Every finding on record at Franklin County Transitional Care

Based on record review, policy review, and staff interviews, it was determined the facility failed to ensure residents remained free from abuse and neglect. This was true for 3 of 6 residents (#2, #14, and #28) reviewed for abuse prevention practices. The facility's failure to prevent, identify, and respond to abuse and neglect created harm for Resident #2 and #14 when staff failed to respond in a timely manner to her complaint of pain, and when they forcibly removed a washcloth from Resident #2; and when Resident #28 experienced psychosocial harm, fear, and decreased self esteem. Findings include: The facility's Freedom from Abuse, Neglect, and Exploitation policy revised 1/23/25 documented: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. [The facility] will actively prevent, identify and report any such situations. Resident #2 was admitted on [DATE], with multiple diagnoses including constipation, chronic pain, and adult failure to thrive. a. A review of the facility's grievance investigation dated 4/20/26, documented on 4/20/26, CNA #3 sent a text message to the DON alleging that Resident #2's needs were not met. CNA #3 was instructed to email the allegation to the DON and Administrator. A review of CNA #3's written statement dated 4/21/26, documented concerns regarding Resident #2's pain and lack of staff response. Following receipt of the statement, the facility requested statements from CNA #6 and LPN #1. On 4/21/26, the facility sent a message to all staff reminding them that residents have the right to receive safe and prompt treatment in a manner that meets their preferences. The investigation included a written statement from LPN #1, dated 4/22/26 at 5:11 PM, documenting: LPN #1 administered pain medication to Resident #2 prior to assisting CNA #7 with transferring Resident #2 to bed. LPN #1 documented Resident #2 required catheter replacement and instructed staff to notify her before putting Resident #2 in bed. After Resident #2 was transferred to bed, Resident #2 complained of right leg pain. LPN #1 documented she asked Resident #2 to describe the pain, and Resident #2 stated: It was really bad pain all over her leg and it felt like her leg was still broke. LPN #1 documented she assessed Resident #2 but did not identify abnormal findings and proceeded with the catheter change. The investigation did not include an interview with Resident #2 or other residents in proximity to the incident. On 7/23/26 at 10:45 AM, Resident #2 was asked about the incident but stated she did not recall the event. During a phone interview on 7/23/26 at 4:12 PM, CNA #3 stated, At approximately 5:25 PM on 4/20/26, she entered the dining room and observed Resident #2 experiencing significant leg pain. CNA #3 stated she approached the doorway and asked three CNAs at the nurses' station if they could assist Resident #2 to bed because Resident #2 was in a lot of pain. CNA #3 stated none of the staff responded. She stated LPN #1 was providing care to residents down the hall and she attempted to call her but was having issues with the radio system. CNA #3 stated she attempted to position Resident #2's leg and provide comfort while waiting for assistance. CNA #3 stated at approximately 5:55 PM, CNA #7 entered the facility, and CNA #3 asked her for help. CNA #7 and LPN #1 then assisted Resident #2 to bed. On 7/23/26 at 11:51 AM, the DON stated the facility did not identify abuse or neglect at the time of the incident and confirmed the facility should have. b. A review of the facility's abuse and neglect investigation dated 6/2/25, documented the facility received a text message from CNA #3 alleging abuse involving an interaction observed between Resident #2 and CNA #5. The text message documented CNA #3 was assisting Resident #2 with her night routine. CNA #3 handed Resident #2 a wet washcloth to wash her face. Resident #2 washed her face and handed the washcloth back. CNA #3 then handed Resident #2 a dry washcloth to dry her face. Resident #2 took the dry washcloth, and before she could dry her face, CNA #5 snatched the dry washcloth out of Resident #2's hand, hung it back on the rack, looked at Resident #2, and stated, We don't do that, do we? A statement from CNA #3 documented Resident #2 subsequently dried her face with her shirt. The investigation concluded CNA #5 displayed inappropriate behavior, and CNA #5 was terminated. The investigation did not include interviews with residents identified during the investigation process who may have witnessed or been in proximity to the incident. On 7/23/26 at 10:47 AM, Resident #2 was interviewed but did not recall the incident. On 7/23/26 at 11:49 AM, the DON stated the investigation confirmed the allegation of abuse. 2. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including an open wound on her right lower leg, polyneuropathy (a medical condition where multiple peripheral nerves throughout the body are damaged at the same time), chronic venous hypertension on right lower extremity (a condition where sustained, elevated blood pressure occurs in the veins of the right leg due to damaged vein valves or blockages), hypertension (high blood pressure, a common condition where blood pushes too hard against the artery walls), diabetes, and anxiety. On 7/21/26 at 3:17 PM, Resident #14 stated she had concerns about staff, but did not want to be specific as she felt her treatment might not be the same. A review of the facilities grievances documented on 7/6/26, Resident #14 had complained to her daughter about the leg wrappings being too tight. Resident #14's daughter called the DON to complain about her mother's pain and to notify the DON that RN #2 was abrupt with Resident #14. The grievance included a statement where RN #2 reported she was able to change Resident #14's leg wrapping sometime later that afternoon. A review of the LTC State Portal did not show a neglect report had been uploaded on 7/6/25 for Resident #14. On 7/24/26 at 9:52 AM, RN #2 stated Resident #14 woke up around 8:00 AM on 7/6/26, and wanted to have her leg wrapping changed from the original wrapping the night before. Due to having other residents to take care of, RN #2 told Resident #14 she could not change her dressings at that time. Around 9:00 AM, RN #2 stated she provided pain medication to Resident #14 along with her regular morning medications. RN #2 acknowledged she did not check in with Resident #14 to see if the pain medication had helped. RN #2 was unclear what time she changed Resident #14's leg wrapping but believed she had changed it around 10:30 AM or 11:00 AM. RN #2 stated, 2 – 2.5 hours was too long for a resident to be in pain. When asked about her nursing progress note indicating she had changed Resident #14's leg wrappings in the late afternoon, she did not respond. On 7/24/26 at 11:10 AM, the DON stated Resident #14's pain medication would take about 45 minutes to become effective, and RN #2 could have checked on Resident #14. The DON stated she did not believe this incident was a neglect case since both parties (Resident #14 and RN #2) had worked through the concern satisfactorily. She stated that this incident was not reported as neglect since the incident had been resolved, but looking at it now, it should have been reported. 3. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including visual loss in both eyes, muscle weakness, diabetes, and depression. A review of an abuse/neglect report dated 6/13/25, submitted to the LTC Reporting System documented Resident #28 had an encounter with staff that left him fearful. The report documented the facility was notified on 6/14/26 that Resident #28 reported to staff he was fearful about comments made to him by CNA #8 during the night on 6/13/26. Resident #28 reported CNA #8 was in his room when she told him,I know where you live. Resident #28 stated he asked CNA #8 if she was stalking him, and Resident #28 reported hearing CNA #8 respond,That's something for me to know and you to find out. A nursing progress note dated 6/14/25 at 9:33 PM, documented staff checked on Resident #28 said he was worried about his family and about not being able to drive over and check on them. A nursing progress note dated 6/15/25 at 10:45 AM, documented the Administrator spoke to Resident #28 about the incident and informed the Administrator he had been CNA #8's Sunday school teacher, and he was confused if CNA #8's comment was made directly about him or the home of his ex-wife. The investigation concluded CNA #8 stated she had spoken before thinking, assuming Resident #28, who she knew personally, would understand her comments as a joke. The investigation documented Resident #28 did not interpret the statements that way, and staff were trained to avoid jest, sarcasm, or other forms of joking that may be perceived negatively by residents or others in the facility. The investigation documented CNA #8 had prior verbal and written warnings regarding her work ethic and following directions from her supervisors. The incident was identified as a last chance warning for CNA #8 to pay closer attention to her language before speaking and to avoid statements that may be interpreted as aggressive or unsafe. The investigation documented that, at Resident #28's request, CNA #8 was allowed to return to work after providing an apology to Resident #28, and informing him when she was in his room and why she was there. On 7/22/26 at 3:45 PM, the surveyor interviewed Resident #28 who did not recall the incident on 6/13/25. On 7/23/26 at 11:08 AM, the surveyor left a message with CNA #8. CNA #8 did not return the call. On 7/24/26 at 11:23 AM, the DON stated as written, Resident #28 experienced verbal abuse by CNA #8. Cross reference F609 and F610.

Based on policy review, record review, and staff interview, it was determined the facility failed to implement its antibiotic stewardship program as required. This was true for all residents residing in the facility. This failure created the potential for adverse events, including inappropriate antibiotic use and development of multi drug resistant organisms. Findings include:A review of the facility's Antimicrobial Stewardship Protocol, revised 3/2/26, documented the facility must:-Assess residents for infection using standardized tools and criteria.-Use Lobes minimum criteria before initiating antibiotics.-Provide education to prescribing practitioners and nursing staff.-Require antibiotic orders to include indication, dose, and duration. A review of stewardship documents received 7/27/26 at 4:19 PM documented the following concerns identified by the facility on 4/16/26:-The facility lacked a defined diagnostic algorithm.-Point Click Care charting was not aligned with McGeer's or Lobes criteria.-Reflex urine cultures were being performed without indication.-UTI antibiotic courses were not consistently reassessed at 72 hours.A review of the facility's Healthcare Associated Infection LTC monitoring dated April 2026 - June 2026, documented the following:- on 4/1/26, Resident #29 reported increased fatigue. The provider ordered the following labs: complete blood count (CBC), comprehensive metabolic panel (CMP) and a urine analysis (UA). The IP conducted a review of the infection control protocol and determined Resident #29 did not meet McGeer's or the LOBES criteria at the time labs and UA were ordered.-On 6/30/26, Resident #16 displayed a change in mental status. Resident #16 was assessed, and no signs or symptoms of infection were identified. A UA was conducted, and Resident #16 was prescribed Cipro 500 mg twice daily for 7 days.The IP conducted a review and determined Resident #16 did not meet criteria.The report documented staff would contact the provider to discontinue the order as Resident #16 did not have urinary symptoms and altered mental status resolved prior to antibiotic therapy initiation.On 7/22/26 at 3:00 PM, IP confirmed infection control screening was not conducted for Resident #29 or Resident #16 . When asked about the infection control protocol for screening residents IP stated, we don't really have a process in place, I came into the position, and the person prior was not doing very much.On 7/22/26 at 5:58 PM, IP stated, the expectation is that they will report the symptoms to the provider, send the culture, use McGreer's and LOBES to ensure they meet criteria, get culture results, then initiate antibiotics. She confirmed screening was not conducted for Resident #29 or Resident #16.

