**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 20 sampled residents, that based on the comprehensive assessment of a resident the facility did not provide care, consistent with professional standards of practice, to prevent pressure ulcers. In addition, a resident with pressure ulcers did not receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident had no treatment orders when a new pressure ulcer was identified. The same resident did not have wound measurements of her heel wound since November 2023 and December 2023 for two additional wounds. The heel wound increased in size and there was no re-assessment of the treatment orders. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, moderate protein-calorie malnutrition, open wound left foot, major depressive disorder and cutaneous abscess of left lower limb. On 2/5/24 at 1:52 PM, an interview was conducted with resident 21. Resident 21 stated she thought she had sores on her body. Resident 21 stated she did not have pain from her sores. Resident 21 stated her sores were kept covered with dressings. On 2/5/24 at 4:10 PM, the facility provided the CMS-802 form. Resident 21 was listed to have a stage 2 and a stage 4 pressure ulcer. Resident 21's medical record was reviewed 2/5/24 through 2/7/24. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 21 had a Brief Interview of Mental Status (BIMS) score of 7 which suggested severe cognitive impairment. The MDS further revealed resident 21 had 1 or more unhealed stage 1 or higher pressure ulcer, three stage 3 pressure ulcers and one stage 4 pressure ulcer. The MDS revealed skin and ulcer treatments were pressure reducing device for bed, turning/repositioning program, nutrition or hydration interventions to manage skin problems, pressure ulcer care, application of nonsurgical dressing other than to feet, applications of ointments/medications other than to feet, and application of dressing to feet. A care plan dated 1/19/21 and revised on 12/4/23 revealed, The resident has potential impairment to skin integrity of the peri area/buttocks r/t [related to] contact dermatitis d/t [due to] incontinence. Scratches & picks at her skin. Multiple wounds at various stages of healing. Stage 4 L heel with h/o [history of] Osteomyelitis. The goal was The resident will maintain or develop clean and intact skin by the review date. Interventions included the following: a. Antibiotics per Medical Doctor (MD) order was initiated on 6/1/23. b. Encourage good nutrition and hydration in order to promote healthier skin was initiated on 1/19/21 and revised on 3/17/21. c. Follow facility protocols for treatment of injury was initiated on 1/19/21 and revised on 3/17/21. d. Keep skin clean and dry. Use lotion on dry skin was initiated on 1/19/21 and revised on 3/17/21. e. The resident needs pressure relief pad to protect the skin while IN BED was initiated on 1/19/21 and revised on 3/17/21. f. The resident needs pressure relief pad to protect the skin while up IN CHAIR was initiated on 1/19/21 and revised on 3/17/21. g. Wound care per MD order was initiated on 5/13/21. A physician's order dated 6/25/21 revealed, left lateral calf Q3D [every 3 days] Clean skin with wound cleanser or normal saline and gauze. If open: Skin prep where drsg will cover. May use santyl on slough, or xenaderm, calcium alginate, Cover with Adhesive foam drsg. Change every 3-7 days, until healed. D/C [discontinue] when healed. one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday]. Another physician's order dated 6/25/21 revealed, (right distal and lateral calf) Q3D Clean skin with wound cleanser or normal saline and gauze. If open: Skin prep where drsg will cover. May use santyl on slough, or xenaderm, calcium alginate, Cover with Adhesive foam drsg. Change every 3-7 days, until healed. D/C when healed. one time a day every Mon, Wed, Fri. A physician's order dated 6/25/21 revealed, Assess wound (right calf distal and medial)for: (A. Increased redness, B. Increased drainage, C. warm to the touch, D. Bleeding, E. Dressing intact, F. Draining thru dressing, G. Need to change the drsg, H. No Drainage, I. Increased pain, J. Notify physician, K. Notify family every shift). A physician's order dated 6/25/21 revealed, Assess wound left lateral calf for: (A. Increased redness, B. Increased drainage, C. warm to the touch, D. Bleeding, E. Dressing intact, F. Draining thru dressing, G. Need to change the drsg, H. No Drainage, I. Increased pain, J. Notify physician, K. Notify family every shift). A physician's order dated 1/15/24 revealed, Juven Oral Packet (Nutritional Supplements) Give 1 packet by mouth every morning and at bedtime related to MODERATE PROTEINCALORIE MALNUTRITION .; UNSPECIFIED OPEN WOUND, LEFT FOOT, SEQUELA. A physician's order dated 1/15/24 revealed, Premier Protein 11oz two times a day related to UNSPECIFIED PROTEINCALORIE MALNUTRITION. A physician's order dated 6/8/21 revealed, Med Pass 2.0 after meals (4OZ) for added nutrition. According to a hospital Discharge summary dated [DATE], resident 21 had pressure ulcers of bilateral lower extremities with an open wound to right foot and lower leg. A nursing progress note dated 9/9/23 at 4:34 PM, revealed .The wounds on both feet had saturated dressings on them. I removed the dressings, legs are extremely dry, scaly and a lot of dead skin. I washed her legs and patted them dry. I cleansed the wounds on the left shin and heel. The sore on the left shin measures 2.5 cm X 2.5cm in diameter. It is beefy red and good blood flow. I placed a poly memfoam pad and covered with a dressing. The left heel has improved, it measures 5.0cm (L) x 5.5cm (W); has beefy red wound bed and good blood flow. I placed a silver poly mem foam pad and covered with a heel dressing. The right foot, the 5th toe had a lot of drainage and the area on the bottom of food [sic]has several open areas. I cleansed it with wound cleanser, patted it dry. I put silver poly mem between 4th and 5th toe; applied poly mem around the base of the toe and bottom of foot and covered with a foam dressing and tape. Will have DON assess the foot and give us suggestions for wound treatment. Booties put on both feet. A nursing progress note dated 11/14/23 at 4:38 PM, revealed .Pillows for support, booties on both feet. She was medicated for pain with scheduled and PRN [as needed] pain medication with good effect. Her appetite has been fair today. She was given additional snacks and fluids. She drank the nutritional supplements. I changed the dressing on her left heel again today, cleansed with NS [normal saline] and patted dry, polymem foam applied to wound bed and foam dressing covering the wound. The wound measured 4.5cm [centimeter] (L) [length] x [by] 4.0cm (W)[width]. Minimal drainage noted. A nursing progress note dated 12/10/23 at 4:35 PM, revealed .Resident had personal care given and repositioned in bed. Pillows for support and booties on her feet. She has been assisted with her meals. Medicated for pain with scheduled and PRN pain medication with good effect. I changed the dressings on the R [right] foot. The two are ason [sic] the outer bottom of the foot are almost healed. I put a dressing on them for protection. The sore on the bottom of the R small toe was cleansed and patted dry. It measured approximately 2.0 cm(L) x 1.5 cm (w). I put a piece of polymem foam in the wound bed and covered it with a dressing. I changed the dressing on the left shin. The wound was cleansed with NS [normal saline] and patted dry. I put a small piece of poly mem foam and covered with a foam dressing. It measured 2.0 cm (L) X 2.0 cm (W). The left heel dressing was changed. I cleansed the area with NS and patted it dry, applied poly mem foam to the wound bed and covered it with a foam dressing. The wound is filling in from the outer perimeters. She had a medium loose BM this shift. Had 450cc output. A physician's visit dated 12/12/23, revealed resident 21 had chronic wounds on her legs. The physician documented, I am actually pretty surprised at home [sic] much improvement we have seen in the wounds. She had a very big gaping wound on her left heel that was infected months ago and that is actually close down quite a bit to where she just has about a 4 cm [centimeters] wound which is pretty crazy. I think care center is been doing a good job changing her dressing and monitoring her wounds as she has made some steady improvement. We will continue with these interventions hopefully get theses healed up all the way and then at that point preventions again to be the biggest key. A nursing skilled charting assessment dated [DATE], revealed resident did not weight bear, had decreased sensation, required assistance with bed mobility, and required assistance with eating. The assessment further revealed Resident is bed-ridden; requires all care done by staff. The Skin/Wound section revealed, Old hematomas on arms from scratching; lotion applied; Nystatin to abdominal fold. Wounds in various stages of healing on both legs; feet and dressing changed as per treatment orders. On 2/6/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a Certified Nursing Assistant (CNA) noticed a wound on a resident, the nurse was notified, and then the nurse would assess the wound and notify the physician to obtain orders to treat the wound. The DON stated resident 21 had wounds on the back of her legs and a wound on her left shin for about 3 to 4 years. The DON stated she had a pressure sore on her left heel and a wound under her right pinky toe. The DON stated the wound under the pinky toe was the size of the tip of a pen. The DON stated resident 21 was on hospice under wounds on her hips had healed. The DON stated she dressed resident 21's pinky toe wound on 2/3/24. The DON stated she used a foam dressing and it was to be changed weekly or when saturated. The DON stated that CNA reported to the nurse if a dressing was saturated. The DON stated there were no physician's orders for the pinky toe wound. The DON stated that nurses would call and ask her what dressings to