**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse by failing to perform background check screenings on current employees, having direct contact with residents. This failure has the potential to affect all 79 residents residing in the facility. This failure resulted in R4 who has a diagnosis of Bipolar Disorder, Depression and Anxiety, experience verbal abuse from a staff member and feeling fear, anger, ashamed and not wanting to come out of room until 8/21/2025. Findings include: R4's Care Plan, not dated, does not address abuse in R4's active care plan.R4's Minimum Data Set (MDS), dated [DATE] and 7/29/2025, documents that R4 is cognitively intact.R4's Serious Injury Incident and Communicable Disease Report, dated 6/20/2025, documents that R4 reported that a few weeks ago, kitchen staff member used inappropriate language towards him.R4's Serious Injury Incident and Communicable Disease Report, dated 6/20/2025, documents that on 6/20/25 V1, Administrator, R4 stated that a few weeks ago, kitchen staff member used inappropriate language towards R4. V10, Cook, immediately suspended per protocol. It continues to document that (R4) was initially interviewed and stated that he was in the dining room rear the kitchen doors when (V10), who was in the kitchen, used inappropriate language towards him. (R4) could not recall the date but stated it was a few weeks ago. (R4) could not recall if anyone else heard the language. On 6/24/25 (R4) was interviewed again. (R4) still could not recall if anyone else heard the language or when the incident happened. When asked if anything else was said during the conversation with (V10), (R4) could not recall anything. When asked if he could have misunderstood what (V10) said because of the noise that is in the kitchen, he agreed that it was possible. In conclusion, the facility was unable to substantiate the allegation of verbal abuse. Due to the noisy environment of the kitchen, this was a misunderstanding of words spoken.On 9/9/2025 at 1:10 PM R4 stated that this occurred sometime ago around April, May or June. R4 stated that R4 was in the dining room. R4 stated that he complained about his food being cold and (V10) said that (V10) was going to whoop R4's ass. R4 stated that he had so many feelings from anger to fear. R4 stated that he was startled, embarrassed and ashamed being talked to that way. R4 stated that he feared he would have to fight V10. R4 stated that he would if he had to but why should he have to. R4 stated that it's hard to be on pins and needles every day. R4 stated that he didn't want to come out of his room while V10 worked at the facility. R4 stated that when he learned that V10 had gotten fired he felt relieved and safe. R4 stated that the facility did ask questions about the incident, but they don't believe him. R4 stated that he knows what he heard and how he felt.On 9/9/2025 at 11:22AM V1 stated that she was made aware of the allegation. V1 stated that V10 was suspended immediately. V1 stated that an investigation was started. V1 stated that the conclusion of the investigation was that the allegation could not be substantiated due to no witnesses and R4 could not verify for sure that this was said. V1 stated that the allegation was unsubstantiated. V1 stated that V10 was let go from the facility on 8/21/2025 for safety reasons.On 9/9/2025 at 11:25 AM V10's background checks were requestedOn 9/10/2025 at 11:42 AM V1 stated that she could not find V10's background checks and could not verify if or when they were completed.On 9/11/2025 at approximately 1:30 PM V1 stated that she is responsible for the background checks. V1 stated that she does not have a business office person at this time, and she is ultimately responsible. V1 stated that the background checks are to be completed upon hire and should have been completed.The facility's Prevention and Prohibition Program, dated 6/1/2025, documents that to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero­ tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment. Or misappropriation of resident property. Procedure II. Screening A. The Facility does not knowingly employ anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment or misappropriation or has been convicted of abusing, neglecting, or mistreating other people.

Based on interview, observation and record review the facility failed to ensure timely assesment for continuity of care for 1 of 3 residents (R1) reviewed for continuity of care in the sample of 3. This failure resulted in R1 with known epilepsy with seiziures, not receiving anti seizure medications for 4 days and being sent out for emergency treatment and had a seizure. Findings include: R1's Facesheet undated documents an admission date of 11/12/2024 and pertinent medical diagnoses of Epilepsy, unspecified., not intractable without status Epilepticus, Localization-related (Focal) (Partial) Symptomatic Epilepsy and Epileptic Syndromes with Complex Partial Seizures, Not Intractable Without Status Epilepticus, Major Depressive Disorder, Single Episode, Unspecified and Unspecified. Unspecified Atrial Fibrillation. R1's Physician Order Summary (POS) dated March 2025 documents R1's pertinent medications as Lacosamide 100 milligrams (mg) twice a day (Epilepsy), Fluoxetine 10 milligrams (mg) daily (Major Depressive Disorder), Metoprolol 1 tablet every 12 hours (Primary Hypertension) Amlodipine 10 milligrams (mg) (Unspecified Atrial Fibrillation), Levetiracetam 1000 milligrams (mg) twice a day all with a Start Date of 1/22/25 and Hold date from 3/14/25 to 3/17/25, Tradjenta 5 milligrams (mg) (Type 2 Diabetes Mellitus) 1 tablet daily Start Date of 2/5/25 and Hold date from 3/14/25 to 3/17/25. R1's Electronic Medication Administration Record (eMAR) dated March 2025 documents R1's 8:00 PM medications were held on 3/14/25, 3/15/25 and 3/16/25 for both 8:00 AM & 8:00 PM doses. The 8:00 AM dose on 3/17/25 was held. On 3/12/25 at 9:51 PM Nurse's Progress notes documents R1 was requesting her new pill. V17 Licensed Practical Nurse documents that R1 was overheard talking to her daughter (V5) about the new pill that she takes 3 times /day and then question as to if the daughter will bring it to her. V17 Licensed Practical Nurse documents that without an order for medication the medication could not be administered. On 3/14/25 at 1:51 PM Nurse's Progress notes documents (V4) Social Service Director addressed the daughter in regards to her giving resident medication while she is on a Leave of Absence (LOA) with her. (V5) daughter was stated that she hasn't given resident any medications , but she did display a bottle of Antibiotics that was suppose to be given from a local pharmacy. The directions for administration were 1 tablet twice a day and there was a total of 10 pills given, but she (R1) only had 4 pills left. (V5) repeatedly stated that she had not given resident (R1) any medications. On 3/14/2025 an email from V7 Nurse Practitioner to V2, Diretor of Nursing, documented an order to hold the medication of R1 due to a report from facility nursing staff that it was a possibility that R1 was being double or tripled dose by V5, her daughter. On 3/20/25 at 9:37 AM V16 Licensed Practical Nurse ( LPN) stated she was the one that was passing medications to R1 when she requested her new pill. As she (V16) was explaining to her that she did not have a new pill. R1 kept repeating that she had a new pill. R1 called her daughter (V5) and the conversation between the two of them was (R1) telling (V5) her daughter that she was not being given the new pill. (V5) R1's daughter came to the facility with a bottle of medicine and wanted it to be given to her mother. (V5) was advised that we could not give the medicine and we would need to obtain an order for the medication. On 3/20/25 at 11:31 AM V17 Nurse Practitioner stated she was on vacation for 2 weeks and V7 Psychiatric Nurse Practitioner (NP) was covering for her. V17 stated she was aware that (R1) was being followed by specialists but do not have any interactions with the specialists. V17 stated she was unaware of the labs ordered by the nephrologist. When she returned from vacation she did have an email from V7 advising that there was a possibility that R1 was receiving double dosages of a medicine thought to be an antibiotic. The move to hold the medication was based on not having any information as to why R1 was on any medication besides what was prescribed. V17 stated the expectation was for the specialist to contact us if they have any concerns. If she had any concerns she would contact them. On 3/20/25 at 11:43 AM V7 Psychiatric Nurse Practitioner stated she was not the regular provider for (R1). The nurse practitioner (V17) was on vacation and she (V7) was just covering for (V17). V7 stated she went with the information that was provided from the staff. The staff assumed (R1) was receiving double or triple doses of some type of medication. She (V7) did not know what the medication was and the staff did not specify the medication because they did not know. What was reported was (V5) the daughter was providing the medication to her mother (R1). On 3/20/25 at 12:25 V4 Social Service Director stated when (V5) daughter of R1 returned her mother (R1) to the facility she (V5) did not bring the medication or share that her mother was on a prescribed medication. We became aware of some medication only after the mother (R1) began asking about her new pill. On 3/20/25 