Based on observation, Food Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was cleaned and sanitized. This deficient practice had the potential to affect the 33 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include:The FDA Code Section 4-602.12 Cooking and Baking Equipment documented food-contact surfaces of cooking equipment must be cleaned to prevent encrustation's that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use.On 7/24/26 at 2:37 PM, cooking saute pans and baking sheets were observed with a black encrusted residue which did not scrape off without effort.On 7/24/26 at 2:40 PM, the Dietitian stated the baking sheets, and saute pans should not have the black encrusted residue.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents medical records were complete, accurately documented, readily accessible, and systemically organized. This was true for 4 of 6 residents (#2, #3, #4, and #14) reviewed for RNA services. This deficient practice created the potential for harm if resident's records did not show physician ordered services were being completed related to resident's rehabilitation programs. Findings include:The facility's Restorative Nursing Program, dated 5/18/20, documented maintenance and restorative services will be provided to residents designed to maintain or improve a resident's ability to the highest practicable level. Restorative aides will implement the plan and for a designated period, perform the activities, and document on the Restorative Aide Worksheet. 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a long-lasting disease where the body's immune system attacks the protective covering of nerve cells in the brain and spinal cord, leading to communication problems between the brain and the body), and anxiety disorders. Resident #3's care plan, revised 6/4/26, documented Resident #3 was to continue to work with Restorative to maintain her functional ability. A review of Resident #3's record, did not include a physician order for Restorative Nursing Program. Resident #3's record, dated May 2026 through July 2026, documented the following restorative programs: -Offer to assist her to ride the NUTSTEP 6 times a week for 10 minutes. -Offer active range of motion 6 days a week for 15 min per day. Include arm and leg exercises. A review of Resident #3's restorative nursing program, dated May 2026 through June 2026 did not document exercise or refusals for the following: NUTSTEP: -May 2026: 29 of 30 days -June 2026: 29 of 30 days. The facility provided three printed calendars dated May 2026 – July 2026 with Resident #3's first name written at the top. The calendars contained handwritten entries documenting restorative opportunities which did not match the restorative nursing documentation in the resident's clinical record. A review of the calendars documented Resident #3 was provided opportunities for only 1 of the 2 restorative programs, which did not match the restorative nursing documentation in the resident's clinical record. 2. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including anxiety, chronic pain syndrome, and a history of urinary tract infections. Resident #4's care plan, revised 7/2/26, documented Resident #4 was to continue to work with Restorative to maintain her functional ability. No physician's orders were located in Resident #4's record. Resident #4's record, dated May 2026 through July 2026, documented to offer to assist her to ride the NUTSTEP 6 times a week for 10 minutes. A review of Resident #4's restorative nursing program, dated May 2026 through June 2026 did not document exercise or refusals for the following: -May 2026: 6 of 31 days -June 2026: 20 of 30 days -July 2026: 17 of 21 days The facility provided three printed calendars dated May 2026 – July 2026 with Resident #4's first name written at the top. The calendars contained handwritten entries documenting restorative opportunities which did not match the restorative nursing documentation in the resident's clinical record 3. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including open wound on right lower leg, polyneuropathy, chronic venous hypertension on right lower extremity, hypertension, diabetes, and anxiety. Resident #14's care plan, revised 2/16/26, directed staff to encourage her to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: group exercises and participate with the restorative program. A review of Resident #14's record documented no physician's orders for restorative services. Resident #14's record, dated May 2026 through July 2026, documented to offer to assist her to ride the NUTSTEP 6 times a week for 10 minutes. A review of Resident #14's restorative nursing program, dated May 2026 through June 2026 did not document exercise or refusals for the following: -May 2026: 12 of 31 days -June 2026: 23 of 30 days -July 2026: 16 of 24 days The facility provided three printed calendars dated May 2026 – July 2026 with Resident #14's first name written at the top. The calendars contained handwritten entries documenting restorative opportunities which did not match the restorative nursing documentation in the resident's clinical record On 7/24/26 at 9:21 AM, the RNA RN stated refusals are noted and usually recorded in the resident's medical record; however, the RNA Aides will usually keep an external hard copy calendar of the resident's refusals and activities which should then be input into the resident's medical record. The RNA RN stated documentation should be completed within 24-hours of the completed or refused activity. For Resident's #3, #4, and #14, the RNA RN stated there were no recorded services or refusals in the resident's medical record. 4. Resident #2 was admitted on [DATE] with multiple diagnoses including constipation, chronic pain, and adult failure to thrive. A review of Resident #2's care plan documented: Resident #2 will participate in restorative nursing service to continue to improve strength and mobility to return home. A review of Resident #2's physician orders did not include an order for restorative nursing services. A review of Resident #2's record dated May 1, 2026 – July 23, 2026, documented the following restorative programs: -Bed mobility: Assist for 15 minutes/day at least 6 days/week; include stretching the right leg with knee brace off while lying flat. -Eating: Offer assistance 6 days/week for at least 15 minutes/day. -Range of Motion (ROM): Offer ROM 6 days/week for at least 15 minutes/day. Resident #2's record documented missed opportunities on the following weeks: ROM: 5/4/26–5/10/26: 1 5/11/26–5/17/26: 2 5/18/26–5/24/26: 1 5/25/26–5/31/26: 1 6/1/26–6/7/26: 6 6/8/26–6/14/26: 5 6/15/26–6/21/26: 6 6/22/26–6/28/26: 6 Eating: 5/11/26–5/17/26: 1 5/18/26–5/24/26: 1 6/1/26–6/7/26: 2 6/8/26–6/14/26: 1 Bed Mobility: 6/1/26–6/7/26: 6 6/8/26–6/14/26: 5 6/15/26–6/21/26: 6 6/22/26–6/28/26: 6 The facility provided three printed calendars dated May 2026 – July 2026 with Resident #2's first name written at the top. The calendars did not include a last name or a date of birth . The calendars contained handwritten entries documenting restorative opportunities. A review of the calendars documented Resident #2 was provided opportunities for only 2 of the 3 restorative programs, which did not match the restorative nursing documentation in the resident's clinical record. On 7/24/26 at 9:13 AM, the MDS Coordinator, who oversees the restorative nursing program, confirmed Resident #2's record included multiple missed sessions. She stated that staff were documenting restorative treatments on a calendar, rather than in the resident's clinical record. The MDS Coordinator stated the expectation is that staff would provide the treatment and document it in the resident record.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and maintained for 7 of 32 residents who resided in the facility. This failure created the potential for cross contamination, increased risk of infection, and adverse events. Findings include: The CDC's website accessed [DATE] titled Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, documents that traditional Standard Precautions are insufficient to prevent MDRO (Multi-Drug Resistant Organisms) spread in nursing homes, where residents often have:-Chronic wounds-Indwelling medical devices-High levels of physical contact with staff-Long lengths of stay-Frequent MDRO colonizationThe CDC further states EBP must be used for residents who:-Have unhealed wounds or chronic skin breakdown.-Have indwelling medical devices such as catheters, feeding tubes, tracheostomies, ports, and PICC lines.-Are colonized or infected with CDC targeted MDROs.The use of EBP requires gown and glove use during high contact care activities such as:-Dressing-Bathing-Transferring-Providing hygiene-Changing linens-Toileting-Wound care-Device careA request for the facility's Enhanced Barrier Precautions policy was made; no policy was provided.The facility's Infection Control Plan revised [DATE], documented that the Infection Preventionist is responsible for overseeing the infection prevention and control program based on epidemiology principles, research, and consideration of resident demographics and disease trends.On [DATE], [DATE], [DATE], [DATE], and [DATE], the State Agency conducted observations throughout the facility and identified no use of Enhanced Barrier Precautions for residents who had chronic wounds or indwelling medical devices.On [DATE] at 3:42 PM, the IP stated the facility previously followed EBP practices but stopped in [DATE] after the Administrator and DON received an update that EBP was no longer necessary.On [DATE] at 5:27 PM, the DON provided documentation of the directive that the facility was following: CMS issued QSO 24 08 NH, dated [DATE], documented EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high contact resident care activities regardless of their multidrug resistant organism status. This guidance is incorporated into F880 Infection Prevention and Control. On [DATE] at 12:12 PM, upon reading QSO-24-05-NH to the DON she stated she misunderstood the memo and thought because the memo expired the facility no longer had to implement EBP.

Based on record review and staff interview, it was determined the facility failed to monitor weight. This was true for 1 of 2 residents (Resident #19) whose record was reviewed for significant weight loss. This created the potential harm for Resident #19 when her 17.8 pound or 14.1% significant weight loss was not identified. Findings include: Based on record review and staff interview, it was determined the facility failed to monitor weight for a resident taking psychotropic medications. This was true for 1 of 2 residents (Resident #19) whose record was reviewed for significant weight loss. This created harm for Resident #19 when her 17.8 pound or 14.1% significant weight loss was not identified. Findings include: CDC's Healthy Weight and Growth resources accessed on 7/30/26, documented an unintended weight loss is a red flag for underlying health issues and should be evaluated promptly in chronic illness using the following clinical practice:-1 week: 2% weight loss-1 month: 5% weight loss-3 months: 7.5% weight loss-6 months: 10% weight lossResident #19 was admitted to the facility on [DATE], with multiple diagnoses including anxiety, chronic pain syndrome, and a history of urinary tract infections.Resident #19's care plan, initiated 6/15/26, directed staff to complete weekly weights, provide Ensure Plus 8 oz twice per day with meals, and notified staff Resident #19 did not want to have a bedtime snack.A review of Resident #19's record documented the following physician orders:-Clonazepam (antianxiety) oral tablet, 1 mg, 1 tablet daily at bedtime due to anxiety, initiated 5/26/26.-Clonazepam oral tablet, 0.5 mg, give 1 tablet in the morning due to anxiety, initiated 5/27/26.-Fluoxetine (antidepressant) HCl oral tablet, 10 mg, give 1 tablet in the morning for depression, initiated 5/27/26.-Regular diet, Ensure clear, 8 oz twice per day with one-ounce LiquaCel (nutritional supplement to boost protein and calories) added, initiated 5/26/26.A review of Resident #19's record documented the following weights:-126.4 pounds (wheelchair) on 6/27/26.-108.6 pounds (standing) on 7/20/26.Resident #19's vital record documented a 14.1% weight loss (-17.8 pounds) on 7/20/26.No weights were recorded between 5/29/26 through 6/26/26, or between 6/28/26 and 7/19/26.Resident #19's record did not document psychotropic medication monitoring for weight loss or appetite changes.A nursing progress note, dated 6/14/26 at 1:53 PM, documented Resident #19 ate 50% or less for 2 or more meals in the day. Resident was encouraged to eat and at this time her weight is stable.A Long-Term Care Evaluation, dated 6/17/26, at 2:40 PM, documented Resident #19 routinely [ate] an apple or berry ensure, and frequently has snacks between meals. No changes in nutritional status noted. A Physician Communication note, dated 6/25/26 at 8:43 AM, documented the DON spoke with [the physician] about [Resident #19's] increased confusion including a recent fall and attempting to use a piece of paper as a remote for the television. [The physician] attribute[d] this to her age and did not want to do anything at that time. Staff continue to encourage oral intake and encourage regular sleeping pattern to see if that helps.A nursing progress note, dated 7/15/26 at 11:05 AM, documented [Resident #19] was sleeping most of the day on 7/14/26. [Resident #19] had requested a Tylenol 3 for a headache. Resident's pupils were PERRL. Resident was alert to person, place, and time but when asked why she was [at the facility] stated, to go get a job. Resident did not eat much either. Resident #19's Nutrition - Amount Eaten Task Report documented Resident #19 percent food consumption:5/26/26 to 5/31/26:-0-25%: 1 of 16 opportunities-26 - 50%: 6 of 16 opportunities-51 - 75%: 7 of 16 opportunities-76 - 100%: 1 of 16 opportunities-Refused: 1 of 16 opportunities6/1/26 to 6/30/26:-0-25%: 10 of 90 opportunities-26 - 50%: 28 of 90 opportunities-51 - 75%: 28 of 90 opportunities-76 - 100%: 19 of 90 opportunities-Refused: 5 of 90 opportunities7/1/26 to 7/23/26:-0-25%: 7 of 69 opportunities-26 - 50%: 22 of 69 opportunities-51 - 75%: 23 of 69 opportunities-76 - 100%: 6 of 69 opportunities-Refused: 6 of 69 opportunities-Unavailable: 2 of 69 opportunitiesResident #19's Nutrition Supplement Record (Ensure) documented the following:-May: Refused 7 of 11 opportunities-June: Refused 40 of 60 opportunities-July: Refused 31 of 46 opportunitiesOn 7/23/26 at 3:46 PM, the Dietitian stated Resident #19's significant weight loss of 14% had not been identified prior to 7/23/26. She stated staff had not notified her of Resident #19's reduction in appetite.On 7/24/26 at 10:05 AM, the Dietitian stated residents are normally weighed weekly, and Resident #19 was care planned for weekly weights. She stated CNA's take weights on resident shower days and will re-weigh if there is a 5-pound increase/decrease, which was not done for Resident #19. The dietitian stated if a psychotropic monitoring system had been in place someone might have seen the weight loss pattern earlier. She could not answer why weekly weights had not been completed between 5/29/26 and 6/27/26 or between 6/27/26 and 7/20/26.Cross reference F605.

Based on record review, policy review, and staff interviews, the facility failed to ensure allegations of abuse and neglect were reported to the State Agency (SA) as required. This was true for 3 of 6 residents (Resident #2, #14, and #28) reviewed for allegations of abuse and neglect. The failure to report allegations in accordance with federal timeframes created the potential for unaddressed harm and lack of external oversight. Findings include:The facility's Freedom from Abuse, Neglect, and Exploitation policy (revised 1/23/25) documented: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. [The facility] will actively prevent, identify and report any such situations. 1. Resident #2 was admitted on [DATE] with diagnoses including constipation, chronic pain, and adult failure to thrive. a.A review of the facility's abuse investigation dated 6/2/25 documented the facility received a text message from CNA #3 alleging abuse involving CNA #5 and Resident #2. The allegation involved CNA #5 forcibly removing a washcloth from Resident #2's hand and speaking to her in a demeaning manner. A review of the Long-Term-Care Reporting Portal documentation showed the allegation was not reported to the State Agency within the required timeframe. On 7/23/26 at 11:49 AM, the DON stated she was unsure of when the allegation should have been reported to the portal. b.On 4/20/26, CNA #2 sent a text message alleging Resident #2's needs were not met, indicating possible neglect. The allegation was forwarded internally to the DON and Administrator. Staff statements were collected on 4/21/26 and 4/22/26. A review of the Long-Term Care Reporting Portal documented the facility did not report the allegation of neglect. On 7/23/26 at 11:51 AM, the DON stated the facility did not identify the incident as abuse or neglect at the time and confirmed the facility did not report the allegation 2. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including open wound on right lower leg, polyneuropathy, chronic venous hypertension on right lower extremity, hypertension, diabetes, and anxiety. On 7/21/26 at 3;17 PM, she told the surveyor she had concerns about staff but did not want to provide details because she feared her care might change. A grievance dated 7/6/26 showed Resident #14 told her daughter her leg wrapping was too tight, and her daughter reported to the DON that Resident #14 was in pain and that RN #2 had been abrupt with her. RN #2 changed the leg wrapping later in the afternoon. A review of the Long-Term Care Reporting Portal showed no neglect report was submitted on 7/6/26. On 7/24/26 At 9:52 AM, RN #2 stated Resident #14 asked for her leg wrapping to be changed around 8:00 AM, but RN #2 delayed due to other duties. RN #2 gave pain medication around 9:00 AM, and RN #2 did not check whether it relieved the pain. RN #2 believed she changed the wrapping around 10:30–11:00 AM. RN #2 confirmed that 2–2.5 hours was too long for a resident to remain in pain. On 7/24/26 at 11:10 AM, the DON stated the pain medication would take about 45 minutes to work and staff could have checked on Resident #14. She also stated she did not consider this incident neglect because the concern resolved, and therefore it was addressed as a grievance rather than reported as neglect. 3. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including visual loss in both eyes, muscle weakness, diabetes, and depression. A review of an abuse/neglect report dated 6/13/25, submitted to the LTC Reporting System documented Resident #28 had an encounter with staff that left him fearful. The report documented the facility was notified on 6/14/26 that Resident #28 reported to staff he was fearful about comments made to him by CNA #8 during the night on 6/13/26. Resident #28 reported CNA #8 was in his room when she told him,I know where you live. Resident #28 stated he asked CNA #8 if she was stalking him, and Resident #28 reported hearing CNA #8 respond,That's something for me to know and you to find out. A nursing progress note dated 6/14/25 at 9:33 PM, documented staff checked on Resident #28 said he was worried about his family and about not being able to drive over and check on them. A nursing progress note dated 6/15/25 at 10:45 AM, documented the Administrator spoke to Resident #28 about the incident and informed the Administrator he had been CNA #8's Sunday school teacher, and he was confused if CNA #8's comment was made directly about him or the home of his ex-wife. The investigation concluded CNA #8 stated she had spoken before thinking, assuming Resident #28, who she knew personally, would understand her comments as a joke. The investigation documented Resident #28 did not interpret the statements that way, and staff were trained to avoid jest, sarcasm, or other forms of joking that may be perceived negatively by residents or others in the facility. The investigation documented CNA #8 had prior verbal and written warnings regarding her work ethic and following directions from her supervisors. The incident was identified as a last chance warning for CNA #8 to pay closer attention to her language before speaking and to avoid statements that may be interpreted as aggressive or unsafe. The investigation documented that, at Resident #28's request, CNA #8 was allowed to return to work after providing an apology to Resident #28, and informing him when she was in his room and why she was there. On 7/22/26 at 3:45 PM, the surveyor interviewed Resident #28 who did not recall the incident on 6/13/25. On 7/23/26 at 11:08 AM, the surveyor left a message with CNA #8. CNA #8 did not return the call. On 7/24/26 at 11:25 AM, the DON stated that abuse and neglect reports should be reported within the first 2 to 24 hours, depending upon the severity of the abuse or neglect. According to the incident report, dated 6/14/25, which included a comment on 6/16/25 at 8:00 AM, Resident #28's verbal abuse was not reported within the appropriate time. Cross reference F600 and F610.