use. The DON stated she Failed on documentation. The DON stated she did not have measurements on resident 21's wounds for a long time. On 2/6/24 at 1:23 PM, a follow-up interview was conducted with the DON. The DON stated there were no physician orders for the wound below the pinky toe. The DON stated she changed all of resident 21's dressings on Saturday night. The DON stated she did not know when resident 21's wound below the pinky toe opened. The DON stated she did not have a policy and procedure for wounds. On 2/6/24 at 1:29 PM, a phone interview was conducted with Physician 1's Medical Assistant (MA). The MA stated she talked to Physician 1 and Physician 1 stated he was not aware of a new wound on resident 21. The MA stated Physician 1 stated that he was aware that resident 21 had chronic wounds. The MA stated that staff usually texted Physician 1 regarding new skin issues and then Physician 1 provided treatment orders. On 2/6/24 at 1:43 PM, an interview was conducted with CNA 1. CNA 1 stated when a resident was bathed she looked at their skin. CNA 1 stated if there were skin issues, she reported to the nurse to have the nurse look at the resident. CNA 1 stated resident 21 had a left heel wound, left calf wound, and something on her right foot. CNA 1 stated resident 21 had her feet and legs in booties so they were floating and not touching the bed. CNA 1 stated resident 21 had a body pillow that they used to rotate her every 2 hours. CNA 1 stated resident 21 had an air mattress. An observation was made of resident 21's legs and feet with CNA 1. Resident 21 was observed in bed with a sheet over her feet and legs. CNA 1 removed the sheet and there were booties on each foot. There was a bandage on the left shin. CNA 1 lifted resident 21's left leg and there was a bandage on the left heel. CNA 1 lifted resident 21's right foot and there was a bandage on the bottom of the foot below the pinky toe. The bandages were dated 2/3/24. On 2/6/24 at 10:56 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the nurses changed wound dressings when the dressing was soiled or leaked through. RN 1 stated that the DON changed bandages when she did wound rounds. RN 1 stated that the DON completed measurements on wounds. On 2/7/24 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the DON had changed resident 21's wound dressings on Tuesday night 2/6/24. On 2/7/24 at 8:09 AM, an interview was conducted with the DON. The DON stated she changed resident 21's dressings on Tuesday night 2/6/24. The DON stated she measured the wounds because the measurements had not been done for a while. The DON stated she took pictures and talked to Physician 1 to obtain wound orders. The DON stated resident 21's wounds were healing and did not know when the pinky toe wound opened up. The DON stated she was going to be measuring wounds on Tuesdays so she changed the wound dressings orders to Tuesday and Friday. The DON stated that she had not been tracking measurements of wounds. The DON provided the measurements obtained on 2/6/24. The left heel measured at 8.5 cm (L) x 6.5 cm (W) x 0.1 cm depth (D). The left shin was 2.8 cm (L) x 2.5 cm (W) x 0.1 cm (D). The wound below the right pinky toe on the ball of foot was 0.4 cm (L) x 0.4 cm (W) x 0.1 cm (D). The note dated 12/10/23 was the last note of measurements. The left shin measurements were 2.0 cm (L) X 2.0 cm (W). The sore on the bottom of the R small toe measured approximately 2.0 cm(L) x 1.5 cm (w). The previous measurement for the left heel were dated 11/14/23. The measurements were 4.5cm (L) x 4.0cm (W). It should be noted the left heel increased in size with no changes to the wound dressing orders since 6/25/21. On 2/12/24 at 11:32 AM, a phone interview was conducted with the DON. The DON stated she was not aware that resident 21's heel wound was larger than the previous measurement in November 2023. The DON stated there were no changes to the treatment orders since June 2021 for the heel and shin wound. The DON did not provide information for why treatments were not changed or different treatments tried since June 2021. On 2/13/24 at 8:30 AM, a phone interview was conducted with the DON. The DON stated on the left heel wound she measured the picture and not the outline of the wound on 2/6/24. The DON stated the wound was actually 4.9 cm (L) by 5 cm (W). The DON confirmed the previous measurements were completed in November 2023 for the left heel wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 3 was admitted to the facility on [DATE] with diagnoses that included dementia, opioid dependence, asthma, restless leg syndrome, depression, anxiety, cognitive impairment, orthopedic aftercare, diabetes mellitus, muscle weakness, history of falls, low back pain, cerebral atherosclerosis, chronic kidney disease, hypothyroidism, hypertension, Parkinson's disease and a history of traumatic fracture On 12/2/19 at 1:01 PM an interview was conducted with resident 3. Resident 3 stated that she had fallen a few times. On 12/3/19 the resident's