipation of needs, and increase of falls with evaluation of the direct root causes. During an interview on 3/28/23 at 3:48 p.m., staff member A said the root cause of each fall is identified but not really documented through the process. Staff member A said it was identified resident #16 was falling due to her decline (in status) and disease process. Resident #16 had a urinary tract infection and pneumonia that added to her confusion. Staff member A said it (identification root cause and process for the evalation of causes), just was not written down. Staff member A said she was new to the position, and it was a learning process. 3. Review of a facility reported incident, dated 9/12/22, showed resident #18 was being assisted by a CNA at his bedside, who was helping him put his pants on, and the resident lost his balance and slid to the floor. Resident #18 needed verbal ques from staff during cares due to blindness. Resident #18 was wearing no skid socks, and his bed was at a low position. He hit his hand on the bed frame and complained of slight tenderness. The facility investigation showed, Resident with no complaints following fall. Denies pain or discomfort, slight purple bruising on 3rd and 4th digits on right hand, ROM within normal limits, no pain reported when performing ROM, no new orders noted from provider. Resident encouraged to not lean too far over while attempting to assist with pulling pants up. Fall mat remains in place. Review of resident #18's EMR, Fall Note, dated 9/12/22, showed: .Fall Huddle: Continue to provide safe environment with check and changes and proper footwear when standing. Review of a facility reported incident, dated 12/7/22, showed resident #18 said he was . trying to get out of recliner and fell on his butt. There were no injuries noted upon assessment. Resident #18 had gripper socks in place and call light within reach. Resident #18 was encouraged to use his call light for assistance. The facility investigation showed, Resident has no complaints of injuries since most recent fall, no pain reported. Fall mat remains present with gripper socks in place, resident encouraged to utilize call light system for assistance. Review of resident #18's EMR, Fall Note, dated 12/7/22, showed: .Fall Huddle: [not completed] Conclusion: Assessed for injury, No injury noted. Neuro checks initiated.2 per (person) extensive assist onto his feet and ambulated with assist to the restroom.Frequent visual checks in place. Was assisted to dining room for breakfast after assistance to the restroom. [sic] During an observation on 3/28/22 at 2:16 p.m., resident #18 was asleep in his bed, lying on his left side. A fall mat was on the floor next to the bed. The bed was pushed up against the wall with the wall to resident #18's back. The resident's bed side table was placed on the fall mat, centered and placed up against the bed. During an interview on 3/28/22 at 2:19 p.m., staff member C stated the resident's bed is to be lowered to the resident's knee level, and any lower would be considered a restraint. Staff member C said the fall mat is placed next to the resident's bed. Staff member C does not usually place the resident's bedside table on the fall mat next to the bed, because if the resident falls out of bed, the resident could hit the bedside table. Staff member C said staff had been educated to always keep the resident's water and personal items within reach so, sometimes staff will put the bedside table right next to the bed, and place it on the fall mat. During an interview on 3/28/23 at 2:30 p.m., staff member D said the beds are not lowered to their lowest level for fall interventions, because it would be considered a restraint. Staff member D also said the bedside table is placed on the fall mat so the resident can have their water and remote nearby. The resident needs to be able to reach their water, so the water needs to be placed right next to the bed. Staff member D said if a resident has an unwitnessed fall, the resident would be assessed, and it would be determined if they have an injury. For any resident fall, fall paperwork would be filled out, a fall huddle would be done, and the needed people would be notified of the fall. Staff member D said the DON and ADON would meet and do an investigation on the possible cause(s) of the fall and come up with intervention ideas to prevent it from happening again. Staff member D said the information was then shared with the staff. Staff member D said fall interventions for each resident would be found on the care plan. During an interview on 3/28/23 at 2:53 p.m., staff member B said beds need to be lowered to their lowest setting, and a fall mat placed next to the resident's bed. The bedside table should not be next to the bed because, if the resident should fall, they could hit the table and it would cause an injury. Staff member B was not aware of the bed being lowered below the resident's knees to be considered a restraint. Staff member B said, We definitely need to do some re-education on some items. During an interview on 3/28/23 at 3:48 p.m., staff member A said beds are to be lowered to the lowest position. Staff member A said, I think there needs to be some conversations and some training to clear the confusion. We have