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to provide an accurate and thorough report to the Long-Term Care Reporting Portal. This was true for 3 of 6 residents (#2, #14, and #28) reviewed for abuse and neglect. This deficient practice created the potential for psychosocial harm if reports of resident verbal abuse or neglect were not thoroughly investigated to ensure resident safety. Findings include:A review of the facility's Freedom from Abuse, Neglect, and Exploitation policy (revised 1/23/25) documented the facility will actively prevent, identify and report any such situations.1. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including an open wound on her right lower leg, polyneuropathy (a medical condition where multiple peripheral nerves throughout the body are damaged at the same time), chronic venous hypertension on right lower extremity (a condition where sustained, elevated blood pressure occurs in the veins of the right leg due to damaged vein valves or blockages), hypertension (high blood pressure, a common condition where blood pushes too hard against the artery walls), diabetes, and anxiety. On 7/21/26 at 3:17 PM, Resident #14 stated she had concerns about staff, but did not want to be specific as she felt her treatment might not be the same. A review of the facilities grievances documented on 7/6/26, Resident #14 had complained to her daughter about the leg wrappings being too tight. Resident #14's daughter called the DON to complain about her mother's pain and to notify the DON that RN #2 was abrupt with Resident #14. The grievance included a statement where RN #2 reported she was able to change Resident #14's leg wrapping sometime later that afternoon. A review of the LTC State Portal did not show a neglect report had been uploaded on 7/6/25 for Resident #14. On 7/24/26 at 9:52 AM, RN #2 stated Resident #14 woke up around 8:00 AM on 7/6/26, and wanted to have her leg wrapping changed from the original wrapping the night before. Due to having other residents to take care of, RN #2 told Resident #14 she could not change her dressings at that time. Around 9:00 AM, RN #2 stated she provided pain medication to Resident #14 along with her regular morning medications. RN #2 acknowledged she did not check in with Resident #14 to see if the pain medication had helped. RN #2 was unclear what time she changed Resident #14's leg wrapping but believed she had changed it around 10:30 AM or 11:00 AM. RN #2 stated, 2 – 2.5 hours was too long for a resident to be in pain. When asked about her nursing progress note indicating she had changed Resident #14's leg wrappings in the late afternoon, she did not respond. On 7/24/26 at 11:10 AM, the DON stated Resident #14's pain medication would take about 45 minutes to become effective, and RN #2 could have checked on Resident #14. The DON stated she did not believe this incident was a neglect case since both parties (Resident #14 and RN #2) had worked through the concern satisfactorily. She stated that this incident was not reported as neglect since the incident had been resolved, but looking at it now, it should have been reported. 2. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including visual loss in both eyes, muscle weakness, diabetes, and depression. A review of an abuse/neglect report dated 6/13/25, submitted to the LTC Reporting System documented Resident #28 had an encounter with staff that left him fearful. The report documented the facility was notified on 6/14/26 that Resident #28 reported to staff he was fearful about comments made to him by CNA #8 during the night on 6/13/26. Resident #28 reported CNA #8 was in his room when she told him,I know where you live. Resident #28 stated he asked CNA #8 if she was stalking him, and Resident #28 reported hearing CNA #8 respond,That's something for me to know and you to find out. A nursing progress note dated 6/14/25 at 9:33 PM, documented staff checked on Resident #28 said he was worried about his family and about not being able to drive over and check on them. A nursing progress note dated 6/15/25 at 10:45 AM, documented the Administrator spoke to Resident #28 about the incident and informed the Administrator he had been CNA #8's Sunday school teacher, and he was confused if CNA #8's comment was made directly about him or the home of his ex-wife. The investigation concluded CNA #8 stated she had spoken before thinking, assuming Resident #28, who she knew personally, would understand her comments as a joke. The investigation documented Resident #28 did not interpret the statements that way, and staff were trained to avoid jest, sarcasm, or other forms of joking that may be perceived negatively by residents or others in the facility. The investigation documented CNA #8 had prior verbal and written warnings regarding her work ethic and following directions from her supervisors. The incident was identified as a last chance warning for CNA #8 to pay closer attention to her language before speaking and to avoid statements that may be interpreted as aggressive or unsafe. The investigation documented that, at Resident #28's request, CNA #8 was allowed to return to work after providing an apology to Resident #28, and informing him when she was in his room and why she was there. On 7/22/26 at 3:45 PM, the surveyor interviewed Resident #28 who did not recall the incident on 6/13/25. On 7/23/26 at 11:08 AM, the surveyor left a message with CNA #8. CNA #8 did not return the call. On 7/24/26 at 11:23 AM, the DON stated as written, Resident #28 experienced verbal abuse by CNA #8. Cross reference F600 and F609. 3. Resident #2 was admitted on [DATE], with diagnoses including constipation, chronic pain, and adult failure to thrive. A review of the facility's abuse investigation dated 6/2/25, documented the facility received a text message from CNA #3 alleging abuse involving CNA #5 and Resident #2. The allegation involved CNA #5 forcibly removing a washcloth from Resident #2's hand and speaking to her in a demeaning manner. The investigation concluded CNA #5 displayed inappropriate behavior and was terminated. However, the investigation did not include an interview with other residents or witnesses identified during the investigation process. On 7/23/26 at 10:47 AM, Resident #2 was asked about the incident but stated she did not recall it. On 7/23/26 at 11:51 AM, the DON confirmed the investigation did not include statements from residents in proximity to the incident and stated the facility should have interviewed them as part of the investigation.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided required written bed hold notification upon transfer out of the facility. This was true for 1 of 1 resident (Resident #8) whose record was reviewed for the discharge process. This failure created the potential for misunderstanding regarding the resident's right to return and the facility's obligation to maintain his bed during hospitalization or therapeutic leave. Findings include:A review of the facility's Transfer and Discharge Notification policy (revised 9/21/22) showed no documentation describing when the bed hold notice must be issued to residents upon transfer.Resident #8 was readmitted on [DATE], with multiple diagnoses including thyroid cancer, dysphagia, and weakness.A record review documented a debulking (a procedure to remove as much as possible of a widespread cancer or tumor) was scheduled for 5/28/26.A Progress Note dated 5/28/26 at 10:55 AM, documented that Resident #8 left the facility at 10:00 AM with his representative in a private vehicle.Resident #8's record included documentation of the facility's discharge process, including:-Practitioners contact information.-Resident representative information.-Physician Orders for Scope of Treatment (POST).However, the record did not include documentation that a bed hold notice was provided to Resident #8 at the time of transfer.On 7/23/26 at 3:08 PM, the DON stated the facility did not provide a bed hold notice to Resident #8. She stated she expected him to return but acknowledged the facility did not formally issue the required bed hold documentation.

Based on observation, policy review, staff interview, and record review, the facility failed to ensure care was provided in a manner that supported and promoted dignity and respect. This was true for 1 of 1 resident (Resident #17) observed during a restorative nursing activity. This failure created the potential for embarrassment, social discomfort, and reduced willingness to participate in the restorative nursing program. Findings include: The facility's Resident Rights Policy (revised 9/22/22) stated, Each resident has a right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. On 7/22/26 at 9:29 AM, Resident #17 was observed ambulating in the hallway with a CNA as part of his restorative nursing ambulation program. During this observation, the resident's urinary catheter drainage bag was hanging from his waistband, fully visible, containing approximately 100 mL of bright yellow urine.On 7/22/26 at 9:30 AM, CNA #4 stated Resident #17 participates in his restorative nursing ambulation program six times per week. When asked about the uncovered catheter bag, CNA #4 stated that placing the drainage bag in a privacy cover was too bulky. She acknowledged that the catheter bag should have been covered to maintain the resident's dignity and privacy during ambulation.

Based on record review, policy review, and staff interviews it was determined the facility failed to provide a Preadmission Screening and Resident Review (PASRR) level II to the designated state agency. This was true for 1 of 1 residents (Resident #3) whose record was reviewed for PASRR documentation. This deficient practice created the potential for harm if Resident #3's coordination of care was not completed between the facility and the designated state agency. Findings include:The facility's policy PASRR for Long Term Care, dated 12/20/24, documented the Social Services Director shall be responsible for keeping track of each resident's assessment, care planning, and transitions of care. Any resident exhibiting a newly evident or possible serious mental disorder will be referred to the state mental health authority for a level II resident review.Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis (a long-lasting disease where the body's immune system attacks the protective covering of nerve cells in the brain and spinal cord, leading to communication problems between the brain and the body), and anxiety disorder.On 5/7/25 Resident #3 was diagnosed with Major Depression (MDD).On 7/24/25 Resident #3 was diagnosed with Post-Traumatic Stress Disorder (PTSD).A review of Resident #3's record did not document a PASRR level II was sent to the state mental health authority on either 5/7/25 or 7/24/25.On 7/23/26 at 9:21 AM, the Social Services Director stated a new PASSR should have been completed and submitted for Resident #3 with the new diagnoses of MDD on 5/7/25 and PTSD on 7/24/25, and it was not.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure bowel management was implemented according to the facility's bowel protocol and the resident's individualized plan of care. This was true for 2 of 12 residents (Resident #1 and #2) whose bowel records demonstrated repeated deviations from the required bowel protocol steps. Improper administration created the potential for unmanaged constipation, discomfort, bowel obstruction, and unnecessary use of PRN medications. Findings Include:The facility's Bowel Care policy, revised 3/4/25, requires the night nurse to:-Review every resident's chart nightly-Identify residents with >24 hours without a BM (bowel movement), or small BM in 48 hours-Identify residents with loose stools-Add residents to the Laxative List accordinglyThe facility's bowel protocol directs staff to administer interventions in a stepwise sequence:Day 1: Increase fluids + provide apple/apricot/prune juiceDay 2: Juice + oral medication (AM/PM)Day 3: Juice + oral medication (AM) + suppository if no BMDay 4: Notify the provider 1. Resident #2 was admitted on [DATE] with multiple diagnoses including constipation, chronic pain, and adult failure to thrive. Resident #2's record documented the following bowel physician orders: - Senokot S Oral Tablet 8.6-50 mg; Give 1 tablet by mouth two times a day related to constipation, initiated on 9/21/23. - Apricot juice, Prune, Juice or Apple juice 4-8 oz the first day without a bowel movement as needed for no bowel movement times one day, initiated 9/20/23. - Bisacodyl Suppository 10 mg; Insert 1 suppository rectally as needed for constipation daily if no results for milk of magnesia, initiated 9/30/24. - Bisacodyl Tablet Delayed Release; give 1 tablet by mouth as needed for constipation may have 1-2 tablets as needed to treat constipation once daily, initiated 9/20/23. - Enemeez Plus Enema 20-283 mg; Insert 1 dose rectally as needed for constipation may have one enema as needed for difficult evacuation, initiated 9/20/23. - Milk of Magnesia Concentrate Suspension; give 30 ml by mouth as needed for constipation may have once daily as needed, initiated 9/20/23. - MiraLax Powder Give 17 gram by mouth as needed for constipation may give in 8 oz of water or juice daily once or twice a day, initiated 9/20/23. - Senokot S Tablet 8.6-50 MG Give 1 tablet by mouth as needed for constipation may have 1-4 tabs by mouth daily, initiated 5/30/24. Resident #2's bowel record documented multiple dates where the bowel protocol was not followed, including incorrect sequencing, premature use of PRN medications, and skipped steps: 3/24–3/27/26: MiraLax given before Day 1; Bisacodyl tablets given on Days 3 and 4 4/17–4/19/26: MiraLax given on Day 1 5/18–5/21/26: Juice given on Day 3 (should be Day 1) 6/3–6/6/26: MiraLax given for 5 consecutive days 6/16–6/18/26: MiraLax given on Day 4 6/25–6/28/26: MiraLax given on Day 3 7/10–7/12/26: Bisacodyl tablets given on Days 3 and 4 On 7/24/26 at 12:08 PM, the DON confirmed Resident #2's record showed improper administration and documentation of the bowel protocol. 2. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including dementia, diabetes, and anxiety. Resident #1's physician's bowel protocol orders included the following: - Apricot juice, prune juice, or apple juice 4-8 oz the first day without a BM every 24 hours as needed for no bowel movement x 1 day, initiated 9/4/24. -Bisacodyl tablet delayed release, give 1 tablet by mouth every 24-hours as needed for constipation. May have 1-2 tables as needed to treat constipation once daily, initiated 9/4/24. -Enemeez plus enema 20-283 mg, insert 1 dose rectally every 24-hours as needed for constipation, may have one Enemeez as needed for difficult evacuation, initiated 9/4/24. -Milk of Magnesia Concentrated Suspension, give 30 ml by mouth every 24 hours as needed for constipation, may have once daily as needed, initiated 9/4/24. -MiraLax Powder, give 17 grams by mouth every 24 hours as needed for constipation, may give in 8 oz of water or juice daily once or twice a day, initiated 9/4/24. -Senokot tablet, 8.6-50 mg, give 1 tablet by mouth every 24 hours as needed for constipation, may have 1-4 tabs by mouth daily, initiated 9/4/24. Resident #1's care plan, initiated 9/4/24, did not include bowel management protocol. A review of Resident #1's medication administration record (MAR) documented the following: April 2026 No BM on 4/7, 4/8, 4/9 and 4/10. - Prune juice administered on 4/16. - Bisacodyl administered on 4/11. - Senokot administered on 4/9, 4/10, 4/18, 4/19, 4/22, and 4/24. Medication was not administered on 4/8 and 4/9. May 2026 No BM on 5/12, 5/13, 5/14 -Bisacodyl administered on 5/27 and 5/30. -Senokot tablet was administered on 5/14 and 5/21. Enemeez was not administered. Medication was not administered on 5/13. June 2026 No BM 6/8, 6/9, 6/10, 6/11, 6/12, 6/23, 6/24, 6/25, 6/27, 6/28, 6/29, and 6/30. -Apricot juice administered on 6/18, 6/29, and 6/30. -Bisacodyl tablet administered on 6/12, 6/13, 6/18, 6/24, and 6/30. -Senokot tablet administered on 6/11, 6/13, 6/15, 6/22, 6/25, 6/26, and 6/29. Enemeez was not administered. Medication was not administered on 6/9 and 6/28. July 2026 No BM 7/7, 7/8, 7/9, 7/16, 7/17, and 7/18. -Bisacodyl tablet was administered on 7/11, 7/18, and 7/19. -Senokot tablet was administered on 7/1, 7/3, 7/8, and 7/18. Apricot juice was not administered. Enemeez was not administered. No medication was administered on 7/9 and 7/17. On 7/24/26 at 12:08 PM, the DON stated, It appears we are not following the protocol as there are blanks [in the MAR] indicating we are not offering medication appropriately. She continued, The bowel protocol would not be included in the care plan unless it had been assessed and identified as a concern. The DON clarified that Day #1 of Bowel management begins 24 hours after a resident does not have a bowel movement.