medical record was reviewed. Event reports revealed that resident 3 had falls on the following dates: 2/21/19, 6/21/19, 7/1/19, 7/4/19, 8/2/19, 9/10/19, 9/20/19, 9/30/19, 10/5/19, 11/7/19. Records revealed: a. The Event Report Worksheet (ERW) from 2/21/19 revealed that [resident 3] was found sitting on the floor. Resident 3 stated that resident 3 tried to sit on a chair and ended up on the floor. The ERW revealed that resident 3 was assessed for injuries and vital signs were taken. No injuries were noted. No intervention was listed on the form. b.The ERW from 6/21/19 revealed that [resident 3] was found on the ground with the chair on the side of her tipped over. Resident 3 stated that she was trying to pick up a puzzle piece. The ERW revealed that resident 3 was assessed for injuries, assisted resident 3 up and vital signs were taken. No injuries were noted. No intervention was listed on the form. c. The ERW from 7/1/19 revealed that the nurse down to room to take [resident 3] her medication. Upon entering room [resident 3] was found sitting on the floor in front of her recliner. Resident 3 stated that she was trying to out something out of her dresser, when she lost her balance as she was turning. Resident 3 then grabbed hold of the foot board of her bed to help guide herself to the floor, where she landed on her butt. The ERW revealed that resident 3 was assessed for injuries. Range of motion performed and vital signs taken. Resident 3 had a skin tear 1 centimeter (cm) x 3.5 cm. Area cleansed with Normal saline, edges approximated well, skin prep to wound and sterri-strips applied. Foam dressing in place over sterri-strip. d. The ERW from 7/4/19 revealed that [resident 3] was found sitting on the floor. Resident 3 stated 'I tried to get up and my legs are swollen. I lost my balance and slide down front of recliner. The ERW revealed that a head to toe assessment was done and the [resident 3] was taken to the bathroom. No injuries were noted and Resident 3 was advised to call and accept more help even though she doesn't like to. No intervention was listed on the form. e.The ERW from 8/2/19 revealed that the nurse found resident 3 was found sitting on the bathroom floor next to the door. Resident 3 stated that she was finishing her shower; she slid down the wall to her bottom. Resident 3 was assessed for injuries and vital signs were done. Resident 3 had a skin tear on her left wrist. No intervention was listed on the form other than resident 3 was reminded to call every time and not do anything on her own. f. The ERW from 9/10/19 revealed that staff was helping resident 3's roommate when [resident 3] yelled for help. When staff went to resident 3's side of the room the found resident 3 sitting in the closet. Resident 3 stated I was getting my clothes in my closet and I lost my balance. I am shaky. Resident 3 was assessed for injuries and vital signs were taken. No injuries were noted. Staff checked her bed alarm which resident 3 had removed from her bed. No intervention was listed on the form. g. The ERW from 9/20/19 revealed that resident 3 was found on the floor in front of her chair. Resident 3 stated that she was trying to get up from her wheel chair and slide to close to the edge. Resident 3 was assessed for injuries, pain, range of motion, staff identified if there was a problem. Resident 3 had a skin tear about 2.5 cm by 1 cm. Staff asked resident 3 to call for help when resident 3 needed it. No intervention was listed on the form. h. The ERW from 9/30/19 revealed that resident 3 was found sitting on the floor between her wheel chair and the recliner in resident 3's room. Resident 3 stated she was transferring from the wheel chair to the recliner when the wheel chair rolled back. Resident 3 stated that she forgot to set the brakes. Resident 3 was assessed for injuries and vital signs were taken. No injuries were noted. Staff placed bed alarm back on chair. i. The ERW from 10/5/19 revealed that resident 3 was trying to set a paper on her table when she lost her balance and leaned against the wall after losing her balance. Resident 3 stated that she didn't fall but, slid to the floor. CNA was in the room because she heard the bed alarm but, didn't make it in time to stop resident 3 from sliding to the floor. Resident 3 was assessed for injuries, assisted to her wheel chair, and vital signs were taken. Resident 3 had a 1.5 cm x1.5 cm skin tear on her elbow the skin tear was cleaned with normal saline and sterri-strips and dressing applied. Reminded resident 3 to let staff help her with transfers and ambulation. Resident 3 stated she was standing working on the puzzle when she turned to sit down and missed the wheel chair. Resident 3 was assessed for injuries. No injuries were noted j. The ERW from 11/7/19 revealed that resident 3 was found crawling on the floor by the desk down the hall. Resident stated she stood up to fix her puzzle turned around to sit down and missed the wheel chair. Staff reminded resident to call for help when resident 3 