had difficulty with staff attending the annual inservice and most staff will just sign off on the policies. Staff member A said staff education was identified as an issue and was one of the process improvement projects. The facility was staffed with a lot of travelers, and they were finding the travelers were challenging the CNA testing. Staff member A said some travel staff would arrive and have no idea what they were being asked to do, shave a resident, or provide peri care. Review or resident #18's MDS, dated [DATE], showed resident #18 had a BIMS score of six; severely impaired cognition. Record review of a facility [NAME] document for resident #18, dated 3/28/23, showed: Safety Be sure [Resident #18's] call light is within reach and encourage [Resident #18] to use it for assistance as needed. [Resident #18] needs prompt response to all requests for assistance Encourage [Resident #18] to use bell to call for assistance Ensure [Resident #18] has unobstructed path to the bathroom. Requires assistance from staff to toilet[Resident #18] will attempt to ambulate and transfer to toilet on own, history of falls Ensure [Resident #18] is wearing appropriate footwear .Fall mat at bedside Follow facility fall protocol Frequent visual checks Q shift .Toileting .Toilet use- 1-2 person extensive assist .Transferring Transfer: [Resident #18] requires extensive 1-2 person assist from with transferring. Use gait belt, provide verbal and directional cues during transfers due to sight deficit Transferring- 1-2 person extensive assist .Mobility Bed mobility- extensive 2 person assist BED MOBILITY: [Resident #18] requires extensive 1-2 person assist, cuing, and weight bearing assistance, to turn and reposition. Use verbal and directional cues during cares d/t blindness .Dressing Dressing- Extensive 1-2 person extensive assist. Review of resident #18's care plan, dated 2/3/23, showed: .[Resident #18] is a high risk for falls r/t blindness in both eyes, poor mobility, unsteady gait and history of falls prior to NH admit. Date Initiated: 02/02/2023 .Revision on: 02/06/2023 .Anticipate and meet [Resident #18's] needs. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Be sure [Resident #18's] call light is within reach and encourage [Resident #18] to use it for assistance as needed. [Resident #18] needs prompt response to all requests for assistance. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .[Resident #18] needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night and personal items within reach. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Ensure [Resident #18] is wearing appropriate footwear such as non-skid socks or shoes when ambulating or mobilizing in w/c. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Fall mat at bedside. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Follow facility fall protocol. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Frequent visual checks Q shift. Date Initiated: 02/03/2023 .Revision on: 02/06/2023 .Place walker within reach at all times when in room. Review of resident #18's care plan failed to show a progression in interventions related to resident #18's falls with dressing, to include with staff assistance, and when safely exiting the recliner, and the plan did not show what individualized resident needs were identified, in an attempt to show staff what needs may be anticipated for the resident for his safety. 4. Review of a facility reported incident, dated 8/18/22, showed resident #17 was found on her knees next to the bed, on the floor. Staff had repositioned resident #17 on her back just prior to the incident. No injuries occurred with the fall. The facility investigation showed, It is suspected the resident used bed cane to pull herself out of bed. Resident unable to verbalize what happened. Resident #17's POA asked the facility to use bed rails and was informed that the facility considers the use of bed rails as a restraint. The facility had concerns for resident safety, and the resident pulling herself out of bed. It was decided to remove the bed cane. Review of resident #17's EMR, Fall Note, dated 8/18/22, showed: Description: at 0130 (1:30 a.m.) resident found on knees, wedge between legs, holding onto bed rail on ground. Resident was repositioned at 0120 (1:20 a.m.) facing east/doorway. Resident pulled self out of bed. No injuries noted. .Fall Huddle: Resident uses side rail to pull self around in bed. Resident last several nocs (nights) chewing at gown/blanket wide awake .Conclusion: Resident seems anxious at night and prefers to chew/grab blanket or nightgown. The facility failed to identify the root causes of the falls or risks associated with them, and document these in the fall documentation. Review of a facility reported incident, dated 8/24/22, showed resident #17 was found on the floor next to her bed. Resident #17 was checked on by the nurse 30 minutes prior to the incident, and resident #17 was lying in bed. The fall mat was in place by the bed, but resident #17's head was resting against the wall. Resident #17 identified her head hurt but no other injuries were found. Resident #17's POA declined resident transport to the ER for an evaluation. The facility investigation showed that resident #17 was unable to verbalize