Based on record review, resident interview, and staff interview, it was determined the facility failed to ensure residents received insulin administration, at the physician ordered time. This was true for 1 of 1 resident (Resident #28) reviewed for medication administration. This deficient practice created the potential for harm if time sensitive medication was not offered as ordered by the physician. Findings include:Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including visual loss in both eyes, muscle weakness, diabetes, and depression.On 7/21/26 at 2:29 PM, Resident #28 stated he had missed an insulin dose but didn't recall which day it was.A physician's order, dated 2/10/26, documented to give Resident #28 insulin glargine, 100 unit/ml, inject 15 unit subcutaneously one time a day related diabetes, at 8:00 AM.Resident #28's care plan, initiated 5/30/25, directed staff to provide diabetes medication as ordered by the provider. An Incident and Accident report, dated 2/28/26, documented staff were preparing to give Resident #28 his evening medication and found his morning medication still in the drawer. Resident #28 had not received his morning medication. The incident report documented Resident #28, the physician, and DON were notified.A review of the Medication Administration Record (MAR) dated February 2026, documented all of Resident #28's morning medications were administered.A review of Resident #28's MAR, dated March 2026 through July 2026, did not document any missed insulin doses.On 7/24/26 at 12:42 AM, the DON stated that the nurse responsible for administering medication to Resident #28 on 4/20/28 documented the medication as administered before entering the resident's room. The DON reported that when the nurse entered the room, Resident #28 was in the bathroom, and the nurse subsequently returned the medication to the cart without correcting the MAR.The DON stated that best practice is to document medication as completed only after the resident has actually received the medication, and confirmed the nurse did not follow this required process.

Based on record review, policy review, and staff interview, it was determined the facility failed to prevent accidents. This was true for 2 of 4 residents (Resident #5 and #28) whose records were reviewed for accident prevention. This deficient practice created a potential for harm when Resident #5 fell while wearing a pressure-relieving boot, and when Resident #28's room items were moved to new locations creating environmental hazards. Findings include:The facility's Risk Assessment for Accidents, Falls, and Care Planning revised 2/24/25, documented the resident environment is to remain as free of accident hazards as is possible, and to provide each resident adequate supervision and assistive devices to prevent accidents including: Identifying hazard(s) and risk(s); Evaluating and analyzing hazard(s) and risk(s); Implementing interventions to reduce hazard(s) and risk(s); and Monitoring for effectiveness and modifying interventions when necessary. 1. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including visual loss in both eyes, muscle weakness, diabetes, and depression. Resident #28's care plan, initiated 5/30/25, directed staff about his limited mobility due to blindness; and to keep a safe environment with even floors free from spills and/or clutter. The facility's I&A report, dated 4/20/26, documented Resident #28 was found on the floor at 6:15 AM trying to get into his recliner. The report documented that Resident #28 was blind and that his garbage can and recliner had been moved and he was trying to put his garbage can back into the correct location, and when he went to sit on his recliner he fell to floor. He had slight redness to the right side of his back. On 7/24/26, the DON stated Resident #28's care plan should have directed housekeeping and nursing staff not to move his room furniture as it could have prevented his fall. 2. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including history of falling, muscle weakness, dizziness and giddiness. The Facility Fall Report dated 4/22/26, documented Resident #5 fell while attempting to self-transfer from his recliner to the restroom without assistance. The report documented Resident #5 was wearing a protective boot on his right foot and a non-skid sock on his left foot. Resident #5's care plan, revised 5/12/26, directed staff to implement the following fall prevention interventions: -Invite Resident #5 to sit in a recliner by the nurse's desk for increased observation during confusion/anxiety. -Labs and x ray ordered. -Provide education about A fib and symptoms. -Staff to round earlier in the morning and ask if he needs to use the restroom. -Ensure hearing aids are charging correctly when removed. -Ensure multiple walkers and clutter are removed from his room. Resident #5's care plan, revised 3/10/26, directed staff to implement the following interventions for suspected deep tissue injury: -Pressure relieving boot on right foot only when in bed. -Float heels and remove shoes when he is in his recliner or bed. On 7/24/26 at 11:59 AM, the DON confirmed Resident #5 should not have been wearing his boot while in the recliner and agreed it may have contributed to his fall.

Based on record review, and staff interview, it was determined the facility failed to prevent harm without adequately monitoring the side effects of psychotropic drug medications. This was true for 5 of 5 residents (#4, #6, #9, #19, and #29) whose medication side effect monitoring were reviewed. This deficient practice created the potential for harm for Resident #4 when her psychotropic medication was not monitored and when Residents #6, #9, #19, and #29 were not monitored for signs and symptoms related to psychotropic medication use. Findings include: A policy for psychotropic use was requested and not provided. 1. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including anxiety, chronic pain syndrome, and a history of urinary tract infections. Drugs.com, accessed on 7/31/26, documented side effects of Clonazepam (an antidepressant) causes drowsiness, poor coordination and dizziness, along with memory disturbances, fatigue, and decreased appetite. An antidepressant care plan, initiated 5/26/26, directed staff to monitor and document side effects and effectiveness. No specific side effects were listed. An anti-anxiety care plan, initiated 5/26/26, directed staff to monitor, document, and report prn adverse reactions to anti-anxiety therapy, including: -Drowsiness, Lack of energy, Clumsiness -Slurred speech, Confusion and disorientation, Depression -Dizziness, Lightheadedness -Impaired thinking and judgment, Aggressive or impulsive behaviors A review of Resident #19's record documented the following physician orders: -Clonazepam oral tablet, 1 mg, 1 tablet daily at bedtime due to anxiety, initiated 5/26/26. -Clonazepam oral tablet, 0.5 mg, give 1 tablet in the morning due to anxiety, initiated 5/27/26. A review of Resident #19's care plan, initiated 6/24/26, documented the following: -6-24-26 unwitnessed fall, no apparent injury -6-25-26 unwitnessed fall, no injury noted -7-7-26 unwitnessed fall, no injury -7-10-26 unwitnessed fall, injury, (head laceration with three staples.) -7-12-26 unwitnessed fall, injury, (fell and hit head.) -7-17-26 unwitnessed fall, minor injury, (fell and hit head.) A review of Resident #19's record documented a 17.8-pound weight loss. On 7/23/26 at 3:03 PM, the DON stated the facility does not monitor side effects of antipsychotic medications. On 7/23/26 at 3:46 PM, the Dietitian stated Resident #19's 14% weight loss had not been identified prior to the interview. She stated staff had not notified her of Resident #19's reduction in appetite. Cross reference F689 and F692. 2. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including dementia and anxiety. The care plan, initiated 6/17/25, directed staff to monitor, document, and report prn adverse reactions of psychotropic medication, including, but not limited to: -Unsteady gait -Tardive dyskinesia, Extrapyramidal Symptoms (shuffling gait, rigid muscles, shaking), Frequent falls -Refusal to eat, Difficulty swallowing -Depression, Suicidal ideations, Social isolations -Blurred vision -Loss of appetite, Weight loss -Behavior symptoms not usual to the person A review of Resident #4's record documented the following active physician orders: -Brexpiprazole oral tablet, 0.5 mg, give 1 tablet per day for dementia, initiated 3/19/26. On 7/23/26 at 3:07 PM, the DON stated the facility did not have side effect monitoring of Resident #4's dementia medications. 3. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including dementia, anxiety, insomnia, and opioid dependence. The care plan, initiated 9/17/25, and updated on 6/6/26, directed staff to monitor every day and prn, psychotropic medications. No specific signs and symptoms were identified, nor were staff directed to record psychotropic medication effects. A review of Resident #29's record documented the following active physician orders: -Escitalopram tablet, 20 mg, daily for anxiety, initiated 9/11/25. -Clonazepam tablet, 0.5 mg daily for insomnia, initiated 11/14/25. -Clonazepam tablet, 0.5 mg daily for anxiety and agitation, initiated 12/5/25. -Trazodone HCl tablet, 50 mg at bedtime for insomnia, initiated 4/16/26. -Brexpiprazole, 2 mg at bedtime for dementia, initiated on 7/10/26. Resident #29's record did not include monitoring documentation for anti-anxiety and antidepressant (psychotropic) medication side effects. On 7/23/26 at 3:07 PM, the DON stated the facility did not have side effect monitoring of Resident #29's antianxiety and antidepressant medications. 4. Resident #6 was readmitted on [DATE], with multiple diagnoses including depression, anxiety, and dementia. Resident #6's care plan, initiated 7/9/25, directed staff to monitor, document, and report PRN adverse reactions to antidepressant therapy, including: -Changes in behavior, mood, cognition -Hallucinations, delusions, social isolation, suicidal thoughts -Decline in ADLs, continence, or voiding -Constipation, diarrhea, fecal impaction -Gait changes, rigid muscles, tremors, movement problems -Falls, dizziness, vertigo -Fatigue, insomnia -Appetite loss, weight loss, nausea/vomiting -Dry mouth, dry eyes A review of Resident #6's physician orders documented an active order for: -Sertraline (antidepressant) HCl 100 mg, one tablet daily for depression, initiated 11/15/25. A review of Resident #6's record documented no use of antidepressant side effect monitoring as required by the care plan. On 7/23/26 at 3:03 PM, the DON confirmed no side effect monitoring was present in Resident #6's record. 5. Resident #9 was admitted on [DATE], with multiple diagnoses including dementia, anxiety, and chronic pain. The care plan, initiated 3/6/24, directed staff to monitor, document, and report PRN adverse reactions to antianxiety therapy, including: -Drowsiness, lack of energy, clumsiness -Slow reflexes, slurred speech -Confusion, disorientation, depression -Dizziness, lightheadedness -Impaired thinking/judgment -Memory loss, forgetfulness -Nausea, stomach upset -Blurred/double vision -Unexpected reactions: mania, hostility, rage, aggressive/impulsive behavior, hallucinations A review of Resident #9's record documented the following active physician orders: -Lorazepam (antianxiety) 1 mg, twice daily for anxiety disorder, initiated 7/11/25. -Escitalopram (antianxiety) 10 mg, at bedtime for anxiety, initiated 6/13/25. Resident #9's record did not include monitoring documentation for antianxiety medication side effects. On 7/24/26 at 11:55 AM, the DON stated the facility did not have official documentation of required side effect monitoring for Resident #9's antianxiety medications.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include: The Idaho Food Code, revised February 2021, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The facility's TCU Resident Food Storage policy dated 11/8/23, documented residents may have food brought in from home sources or gardens from family or friends with the provision that they are marked with the resident's full name, the date opened, and that the goods are checked for safety when brought in to the facility, i.e. sealed jars, expiration dated, etc. On 5/27/25 at 9:00 AM, with Dietary Coordinator present, observed in the walk-in freezer, the following food storage related issues. - One bag of biscuits was not sealed and opened to room air, - One large Ziploc bag of sandwiches was not dated. - Large amounts of ice build up on floor and fans in the walk-in freezer unit. On 5/27/25 at 9:15 AM, the Dietary Coordinator stated the ice buildup needed to be addressed, food items should be properly sealed and properly dated and were not. On 5/29/25 at 10:03 AM, with the assistant Dietary Coordinator present, observed the following issues in the nourishment room refrigerator which contained resident refrigerated food items. - Opened relish container with no open date or name of resident, - Opened container of homemade jelly/jam with 2024 date documented on the lid and no name of resident, - Ziploc bag of sliced cheese with no date. On 5/29/25 at 10:05 AM, the assistant Dietary Coordinator stated refrigerated resident food items must be dated and have resident names or be disposed of.