needed it and to lock the wheel chair breaks Care plan stated the following for falls on 6/21/19, 7/1/19, 7/4/19, 9/10/19, 10/5/19, 6/11/19: Focus: The resident had has an actual call (date) with (Specify) poor balance, poor communications/comprehension, and unsteady gait. Goals: The resident will resume usual activities without further incident through the review date. (OVERDUE) Intervention/Tasks: Continue interventions on the at-risk plan. For no apparent acute injury, determine and address causative factors of the fall Monitor/document/report (As need) PRNx 72hours to MD for (Signs and symptoms) s/sx: Pain, bruises, change in mental status. New onset: Confusion, sleepiness, inability to maintain posture, agitation. There are no assigned tasks. The Care plan addressed the fall after resident 3 had fallen but, once the care plan had been developed it was never reviewed or revised to prevent future falls. The care plan has not been updated since 7/6/19. 4. Resident 8 was admitted to the facility on [DATE] with diagnoses that included dementia, altered mental status, acute kidney failure, thyrotoxicosis, hearing loss, hypertension, and history of falls. On 12/3/19 the resident's medical record was reviewed. Event reports revealed that resident 8 had falls on the following dates: 6/11/19, 8/9/19, 8/30/19. Record reveals: a. The Event Report Worksheet (ERW) from 6/11/19 revealed that resident 8 was found sitting on the floor by the doorway to the bathroom with her brief around her ankles. Resident stated that she slipped and fell. The ERW revealed that resident 8 was assesses for injuries, vital signs were taken, range of motion was assessed. Resident was helped to the bathroom and was given a shower. No injuries were noted and no interventions were listed. b. The ERW from 8/9/19 revealed that call light was going off when CNA went to answer the call light resident 8 CNA found resident 8 on the floor. Resident 8 stated that she missed the toilet. The ERW revealed that resident 8 was assisted to the toilet and then bed, vital signs taken. No injuries noted. Intervention was to remind her to use the call light. c. The ERW from 8/30/19 revealed that resident 8 had picked up a box of the floor and threw it which caused resident 8 to loss her balance and fall. Due to dementia resident was unable to explain the fall. The ERW revealed that resident 8 was assessed for injury, vitals were taken. No injuries and interventions were noted. d. The ERW from 11/21/19 revealed that resident 8 was picking eggs up off the floor and slipped. Resident 8 landed on her buttocks. Resident 8 stated that she was picking up eggs off the floor and that resident 8s wrist hurt. The ERW revealed that resident 8 was assisted up, vital signs were taken, and range of motion was checked. Resident 8 was placed on the couch to rest. No injury or interventions were noted. Care plan initiated on 6/5/19 and revised on 7/28/19 stated the following: Focus: The resident 8 has limited physical mobility, history of falls and forgets her walker. Goals: The resident will maintain current level of mobility, able to walk with four wheel walker and supervision. Interventions: Ambulation: The resident 8 is able to walk with four wheel walker but requires supervision and reminders to use her walker. Resident 8 has had three falls sense the care plan was updated. On 12/3/19 at 2:47 PM CNAs 1, CNA 2, and CNA 3 during a simultanous interview stated that bed and wheel chair alarms were placed on resident 3's wheel chair and bed when resident 3 fell the first time. On 12/3/19 at 3:22 PM Registered nurse (RN) 1 during an interview stated that nurses are supposed to update the care plan after each fall. On 12/3/19 at 3:25 PM, the Assistant Director of Nursing (ADON) during an interview stated that after a resident has a fall the nurse on shift should update the care plan. A review of the care plans showed that the falls were documented but no interventions were added to prevent future falls. 2. Resident 6 was admitted to the facility on [DATE] with diagnoses which included Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, acute kidney failure, retention of urine, dementia with behavioral disturbance, weakness, repeated falls and anxiety disorder. On 12/2/19 at 3:35 PM resident 6 was observed sitting in the wheelchair in the common area in his unit. On 12/3/19 at 1:30 PM resident 6's medical record was reviewed. Record revealed that resident 6 had falls on following dates: 6/8/19, 6/9/19, 7/30/19, 7/31/19, 8/7/19, 9/6/19, 10/1/19, 10/3/19, 10/8/19, 10/16/19, 10/21/19, 10/27/19 and 10/28/19. Records revealed following: a. The Incident Report from 6/8/19 revealed that, Bed alarm went off. CNA's (Certified Nursing Assistant) down to room, upon entering found resident sitting on the floor leaning against his bed. Resident unable to give description. This incident report revealed that resident did not sustain an injury. He was assessed and his vital signs (VS) were taken. There was no intervention listed on the