what had happened, and it was suspected she had rolled out of bed. The POA and physician did not want the bed cane placed back on the bed. The fall mat was present, and the staff were encouraged to perform more frequent visual checks. Review of resident #17's EMR, Fall Note, dated 8/24/22, showed: Description: Resident was found by CNA at 2140 (9:40 p.m.) on the floor next to her bed with most of her body on the mat, but her head wedged up against the wall in her room. Resident was on her abdomen. Resident was facing East and lying on her (L) [left] side the last time this narrator saw her which was approximately 30 minutes before incident. .Fall Huddle: Completed. Suggested by CNA and other CNA's as well that resident have the cane bar replaced in her bed. Conclusion: Resident is nervous and afraid. She is lying on her (R) [right] side at this time facing the window. She does calm down when she is talked to quietly. During an observation and interview on 3/28/23 at 11:47 a.m., NF1 said resident #17 had a few falls when she first arrived at the facility. Resident #17 was not ambulatory, was reliant on staff for full assistance, and the Hoyer lift was used for transfers. NF1 said he was in the facility almost daily to sit with the resident, and to assist her as needed. Resident #17 was seated in a chair with the Hoyer lift sheet beneath her. She would make eye contact with her husband and with this surveyor. Resident #17 was nonverbal. NF1 reminded resident #17 to chew and swallow the chocolate she was eating. Resident #17 would stare at him but provided no response. Review of resident #17's MDS, dated [DATE], showed resident #16 had no BIMS score. Record review of a facility [NAME] document for resident #17, dated 3/28/23, showed: Safety Be sure [Resident #17's] call light is within reach and encourage [Resident #17] to use it for assistance as needed. [Resident #17] needs prompt response to all requests for assistance Fall mat: Staff to place fall mat at bedside when in bed Follow facility fall protocol Frequent Visual check Q shift .Transferring Transfers: [Resident #17] is dependent on staff for transfers. MANDATORY HOYER FOR ALL TRANSFERS. .Communication Anticipate and meet [Resident #17's] needs. [Resident #17] is aphasic and cannot verbalize needs. Review of resident #17's care plan, dated 2/13/23, showed: .Focus: [Resident #17] is a high risk for falls r/t poor mobility, cognitive impairment (frontal temporal dementia), and psychotropic medication use (trazodone) Date Initiated: 2/13/23 .Interventions: .Anticipate and meet [Resident #17's] needs. [Resident #17] is aphasic and cannot verbalize needs. Date Initiated: 2/13/23 .Be sure [Resident #17's] call light is within reach and encourage [Resident #17] to use it for assistance as needed. [Resident #17] needs prompt response to all requests for assistance. Date Initiated: 2/13/23 .Fall mat at bedside. Date Initiated 2/13/23 .Perform hourly visual checks each shift. Date Initiated 2/13/23 .Review information on past falls and attempt to determine cause of falls, Record possible root causes. Alter remove any potential causes if possible.Date Initiated: 2/13/23 .Staff to assist [Resident #17] to change position while in bed alternating form Rt (right) side to back at least every 2 hours while in bed. Make sure heels are elevated and pillow is placed between knees to reduce pressure. Date Initiated: 2/13/23 . Review of resident #17's care plan failed to show a progression in interventions related to resident #17's falls or increased anxiety, specific identification of needs to anticipate, barriers to her cognition, or how this may relate to her understanding of encouragement with use of interventions. During an interview on 3/28/23 at 2:53 p.m., staff member B said when a resident has an unwitnessed fall, they look at different things to determine how the fall occurred. The staff look at the environment for hazards, check charting to see when the resident was last rounded and checked, and check for any underlying factors that may have caused the fall. Staff member B gave an example of resident #17's falls. Resident #17 had a cane next to her bed and would grab the cane and pull herself out of the bed. The facility removed the cane and resident #17 has had no further falls. Staff member B was unable to answer why resident #17 was using the cane to pull herself out of bed. Staff member B said they may need to have more discussion and look further into why residents are getting up and falling. Staff member B said the CNA staff had a [NAME] they referenced for each resident that showed the individualized fall interventions that were in place. During an interview on 3/28/23 at 1:10 p.m., staff member A said all falls were reviewed at a weekly UR (Utilization Review) committee meeting. Safety committee meets quarterly at the hospital, and falls were also discussed. Staff member A said the facility had previously had a process improvement project for falls but it had not been identified as an issue recently, and the facility may need to initiate it again. Staff member A said the facility policy was to go completely restraint free. This took away a lot of the tools or options the facility used for fall prevention. Most of the falls were identified