Based on record review, policy review, document review, and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an Advance Directive. This was true for 6 of 25 Residents (#3, #5, #8, #9, #10, and #22) whose records were reviewed for advance directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning. Findings include: The facility's TCU Advanced Directives policy dated [DATE], documented the following under Procedures; - 1. Upon admission the resident/representative will be given the form Your right's as a patient to make medical treatment decisions. After reading this form they will be ask(ed) to sign that they have read and received the form and to declare if they already have advanced directives and what kind. - 4. If the resident already has made advanced directives, the admitting nurse will invite them to bring copies of the advanced directives to the facility to be placed in the residents' chart. - 5. If they have not established advanced directives but wish to, they will be referred to social services to have the option to create a (1) Living Will/Durable Power of Attorney for Health Care (2) POST, or (3) declare CPR status. - 6. Advanced Directives will be reviewed and discussed with the resident/representative upon the residents annual admitted by social services or as often as the resident/representative desire. The facility's Your Rights As A Patient To Make Medical Treatment Decisions document only contained information pertaining to living will and durable power of attorney for health care, and had not contained documentation declaring the status of an Advance Directive. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including dementia and depression. On [DATE], Resident #3's medical record had not contained documentation of Advance Directives and no documentation that the facility had offered to assist her with formulating an Advance Directive. On [DATE] at 10:28 AM, the DON stated the facility had Resident #3 document if she wanted CPR or not and that was the extent of their Advance Directives. On [DATE] at 10:30 AM, the Social Worker stated during annual admitted review with Resident #3, there was no documentation that Advanced Directives were discussed or confirmed. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease and chronic respiratory disease. On [DATE], Resident #5's medical record had not contained documentation of Advance Directives and no documentation that the facility had offered to assist her with formulating an Advance Directive. On [DATE] at 10:28 AM, the DON stated they had Resident #5 document if she wanted CPR or not and that was the extent of their advance directives On [DATE] at 10:30 AM, the Social Worker stated during annual admitted review with Resident #5, there was no documentation that Advanced Directives were discussed or confirmed. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including depression and chronic obstructive pulmonary disease (a progressive lung disease characterized by airflow limitations and chronic respiratory symptoms). On [DATE], Resident #8's medical record had not contained documentation of Advance Directives and no documentation that the facility had offered to assist her with formulating an Advance Directive. On [DATE] at 10:28 AM, the DON stated they had Resident #8 document if she wanted CPR or not and that iwas the extent of their advance directives. On [DATE] at 10:30 AM, the Social Worker stated during annual admitted review with Resident #8, there was no documentation that Advanced Directives were discussed or confirmed. Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including dementia and depression. On [DATE], Resident #9's medical record contained a POST document but had not contained documentation of Advance Directives and no documentation that the facility had offered to assist him with formulating an Advance Directive. On [DATE] at 10:28 AM, the DON stated they had Resident #9 document if he wanted CPR or not and that was the extent of their advance directives. On [DATE] at 10:30 AM, the Social Worker stated during annual admitted review with Resident #9, there was no documentation that Advanced Directives were discussed or confirmed. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including anoxic brain damage (an injury that caused the brain to not receive oxygen) and diabetes. On [DATE], Resident #10's medical records had not contained documentation of Advance Directives and no documentation that the facility had offered to assist him with formulating an Advance Directive. On [DATE] at 10:28 AM, the DON stated they had Resident #10 document if he wanted CPR or not and that was the extent of their advance directives On [DATE] at 10:30 AM, the Social Worker stated during annual admitted review with Resident #10, there was no documentation that Advanced Directives were discussed or confirmed. Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including chronic viral hepatitis (infection that causes liver inflammation and damage) and dementia. On [DATE], Resident #22's had not contained documentation of Advance Directives and no documentation that the facility had offered to assist her with formulating an Advance Directive. On [DATE] at 10:28 AM, the DON stated they had Resident #22 document if she wanted CPR or not and that was the extent of their advance directives. On [DATE] at 10:30 AM, the Social Worker stated during annual admitted review with Resident #22, there was no documentation that Advanced Directives were discussed or confirmed. 52524

Based on record review, policy review and staff interview, it was determined the facility failed to ensure residents care plans were revised and updated. This was true for 2 of 12 residents (#1 and #19) whose care plans were reviewed. This created the potential for harm when residents' care plans were not revised to reflect care or fall prevention needs. Findings include: The facility's Care Plan policy, revised September 2022, documented the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's Risk Assessment for Accidents, Falls, and Care Planning policy dated 2/24/25, documented care plans will be specifically developed for each resident to mitigate the risk of falls utilizing the TCU care planning regarding falls procedure. Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. a. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (a progressive lung disease characterized by airflow limitations and chronic respiratory symptoms) and depression. On 5/27/25, Resident #1's record documented falls on 12/2/24, 12/12/24, 1/27/25, 2/11/25, and 4/20/25. Resident #1's care plan had not addressed fall interventions related to each fall occurrence. The following dates identifies each fall and the facility's Fall Committee documentation. - 12/2/24 - Resident #1 considered a high fall risk, was found sitting on the floor after a fall and the following interventions had previously been implemented - move resident's room closer to nurses station, frequent rounding, touch call light, repeated education, urinal at bedside. - 12/12/24 - Resident #1 fell as CNA was walking into his room. Plan - staff have been reminded to ensure the urinal is within his reach and to keep it empty. - 1/27/25 - Resident #1 fell out of bed due to oxygen tubing. Plan - Given shorter tubing. - 2/11/25 - Resident #1 slipped off his bed, stating his shoe slipped off. No plan noted. - 4/20/25 - Resident #1 slipped off his bed, stating his feet slipped. Plan - Staff to ensure non-skid footwear is on resident prior to leaving room. None of the facility's Fall Committee documented interventions for Resident #1 were care planned following each fall incident. On 5/28/25 at 2:24 PM, the DON stated Resident #1's care plans should have been updated to address each fall related issue but were not. The fall committee did investigate and commented on each fall but this information did not get transferred into Resident #1's care plans. b. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension (high blood pressure). On 5/28/25, Resident #19's care plan had not documented resident wandering incidents or interventions to address wandering. On 5/28/25 at 8:58 AM, review of progress note, dated 5/16/25, documented Resident #19 was very agitated and wandered outside of the facility and was walked back inside. Additional progress notes dated, 3/18/25, 4/2/25, and 4/6/25, documented Resident #19 wandering about the facility. The MDS admission assessment, dated 3/24/25, documented Resident #19 had experienced wandering experiences 1-3 times. On 5/28/25 at 10:30 AM, the Social Worker and DON stated care plans are to be updated and had not been. 51121

Based on observation, interview, and record review, it was determined the facility failed to ensure the MDS assessment accurately reflected resident's status. This was true for 1 of 12 residents (Resident #21) whose MDS, care plan, and nursing assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments. Findings include: Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and stroke. Resident #21's MDS height measurement were documented as follows: - 7/3/24, documented his height at 66 inches. - 10/2/24, documented his height at 63 inches. - 12/31/24, documented his height at 66 inches. - 4/2/25, documented his height at 63 inches. On 5/28/25 at 10:29 AM, the Administrator stated she was not sure why Resident #21's height discrepancies were put into the MDS assessments.

Based on observation, State Operations Manual, and interviews, it was determined the facility failed to ensure safe water temperatures in resident rooms. This was true for 2 of 5 resident rooms (12 and 15) whose water temperatures were checked. This deficient practice placed residents at risk for harm when using room sink water. Findings include: State Operations Manual Appendix PP, 483.25d, Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time exposure. Table 1. Time and Temperature Relationship to Serious Burns Water Temperature Time Required for a 3rd Degree Burn to Occur 155 F 1 second 148 F 2 seconds 140 F 5 seconds 133 F 15 seconds 127 F 1 minute 124 F 3 minutes 120 F 5 minutes 100 F Safe Temperatures for Bathing NOTE: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including pneumonia and hemiplegia and hemiparesis following stroke (Hemiplegia refers to complete paralysis on one side of the body, while hemiparesis refers to weakness on one side of the body). On 5/27/25 at 1:26 PM, Resident #17 stated his room (12) water temperature was very hot. The following resident room water temperatures were found to be above 120 degrees Fahrenheit (F). - On 5/27/25 at 1:28 PM, the sink water temperature was 125 degrees F in room [ROOM NUMBER]. - On 5/27/25 at 1:42 PM, the sink water temperature was 126 degrees F in room [ROOM NUMBER]. On 5/28/25 at 2:12 PM, the Administrator stated the maintenance department verified the water was too hot and found the boiler setting at 122 degrees F which has been corrected.