form. b. The Incident Report from 6/9/19 revealed that, Call light sounding and staff ran (sic) to room and [Resident 6] was 1/2 lying and 1/2 sitting on the floor. Resident unable to give description. This incident report revealed that resident did not sustain injury. Resident 6's VS were taken, head to toe assessment completed and he was put back in bed. There was no intervention listed on the form. c. The Event Report Worksheet from 7/30/19 revealed that resident 6 had fall at 6:30 AM. Per this report, aide walked by room and found him [Resident 6] on floor. Bed-alarm on and working, but his arm [Resident 6's] was on it so did not go off.; [Resident 6] unable to explain, was assessed and assisted up. The intervention listed on the report was,Unable to prevent him sliding out of bed at his will. The report revealed that Care Plan was updated and Red star was placed on residents door. d. The Event Report Worksheet from 7/31/19 revealed that resident 6 had fall at 6:00 AM. Per this report, heard bell go off, found him [Resident 6] on floor next to his bed same as yesterday.; [Resident 6] unable to explain, was assessed, help up into bed, V/S. The intervention listed was, ?Fall cushion pad next to bed?. The report revealed that Care plan was updated and Red star was placed on residents door. e. The Event Report Worksheet from 8/7/19 revealed that resident 6 had fall at 6:30 AM. Per this report, pt found on floor at side of bed.; Dementia-pt unable to verbalize occurrence. The intervention listed was, staff assisted pt up and ambulate to BR (bedroom). Assessed for injury. VS taken. PT up and ambulated to south dining area for observation. f. The Event Report Worksheet from 9/6/19 revealed that resident 6 had fall at 8:15 AM. Per this report,[Resident 6] was sitting on his butt and back against bed when I got there. While waiting for help resident rolled onto left side.; [Resident 6] confused. The intervention listed was,assessed for injuries, ROM (range of motions) and gait, assisted back on bed, V/S taken, resident showered, notified all parties. The report revealed that Care Plan was updated and Red star placed on residents door. g. The Event Report Worksheet from 10/1/19 revealed that resident 6 had fall at 7:15 AM. Per this report, Bed alarm went off, found him {Resident 6] wrapped in his blankets sliding to floor-assisted him to floor. No injuries. The intervention listed was, assisted up onto bed, toileted.; Unable to prevent, keep monitoring. The report revealed that Red star was placed on residents door. h. The Event Report Worksheet from 10/3/19 revealed that resident 6 had fall at 4:00 PM. Per this report, [Resident 6] was found just inside staff breakroom on the floor. Per this report, [Resident 6] sustained 1 centimeter (cm) lac (laceration) on r(right) back of head. The intervention listed was, assess for injury, obtain vitals. Ensure that he has a chair alarm at all times. The report revealed that Care Plan was updated and Red star was placed on residents door. i. The Event Report Worksheet from 10/8/19 revealed that resident 6 had fall at 8:00 AM. Per this report, [Resident 6] was found on the floor of his room next to his bed kneeling. The intervention listed was, assess for injury, obtain vitals. Frequent monitoring in the morning. The report revealed that Red star was placed on residents door. j. The Event Report Worksheet from 1016/19 revealed that resident 6 had fall at 9:20 PM. Per this report, Alarm sounding, [Resident 6] sitting on floor (upright) next to bed with right hand on side rail. Resident 6's description of the incident was was, I was waiting for you, I guess. The intervention listed was, Skin assessment, VS, given fluids, tucked back into bed with warm blanket. The report revealed that Red star was placed on residents door. k. The Event Report Worksheet from 10/21/19 revealed that resident 6 had fall at 3:50 AM. Per this report, [Resident 6] was on the side of bed with arms and torso mostly on left side, legs on floor also on left side. There was no interventions listed. l. The Event Report Worksheet from 10/27/19 revealed that resident 6 had fall at 1:00 AM. Per this report, no witness to the fall. Post fall witness CNA's found pt. on floor with head resting on bed. The intervention listed was, assess, V/S, motor function. Need to find how resident fall so fast. m. The Event report Worksheet from 10/28/19 revealed that resident 6 had fall at 8:45 PM. Per this report, when light and alarm went off and the time we got there, pt. is already with body on the floor almost in sitting position. The intervention listed was, assess, notify DON, family and DR. Continue to identify how to prevent this from happening. The report revealed that Care Plan was updated. Records revealed Care Plan dated 5/24/19 with following focus:The resident is at HIGH risk for falls r/t (related to) severe weakness, recent acute illness. The goal listed was, The resident would be free of falls through the review date. The interventions listed were, The