at 4:20 PM V2 Director of Nursing stated we did what we were supposed to do. The staff continued to give prescribed medication until able to contact a provider. The order was via email dated 3/14/25 to Hold medications and to monitor (R1). Staff continued to monitor R1 until she was sent to the emergency room 3/17/25. R1's medical records from a local hospital dated 3/17/25 documents residents seizure medications were stopped few days ago per the order of nursing home staff after they had negative interactions with (V5) patient's daughter . While in Triage patient had a tonic seizure lasting less than 1 minute. Patient was postictal and had a nasal trumpet inserted. On 3/21/25 at 10:26 AM V22 Medical Director stated the Nurse Practitioner's should be having contact with the specialist. On 3/21/25 at 2:30 PM V26 pharmacist stated the nurse practitioner dropped the ball, the nurse practitioner should have reviewed the medication before 3 days. It is definitely concerning because Lacosamide has a half-life of 13 hrs and Keppra has a half life of 6-8 hrs. Those meds are significant, while overdosing might be a concern, review of the medication and further assessment was warranted. Do not feel the facility was at fault, the problem lies with the nurse practitioner as a provider not reviewing or assessing the resident sooner. The facility did not have a policy on Continuity of Care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with a diagnosis of epilepsy/seizures received their anti-convulsant medications as ordered by the physician for 1 of 3 (R14) residents reviewed for medications in the sample of 3. This failure resulted in R14 missing 10 doses of his anti-convulsant medication and requiring evaluation and treatment in the emergency room (ER) following seizure activity. Findings include: R14's facesheet dated 4/29/25 documents his diagnosis to include epilepsy, unspecified, intractable, without status epilepticus and localization-related (focal) (partial) symptomatic epilepsy, epileptic syndromes with complex partial seizures, intractable, without status epilepticus, and other seizures. R14's care plan dated 4/29/25 documents The resident has a seizure disorder. Interventions for this care plan include give seizure medications as ordered by doctor. Monitor/document side effects and effectiveness. R14's medication administration record (MAR) dated 3/1/25-3/31/25 documents R14 did not receive his oxcarbazepine (anti-seizure medication) oral tablet 600 mg (milligrams) two tablets at 6:00 PM on 3/29/25 and at 8:00 AM on 3/30/25. R14's progress note dated 3/29/25 at 5:05 PM documents: orders-administration note oxcarbazepine oral table 600 mg give 2 tablets by mouth two times a day for epilepsy-awaiting med. R14's progress note dated 3/30/25 at 8:47 AM documents his oxcarbazepine was not available and reorder awaiting pharmacy. R14's [DATE]/30/35 at 8:39 AM documents R14's lacosamide oral tablet (anti-seizure medication) 100 mg give one tablet by mouth two times a day for epilepsy was not available, reordered awaiting pharmacy. R14's MAR dated 4/1/25-4/30/25 documents he did not receive his lacosamide on 4/3/25 (PM dose) 4/6/25 (PM dose) 4/7/25 (PM dose) and 4/8/25 (AM and PM dose). R14's Controlled Drug Receipt/Record/Disposition Form dated 3/22/25 documents he ran out of his lacosamide 100 mg tablets on 4/5/25 after PM dose. R14's Drug Receipt/Record/Disposition Form dated 4/9/25 documents he did not receive his next dose of lacosamide until 4/9/25 at 8:30 AM. There is no documentation on these count sheets of R14 receiving AM doses of lacosamide on 4/6/25 or 4/7/25 AM doses. R14's progress note date 4/1/25 at 4:45 PM documents Seizure activity noted in bed. Clonic episode lasting 2.5 minutes. Emesis noted. Resident placed in recovery position until seizure completion. EMS called. Post ictal phase noted with pupils dilated to 6. Walking around room without purpose and combative with staff. Unable to answer questions or respond appropriately. VS: 98.2, 88, 22, 131/74, and 95% on room air. No signs of pain or injury. Sent to (local hospital) for evaluation and treatment. On 4/29/25 at 12:50 PM V6 Nurse Practitioner stated she was first notified by staff to refill R14's lacosamide on 4/8/25. V6 stated she was reviewing R14's information from 4/6/25 and 4/7/25 and was not notified, but she would not know if staff reached out to another provider. V6 stated yes, it would be significant for R14 to receive anti-seizure medication since R14 has had seizures since the age of 9 and R14 is a difficult case and he needs to take his anti-seizure medications as ordered. On 4/29/25 at 1:50 PM V7 Pharmacy [NAME] Lead stated pharmacy was notified by fax on 4/8/25 at 7:21 PM requesting refill on R14's lacosamide. On 4/29/25 at 1:55 PM V8 Pharmacist stated lacosmide has a half-life of 13 hours, and R14 would have been sub therapeutic after 24-30 hours. V8 stated lacosamide was filled by pharmacy on 4/8/25 and started on 4/9/25. V8 stated R14 was sub therapeutic on 4/8/25 and 4/9/25 and was therapeutic by 4/10/25. V8 stated R14 was not therapeutic for 1 day and would not recommend doing this again. V8 stated R14 dodged a bullet that R14 did not have a seizure during that time. V8 stated he would consider this a significant medication error. V8 stated it is never recommended that a resident with a history of seizures misses any of their medication. On 4/29/25 at 1:22 PM V9 Registered Nurse (RN) stated she does not recall R14 ever being out of lacosamide, and if she pulled from pharmacies emergency stock of medication it would have been documented on a sheet. V9 stated she does not remember ever pulling a lacosamide for R14. V9 stated she is unsure of where she got R14's lacosamide doses on 4/625 and 4/27/25. On 4/29/25 at 2:20 PM V2 Director of Nursing (DON) stated as part of the plan of corrections she was auditing residents who took seizure medications. V2 stated if she saw a missed medication she would educate the nurse, and then should have documented everything in the resident's electronic medical record (EMR). V2 stated she went back and had to put late entries in some of the resident's progress notes related to missed medications. V2 acknowledged R14's controlled drug receipt/record/disposition form that stated R14 ran out of lacosamide after 4/5/25 PM and did not resume until 4/9/25 AM. V2 stated she has no idea how V9 RN would have gotten and documented lacosamide since the medication was not in the facility. V2 stated V11 Medical Doctor (MD) was called on 4/8/25 letting him know R14 needed a signed script for lacosamide. V2 unable to provide documentation of why R14's lacosamide was not refilled and available on 4/6/25. On 4/30/25 at 10:48 AM V2 stated lacosamide is not included in the emergency kit. The facilities policy revised 7/18/18 Emergency Pharmacy and Emergency Kits documents, Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved Emergency Medication kit/box or by special order from MAC Rx. MAC Rx supplies emergency medications including emergency drugs, antibiotics, controlled substances, and products for infusion in limited quantities in compliance with applicable state and federal regulations to serve the immediate clinical needs of the resident. The facilities policy undated policy Receiving Controlled Substances documents Procedures: H. Controlled substances are reordered when a four (4) day supply remains to allow for transmitted of the required written prescription to the pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide adequate supervision and progressive devices to prevent falls for one of thirteen residents (R2) reviewed for falls in the sample of 50. This failure resulted in R2 falling from the toilet when left unsupervised and sustained multiple rib fractures and laceration to his head. Findings include: R2's Cumulative Diagnosis Log undated documents diagnoses Paranoid Schizophrenia, anemia, hypothyroidism, hyperlipidemia, gastroesophageal reflux disease, vitamin D deficiency, anxiety, repeated falls, and major depressive disorder. R2's Fall Risk assessment dated [DATE] documents, a score of 20. 10 or more points = High Risk Score. R2's MDS, (Minimum Data Set), dated 09/13/23 documents, a BIMS, (Brief Interview of Mental Status), score of 15 out of 15. The MDS documents, that R2 requires limited assistance of one person for bed mobility, transfer, locomotion on unit, locomotion off unit, and personal hygiene. The MDS documents, that R2 requires extensive assistance of one person for toilet use. The MDS documents, that R2 is not steady, only able to stabilize with staff assistance. R2's Care Plan dated 03/07/19 documents, Has risk factors for falls: balance, assistive devices, needs assist for transfer, vision problems, medical conditions, meds, poor safety awareness, and behaviors put resident at risk. R2's Interventions: 02/26/23 r/t, (related to), fall, staff to check on frequently when in bed. 03/06/23 r/t fall, staff to utilize pressure alarm for bed and wheelchair. 08/17/23 r/t fall, educated resident and staff to ensure that w/c, (wheelchair) is locked during all transfers. 