as falling out of bed and onto a fall mat, or from a recliner while getting up without assistance, and not using or remembering to use the call light. The facility no longer used scooped mattresses or any type of sensor alarm. Staff member A said the staff do frequent rounding, and the four P's program (pain, positioning, potty, and possessions). Staff member A said the facility was limited on what could be done. She educates the staff on the four P's and to check the resident frequently, not just every hour. Staff member A said the facility does not perform safety evaluations on residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development and worsening of a pressure injury, document wound progression, notify the appropriate physician, and failed to prevent a new pressure injury for 1 (#11) of 2 sampled residents. Findings include: During an observation on 8/16/22 at 12:10 p.m., resident #11 was asleep in his recliner. Both his feet had on thin (1/2 inch) foam heel protectors. His heels appeared to have pressure on them from the recliner foot rest. Staff member B was asked to view his feet on the recliner, and she stated the resident should have had pillows under his feet to float his heels to prevent pressure. She stated the resident's pressure injury started as a blister on his right heel. She was not sure of the root cause of the pressure injury. Staff member B stated the facility had been using the blue foam heel protectors for ten years. Review of resident #11's Nursing notes showed: 5/17/22 - Blister on right heel pressure area was popped this morning sometime. Orders wrote for daily Biatain dressing change, blue foam booties when in bed. 5/17/22 - Right heel has an open area the heel has a large blister like area with a black center. Not soft to the touch. Heels floated. 5/19/22 - Dressing changed on right heel, having a large amount of drainage. 5/24/22 - OT alerted this nurse that resident needed dressing to wound on right heel changed as it was actively bleeding through his slipper sock after walking to the bathroom with OT. The wound measured 3 x 3 cm circular area of eschar type tissue located in center area of heal wound. Provider alerted to changes in wound, PT eval for wound care ordered. 7/19/22 - When changing dressing on right heel, a foul odor was noted and has been noted, slightly for the last couple of days. ADON and charge nurse aware and will have (NP) look at it when he comes on Thursday. 7/21/22 - The NP was here to evaluate resident #11's right heel. The treatment was changed to a piece of promogran and cover with Allevyn. Review of resident #11's Wound Assessment, dated 5/17/22, showed a right heel pressure injury with no measurements, staging (severity), or description. Review of resident #11's Wound Assessment, dated 5/24/22, showed right heel pressure injury, it was Unstagable, with no measurements or description. Review of resident #11's Physical Therapy Note, dated 5/24/22, showed an area of adhered black eschar in the center of the wound that is 20 x 15 mm. Wound is not staged as quality of tissue under eschar is unknown. No further wound care needed by PT at this time. Review of resident #11's Wound Assessment, dated 5/31/22, showed a heel wound 4 x 7 cm with eschar noted in the center of the wound. Review of resident #11's Wound Assessment, dated 6/23/22, showed a right heel wound measuring 4 x 4 x .2 with no description or staging. Continue with daily dressing changes. Review of resident #11's Wound assessment, dated 7/11/22 showed a right heel wound measuring 4.5 x 4.5 x. 2 cm. Eschar noted on lower end of wound beefy red in the middle. Review of resident #11's Physical Therapy Wound Care Evaluation, dated 8/5/22, showed the right heel wound was not improving and may be getting worse as patient has LE edema and tends to dig his heel into the ground. PT is ordered for wound care. The description showed moderate serosanguineous drainage, and a hard reddish black eschar in the center of the wound. An [NAME] boot (protective boot) was prescribed as the treatment. Review of resident #11's Physical Therapy Wound progress note, dated 8/9/22, showed the wound depth was pinpoint at 10 o'clock with tunneling over to 2 o'clock. Wound has 40% red granulation tissue and 60% yellow slough. During an observation and interview on 8/16/22 at 12:50 p.m., staff member E completed wound care on resident's right heel. She stated the wound had improved since the use of the [NAME] boot. She stated the blue foam heel protectors were better than nothing even though they were old. A new intact blister on the left medial heel was also noted, measuring 3 cm x 2.7 cm. Staff member B did not know the cause of the new pressure injury. During an interview on 8/17/22 at 9:05 a.m., staff member B stated it probably should have been the charge nurse's responsibility to notify the NP that resident #11's pressure injury was not healing. She did not know why the NP was not informed sooner than 8 weeks after the wound was identified. Staff member B stated the CNAs' are responsible for daily skin checks for all residents during care. Skin checks prior to the identification of the right heel pressure area were not available because the electronic system saved them for 30 days only.