Based on observation, staff interview, and record review, it was determined the facility failed to prevent avoidable pressure ulcers (PU) and that PUs were consistently and thoroughly assessed and monitored for 1 of 2 sample residents (#1) reviewed for PUs. Resident #1 was harmed when a previous Stage II PU at the left gluteal fold reoccurred as an SDTI (suspected deep tissue injury) then deteriorated to Stage IV with tunneling and osteo[DIAGNOSES REDACTED] (infection of the bone); a right hip Stage II PU developed related to a catheter tubing; and, an SDTI developed to the right great toe from an unknown cause. Findings include: Resident #1 was admitted to the facility 4/11/12 with multiple [DIAGNOSES REDACTED]. The resident's annual and three most recent quarterly MDS assessments, dated 6/26/14, 4/3/14, 9/25/14, and 12/18/14 respectively, all coded moderately impaired cognitive; short and long-term memory impairment; usually understood by others and able to understand others; extensive assistance for bed mobility, dressing, and personal hygiene; total assistance for transfers, eating, toileting, and bathing; functional limitation in both upper and both lower extremities; [MEDICAL CONDITION] and indwelling urinary catheter; and at risk for PUs. The 4/3/14 quarterly MDS also coded 1 unhealed Stage II PU and 1 unstageable PU due to SDTI, neither of which were present on admission or the previous MDS assessment. Skin/ulcer treatments included a pressure reducing device for the chair and bed, PU care, and application of ointments/medications other than to feet. The 6/26/14 annual MDS also coded 1 healed Stage II PU with skin/ulcer treatments of pressure reducing device for the chair/bed and application of ointments/medications other than to feet. The 9/25/14 quarterly MDS also coded 1 unstageable PU due to slough and/or eschar with skin/ulcer treatments of pressure reducing device for the chair/bed, PU care, and application of ointments/medications other than to feet. The 12/18/14 quarterly MDS also coded 1 Stage IV PU with the same skin/ulcer treatments as the 4/3/14 and 9/25/14 MDS assessments. The resident's 7/2/14 PU CAA documented the indicator was "existing" PUs and "...remains a high risk for developing pressure ulcers at this time..." The resident's care plan documentation included the following problems and their associated goals, approaches/interventions, and the date of change: * "5/01/12 Risk for Skin Breakdown Has history of pressure ulcers" - "Prevent pressure ulcer maintain/reduce RAPU (risk assessment for PUs) score RAPU= 14 High risk" - "...Has air bed...10/16/12" "Use draw sheet...Reposition q (every) 2 hrs (hours) when in bed...6/15/12" "Uses air cushion in wheelchair; May be up for periods 2 hrs only...12/18/14" "...wears multi boots on both feet (undated)" "May go 4 hrs between positioning during the night to allow for deep sleep...8/21/12" "Catheter tubing positioned to maintain skin integrity q 2 hrs while awake and q 4 hours during the night...5/13/13." * "8/25/14 Impaired Skin Integrity...unstageable pressure sore...12/18/14 Now a stage IV" - "Ulcers will heal without complications" - "Wound care per policy/treatment sheet, Wound Specialist, physician (undated)" "Monitor, evaluate, readjust, and document interventions and outcomes (undated)" "Visits to wound clinic 2 x (times) month-follow Doctor's orders (undated)" * "12/18/14 Hx (history) of wound infection" - "...Most recent wound infection 11/26/14." * "4/14/12 Nutritional Status: Serious nutritional risk r/t complicated medical course...Hx pressure sore... - "Diet Order Regular with high protein supplements...6/15/12" - "8/25/14 Actual skin breakdown..." - "...wound will heal..." - "11/26/14 Infected wound-delayed healing" - "6 oz (ounce) high protein shake with each meal; 8 oz high protein shake between meals...8/25/14" "recommend zinc supplement...and iron supplement x 3 months until wound heals...8/25/14" "encourage fluids...8/25/14." - "2-8-15 [DIAGNOSES REDACTED]..." - "wound & (and) bone infection will resolve..." - "Vancomyacin (sic) IV (intravenous), [MEDICATION NAME] IV as ordered (undated)..." A 3/3/14 Incident Report (IR) for Resident #1 documented, "Found pressure sore stage II 3 x (by) 2 x 0.1 (cm) in left gluteal fold...0.2 open area, serosanguinous drainage, small amt (amount)...Area cleansed and [MEDICATION NAME] border lite 4 x 4 placed...Recently it was decided that resident be allowed to make decision whether or not she should lay down after lunch...I suggest...allow (resident's name) to feel like she has control by giving her a choice. For example: What movie would you like to watch while you are in bed?...(Resident's name)...mental age of a 4 or 5 yr (year) old. We are unable to educate her. She does not always comprehend consequences either...did lie down after lunch today...up for much longer periods of time the 2 days before." Equipment involved was a wheelchair. A 3/4/2014 Department Head Investigation documented, "...could be related to resident choice to sit up longer in chair. Will make return to former need to lay down after lunch...Skin nurse...to follow closely...approach above will be good for staff to adopt. Will discuss Staff Meeting 3/5/2014." The resident's Skin Assessment and Treatment records (SA/T) and Skin Notes and Treatment Records (SN/TR) for March 2014 documented the left gluteal fold Stage II PU, labeled as "H1," on 3/3, 3/10, and 3/31. The SN/TR referred to photo mount sheets and on 3/31 noted the PU was, "Resolved..." The left gluteal fold Stage II PU photo mount sheet/assessment documentation included: * 3/3/14 - "Stage 2" PU, "Size (LxWxD (length by width by depth)) "3 x 2 x 0.01 cm (centimeters)," "Dressing/Comments: Wound [MEDICATION NAME]. Have repositioned resident off of area. Open area is 0.25 x 0.50 cm. Small areas superficial..." * 3/10/14 - "Stage II" PU, "Size...NA (not applicable)," "Dressing/Comments: Area cleansed (after) shower. Wound almost healed. Only pinpoint size area open...No measurements taken at this time." * 3/31/14 - "Dressing/Comments: Resolved skin intact and blanching..." There was no documented evidence the facility assessed/monitored the left gluteal fold Stage II PU for almost 3 weeks between 3/10-3/31/14 (20 days). The resident's SA/T records and SN/TR for May and June 2014 documented a left "inner" thigh "abrasion," labeled as "A1." The SN/TR documented the abrasion on 5/19, referred to photo mount sheets, and on 6/17 documented "L inner thigh resolved." The facility provided only two photo mount sheet/assessments, 5/19/14 and 6/17/14. There was no documented evidence the facility reassessed/monitored the left inner thigh abrasion for 4 weeks between 5/19 and 6/17/14 (28 days). In addition, an IR regarding this abrasion was requested but was not provided by the facility. An 8/6/14 IR for Resident #1 documented, "...abrasion noted on left buttock area...where attends (sic) can slide across this spot." Contributing factors included, "Need to be careful when placing or taking attends off not to cause friction" and "Comments: Resident at high risk for skin concerns. This area of concern will be watched closely and care has been instructed to aides with placing and removing attends." The SA/T records and SN/TR for August 2014 documented the left buttock abrasion noted on 8/6, was labeled "A1" until 8/27 when the label was changed to "L1" for unstageable. An 8/27/14 IR for Resident #1 documented, "...sore red area left inner thigh...abrasion like...dressing was removed...yellow slough in wound bed...This site was previously labeled A1- for abrasion when it was first noted on 08-25-2014, label changed to L1-unstageable on 8-27-2014. Photo placed in skin book..." Regarding contributing factors and witnesses, "NO ANSWER" was documented. And, comments by the DON on 10/14/14 (1 1/2 months later) documented, "Area noted by aide and then LPN got involved. Wound in different location. Resident has contractures of her legs. Left leg lays sideway when she is in bed. Area to be watched closely." Photo mount sheet/assessments regarding the "L1" SDTI/unstageable PU documented: * 8/27/14 - "(L) inner thigh" SDTI size 2 x 1.5, wound bed 80% yellow (slough), moderate amount serosanguineous drainage; Note: The next assessment was 10 days later. * 9/7/14 - "(L) inner thigh" "Pressure Ulcer...SDTI" size increased to 3 x 3.5, moderate amount serosanguineous drainage, wound bed yellow, and now foul odor and eschar present, "Offload-until consult (with) PT (physical therapy); A 9/7/14 IR documented, "...found that wound advanced; pic taken." "Contributing factors: NO ANSWER." Comments, "Discussed with (LN's name). This Unstageable is the same...left ischial tuberosity." * 9/11/14 - Location was changed to "(L) ischial tuberosity (IT)" size increased to 5.2 x 3, no odor, small amount serosanguineous drainage, wound bed 5% yellow & 80% eschar, "bone palpable...Off loading in bed. Roho placed in wheelchair yesterday." * 9/12/14 - (L) IT size 3.2 x 3, moderate odor, small amount serosanguineous drainage, 40 % yellow and 60% eschar after debridement by PT, "...Unable to determine depth D/T (due to) eschar present." * L1 was reassessed every 1 to 3 days between 9/17 & 9/26/14. * 9/26/14 - (L) IT size 3.4 x 3 x 2.6, wound bed 70% yellow, debrided by physician; * 9/29/14 - (L) IT size 3.6 x 3 x 2.8, wound bed 50% yellow & 50% red granulation, "Green drainage...foul odor...New wet to dry drsg (dressing)..." * 10/8/14 - (L) IT, "No eschar...depth...(increased)...Wet to dry drsg...Normal gel with Ag (silver)...in wound bed...Odor not as bad...started on [MEDICATION NAME]...10-7-14." * 10/24/14 - (L) IT size 8.4 x 4.4 x 3.8, large amount serosanguineous drainage, wound bed 30% yellow/70% red granulation, "...Wound vac placed with Santyl directly in wound bed..." * 10/27/14 - (L) IT size 2.5 x 1.6 x 3.5, "Drainage consistent with wound vac usage. Fowl (sic) odor...Resident showed signs of discomfort during wound cleansing." * 11/7/14 - (L) IT size 3 x 1.7 x 3, moderate amount green/yellow serous & sanguineous purulent drainage and foul odor, wound bed 70% "gray/brown," "...wound sides appear gray/brown...Yellow @ base appears thicker...on [DEVICE]" * 11/12/14 - (L) IT, size 3 x 1.5 x 3.7, foul odor, wound bed 70% brown. * 11/14/14 - (L) IT size 2.6 x 1.6 x 4.4, large amount sanguineous drainage, foul odor. * 11/20/14 - (L) IT size 3 x 2.4 x 5, "Wound debrided...at wound clinic on 11-19-14. Drsg (changed) this am per new order... * 11/24/14 to 3/9/15 - The PU size continued to vary. However, the depth of the PU increased and was noted as 7.8 on 12/29/14. On 1/9/15, 50% eschar in the wound bed was noted again. On 1/26/15, the PU was documented as a Stage IV and tunneling at the (L) and (R) side of the PU was noted for the first time. The (L) side tunneling was 9 cm (R) side was 6 cm. By 3/9/15, the PU size was 3.5 x 2 with 100% red granulation in the wound bed and (L) side tunneling was 8.5 while (R) side tunneling increased to 10.5. The resident's pelvis radiology report, dated 2/6/15, documented, "[DIAGNOSES REDACTED] of the inferior left pubic ramus with destructive changes and abnormal periostitis and trabecular pattern." The resident's September 2014 SA/T also documented documented a new Stage II PU, labeled "H1," on 9/19 and documented as, "9/19...H1 - New - See photo mount sheet" in the September 2014 SN/TR. The "H1" PU was not mentioned again in either the September or October SA/T or SN/TR. However, the November 2014 SN/TR noted, "11/1...H1 (R) hip - blister - resolved - unknown when." The 9/19/14 (R) hip Stage II PU photo mount sheet/assessment documented, "Wound type blister-crater" size 3.7 x 0.5 cm" and "*Resolved. 11/1/14, see skin sheet." The IR and all documentation regarding the (R) hip Stage II PU was requested. On 3/13/15 at 3:00 p.m., the DON informed the surveyor that an IR was not found. However, the DON provided the resident's Patient Progress Notes (PNN) for 9/19 and 9/20/14. The PNN included a 9/19 entry which documented, "Skin...Open area, no weeping or bleeding, small sore on right back side hip. Looks like maybe from laying on cath hose." And lastly, a 3/25/14 IR for Resident #1 documented, "Lg (large) bruise or blood blister found to right great toe...had black boots on this shift. Found...when removing boots and getting her ready for bed...(no) s/s (signs/symptoms) of pain..." and "Suspect that toe was caught or smashed during a transfer more care should be taken when transferring resident." "Unknown" was documented regarding property or equipment involved. And, a 3/27/2014 Department Head Investigation documented, "...seen by DON. Not sure how this occurred as she has had boots on. Will be watched..." The SA/T records and SN/TR for March, April, and May 2014 documented the right great toe bruise/blister as an SDTI and the SN/TR referred to photo mount sheets. The right great toe PU photo mount sheet/assessments were dated 3/25/14, 4/7/14, 4/16/14, 4/24/14, 5/8/14, and 5/22/14. There was no documented evidence the facility assessed/monitored the right great toe SDTI between 3/25 & 4/7 (12 days), between 4/7 & 4/16 (8 days), between 4/24 & 5/8 (13 days), and between 5/8 & 5/22/14 (13 days). On 3/11/15 at 1:30 p.m., the DON was asked about the resident's 3/3/14 left gluteal fold PU, the 5/19/14 left inner thigh abrasion, the 8/6/14 (L) buttock abrasion that was changed to a (L) inner thigh SDTI on 8/27/14 and changed again to a left IT unstageable PU on 9/11/14, the 3/27/14 (R) great toe SDTI, and the 9/19/14 (R) hip Stage II PU. The DON asked LN #1 to join the interview. LN #1 compared the photo mount sheets for the aforementioned (L) gluteal fold/inner thigh PU/abrasions to the (L) IT PU photos then stated, "It's the same area. It depends on how she's laying. It's the same place." LN #1 said the "sideways" position of the resident's left leg and how the resident was positioned during assessments made it difficult to determine the anatomical location. The DON said she would review the resident's clinical record and meet again with the surveyor. On 3/12/15 at 9:30 a.m., Resident #1 was observed laying in bed while LN #6 and LN #7 prepared for the (L) IT Stage IV PU wound care/dressing change. The resident's hips were shifted to the right and her left leg was contracted laterally, or outward. The resident's toes were visible and all of them were intact without evidence of impairment. In addition, when the LNs repositioned the resident, the skin on her (R) hip was intact without evidence of impairment. LN #6 informed the surveyor that the old (L) IT dressing "fell off" during the resident's shower. LN #6 said she had already removed the packing and placed Vasche Wash soaked 4x4 gauze into the PU while the resident was in the shower room. LN #6 removed the soaked gauze, which she said had been in place for 10 minutes. The wound bed of the deep PU appeared to be 100% red granulation tissue, without drainage or odor, and the surrounding skin was pink and intact. LN #6 measured the PU tunnels, which were 9 cm on the (L) and 9.7 cm on the (R). The LN #6 then packed the PU, tunnels, and "the pocket where the bone is in the center" with 2 inch wide [MEDICATION NAME], covered it with 2 small pieces of [MEDICATION NAME], a 2x2 [MEDICATION NAME], and a padded 4x4 border dressing which she secured at the inferior (bottom) aspect with [MEDICATION NAME] tape. On 3/12/15 at 11:00 a.m., the DON was again interviewed about the resident's PUs. The Registered Dietician (RD) was present. When asked when the Roho cushion was added to the resident's wheelchair (w/c), the DON said a w/c cushion was "always" in place since the resident was admitted and it was "upgraded" to the Roho. Regarding the 3/25/14 (R) great toe SDTI, the DON said the IR documented it could have happened during a transfer. The DON said she was sure she had talked to the staff involved but that she had not documented it. The RD said PU prevention interventions "haven't changed" since the resident was admitted to the facility. The RD provided information about osteo[DIAGNOSES REDACTED] and said the resident's osteo[DIAGNOSES REDACTED] could have been present "for years" before it "erupted." The RD added, "We don't know which came first, osteo[DIAGNOSES REDACTED] then the wound or the wound then osteo[DIAGNOSES REDACTED]." The DON called LN #6 and asked her to join the interview. On 3/12/15 at 11:45 a.m., LN #6 joined the interview with the DON and RD. When asked about the (R) great toe SDTI, the LN stated, "It happened during a transfer. It got bumped." When asked about the (L) IT PU, LN #6 stated, "In August I thought it was from her Attends (incontinence brief) so I had them (CNAs) take it off. Then I was off a couple of days and when I came back, the Attends was on again. The staff said it was a dignity issue. I had them take it off and leave off the Attends after that." LN #6 said the resident had another small area on the (R) inner thigh "that was caused by the Attends before the (L) side issue." The LN agreed to provide documentation about the (R) inner thigh issue, however, neither she, nor any other staff, provided any other information. On 3/12/15 at 2:30 p.m., the DON informed the surveyor the requested IRs were not found. Resident #1 was harmed when the facility failed to prevent new and recurrent PUs. The resident's (L) gluteal fold/inner thigh/IT PU reoccurred after incontinence briefs continued to be used, and it deteriorated to a Stage IV PU with 2 tunnels and bone infection; a catheter tubing caused pressure on the resident's hip; and, the cause of a (R) great toe SDTI was unknown. In addition, the facility did not consistently monitor and thoroughly assess the 3/3/14 Stage II (L) gluteal fold PU, the (R) great toe SDTI, or the (R) hip stage II PU. On 3/12/15 at 4:50 p.m., the Administrator was informed of concerns regarding PUs. The facility did not provide any other information which resolved the PU issues.