09/06/23 r/t fall, instructed to use call light and wait for assistance. R2's Nurses Note dated 11/06/22 at 6:27 AM documents Resident has a fall this morning he stated that his pain was 5 he was found lying on his left side. Stated that his left hip hurts. Vitals were B/P, (blood pressure), 120/58, P (pulse) 88, R, (respiration), 21, T, (temperature), 97.1. He stated that he was trying to put his tablet in his drawer. R2's Quality Improvement Review Note dated 11/07/22 at 9:00 AM documents, QA, (quality assurance), committee met to review fall on 11/07/22, resident attempting to put item in drawer, encourage to ask for assistance. No note written for fall on 11/22/22. On 11/16/23 at 3:00 PM, V2, DON, (Director of Nursing), stated that she could find a nurses note about any fall on 11/22/22. R2's Quality Improvement Review Note dated 11/22/22 at 9:15 AM documents, QA committee met to review fall with no injury noted. Resident was attempting to sit in w/c and missed, resulting in him sitting on floor in front of wheelchair. Encouraged resident to use call light and wait on staff assistance. Medical workup obtained. R2's Nurses Note dated 02/26/23 at 8:40 AM documents, This nurse passing HS meds when resident reported to nurse having severe pain 8/10 to left rib area. This nurse asked what happen to area, he reports he had a fall at 3a (SIC) while attempting to go to restroom in bedroom. Resident was able to recall event and states prior to falling he felt dizzy. Resident states he fell on the toilet landing on his left side and hitting head on the wall. Resident states he did not report incident sooner because he was scared and thought Jesus would heal him sooner. This nurse does not see any visible injuries. VS, (vital signs), WNL, (within normal limits). ROM, (range of motion), WNL. Lying in bed currently. Schedule PP, (pain pill), given. Call light in reach. Will follow up with NP, (Nurse Practitioner), for orders to send to ER, (Emergency Room). R2's Nurses Note dated 02/27/23 at 2:00 AM documents, Nurse from (local hospital) called states resident is being d/c, (discharge), with multiple rib fracture and sternum mass on liver, no transportation to get resident back to facility, phone call to (V1) administrator to make her aware of situation, states (psychosocial program) can pick him up from hospital @ 7a (SIC) when they arrive. R2's Quality Improvement Review Note dated 02/27/23 at 10:30 AM documents, QA committee met r/t fall reported on 02/26/23. Resident reported to staff nurse that he fell overnight trying to go to bathroom w/o, (without), assistance, stated he felt dizzy and fell over toilet, he was sent to ER for eval, resident sustained multiple rib fractures from unwitnessed fall, he returned back to facility, staff to check more frequently when in bed. R2's Nurses Note dated 03/06/23 at 8:45 AM documents Resident was ambulating to bathroom on his way back out of bathroom he lost his balance, fell to floor landing on his left side. States he hit his head. Assessment by nurse. Moves all extremities WNL for this resident neuro checks started. V/S 120/77 - 66 - 18 - 97.8 96% RA, (room air), O2 sats, (oxygen saturation). C/o, (complaint of), pain to left ribs area. R2's Quality Improvement Review Note dated 03/07/23 at 10:15 AM documents QA committee met r/t fall on 03/06/23, resident attempted to go to bathroom without assistance. Resident lost balance and fell, staff to utilize pressure alarm for bed. R2's Nurses Note dated 05/19/23 at 11:35 AM documents, resident chair alarm going off. CNA went to room and resident noted to be on knees on the floor. this nurse came to room and resident was getting up from floor by himself. Resident states he has no pain to knees. Resident states he also hit his left shoulder on his roommate's bed. denies pain to shoulder and ROM WNL. Redness/abrasions noted post-fall. Attempted to call emergency contact (POA) but the number is incorrect. Attempted to call NP x 2 but went voicemail and voicemail is full. Will try again. neuro checks WNL - ROM WNL. VS 126/74, 72, 18, 97.5, 96% RA. Resident denies hitting head. Will monitor. Spoke with NP - 0 new orders. monitor for bruising/pain. No Quality Improvement Review Noted for fall on 05/19/23. No intervention noted for fall on 05/19/23. R2's Nurses Note dated 08/17/23 2:10 AM documents, Resident had a fall in bedroom. Staff was in room with resident. No injury noted. NP was notified. Administrator was notified. Resident emergency contact notified. R2's Quality Improvement Review Note dated 08/12/23 9:30 AM documents QA committee met r/t fall with zero injury noted on 08/17/23. Resident attempted to sit back in w/c after incontinent care with CNA, (Certified Nurse Aide), and w/c moved causing him to land on buttocks. Educated resident and staff to ensure that w/c is locked during all transfers. R2's Nurses Note dated 09/06/23 at 6:25 AM documents, Resident had a fall in his room. Writer went to resident room. Found him on the floor sitting on his buttocks. Resident stated, that he was trying to go to his closet to shut the door and went in the opposite direction and slipped and felled (SIC). No injury noted. Vitals are B/P 130/80, P - 113, R 22, T 97.4. Notified emergency contact, notified NP, notified Administrator, notified DON. Will follow facility protocol related to falls. R2's Quality Improvement Review Note dated 09/07/23 at 9:15 AM documents QA committee met r/t fall on 09/06/23 with no injury noted. Resident stated he was closing his closet door and walking backwards and fell, instructed to utilize call light and wait for assistance. R2's Nurses Note dated 11/06/23 at 6:27 AM documents Resident has a fall this morning he stated that his pain was 5 he was found lying on his left side. Stated that his left hip hurts. Vitals were B/P 120/58, P 88, R 21, T 97.1. He stated that he was trying to put his tablet in his drawer. No Quality Improvement Review Noted for fall on 11/06/23. No intervention noted for fall on 11/06/23. On 11/17/23 at 10:59 AM, R2 observed sitting in dining area in wheelchair unsupervised. Chair alarm noted attached to resident. On 11/17/23 at 10:55 AM, V16, CNA stated that they use bed and alarms to prevent (R2) from falling. She stated that he started ambulating with a walker under supervision with a wheelchair following. On 11/17/23 at 11:30 AM, V12, LPN, (Licensed Practical Nurse), stated that to prevent (R2) from falling they use bed alarm and chair alarm. (R2) is a one assist from staff. She stated that they re-educate him on using the call light. On 11/17/23 at 12:45 PM, V2, DON stated that she would expect there to progressive interventions added to a resident's care plan following a fall. Facility's Fall Prevention policy dated 11/10/18 documents To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to initiate appropriate interventions to prevent the dislodgement of 1 of 3 residents (R3) reviewed for gastrostomy tube, (g-tube), placement. This failure resulted in R3 gastrostomy tube being dislodged, causing R3 pain, and being sent to local emergency room and he had to be hospitalized for the replacement of the g-tube. R3's admission sheet documents, that R3 was admitted [DATE]. R3's Care Plan, dated 7/7/23, documents, that R3 receives enteral nutrition support. Related diagnosis: Hypoxic Ischemic Brain Injury, G-Tube 18 FR R3's Nurses Notes, dated 9/17/22, documents, that the nurse entered the room for feeding and flush and noticed R3's gown wet. G-tube displaced and deflated. R3's Nurses Notes, dated 10/14/22 at 10 AM, documents, Resident was getting out of bed with assist with CNA. G tube sliding in and out balloon was deflated. Order was received to send R3 to ER. R3's Nurses Notes, dated 2/20/23 at 9:45 AM, documents, resident was sent to the (local) hospital r/t, (related to), G-tube kept popping out. R3's (Local Hospital) Patient Visit Information, dated 2/20/23, documents, that R3 was seen today for gastrostomy tube dysfunction. R3's G-tube was replaced. R3's Discharge summary, dated [DATE], documents, that R3 is [AGE] year-old patient with a history of stroke, hypertension, sleep apnea, paraplegia, who present to the ED, (Emergency Department), complaints dislodged G-Tube. It documents, that R3 was taken to the GI lab, (Gastrointestinal Laboratory), and G-tube was successfully replaced. R3's Progress Note, dated May 11, 2023, documents, that the reason for visit: presents after hospital stay for GT (Gastrostomy Tube) replacement. On 8/9/2023 at 8:14 AM V10, R3's mother, stated, that R3 came to the facility because he needed 24-hour care. V10 stated, that R3's g-tube has come out multiple times since being at the facility. V10 stated, that it was a total of six times while at the facility. V10 stated, that shortly after being at the facility R3 had to go to the emergency room because, his g-tube came out. V10 stated, that it had to hurt each time when that g-tube with the ball on it was pulled out of the small hole in his stomach. V10 stated, it would hurt me. V10 stated, that R3 cannot express himself, due to his stroke, but that doesn't mean that the pain isn't there. V10 stated, that each time his g-tube comes out he must go to the emergency room to get it put back in. V10 stated, that it's ridiculous. V10 stated, that the being pulled and jerked from bed to stretcher to bed to stretcher has too uncomfortable and painful as well. V10 stated, that her son would not be ok with this. V10 stated, that her son would not be ok with being in pain and taken back and for to the hospital. V10 stated, that she feels bad for him. V10 stated, that she was informed that the g-tube came out during care. V10 stated, that they are supposed to be trained to care for R3. V10 stated, that she was told that in May his feeding came out