resident uses bed & chair electronic alarm. Ensure the device is in place as needed.; Pt. evaluate and treat as ordered or PRN (as needed).;Low bed to decrease risk of injury.; Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.; Anticipate and meet the resident's needs. Record revealed Care Plan dated 10/29/19 with following focus:[Resident 6] frequently slides out of bed. Family, staff and MD are aware of this problem. The goal listed was, [Resident 6] will not sustain injury from sliding out of bed. The interventions listed were, If [Resident 6] slides out of low bed, help him of the floor, and write a progress note about the incident. No need to notify family/ MD or to complete the facility fall protocol.; Utilize low bed and leave it locked at lowest position when [Resident 6] is in bed. Records revealed that the facility created separate care plans for each resident 6's fall. The goal listed for all falls was, The resident will resume usual activities without further incident through the review date. The interventions listed for all falls were, Continue interventions on the at-risk plan.; For no apparent acute injury, determine and address causative factors of the fall.; Monitor/document/report PRN x 72h (hours) to MD for s/sx: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. An interview with the Director of Nursing (DON) was conducted on 12/03/19 at 3:52 PM. She stated that resident 6 had few falls and they were all when he slid of the bed. The DON stated that they moved resident 6 closer to nursing station, lowered his bed to low position, implemented bed and chair alarm usage. The DON stated that resident 6 was stationed close to nursing station during the day so the staff kept an eye on him. The DON stated that resident 6 was confused and not able to explain how the falls occurred or to follow education/ directions provided. The DON stated that she did not have time to put all interventions on resident 6's care plan. Based on observation, interview, and record review it was determined, for 4 of 25 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, three residents had multiple falls with inadequate interventions in an attempt to decrease the number of falls. The findings for resident 47 were found to have occurred at a harm level. Resident identifiers: 3, 6, 8, and 47. Findings include: 1. Resident 47 was admitted to the facility on [DATE] with diagnoses that included weakness, disorientation, dementia, a history of falls, paranoid personality disorder, heart failure, and generalized anxiety disorder. Resident 47's medical record was reviewed on 12/3/19. An admission Minimum Data Set (MDS) assessment indicated that resident 47 had a short term and long term memory problem, with a Brief Interview for Mental Status (BIMS) of 6. Incident reports were reviewed for resident 47 and revealed the following: a. On 1/9/19, resident 47 was standing in front of her sink. The staff member with her turned away, the resident fell on her buttocks - hurting her lower back. Interventions listed to prevent further incidents included bed tender (bed alarm) remains in place - pt (patient) checks started - standby assist - pt teaching. b. On 3/13/19, resident 47 was found on the floor crawling on her hands and feet. The report indicated that resident 47 had left her walker in her bedroom. The reports also indicated that Resident has dementia and is confused, needs verbal reminders and cueing. There were no interventions listed on the incident report to prevent further falls. c. On 4/18/19, staff found resident 47 on her butt in the south dining room. No interventions were listed to prevent further incidents. [Note: A replacement care plan was initiated in a new electronic medical records system on 5/22/19. This care plan included interventions to prevent falls such as anticipate and meet the resident's needs, make sure the call light is in reach, follow the facility protocol for falls, and ensure the bed alarm is in place.] d. On 6/12/19, resident 47 went to sit on couch after walking back from breakfast. She couldn't pick her feet up (shuffles while walking) and lost footing when she hit the sticky spill. Interventions listed to prevent further incidents included cleaning up the spill. The resident's care plan was updated to include continue interventions, monitor for 72 hours, and determine the cause of falls. e. On 7/13/19, resident 47 was found laying on lt (left) side in front of couch in south dining area. No interventions were listed to prevent further incidents. Resident 47's care plan was not updated to include additional interventions to prevent further incidents. f. On 7/17/19, resident 47 was found on the floor with back against the closet [and] walker near by . Resident stated she got herself off the toilet and went [down] onto her butt. Interventions listed to prevent further incidents included Do not leave resident unattended in BR (bathroom); supervision when ambulating. Resident 47's care plan was not updated to include additional