Based on observation, staff/resident interviews and record review, it was determined the facility did not ensure indwelling catheters were only used when clinically indicated for 2 of 4 sampled residents (#1 and 2) identified to have catheters. Resident #1 was harmed when she developed pressure ulcers from the catheter tubing and urinary tract infections. Resident #2 did not have a clinical [DIAGNOSES REDACTED]. In addition, 2 of 4 sampled residents (#1 and 6) were put at risk for infection when Resident #1 was observed with the catheter bag and tubing dragging on the floor and Resident #6, who had a supra pubic catheter, was observed with the catheter bag and tubing positioned above the bladder. Findings include: 1. Resident #1 was admitted to the facility on [DATE] after falling at her residence and fracturing her ankle. The resident also had [DIAGNOSES REDACTED]. The resident's current physician recapitulation orders for September 2012 documented an order for [REDACTED]. The resident's admission MDS, dated [DATE], documented she had an indwelling catheter for the entire prior seven days. admission orders [REDACTED]. The resident's current care plan was dated 9/13/12. A problem identified 6/23/11 documented, "At risk for UTI (urinary tract infection) because of indwelling catheter. Last UTI resolved 2/10/12." The goal was to "Decrease potential for UTI." Approaches included: * "Monitor catheter-change catheter/catheter bag prn (as needed). * Encourage fluids; monitor urine for sediment, cloudy, odor, blood, amount. * Monitor labs as ordered; Good peri care. * Report problems with urine or fever promptly to Charge Nurse/Physician." (NOTE: Approaches were not dated to indicate when they were implemented). The resident's "Bladder And Bowel Assessment" was dated as last assessed on 9/7/12. The following was documented: "Bladder and bowel pattern at admission: Prior to admission (Resident #1) was continent of urine and bowel. She told me that she would occasionally 'dribble' on her way to the toilet. She added that she wouldn't take her [MEDICATION NAME] regularly because 'it would make me have to go to the toilet every 15 minutes. It was hard for me to go to the bathroom that much. I would rather have swollen legs'. She was admitted with an indwelling catheter." The resident was documented to be continent of bowel. For perception of need to void the documentation indicated, "Unable to determine-has indwelling catheter." Contributing factors to incontinence were: "acute illness, chronic illness, mental status, affecting medication's, psychological status." Comments: "(Resident #1) was continent of both bowel and bladder prior to admission. She fell and fractured her ankle 6/13/11. She is morbidly obese, was unable to bear weight at that time, and required the use of mechanical lift for all transfers. She takes [MEDICATION NAME] and has a 'nervous bladder.' It was determined on her admission by the doctor, skin team, and resident that it would be best to have an indwelling catheter until she is able to bear weight to protect her skin from breakdown and help with pain management. She remains unable to bear weight at this time because her knees hurt and cannot support her weight. She wants the catheter to remain in because of the [MEDICATION NAME] making her need to urinate frequently. She states 'I just can't get onto the commode or bedpan fast enough when the [MEDICATION NAME] kicks in and I know that I will be dribbling and wet no matter how many times the CNAs change me. As long as I have to be on [MEDICATION NAME] I want to keep an indwelling catheter.' Catheter is changed monthly and prn. She is monitored for s/s (signs/symptoms) of UTI." physician progress notes [REDACTED]. 9/16/11- "(Resident #1) staates (sic) that often times the catheter will pull and bother her. She isn't able to get and go (sic) to the bathroom." The note further indicated the fracture was healed but due to deconditioning the resident could not stand and she had lost 40 pounds. 9/28/11- The physician documented a UA (urine analysis) would be done but did not comment on the catheter. 11/26/11- Documented the resident was "doing fine." No comments about catheter or result of UA. 12/15/11 (dictation date)- "...She has been having a little bit of urinary difficulty so we did a UA that was positive. We are waiting for a culture. In the meantime, we are going to go ahead and treat." The physician [MEDICATION NAME] mg (milligrams) twice a day for ten days and [MEDICATION NAME] twice a day for ten days. 1/28/12- No documentation regarding UTI from prior visit. 3/31/12 (dictation date)- "The patient has been having some problems. She had a urinary tract infection for which we have treated her. She is extremely hypoxic even during day and with oxygen on...A(ssessment): urinary tract infection...P(lan): We will keep the antibiotics..." Nurse progress notes contained the following documentation for 2012: 2/2- "...on (antibiotics) for UTI..." 2/28- "...Has catheter in trying to prevent UTIs." 3/13- "...UA sent to lab per teams request..." 3/15- "New order for UTI given by (physician name). Resident was feeling 'miserable' with HA (headache) and temperature of 100.5..." 3/16- "...Seems to be tolerating [MEDICATION NAME] for UTI..." 3/22- "...She is getting discouraged with not feeling well..." 3/26- "...UTI treated and antibiotic therapy completed yesterday." 4/8- "Resident called stating 'it felt like her cath(eter) was 1/2 way out.' Was able to pull out cath/balloon intact. Inserted new 18Fr (French) 30 cc balloon... No complaints during insertion..." 4/20- "Resident urinary cath leaking. CNA had to change bed out despite 900 cc out. Cath repositioned will watch and change on day shift if further problems." 4/21- "1000 Foley leaking. Removed 18 Fr and applied 20 Fr 30 cc balloon. Urine return. Attached bag. Patient tolerated well." 4/27- "Attempted to flush (Resident #1's) Foley catheter. with 30 cc sterile H2O (water) several times as catheter leaking around meatus in moderate amount. Unsuccessful to remove sludge in catheter by aspiration flushing. Catheter removed. (Number) 20 French ... inserted without difficulty. Some sediment in plug came out (illegible) from new catheter and urine followed. Wrote nursing order to flush catheter with 50 cc sterile H2O every shift to prevent further plugging from occurring." (NOTE: This directive was not care planned). 4/29- "flushed catheter-some resistance-also told to come with CNAs to look at buttocks...open sore at the top of coccyx..." 4/30- "flushed cath after bath and leaked; went to advanced balloon- unable to drain; catheter R&R (unknown acronym) with 16 French 30 cc balloon...resident tolerated well..." 5/2- "RN called to office in regards to catheter problem of sediment and drainage causing the need to change it frequently." 5/6- "Foley catheter again plugged and unable to aspirate or flush catheter. Removed. #18 French 30 cc catheter inserted without difficulty. Large amount white discharge noted around urethra and vagina behind labia." 5/8- "Dr. (name) notified of catheter and ongoing issues, resident & spouse irritated @ (at) no results & wants catheter out! Discussed skin issues with resident & [MEDICATION NAME] over for today." 5/9- "MD notified of catheter being left out over noc (night) d/t (due to) it being completely plugged off so new order for [MEDICATION NAME] that was ordered was never started..." 5/16- "New order from provider. Discontinue current [MEDICATION NAME] flushes. Start [MEDICATION NAME] 30 ml (milliliters) twice daily through catheter; clamp for 10 minutes, then release." Nurse notes for June only documented for days 2, 12 and 30. There was no documentation related to the catheter. Notes for July indicated the catheter was changed without incident on 7/13/12, and no other concerns with the catheter were noted. Notes for August were documented for days 8/7, 8/8, 8/20 and 8/30 without reference to the catheter. Only 5 days in September contained documentation. On 9/1/12 a note documented blood in the peri area with catheter secure and in place. On 9/2/12 the catheter was functioning properly and minimal peri bleed. The documentation did not indicate an assessment that indicated the cause of the peri blood. Resident #1 was observed and interviewed in her room on 9/25/12 at 11:15 am. She was in her bariatric bed lying on her back. There were side rails on the bed. The resident's catheter bag was attached to the side rail. It was on the floor in addition to some of the tubing. She was asked about the use of the catheter. She indicated she insists upon using it. When asked if staff at the facility had educated her on the risk of infection with use of the catheter she said, "No." On 9/26/12 at 9:30 am, the resident was assisted to a group meeting held with surveyors. As she was pushed in her wheel chair, the catheter bag and some of the tubing was dragging along the floor. The DON was interviewed on 9/26/12 at 8:10 am. The DON was asked about the 5/8/12 nurse progress note that indicated the resident and spouse wanted the catheter removed. The DON said that if she remembered correctly upon attempting to remove the catheter the resident would not let them. The DON was advised there were no nurse' notes that indicated this. When asked if the resident received any counseling for her reported resistance to care, the DON indicated the facility Social Worker would be the only one that had provided psychosocial interventions for the resident. Refer to F250 as it relates to findings for this resident who did not receive social services for behavioral symptoms of resisting care. The wound nurse (LN#3) stated on 9/27/12 at 11:00 am, Resident #1 had a total of five Stage II pressure sores on September 19, but three had healed. She stated the resident still had a Stage II pressure sore to the groin from her Foley catheter tubing and had developed a open area found on 9/25/12 to the fold by the hip area. She said the hip wound could have been caused by heat and/or shearing. Refer to F314 as it relates to findings for this resident of multiple recurring pressure sores. The facility did not provide psychosocial services to determine if better cooperation could be obtained from the resident related to her catheter use. In addition, they failed to show comprehensive assessment for continued use with established risk to benefit for the catheter use, even though Resident #1 had developed multiple problems with the use of a catheter. The facility failed to ensure the catheter tubing was placed so the resident did not develop pressure sores from the tubing or ensure the catheter and tubing were not contaminated when attached to her bed or when she was transported in a wheel chair. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment was dated 8/1/12. The MDS documented in the Bowel and Bladder section H, showed no indwelling catheter and no urinary toileting program in place. The DON was interviewed after the initial tour on 9/24/12 at 2:45pm. She stated resident #2 had a foley catheter in place. A "Multi-Disciplinary Documentation Form" nursing note on 7/25/12, stated physician was notified of skin problems (not staged) and verbal orders were given to, "place catheter if resident will allow it." The Physician's Telephone Orders form, dated 7/28/12, directed, "Place catheter if resident will allow it." A "Multi-Disciplinary Documentation Form", nursing note on 7/28/12 regarding catheter issues stated, "...Resident had agreed to earlier in the day. Resident felt that she was coerced into having a catheter by a CNA and did not have a choice. I explained skin integrity & issues with her & she at this time does not want a catheter placed." A "Multi-Disciplinary Documentation Form", nursing note on 8/11/12 stated, "Placed foley ...catheter ...tolerated well." The resident was interviewed on 9/26/12 at 10:30 am, where the catheter issue was brought up. She stated having the catheter was, "easier this way." When asked easier for whom, she stated, "Easier for me and the staff. " The DON was interviewed on 9/27/12 at 1:40. She stated due to the resident's large girth, the resident was not able to use a commode and using a bed pan prior to 8/11/12, created a potential fall risk due to the size of the bed in relation to the resident's size. When asked if a bed pan was tried after a bariatric bed replaced the resident's old bed on 9/6/12, she stated, "We should have." Guidance at F315 includes: "... Indwelling Catheter Use - The facility's documented assessment & staff approach to the resident should be based on evidence to support the use of an indwelling catheter. Appropriate indications for continuing use of an indwelling catheter beyond 14 days may include: * [MEDICAL CONDITION] that cannot be treated or corrected medically or surgically, for which alternative therapy is not feasible, & which is characterized by: - Documented post void residual (PVR) volumes in a range over 200 milliliters (ml); - Inability to manage the retention/incontinence with intermittent catheterization; and - Persistent overflow incontinence, symptomatic infections, and/or renal dysfunction. * Contamination of Stage III or IV pressure with urine which has impeded healing, despite appropriate personal care for the incontinence; and * Terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain." 3. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: - Had short and long term memory issues, - Was usually understood for communications, - Required extensive assistance for transfers, dressing, eating, personal hygiene and bathing. - Had a catheter. Review of the resident's care plan, dated 9/13/12, documented the problem, dated 12/19/07, "At risk for INFECTION (related to) suprapubic catheter...." The interventions were: - "Change cath(eter) (every) 2 (weeks)... - Monitor urine for sediment, cloudy, odor, blood, amount, monitor labs.... - Report any s/s(signs and symptoms) of infection to charge nurse, MD." The resident was observed on 8/25/12 from 12:00 p.m. until 2:15 p.m. and on 9/26/12 from 8:12 a.m. until 9:24 a.m. During the observation time, the resident was sitting in his wheelchair. The left arm rest of the wheelchair had about a 3 inch raised padding on it. This put the wheelchair arm height at about the resident's mid chest. The suprapubic catheter exited the resident at the lower portion of the abdomen. The tubing for the catheter was observed to be draped over the top of the wheelchair left arm rest during these observation times. This put the output of the catheter at about 8 inches below the tubing. With the tubing this high, the urine being collected in the bladder would not be able to be drained effectively and put the resident at risk for infections and other issues. The DON was informed of the observation on 9/27/12 at 4:00 p.m. No further information was provided.