during a transfer. V10 stated, that she knew R3 was in pain and that she felt helpless. On 8/9/2023 at 3:44 PM V11, LPN, stated, that she provided care for R3. V11 stated, that R3's g-tube was pulled out a couple time when the staff turned him and cleaned him. R3 stated, that the tubing was under the cover and got pulled in the process. V11 stated, that R3 could not move his arms and could not have pulled them out himself. On 8/10/2023 at 2:00 PM V4, LPN, stated, that R3 was a quadriplegic and could not move without staff assistance. V4 stated, that R3 could not move his hands. V4 stated, that R3's g- tube came out multiple times. V4 stated, that she was not sure how many times. V4 stated, R3 was not capable of pulling the tubing out. V4 stated, that she was the nurse when R3's g-tube was pulled out during a transfer. V4 stated, she was able to get R3 out to the emergency room for g-tube replacement. V4 stated, that it was a while ago and she was unable to say what exactly happened. V4 stated, that it was pulled out during a transfer. V4 stated, that R3 did not have an abdominal binder. V4 stated, that they asked for a longer tubing, but did not get one. V4 stated, that the binder would have probably worked and kept his tubing from being pulled out, but they did not get one. On 8/14/2023 3:56 PM V14, Doctor, stated, that with the number of times that the g-tube was dislodged, he would have expected some interventions have been put into place. V14 stated, that an abdominal binder may or may not be appropriate depending on the patient, because it compresses breathing. V14 stated, that other interventions could have been put in place to prevent dislodgement like if the resident is pulling out then positioning the tubing so that the patient could not reach. V14 stated, that if the g-tube is being dislodged during care then getting a longer tube. V14 stated, that if the tubing was leaking then getting the appropriate tubing. V14 stated, that a dressing could have been applied to help maintain placement. V14 stated, that he would expect interventions to be put in place. On 8/14/2023 at 4:05 PM V11, LPN, stated, that the initial pull through the opening would cause R3 pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to assess and conduct root cause analysis of falls and implement progressive interventions to prevent falls for 1 of 3 residents (R2) reviewed for falls in the sample of 6. This failure resulted in R2 falling and sustaining a hip fracture. Findings include R2's Cumulative Diagnoses Log in R2's paper medical record undated documents diagnoses of essential hypertension, cerebrovascular accident (stroke) and schizophrenia. R2's Cognitive assessment dated [DATE] document, R2 was severely impaired for cognition and activities of daily living. R2's Psychosocial assessment dated [DATE] and 9/22/2022 document R2 has severe impairment in judgement, and safety awareness. R2's Discharge Evaluation dated 2/16/2022 and 9/22/2022 document R2 was forgetful and had safety awareness. R2's Discharge Evaluation dated 6/27/2022 and 9/22/2022 document R2 has a history of falls in the last 30 days. R2's Medical Records does not have a Fall assessment completed for R2 before 9/7/2022. R2's emergency room visit dated 3/1/2022 documents, Chief complaint: Fall. Patient is a [AGE] year-old male presenting to our facility after he slipped out of a chair at a nursing home. I spoke with the nurse at the facility, and she states that the patient was found on the floor near to his wheelchair as if he had slipped out of the chair this morning. R2's Nurse's Note, dated 4/27/222 documented Resident was in the T.V. room when I heard resident fall. It was unwitnessed. Full assessment done. The Nurse's Note did not document R2 sustained injury from this fall. R2's Care Plan was not revised with any interventions to address R2's fall on 4/27/22 or progressive interventions to prevent future falls. R2's Minimum Data Set (MDS) dated [DATE] document R2 was severely impaired for cognition. R2's Nurse's Note, dated 5/20/2022 at 5:20 PM, documents Resident fell in hallway, trying to walk, unwitnessed fall. The Nurse's note documented neuro checks were started and family and physician were notified. The Nurse's Note did not document what the facility put into place after this fall to prevent R2 from future falls. R2's Nurse's Notes dated 5/20/2022 at 5:30 PM, Resident got out of bed and fell again. EMT (Emergency Medical Technician) called to transport to hospital. R2's Nurse's Note, dated 5/20/22 at 10:15 PM, documented R2 had no injuries and would be returning to the facility. R2's Care Plan does not document this fall and his medical records do not document any progressive interventions for either of his two falls on 5/20/2022. R2's Nurse's Note, dated 5/23/2022 at 5:35 AM, document Environmental manager reported resident was on the floor, this nurse assessed resident and found abrasion on right side lower back, MD, DON, Administrator and (family) notified. The Note documents EMT (Emergency Medical Technician) called and left facility at 3:50 PM to transfer to (Hospital). R2's Nurse's Notes dated 5/23/2022 at 10:21 PM, documents Placed a call to (Hospital) to check on resident status. Spoke to his nurse and was informed resident was admitted c (with) hip fx. (fracture), subacute CVA et (and) fall. R2's Care Plan and Medical Records does not document any progressive interventions for R2's fall on 5/23/2022. R2's Hospital Procedure Note dated 5/24/2022 document a displaced right hip femoral neck fracture subacute. R2's Hospital Discharge Records dated 5/29/2022 at 1:42 PM, documents, Visit reason: Right hip fracture, CVA subacute fall. Medical Problem: Closed displaced fracture of the neck of right femur, acute cerebrovascular accident, fall. R2's Nurse's Note, dated 8/29/22 at 4:10 PM, documents FOF (found on floor) on knees in dining room. No injuries to pt.'s (patient's) knees. See incident report for falls. The facility had no documentation of this incident report to review. R2's Care Plan was not revised after this incident to address progressive interventions to prevent R2 from potential future falls. R2's Nurse's Note, dated 9/1/22 at 3:40 PM documents Resident FOF (found on floor), assessed no apparent injuries. Assisted to w/c (wheelchair) per (full body mechanical) lift accompanied by multiple staff. R2's Care Plan, revised on 9/1/22, documents r/t (related to) fall, pressure alarm for chair. R2's Hospice Discharge summary dated [DATE] document under health history- history of falling. Summary of Care: Patient admitted to hospice after sustaining a fall and broken hip. During hospital admission patient found to have CVA (cerebral vascular accident). R2's Fall Risk assessment dated [DATE] documents a score of 17 (Score of 10 points or more equal to high risk for falls). R2's Progress's Notes dated 9/7/2022 document, Resident was sitting in wheelchair in TV room and chair alarm sounded. This nurse went to assist resident to scoot back in his wheelchair, resident fell forward onto floor. Resident did not hit his head and no visible injuries were observed. R2's Care Plan, revised on 9/7/22, documented r/t fall, pressure alarm for chair (and) keep in visual when out of bed. R2's Quality Improvement Review Note dated 10/6/2022 at 9:00 AM, documents, IDT meeting held related to fall 10/5/2022 with small abrasion to right forehead. Resident dizzy, neuro checks were initiated. Resident sent to ER (emergency room) for evaluation and returned. Continue with neuro checks. Reeducated resident of the importance of using a call light for assistance. There is no documentation in R2's Nurse's Note that R2 fell on [DATE]. There is no documentation of R2's fall on 10/5/2022 on the facility's fall log. R2's Medical Records do not have any other documentation including the incident reports documenting this fall. R2's Care Plan was not revised after this fall with progressive interventions to prevent future falls. On 11/10/2022 at 9:35 AM, the facility provided an incident report and R2 was documented for an incident on 9/1/2022 at 3:35 PM, fall in dining room, no injury and 9/17/2022 at 3:00 PM, falling at Recreation Room, No injury. No other incident reports were provided. There was no documentation in R2's medical record he fell on 9/17/22. On 11/10/2022 at 2:41 PM, V8, Corporate assisting with Director of Nursing duties stated, For any fall I would expect staff to notify the physician and Power of Attorney of the fall and wait for orders from the doctor. All falls should be charged in the Nurse's Notes and all falls should be addressed at the Quality Assurance Meetings and the Care Plan updated to address the fall. On 11/10/2022 at 2:52 PM, V1, Administrator stated, Whenever a resident falls I expect all staff to assess the residents, get the resident comfortable, complete a nursing report, notify the physician and POA and incorporate any follow up with any physician orders. I expect this to all be documented in the Nurse's Notes and fall reporting. We do a quality assurance every morning and we do updates and would address any falls. The Minimum Data Set (MDS) Coordinator would then update the care plan to reflect the care and interventions that were put in place. I am not sure why those things are not in place for (R2). This is the only Care Plan we have for (R2). On 11/10/2022 at 3:03 PM, V10, Speech Therapist stated, Physical Therapy staff have already left for