interventions to prevent further incidents. g. On 8/29/19, resident 47 was found laying on the floor in front of her closet, her chair cushion along with her alarm was on the floor with her. Interventions listed to prevent further incidents included Resident in view of staff when not in bed. Resident 47's care plan was not updated to include additional interventions to prevent further incidents. h. On 10/17/19, staff was assisting resident in transferring from chair to standing position down in dining room. Staff then placed resident's walker in front of her with gaitbelt in place. Staff proceeded with transferring resident. Staff asked resident to stand still while she handed another resident her walker so she could leave dinning (sic) room as well. Resident standing stated ok in response to staff's instructions. Staff then removed hand from standing resident's gaitbelt while standing next to resident. Staff handed other resident her walker when staff heard resident say Oh! Was unable to stop resident from falling . Resident hit head L (left) hip L elbow forearm on wall. Interventions listed to prevent further incidents included training on ambulating one person at a time [with] gait belt [and] walker. Nurses notes for resident 47 on 10/17/19 indicated the following: CNA (Certified Nursing Assistant) reported at 0900 (9:00 AM), staff was assisting resident in transferring from chair to a standing position down in dining room resident. Staff then placed resident's walker in front of her with the gait belt in place staff proceeded with transferring the resident. Staff asked resident to stand still while she handed other resident her walker so she could leave the dining room as well. Resident standing stated ok in response to staff's instructions. Staff then removed hand from standing residents gait belt while standing right next to standing resident handed other resident walker when staff hear OH! from standing resident staff was unable to stop standing residents fall. Standing resident fell landing on left hip left arm hitting her head on dining room wall. Staff notified nurse. I was giving a resident her AM medications, I told them to leave her until I got down there to assess her. I went down as soon as I was done giving the medications to another resident. [Resident 47] was very anxious and in pain. V/S taken . Pain at a 10. I had her raise her arms and she did so, I had her grip my hands and she did. DON (Director of Nursing) got there and I asked resident to move her legs and she stated I can't they hurt. No bruising noted on the back of her head at this time. She does have a light bruise showing up on her left elbow. We assisted resident into a wheelchair. She would not bear any weight on her left leg. DON notified [name of physician]. all documents were sent with resident and staff to take to [name of local hospital] for medical evaluation and x-ray of Left hip d/t (due to) pain. A review of the emergency department notes from the hospital revealed that resident 47 sustained a left hip fracture, and the family declined surgical intervention. The resident returned to the facility the same day. On 12/3/19 at 2:30 PM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that on 10/17/19, she was assisting resident 47 out of the dining room, while holding on to a gait belt around resident 47's waist. CNA 4 stated that resident 47 was standing up, and was holding on to her walker. CNA 4 stated that just as we got to the corner of the table, another resident asked for help. CNA 4 stated that she spoke with the other resident while holding on to resident 47's gait belt. CNA 4 then changed her statement, saying that she actually let go of resident 47's gait belt, but did have one hand on resident 47's walker. CNA 4 stated that resident 47 dropped to the ground suddenly with no warning. CNA 4 stated that she later received training not to let go of a resident's gait belt. CNA 4 stated that despite resident 47's previous falls while ambulating with a walker, resident 47 was doing better on the walker that day. CNA 4 stated that resident 47 would use a wheelchair or a walker based on how cognitive she was and how well she stood on a particular day. On 12/4/19 at 8:09 AM, an interview was conducted with CNA 5. CNA 5 stated that she witnessed resident 47's fall on 10/17/19. CNA 5 stated that CNA 4 came to the dining room to assist resident 47 back to the resident's room. CNA 5 stated that CNA 4 was assisting resident 47 by holding on to the resident's gait belt as resident 47 ambulated with her walker. CNA 5 stated that CNA 4 let go of the gait belt and turned her back on the resident to assist another resident. CNA 5 stated that resident 47 lost her balance and tipped over to the left, hitting the wall and sliding down onto the floor. CNA 5 stated that resident 47 did not just fall all of a sudden. On 12/3/19 at 3:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after resident 47's fall on 10/17/19, staff had been inserviced on the proper use of gait belts.