Based on staff interview, record review, and review of facility Incident Reports, it was determined the facility failed to prevent the development of pressure ulcers for 2 of 2 residents (#s 1 & 2) reviewed for pressure ulcers. This failed practice resulted in harm when Resident #1 developed 3 Stage II pressure ulcers from the foley catheter tubing and Resident #2 developed one Stage III pressure ulcer from the foley catheter tubing. Findings included: A recertification survey was conducted at the facility on 9/28/12. The facility was cited at F314. The citation documented, "...the facility did not ensure that avoidable Stage II pressure sores did not develop for (Resident #s 1 and 2). These residents were harmed when they developed multiple Stage II pressure sores and the facility had not implemented preventative measures in a timely manner to prevent pressure sores." Resident #1 developed one Stage II pressure ulcer from the foley catheter tubing. According to the facility's POC, Resident #1's foley catheter "tubing has been repositioned to prevent further pressure. Staff have been instructed on how to accomplish this via meeting and demonstration." An Inservice Education form, dated 10/10/12 and attended by CNAs, LNs, Activity staff, and RNAs, documented, "...O. ... (one) resident developed hers (pressure ulcer) from pressure from...her catheter tubing. ...we are really going to concentrate on positioning the tubing correctly and ensuring that there is no pressure at all times. P. ...we are concentrating on the positioning (of the foley catheter)..." The facility alleged compliance with the POC on 11/2/12. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 10/25/12, coded: * BIMS of 15 indicating cognition intact * Extensive assistance of 2 or more persons for bed mobility * Totally dependent on 2 or more persons for transferring * Indwelling catheter Resident #2's facility Incident Report, dated 11/19/12, documented, in part: * "Skin assessment done just before shower a new pressure area found on back of L (left) thigh just above crease of knee. Inside area white/yellowish outer area. * ...Department Head Investigation: ...Skin team feel the area mentioned is consistent where catheter sitting. Plan: make sure catheter properly placed not rubbing or causing pressure. Skin team will follow." The report was signed by DON #2 and the LN preparing the report on 11/19/12. Resident #2's Wound Documentation Form, dated 11/19/12 at 8:00 am and signed by an LN, documented, in part: * Location: "Back of thigh (above) knee" * Pressure Ulcer: "Stage III" * Wound type: "pressure" * Size LxWxD (length by width by depth): ".5 x .1 cm," no tunneling or undermining * Wound bed: "yellow" * Surrounding Skin Color: "Bright red" * Dressing/Comments: "Inside white/yellowish in color out area surrounded dark purple, area is not blanching." There was no odor or exudate from the pressure ulcer. Resident #2's Wound Documentation Form, dated 11/21/12 at 8:30 am and signed by an LN, documented, in part: * Location, stage, wound type and size had not changed from the 11/19/12 assessment. * Wound Bed: "Red granulation, Pink [MEDICATION NAME]" * Surrounding Skin Color: "pink" * Wound Edges: "normal for skin" * Dressing/Comments: "Inside now pink in color, out dark red area, (not) open, (no) blanching, appears to be healing." Resident #2's Wound Documentation Form, dated 11/26/12 at 11:00 am and signed by an LN, documented, in part: * Location and stage unchanged from 11/21/12 assessment * Size: ".5 cm x 1 cm (Note: The width had increased from 0.1 cm to 1.0 cm.) * Wound Bed: "yellow, Red granulation" * Surrounding Skin Color: "Bright red" * Wound Edges: "Normal for skin" * Dressing/Comments: "inner part of wound has small area of red showing. Area cleaned and [MEDICATION NAME] border lite 3 x 3 placed at this time." Resident #2's care plan documented the problem, dated 8/11/12, "At Risk for UTI r/t (related to): Indwelling catheter..." Interventions included, "Monitor catheter-change catheter/catheter bag every month and prn." A hand written note in the problem area documented, "dc'd (discontinued) 11/26/12 cath(eter) leaking." Another problem, dated 2/8/11, documented, "Risk for Skin Breakdown." Interventions included, "...Reposition q 2h (every 2 hours)." Note: There were no interventions on the resident's care plan under any problem area related to the positioning of the foley catheter tubing. On 11/29/12, the QMC provided Resident #2's CNA Care Record form for November 2012. This form included documentation that the CNA performed skin fold checks and repositioned the resident in bed. There was no documentation on the form regarding positioning of the catheter tubing. Facility staff had been informed of proper positioning of foley catheter tubing from an inservice meeting and demonstration according to the Inservice Education on 10/10/12. Resident #2 developed a stage III pressure ulcer from the improper placement of her foley catheter tubing. The facility provided no documentation that staff correctly positioned the catheter tubing to prevent pressure ulcers when turning the resident, when she was lying in bed, or when she was sitting in a chair. On 11/30/12 at 9:00 am, the Administrator, CNO, DON #2, and QMC were informed of the continued non-compliance at F314 regarding pressure ulcers. The facility provided no other information or documentation that resolved the concern. 2. Resident #1 was admitted to the facility on [DATE] after falling at her residence and fracturing her ankle. The resident also had [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 9/6/12, coded: * BIMS of 15 indicating cognition intact * Extensive assistance of 2 or more persons for bed mobility * Totally dependent on 2 or more persons for transferring * Indwelling catheter The following two Incident Reports documented the facility's continued non-compliance as it related to the development of three new pressure ulcers due to Resident #1's foley catheter tubing: 11/23/12: * "While performing hs (hour of sleep) cares CNA noticed (1) closed blister (1) opened blister & (1) white pustula..." This entry was signed by an LN. * "Department Head Investigation: Date: 11/26/12. Discussed with Skin Nurse. This problem is also related to obesity & cath(eter) placement. Ongoing concern. Continue working toward solutions." This entry was signed by DON #2. 11/26/12: * "New lesion/abrasion area found on R (right upper) thigh .3 x .4 cm...from friction/moisture in bed..." This entry was signed by an LN. * "Department Head Investigation: Date: 11/26/12. Discussed with Skin Nurse. Lesion relating to catheter R thigh. Will reinforce frequent check of cath placement on leg by all personnel involved with her cares." This entry was signed by DON #2. Two Wound Documentation forms, dated 11/24/12, documented in part: * Location: "(Upper) R Thigh" * Pressure Ulcer: "Stage II" * Wound type: "Blister" * Size LxWxD: "1 cm x 1.3 cm." No tunneling or undermining was identified. * Wound bed: "Closed" * Surrounding Skin Color: "Normal for skin." There was no odor or exudate from the pressure ulcer. * Location: "(Upper) R Thigh" * Pressure Ulcer: "Stage II" * Wound type: "Blister" * Size LxWxD: "1 x 2 cm." No tunneling or undermining was identified. * Wound bed: "Pink [MEDICATION NAME]" * Surrounding Skin Color: "Normal for skin." There was no odor or exudate from the pressure ulcer. NOTE: There was no Wound Documentation form provided to the survey team for the pressure ulcer identified on the 11/26/12 Incident Report form. Resident #1's care plan documented the problem, dated 6/23/11, "At Risk for UTI because of Indwelling catheter..." Interventions included, "Monitor catheter-change catheter/catheter bag prn." There was no intervention to re-position the foley catheter tubing to prevent skin breakdown. There were no new interventions through 11/26/12. Another problem, also dated 6/23/11, documented, "Risk for Skin Breakdown." Interventions included, "...Indwelling catheter to prevent skin breakdown..." This identified problem was last updated 5/29/12. There was no intervention regarding re-positioning the foley catheter tubing. Resident #1's most recent care plan documented the problem, dated 11/23/12, "2 Stage II Dqs (decubitus pressure ulcers) on R/upper thigh." Interventions included in part, "Catheter dc'd (discontinued) 11/27/12." NOTE: The care plan was not updated to include the third foley catheter-related pressure ulcer that developed on 11/26/12. On 11/29/12, the QMC provided Resident #1's CNA Care Record form for November 2012. This form included documentation that the CNA performed skin fold checks and repositioned the resident in bed. There was no documentation on the form regarding re-positioning of the foley catheter tubing. According to the facility's POC, Resident #1's foley catheter "tubing has been repositioned to prevent further pressure..." Resident #1 developed three new foley catheter-related pressure ulcers after the facility's alleged compliance date, 11/2/12. On 11/30/12 at 9:00 am, the Administrator, CNO, DON #2, and QMC were informed of the continued non-compliance at F314 regarding pressure ulcers. The facility provided no other information or documentation that resolved the concern.

Based on observation, staff/resident interviews and record review it was determined the facility did not ensure that avoidable Stage II pressure sores did not develop for 2 of 2 sampled residents (#1 and 2). These residents were harmed when they developed multiple Stage II pressure sores and the facility had not implemented preventative measures in a timely manner to prevent pressure sores. Findings include: 1. Resident #1 was admitted to the facility on [DATE] after falling at her residence and fracturing her ankle. The resident also had [DIAGNOSES REDACTED]. The hospital emergency room report, dated 6/12/11, documented stasis ulcers to the resident's shins but did not document any other open areas or a finding of pressure sores. The resident's annual MDS, dated [DATE], documented she required extensive or total assistance for most of her ADL care. The resident's current care plan was dated 9/13/12. A problem identified, 6/23/11 documented, "Risk for skin breakdown r/t (related to): Obesity and decreased mobility." The goal was to prevent pressure ulcers and included a high risk category for developing pressure ulcers. Approaches included: *maintaining nutrition and hydration *improving health of skin and keeping clean and dry with good peri care, bathing, change of bed linen per schedule and as needed *encourage the resident to get out of bed daily *indwelling catheter to prevent skin breakdown and toilet as needed *high density foam pad in wheelchair and lumbar support pad behind back *low bariatric bed with pressure reducing mattress *maintain current activity level, mobility, and range of motion (NOTE: Approaches were not dated to indicate when they were implemented). On 5/29/12 "Impaired skin integrity" was added to the care plan. The goal indicated "ulcers will heal without problem." Approaches included: *"Ulcer care per policy/skin team/treatment sheet. *Monitor, evaluate, readjust, and document interventions and outcome" Directly under this addition, documentation on 7/30/12, indicated the resident had 2 Stage II pressure sores from shearing and 1 unstageable pressure sore. Facility incident reports were reviewed and contained the following documentation: 4/23/12- "Stg (stage) II 2 x 2 cm on R(ight) lower buttock (blister) happened from sling. The "Department Head Investigation" portion documented, "Staff instructed to use bariatric lift/sling (with) resident- sling rubbed on area because it was hour glass shaped- skin team to follow." (NOTE: There were no interventions on the care plan to direct use of a bariatric sling). 7/30/12- "...on R back leg near buttock .5 x .4 cm (centimeter) spot open [MEDICATION NAME] applied to open area." The investigation documented, "resident bed bound-bariatric areas prone to breakdown-skin team tomorrow." 9/16/12- "New open lesion found on L (left) buttock crease area .5 x .5. In R groin area opened blister .6 x .2 cm, and blister not open 3 x 1 cm r/t pressure from cath(eter) tubing [MEDICATION NAME] border light applied." The investigation documented, "areas from catheter et (and) moisture- staff to position catheter so it does not create pressure- skin team to follow." (NOTE: The care plan did not have an approach related to positioning of the catheter tubing to prevent pressure sores. The care plan did indicate the catheter was initiated to "prevent skin breakdown."). Refer to F315 as it relates to additional findings related the Resident #1's use of a catheter without a clinical diagnosis. Skin Assessment and Treatment forms from February through September 2012 were reviewed and contained the following documentation: February- No documentation of pressure sores. March- No documentation of pressure sores. April- No documentation of pressure sores. May- "5/29/12 Open area to L buttock .7 x .5 cm area cleaned [MEDICATION NAME] applied." The pressure sore was a Stage II without exudate or odor. Scant sanguineous fluid. The wound bed was with 100% red granulation and surrounding skin was normal. June- The wound to the left buttock increased in size to 5 x 2 cm. A new dressing was applied. The resident developed another Stage II open area to the left buttock that measured 5 x 5 cm. Documented wound cause was "excessive dryness, friction, shearing." One pressure sore on the left buttock resolved. The other was healing and had become two small areas within the original wound, measuring .5 x .5 cm and .2 x .2 cm. July- The second wound that developed on the left buttock was resolved. August- "...Red line from Foley intact blanches and when off loaded area (resolved)." September- The resident had developed Stage II pressure sores to her right buttock and thigh. Also an open area and blister to right groin area (caused by Foley catheter tubing), Stage II .6 x .2 cm for one wound and 3 x 1 cm. The left buttock had a Stage II that measured .5 x .5 cm. Resident #1 was observed and interviewed in her room on 9/25/12 at 11:15 am. She was in her bariatric bed lying on her back. There were side rails on the bed. The mattress was between 3 and 4 inches thick and had a blue water proof covering around it. The resident stated she did not have an air bed. When asked if she took meals in the dining room she indicated she usually ate in her room. She was asked if she attended any activities and she said not as much as she used to. She said when she got up the lift had to be used to transfer her. The DON was interviewed on 9/26/12 at 8:10 am. She stated the resident did not have an air bed and had only recently received a bariatric bed. She was asked why the wounds the resident had developed would be unavoidable. She said the resident is a "bariatric patient and refused to move off her bottom." When asked if the resident was ever considered for an air bed that would automatically provide repositioning she stated, "Well we have some air beds." When asked if the resident had ever been on an air bed the DON responded, "No." The DON was asked if the resident received any counseling or other psychosocial interventions. The DON said, "No psychosocial except (Social Worker named)." The surveyor reviewed the Social Work section of the record with the DON and found only one social services note related to resisting care. Refer to F250 as it relates to social services for behavioral symptoms of resisting care. The wound nurse (LN#3) stated on 9/27/12 at 11:00 am, Resident #1 had a total of five Stage II pressure sores on September 19, but three had healed. She stated the resident still had a Stage II pressure sore to the groin from her Foley catheter tubing and had developed an open area found on 9/25/12 to the fold by the hip area. She said the hip wound could have been caused by heat and/or shearing. The facility did not provide psychosocial services to determine if better cooperation could be obtained from the resident related to prevention of pressure sores. the facility failed to ensure the catheter tubing was placed so the tube did not cause pressure sores. Timely interventions for better positioning of the resident in bed were not implemented. 2. Resident #2 was admitted to the facility on [DATE]with [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], coded she was 67 inches tall and weighed 352 pounds. According to her MDS, she required extensive assistance in her activities of daily living (ADL's) and there were no pressure sores present. Resident #2's "Multi-Disciplinary Documentation Form" nursing notes, dated 7/25/12, documented, "MD notified of skin problem, order given to place catheter if resident will allow it." There was no other documentation on the location or size of the skin problem referred to in the notes. The resident's "Skin Notes and Treatment Record" from 9/1/12 through 9/18/12 stated there were no Stage II pressure sores present. However, on 9/19/12, the skin notes documented the resident had two Stage II pressure sores. The facility documented one pressure sore to the inner left thigh measuring 13cm by .5cm (centimeters) and another pressure sore on the left buttock measuring 2cm by .5cm, both due to "pressure from attend"(incontinent brief). The resident's current care plan was dated 9/13/12. A problem identified, "Risk for skin breakdown due to weight, right leg contracture, and [MEDICAL CONDITION]." The goal was to prevent pressure ulcers and documented the resident was at high risk for developing pressure ulcers. Approaches included: * "Maintaining nutrition and hydration," * "Maintain or improve health of skin: keep clean and dry, good peri care, Bath/change bed linen per schedule and prn (as needed)," * "Repostion q (every) 2hrs," * "Has a pressure reducing mattress; keep pressure off heels," * "Maintain current activity level, mobility, and range of motion," * "Right foot peddle (sic) support when up in WC (wheelchair) to keep foot from sliding off," The Skin nurse was interviewed on 9/27/12 at 10:55 am. She stated the pressure sores were possibly attributed to friction and sheering from the resident's attends and the inability for the resident to shift in her wheelchair due to her weight and size (Note: there were no nurses notes, skin notes, or a wheelchair evaluation indicating the wheelchair was a possible cause). The DON was interviewed on 9/27/12 at 1:40 pm and stated an electric wheelchair has been ordered to accommodate the resident's current weight and physical limitations, which should relieve pressure in the troubled areas. She also stated the resident does have a bariatric pressure reducing mattress, but does not have an air mattress. The DON provided an email received on 8/27/12 at 9:16 am from the Physical Therapy (PT) department. The email indicated a company, who supplies electric wheelchairs, would be at the facility on 9/4/12 at 10:30 to give a demonstration of the wheelchair. The DON also provided an email sent to PT on 9/24/12 at 10:56 am, with an attached example of a wheelchair assessment. The facility took a month before the approval of a new electric wheelchair was finalized and the resident still did not have the new chair by 9/28/12, when last observed. On an observation of Resident #2 on 9/25/12 at 9:45 in her room, the resident appeared to barely fit into her current wheelchair and did not appear to be able to shift in the chair as needed. Although the facility recognized the need to address the pressure issues, it failed to prevent pressure sores by quickly assessing the cause of the sores and implementing an effective plan before 2 Stage II ulcers were discovered, causing harm to the resident. No other documentation was provided by the facility.