the day. I worked with (R2) a little but he was very confused and was not able to communicate with me except yes or no questions and his answers would always fluctuate. He had some severe communication deficits. I am not sure if he could tell you what was going on with him. Again, very confused. On 11/15/2022 at 11:29 AM, V11, Family of R2 stated, My father had a history of falls, and he could not verbally speak or tell you what was going on with him. Whenever he would fall, I would get a call telling me he had fallen but I never had any Care Plan meetings talking about his falls or anything the facility was doing to make sure he was safe and anything they were doing to prevent him for falling. Then he kept falling and fell and broke his hip. On 11/15/2022 at 11:48 AM, V3, Registered Nurse stated, I work, by choice. I am the Registered Nurse working here all but maybe 2 or 3 days a month. I usually worked weekends too. We currently do not have a full time Director of Nursing. (R2) was unsteady on his feet before his amputation. He could not talk to you really and he had some good days and bad days. Some days he could answered 'yes ma'am' to you other days he could not respond. I do not remember anything related to if he was at a fall risk or if he had any falls with injury honestly, I do not remember. On 11/15/2022 at 12:13 PM, V12, Nurse Practitioner stated, For any falls I would expect the facility to contact us, document the falls in the Nurse's Notes and address interventions and always document in the Care Plan. I am not sure what happened with (R2) and why his falls were not documented. The Facility Fall Policy with a revision date of 11/10/2018 documents, To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Assessments of Fall Risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. The admitting nurse will assign the temporary risk category. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of a fall in the nurse's notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA (certified nursing assessment) assignment worksheet. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to timely identify, assess, monitor and provide treatments for pressure ulcer treatment and prevention for 1 of 3 residents (R59) reviewed for pressure ulcers in the sample of 42. This failure resulted in R59 developing 3 facility acquired pressure ulcers requiring a right above the knee amputation. Findings Include: R59's Facesheet documents admission to facility on 2/3/2021 with diagnosis of Coronary Artery Disease, Chronic Kidney Disease, Type 2 Diabetes, Hypertension with heart failure, dysphagia following cerebral infarction (stroke). R59's Minimum Data Set (MDS) dated [DATE] documents R59 is at risk for pressure ulcers but had no pressure ulcers present. R59's MDS also documents he is totally dependent on staff for bed mobility and all ADLs (activities of daily living), and has impairment on lower extremity one side. R59's Nursing Assessment sheet dated 5/29/2022 has no documentation of pressure ulcers. R59's Physician Order Sheets (POS) dated 5/29/2022 documents skin checks weekly Sunday 2-10 (on evening shift). R59's Nurse's notes dated 5/2/22-6/4/22 have no documentation of the presence of any issues with R59's heels. R59's Nurse's notes dated 6/5/2022 documents (R59) has 2 pressure ulcers to bilateral heels. Left heel 7X5 (w), 3X3 (L), Right 3X10 (w), 7X3 (L) with eschar. R59's Nurse's notes dated 6/5/2022 documents, Clean right and left heel ulcers with normal saline and apply Neosporin ointment and non adhesive dressing daily for 5 days. R59's Physician Order (PO) also documents this same order. R59's PO dated 6/6/2022 documents, Povidine iodine 10% solution apply to left and right heel daily. R59's 6/2022 Treatment Administration Records (TAR) Weekly Summary documents 6/5/2022 Right heel- pressure ulcer 3x10 (w), 7x3 (L) Eschar, Left heel- pressure ulcer 7x5 (w) 3x3 (L) red and inflamed. No other documentation of weekly summary of pressure ulcers on 6/2022 TAR. R59's Nurse's notes dated 6/6/2022 documents (R59) has black mark on left heel and red mark on right heel. (Wound doctor) viewed marks and ordered betadine to both heels daily. R59's Nurse's Notes, dated from 6/7/22-10/9/22, have nothing documented about R59's bilateral heel pressure ulcers. R59's 7/2022 TAR has no documentation of weekly summary of pressure ulcers. R59's TARs regarding weekly skin checks shows no skin checks completed on 6/12/2022, 6/19/2022, 6/26/2022, 7/3/22, 8/7/22, 8/14/2022, 9/10/2022, 9/17/2022, 9/24/2022. R59's TAR regarding betadine to bilateral heels shows no treatments on 6/17/2022, 6/20/2022, 6/26/2022, 6/30/2022, 9/10/2022, 9/11/2022, 9/12/2022, 9/13/2022, 9/14/2022, 9/15/2022, 9/16/2022, 9/17/2022, 9/18/2022, 9/19/2022, 9/21/2022, 9/22/2022, 9/23/2022, 9/24/2022, 9/25/2022, 9/26/2022. R59's Wound physician notes dated 8/2/2022 document Site 1 Unstageable DTI (Deep Tissue Injury) of the left heel partial thickness with intact skin of greater than 73 days duration. Wound size 2 x 3 x Not measurable cm (centimeters). Continue betadine twice daily. Site 2 Unstageable DTI of the Right heel partial thickness with intact skin of greater than 62 days duration. Wound size 4 x 5 x Not measurable cm. Continue betadine twice daily. Etiology of both: pressure. Factors complicating wound healing: Diabetes Mellitus. This was the first visit by wound physician. https://npiap.com/page/PressureInjuryStages documents the definitions, Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). R59's Wound physician notes dated 8/9/2022 document Site 1 Unstageable DTI of the left heel partial thickness with intact skin. Continue betadine twice daily. No change in wound size or wound progress. Site 2 Unstageable due to necrosis of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue betadine twice daily. Surgical excisional debridement procedure performed on right heel wound. R59's Wound physician notes dated 8/16/2022 document Site 1 Unstageable DTI of the left heel partial thickness with intact skin. Wound size 2 x 1 x not measurable cm. Continue betadine twice daily. Wound progress: improved. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound size 4 X 5 X not measurable cm. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue betadine twice daily. R59's Wound physician notes dated 8/23/2022 documents Site 1 Unstageable DTI of the left heel partial thickness with intact skin. No change in wound size or wound progress. Continue betadine twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue betadine twice daily. R59's Wound physician notes dated 8/30/2022 documents Site 1 Unstageable DTI of the left heel partial thickness with intact skin. No change in wound size or wound progress. Continue betadine twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound size 4 X 4 X not measurable cm. Wound has thick adherent black necrotic tissue 100%. Wound progress: improved. Continue betadine twice daily. R59's Wound physician notes dated 9/6/2022 documents Site 1 Unstageable DTI of the left heel partial thickness with intact skin. No change in wound size or wound progress. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue betadine twice daily. R59's Nurse Practitioner progress notes dated 9/8/2022 documents Skin normal temp and color. R59's Nurse Practitioner progress notes dated 9/12/2022 documents Skin normal temp and color. R59's Wound physician notes dated 9/14/2022 documents Site 1 Unstageable DTI of the left heel partial thickness with intact skin. No change in wound size or wound progress. Continue betadine twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue betadine twice daily. R59's Wound physician notes dated 9/20/2022 documents Site 1 Unstageable DTI of the left lateral heel partial thickness with intact skin. No change in wound size or wound progress. Continue betadine twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. No change in wound size or wound progress. Continue betadine twice daily. Surgical excisional debridement procedure performed on right heel wound. Site 3 new Unstageable DTI of the left medial heel partial thickness with intact skin of greater than 2 days duration. Wound size 3 x 3 x not measurable cm. Etiology: pressure. Betadine twice daily. R59's Care Plan, start date 9/20/2022 and reviewed 9/22/22, documents Pressure Ulcer Present. Braden score 21 (Total score of 12 or less represents HIGH RISK for pressure ulcer). Risk factors include incontinent of bowel and bladder and needing assistance for transfers. Interventions include, assess for cause of pressure of pressure ulcer. Observe for pressure cause friction and contributing factors. Complete avoidable/Unavoidable pressure ulcer assessments as needed to investigate contributing factors and preventions interventions used. Nurse to measure and monitor wound status progression or deterioration every week. Notify Medical Doctor (MD) and family of changes, Document physician response. Treatments as ordered. Pressure relieving device in wheelchair and pressure reducing mattress. Pressure reduction boot when in wheelchair. Float heels when in bed. Skin risk assessment. Braden scale weekly for 4 weeks upon admission or readmission and then quarterly and as needed. R59's medical record has no documentation of a Pressure Ulcer Care Plan prior to the one initiated on 9/20/22 although R59 was identified with pressure ulcers on 6/5/22. R59's Minimum Data Set (MDS) dated [DATE] documents R59 is at risk for pressure ulcers, has 3 unstageable pressure injuries presenting as deep tissue injuries, none of which were present on admission. R59's MDS also documents he is totally dependent on staff for bed mobility and all ADLs (activities of daily living), and has impairment on lower extremity one side. R59's Treatment Administration Records (TAR) regarding weekly skin checks shows no skin checks completed on 6/12/2022, 6/19/2022, 6/26/2022, 7/3/22, 8/7/22, 8/14/2022, 9/10/2022, 9/17/2022, 9/24/2022. R59's TAR regarding betadine to bilateral heels shows no treatments on 6/17/2022, 6/20/2022, 6/26/2022, 6/30/2022, 9/10/2022, 9/11/2022, 9/12/2022, 9/13/2022, 9/14/2022, 9/15/2022, 9/16/2022, 9/17/2022, 9/18/2022, 9/19/2022, 9/21/2022, 9/22/2022, 9/23/2022, 9/24/2022, 9/25/2022, 9/26/2022. R59's Wound physician notes dated 9/27/2022 document Site 1 Unstageable DTI of the left lateral heel partial thickness with intact skin. No change in wound size or wound progress. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. Wound size 3.8 X 4.1 X not measurable cm. Wound progress: improved. Add Alginate Calcium with Kerlix (gauze wrap) once daily, Change betadine to once daily. Surgical excisional debridement procedure performed on right heel wound. Site 3 Unstageable DTI of the left medial heel partial thickness with intact skin. Wound size 3 x 2.8 x not measurable cm. Wound progress: improved. Continue betadine twice daily. R59's Physician Order Sheets dated 9/27/2022 documents Right heel betadine and alginate and gauze wrap daily. R59's Wound physician notes dated 10/4/2022 document Site 1 Unstageable DTI of the left lateral heel partial thickness with intact skin. Wound size 1.6 x 1 x not measureable. Wound progress no change. Continue betadine twice daily. Site 2 Unstageable (due to necrosis) of the right heel full thickness. Wound has thick adherent black necrotic tissue 100%. Wound size 4 X 4 X not measurable cm. Wound progress: no change. Continue Alginate Calcium with Kerlix once daily and betadine once daily. Surgical excisional debridement procedure performed on right heel wound. Site 3 Unstageable DTI of the left medial heel partial thickness with intact skin. No change in wound size or wound progress. Continue betadine twice daily. R59's Nurse Practitioner progress notes dated 10/10/2022 documents presents for nursing report that Right heel wound has increased drainage and odor. Nursing reports he has been followed by (Wound Consultant) for wound care. Skin: right heel with large unstageable wound moderate amount of serosanguinous drainage, right foot is red and warm to touch, + odor. Left heel with blister and blister to left great toe. Assessment and plan: right and left heel wound: concern for sepsis vs osteomyelitis. Transfer to ER (emergency room) for further care of wounds to bilateral heels. R59's Nurse's notes dated 10/10/2022 (R59) sent to ER due to wound on right heel having a foul order. R59's Hospital H&P (history and physical): HPI History of Present Illness report dated 10/10/2022 at 4:15PM documents Chief Complaint right foot wound. It continues, R59 presents for evaluation of a malodorous, nonhealing right foot wound. Plan x rays of the foot showed multiple pockets of gas and recommends were to proceed with right above the knee amputation urgently. It further documents a right above the knee amputation was performed without complications. Assessment and plan 1. Severe sepsis 2. Necrotizing soft tissue infection 3. Diabetic infection of right foot: Status post above-the-knee amputation. He has large unstageable pressure ulcer on the left heel. R59's hospital discharge Patient Signature Page, given to patient on 10/13/22, documents R59 was seen for: Severe sepsis, cellulitis of right foot, acute hypernatremia. R59's Nurse's notes dated 10/13/2022 documents (R59) readmitted with right above the knee amputation (AKA). Waffle boot to left foot with heel protector. Stump sock to right AKA. On 10/19/2022 at 1:15PM, R59's right above the knee amputation Wound site was clean and dry with sutures intact. No drainage observed. Left heel appeared soft, intact and red with minimal drainage. On 10/20/2022 at 3:50PM, V20, Nurse Practitioner, stated, Our practice wasn't following (R59)'s wounds because he was being followed by a wound company. I am the one who sent (R59) out to the hospital. I asked the nurse taking care of (R59) the day he went out, how long his wound had smelled and she said just that day. It is hard to say if missing a treatment would have contributed to the gangrene. I would expect treatments to be completed as ordered. I would also expect the care plan to be updated so everyone is aware of changes. On 10/21/2022 @ 9:15AM, V4, Infection Preventionist, stated I was the nurse the day (R59) went out. Staff noticed the smell and thought (R59) just needed a shower. I had the Nurse Practitioner look at it and she sent him out. On 10/20/2022 at 2:30PM, V17, Certified Nursing Assistant (CNA), stated I knew his foot looked bad because it was black. It smelled terrible the day he went out. I didn't smell it before that. The Facility's Decubitus Care/ Pressure Areas policy and procedure, revised 1/2002, documents, Policy: To ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. It continues, Procedure: 1. Upon notification of skin breakdown, an Newly Acquired Skin Condition report will be completed and forwarded to the Director of Nurses. 2. The pressure area will be assessed and documented on the Pressure Sore Record form. And, 3. Notify the physician for treatment orders. 4. Documentation of the pressure area must occur upon identification and at least once each week on the Pressure Sore Record. 5. Reevaluate the treatment for response at least every two (2) to four (4) weeks. Most pressure areas will respond to treatment in this amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order. 7. Initiate problem on care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision for 1 of 4 residents (R111) reviewed for elopement in the sample of 42.This failure resulted in R111 leaving the facility on 12/11/2021 without any of the staff attempting to stop him or alerting any staff he was leaving. R111 left the facility unnoticed without staff intervention. Findings include: R111's Progress Notes dated 11/9/2022 at 6:36 PM, documents, Resident is a new admit from (Hospital). He was admitted on [DATE] for a fall. He was found in his garage. No injuries substantiated. Increased confusion noted from family. Diagnosis of: kidney disease, HIV positive, HTN (hypertension), nephrectomy. He is orientated to himself. He is ambulatory but has issues with balance. R111's Elopement Evaluation dated 11/9/2022 documents: Resident is able to exit the building; requires assistance once outside the building; poor decision making; inability to identify safety needs; severe mental illness. R11's Score 6, High Risk= 5-10. R111's Care Plan documents a diagnosis of dementia. R111's Cognitive Assessment for November 2022 documents R111 was moderately impaired for cognition. 111's Nutritional Assessment documents a diagnosis of altered mental status, dementia, malnutrition, nephrectomy and AIDS. R111's Psychosocial Social Service Progress Notes dated 12/3/2021, Resident entered Social Service Office to inquire about his car. Social Service Director (SSD) reminded resident that his car was at his house in the garage and SSD also reminded resident that resident was very thankful. R111's Care Plan with a start dated of 11/22/2021 documents (R111) discharge not feasible due to care needs. R111's care plan with a goal date of 3/12/2022 for Behavior documents, (R111) may seek to leave home. Related diagnosis include: Altered mental status due to metabolic encephalopathy. Desires discharge from facility. Brief Interview Mental Status of 9 (9 out of 15= moderately impaired cognition) on admission assessment. (R111) has a cell phone and is able to make and receive calls independently. Validate (R111's) desires to leave the facility. Allow him to verbalize feelings. Seek to resolve any concerns. Educate (R111) on the need to sign out of the facility if going out on leave. R111's Psychosocial Social Service Progress Notes dated 12/2/2021, Friend in facility visiting resident and he asked to speak with myself (V14) (SSD) friend came to SS (social service) office and introduced himself (V14) and he began providing information about resident's family and informed friend that family relationships was beyond my practice and that my jobs was to ensure that resident was taken care of while in our facility friend then stated that upon discharge that resident could move with him and his mother. SSD informed friend that she (SSD) would inform resident of his friend's offer and he was very thankful. Very thankful. R111's Nurse's Notes dated 12/11/2021 at 11:17 AM, I was informed that resident did not return from out on pass. I immediately drove to the facility at this time, already notified corporate, and called all department heads, resident's brother, and police while staff did an outdoor facility grounds and neighborhood search. Staff had thought resident went out on pass but not sure of the visitor he left with. On 10/21/2022 at 9:10 AM, V4, Registered Nurse (RN) stated, I remember I got a phone call in the middle of the night telling me (R111) was missing. Those are my notes in his chart documenting the elopement. We think (R111) left with a visitor. We have a locked door that needs a code in order to open the doors. We are not allowed to give the code out to anyone including visitors. We are supposed to assist them. We discussed it at the meeting and we do not know how (R111) got out of the facility. On 10/21/2022 at 12:34 PM, V28, Housekeeping/ Activities, stated, I remember working that night and I saw (R111) with his bags packed. He told me his boyfriend was coming to pick him up and take him home. I did not see him leave or help him with the code to get out. We are not to ever give out the door codes to visitors. I never questioned him about leaving or checking to see if he was okay to go home. I was pushing my laundry cart and just making conversation. R11's Incident Report dated 12/15/2021 document, On 12/11/2021 at 10:30 PM, staff reported that (R111) was out on a visit and had not returned to the facility. Investigations began immediately including notifications to police, physician and family. During this investigation, staff and alert residents were interviewed. Two housekeepers stated they saw (R111) leave out the door by Nurse's station rolling a Suit Case and was with another male whom was there visiting with (R111) around 2:30 PM. The oncoming Nurse received report from previous Nurse. The nurse that come on shift asked where the Resident was at because he was not in the room and the Nurse stated that the Resident was out on a visit and had not yet returned. When resident's brother was called to inquire when resident would be returning, he stated that (R111) was not with him and he was not sure who visited him earlier. The oncoming Nurse immediately contacted Administrator and Assistant Director of Nursing (ADON), to notify them that the resident was out of the facility and had not returned, head count completed and (R111) was not counted. Staff immediately looked outside, looked in all rooms, bathrooms, storage areas, closets, laundry area etc. Staff and alert residents were interviewed for possible sightings. Facility conducted a thorough search of the grounds including outdoor shed, staff members worked together to sweep each consecutive room to avoid possibility of resident moving to adjacent room undetected. ADON, Administrator was called immediately. Investigation began immediately including notification to police, physician and family. Staff searched parked cars, ditches, expanding search through the neighborhood by foot and car also. Police were given a description of resident and clothing worn and they immediately began assisting with search. Search was done of facility, grounds and expanding search through community by foot and car. Police notified the facility that they sent ping to the Residents cell phone to track his location. Administrator contacted every possible contact for the Resident. The following morning 12/12/2021 at 9:33 AM. (R111) made contact with facility Social Service (V10) and informed her that he was at his Residence and that he was safe. He informed Social Service that he left the facility with his friend on 12/11/2021 and that his friend will be staying with him and helping him at home. On 12/12/2021 at 9:33 AM, Social Service Director informed (R111) that she would meet him at his residence and the resident agreed to that. Resident informed SSD that he did not want to come back and that he wanted to stay at his residence with his friend. Resident signed Against Medical Advise (AMA) and gave the resident the rest of his belongings. Family, and Physician notified. R111's medical records does not document any outing visit he took on 12/11/2021. R111's Interdisciplinary Summary dated 12/11/2021, At facility calling resident family and friends. Family and friends did respond and stated that they hadn't heard from resident. Informed both parties to have resident call. Facility to confirm his safety. On 10/20/2022 at 11:34 AM, V10, Social Service Director, stated, When (R111) came into the facility, he had a lot of confusion. He was HIV positive, he had hypertension. He was very confused and was always wanting to know where his car was. He liked to play the piano and he would have visitors come and visit him. His son would come and other male friends. One Saturday in December, I got a call from (the former Administrator) because (R111) was missing. I was not working that day so I cannot say how he got out of the facility. All I know is that he got out on the afternoon because some housekeepers saw him leave the building with another person. As soon as I got the call, I came in and started call his cell phone and family. The family did not know where he was at. The next day, (R111) called me and told me he was safe and I went to his house. I never went inside his house. There was another man there and he was yelling out at me and telling me (R111) was not going back to our facility and he was going to take care of (R111). He (the other man) said he was staying with him (R111) and he (R111) was not going back. I tried to talk to (R111) and he nodded to everything the other man was saying. I do not know the name of the man that was yelling at me. I think it was his partner but that is just a guess. I asked (R111) if he wanted to come back and he shook his head 'no' and then (I) asked him to sign the Against Medical Advice (AMA) papers and he did and I left. R111's elopement and medical records do not document who was at R111's house and who stated they would be assisting with his care. There was no name or person identified by the facility assisting R111 with his care. On 10/21/2022 at 9:01 AM, V25, Activities, stated, I was working in the business office the day (R111) eloped. I do not know how he got out of the building. That night, I got a call telling us he was missing, but I was not aware of anything while I was working that Saturday. On 10/21/2022 at 9:46 AM, V1, Administrator, stated, I was not here working at the time (R111) eloped from the facility. I would expect statements to be included from staff working that day of what they saw and interviews documenting it. I would expect the administrator to view the cameras to see what happened and how (R111) even got out of the building. Staff are to never give out codes to visitors. Our cameras are only good for seven days so I cannot even tell you what was on the camera. I would expect staff to never give out codes and for staff to never assist a resident with leaving without checking with others to make sure they are cleared to leave. The Facility Missing Resident Policy with a revision dated 8/13/2014, documents, It is the policy of (Facility) that reasonable precautions are taken to minimize the risks of resident elopement attempts. Reasonable precautions include, but are not limited to door alarms, personal door alarm activities devices, staff intervention, staff education regarding response to door alarms and individual resident intervention. It is the policy of (Facility) to demand immediate response to elopement attempts, door alarm activation and participating in search attempts in the event that a resident is deemed missing. The Door Alarm Policy with a revision date of 10/2006 documents, It is the policy of the (Facility) to ensure resident safety and security through the use of door alarms. Door alarms require immediate attention and response by facility staff to ensure the safety of all residents. Disengaging the alarms is not allowed until the reason for activation is determined. Steps to be taken: Go directly to the door where the alarm is sounding. Go completely outside the door to view the environment. Initiate a search of the immediate area if no resident or visitor is visualized. Instruct visitor or vendors how to properly disengage the alarm before leaving the facility. Conduct an immediate count of all residents. Initiate the Missing Resident Policy when unable to account for all residents. B. Based on interview and record review, the facility failed to perform a safe transfer for a dependent resident for 1 of 6 residents (R9) reviewed for falls in the sample of 42.This failue resulted in R9 falling out of a full mechanical body lift. Findings include: R9's Nurses Notes dated 8/4/22 at 2:00 PM document, Resident had a fall. She fell out of the (full body mechanical lift) sling. Staff stated that one of the straps was not connected while lifting her up. She has bilateral 4 inches of scratches to elbow. No other injury noted. NP (Nurse Practitioner) was notified . She was in the building. Administrator was notified. Resident is on 15 minute checks and neurochecks. Resident is laying in bed at this time. X-rays was ordered to sacrum, coccyx, lumbar spine, x-rays bilateral elbows. R9's Minimum Data Set (MDS) dated [DATE] documents she is severely cognitively impaired. It also documents she is dependent on staff for transfers. R9's Care Plan dated 7/13/22 documents, (P) Problem: Resident has risk factors that require monitoring and intervention to reduce potential for self injury. (Consider medical conditions, sensory alterations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, medications, restrictions, restraints). A new approach added to this care plan dated 8/4/22 documents, Related to fall, staff to ensure that resident understands transfer process. On 10/19/22 at 1:35 PM, V7, Licensed Practical Nurse (LPN), stated she was the nurse on 8/4/22 and documented R9's fall. V7 stated (V11) and (V12) Certified Nursing Assistants (CNAs) were transferring R9 when she had a fall from the full body mechanical lift. V7 stated R9 fell to the floor and she thinks R9 was caught and lowered to the floor by the CNAs. On 10/19/22 at 2:00 PM, V1, Administrator, presented R9's document, Quality Improvement Review dated 8/5/22 at 9:30 AM which documents, QA (Quality Assurance) committee meet to review fall on 8/4/22, staff reported resident fell out of (full body mechanical lift) sling b/c (because) one of the straps was not connected. Resident sustained bilateral scratches to elbow, no other injury noted. Resident complained of no pain or discomfort, was placed on 15 minute checks with neuro checks. Staff educated on transfer process and proper sling placement. X-rays were ordered with no findings. R9's Fall Risk assessment dated [DATE] documents a score of 22 indicating she is high risk of falls. R9's x-ray reports dated 8/4/22 of coccyx/ sacrum/lumbar region and right and left elbows document R9 did not have any fractures from her fall. On 10/19/22 at 3:48 PM, V11, CNA, during phone interview, stated she and another CNA (V12) were transferring R9 from her chair to the bed when R9 fell on 8/4/22. V11 stated V12 had attached the straps of the sling to the lift. V11 stated she was observing and controlling the remote to lift R9 out of her chair. V11 stated they had just lifted R9 and removed her chair from under her and one of the straps on the side of the sling just snapped out and R9 fell to the floor onto her butt. V11 stated R9 was not that high, but they were not able to slow her fall and she fell directly to the floor. V11 stated R9 had complained of pain to her elbows or ankles, she could not remember which, but any injury she sustained was minor. V11 stated she did not help transfer R9 from the floor to her bed but three staff lifted R9 from the floor without the mechanical lift and placed her in her bed. V11 stated she had not received any training on using the full body mechanical lift, but was just told briefly how to use it during her orientation. On 10/19/22 at 3:59 PM, V12 stated she and V11 were transferring R9 from her chair to her bed when R9 fell from the (full body mechanical lift). V12 stated R9 was already hooked up to the lift when she walked into R9's room. V12 stated that was her first day working in the facility and she did not know why they had V11 training her because V11 was a brand new CNA herself. V12 stated she thinks V11 had not hooked up the sling straps to the mechanical lift correctly and that is why R9 fell from the sling. V12 stated R9 was not very high in the air when she fell and she did not think R9 was injured. V12 stated she had experience using full body mechanical lifts during her time as a CNA but did not receive any instructions from the facility regarding their policy for using the lift. V12 stated after R9's fall, V7, LPN, did educate her and V11 on using the lift. V12 stated she, V7, LPN and V6, CNA, lifted R9 from the floor and put her into her bed after her fall. The facility's policy, Mechanical Lift revised 10/30/08 documents, Policy: The mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety and security for residents and nursing personnel. Under Procedure it documents, 9. Attach the appropriate colored loops on the bars.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer medication as ordered for 1 of 25 residents reviewed for medication (R8) in the sample of 42. This failure resulted in R8's significant med errors of missing two doses of insulin with subsequent need for transfer to the emergency room (ER) due to elevated blood sugar. Findings include: R8's Undated Face Sheet documents she was admitted on [DATE]. R8's Care Plan, dated 4/15/2022 and reviewed 7/13/2022 R8's care plan did not address R8's had diabetes or any goals or approaches. R8's Minimum Data Set (MDS) dated [DATE] documents R8 iscognitively impaired and has a diagnosis of diabetes. R8's Physician Order Sheet (POS) dated 9/26/2022 documents Lispro 5 units subq (subcutaneous) TID (three times a day) with meals breakfast and lunch. Glargine 20 units subq at bedtime (HS.) There was no sliding scale insulin order on the readmission POS dated 9/26/2022. R8's Medication Administration Record (MAR), dated 9/26/2022, documents Lispro 5 units subq TID with meals breakfast and lunch. There was no documentation Lispro insulin was administered at 4:00 PM on 9/26/2022 and no documentation glargine insulin 20 units was administered at 8:00 PM. R8's Nurse's Note, dated 9/26/2022, has no documentation of why R8 didn't receive the two doses. R8's Nurse's Notes dated 9/27/2022 at 11:20 AM document notified MD (physician) via internal electronic system of elevated blood glucose reading high. N.O. (new order) given to give 10 units Humalog subq now and to recheck reading in 1 hour. 12:30 PM rechecked resident blood glucose at this time. Blood glucose reading hi. Notified MD via internal electronic system. N.O. send to ER and give 5 units. 1:00 PM called EMS (Emergency Medical Services)/ambulance for transport. Called local hospital with report. Called 911 for transport. 1:32 PM Resident left facility via ambulance with emergency medical technicians (EMTs) x4. R8's ER Visit Note, dated 9/27/2022 documents HPI (history of present illness) patient is an [AGE] year-old female who presents ER with hyperglycemia (high blood sugar.) Apparently today at the nursing home her blood sugars have been running in the 400s and they cannot get it controlled with her new sliding scale insulin. Nursing home contacted and they did not give the patient (R8) her Lantus (glargine insulin) last night. Blood sugar coming down with 1 dose of insulin 10 units. We will have patient's home Lantus tonight and inform the nursing home that they can readminister tomorrow. Additional instructions: your blood sugar was elevated because you did not receive your Lantus last night. You were given your home Lantus dose while in the ER today. R8's POS, dated 9/26/2022 documents no physician's order for sliding scale insulin. On 10/20/2022 at 12:45 PM, V13, Consultant RN (Registered Nurse), stated she expects staff to administer medications per physician's orders. V13 stated when a resident is readmitted to the facility, she expects staff to document a nurse's note to state the resident was readmitted , so all staff know the resident is back in the facility. V13 stated the facility holds resident's bed and medications for 14 days when they are discharged . V13 stated the 14th day the medications are returned to the pharmacy. V13 stated if R8 was discharged on 9/12/2022 and readmitted on [DATE], that was 15 days so her medications would have to be reordered from the pharmacy and she expected the medications to be available at the facility within a few hours of the resident being back at the facility. V13 stated insulin is considered a significant medication because if the resident misses a dose of insulin the resident's blood sugar can quickly plummet. V13 stated she expected staff to either retrieve insulin from the facility's insulin emergency kit or call the pharmacy and get a STAT (immediately) run from the pharmacy to deliver the insulin so the resident doesn't miss a dose. When staff obtain insulin from the facility's emergency kit or contact pharmacy for a STAT delivery of insulin, she expects staff to document a nurse's note, so staff know what has been done to ensure the resident gets the physician prescribed medication. V13 stated if the box for the corresponding date is blank on the resident's MAR that means the medication wasn't administered. On 10/20/2022 at 3:45 PM, V20, Nurse Practitioner (NP), stated when a resident is readmitted to the facility if the resident was on the medication in the past, she expected the medication to be immediately available to the resident and if the medication was not available, she expected staff to utilize the facility's insulin emergency kit to ensure the physician order medication in a timely manner. V20 stated she expected staff to document physician's orders correctly and to administer insulin as prescribed. V20 stated she wasn't aware R8 missed two doses of insulin on 4/26/2022, she stated the insulin should have been available and administered per physician's orders. V20 stated insulin is considered a significant medication because of what can occur if the resident doesn't receive a scheduled dose which includes diabetic coma. The Facility's Medication Administration Policy revised 11/18/2017, documents each facility shall establish a policy for the routine time of medication administration. Medications must be prepared and administered within one hour of the designated time or as ordered. Medications must be identified by using the 7 rights of administration which includes right resident, right drug, right dose, right consistency, right time right route and right documenation. After a medication is given, record the date, time and name of drug, dose and route on the resident's individual MAR. Document any medications not administered for any reason by circling initials and documenting on the back of the MAR the date, the time, the medication and dosage and the reason for omission and initials. If the medication is not available for the resident, call the pharmacy and notify the physician when the drug is expected to be available. Nofiy the physician as soon as practical when a scheduled dose of a medication has not been administered for any reason.