Every finding on record at Life Care Center of Idaho Falls

Based on observation, resident and staff interviews, record review, and policy review it was determined the facility failed to assess whether residents had the ability to self-administer their medications for 1 of 1 residents (Resident #63) reviewed for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident. Findings include: The facility's Self-Administration of Medication policy, reviewed 9/15/25, documented the facility will ensure that each resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) to determine if the resident is safe to self-administer medications. Procedure 4. The interdisciplinary assessment will be completed in the electronic medication record, and results reviewed with the resident and/or responsible party .Resident #63 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including multiple myeloma (cancer of the bone marrow's plasma cells) and diabetes. On 3/17/26 at 3:07 PM, observed Resident #63 sitting in his room placing drops in his eyes. On 3/17/26 at 3:16 PM, observed a bottle of Refresh Tears sitting on Resident #63's bedside table. On 3/17/26 at 3:27 PM, Resident #63's medical record reviewed with no documentation of a physician order for Refresh Tears, and no IDT self-administration assessment. On 3/17/26 at 3:52 PM, the DON stated Resident #63 should not have had the Refresh Tears at his bedside and had not been assessed by IDT for self-administration of medications.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an advance directive. This was true for 4 of 24 residents (#4, #33, #42, and #67) 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 Advance Directives policy, last reviewed 12/1/25, documented All residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care including.the formation of advance directives upon admission.Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including Polyneuropathy (a condition involving damage to multiple peripheral nerves) and diabetes. Resident #42's medical record had not included an advance directive for healthcare or information on his right to formulate an advance directive. On 3/17/26 at 1:10 PM, the Social Services Director stated, there is no Durable Power of Attorney for Healthcare for Resident #42, only the Power of Attorney for Financial Affairs. Resident #67 was admitted to the facility on [DATE], with multiple diagnoses including fracture left femur (thigh bone) and dementia. Resident #67's medical record had not included an advance directive for healthcare or documentation she was provided with information on her right to formulate an advance directive. On 3/17/26 at 4:48 PM, the Social Services Director stated, there is no Durable Power of Attorney for Healthcare for Resident #67, only the General Power of Attorney. On 3/17/26 at 4:49 PM, the DON stated Resident #42 and Resident #67 had a financial DPOA but did not have an advance directive for healthcare and was not offered to formulate one. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including Hemiplegia and Hemiparesis affecting the left dominant side following a cerebral infarction (stroke). Resident #4's medical record had not included an advance directive for healthcare or information on his right to formulate an advance directive. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including cancer, hypertension, and spinal stenosis in the lumbar region (the narrowing of the spinal canal causing pain, numbness, and leg weakness). Resident #33's medical record had not included an advance directive for healthcare or documentation she was provided with information on her right to formulate an advance directive. On 3/17/26 at 3:20 PM, the DON stated Resident #4 and Resident #33 had a financial DPOA but did not have an advance directive for healthcare and was not offered to formulate one.

Based on observations, interviews, and review of facility policy, it was determined the facility failed to ensure residents were provided with a safe, clean, and homelike environment. This was true for 1 of 18 resident rooms and other areas throughout the facility which were observed. This deficient practice created the potential for diminished quality of life and resident safety including infection and cross-contamination. Findings include: The facility's Daily Room Cleaning policy, revised date 10/28/25, documented Procedure 4. Daily cleaning of resident bathrooms b. Clean the toilet bowl daily. The facility's Housekeeping Services - Cleaning Resident Shower Room policy, issued date 10/28/25, documented Procedure: Cleaning Resident Shower Room - Routine Cleaning (Daily) 1.b. Housekeeping should clean resident shower/bath area twice daily.The following areas were observed for clean and homelike environment: On 3/16/26 at 4:32 PM, observed in Resident room [ROOM NUMBER]:Toilet with thick black ring of debris above bowl water line and under rim of toilet, room sink heavily stained with brown residue On 3/18/26 observed: a. Hall 3 - shower with blackened thick debris on floors and tiles, toilet with black/brown debris line around water line and rusty brown discoloration in toilet bowl. Black debris around wall and floor line. Floor under sink with rusty brown area between tiles and wall. b. Hall 4 - shower with blackened thick debris on floors and tiles, toilet with black/brown debris at water line and under toilet rim, toilet seat with discoloration, rusty brown and black ring around entire toilet base, caulking missing at floor and wall line, black debris at floor and wall line and up the tiled wall for 2 tile height. On 3/19/26 at 9:38 AM, the Maintenance Director stated, the Hall 3 and Hall 4 showers do not look like they have been cleaned and should have been. On 3/19/26 at 1:16 PM, the Housekeeping Manager stated, the CNAs clean the shower (wipe down) between each resident shower and housekeeping looks at each shower room at the end of the day to see that the shower room is clean. The shower rooms should have been cleaned but had not been.

Based on policy review, record review and staff interview, it was determined the facility failed to ensure a written notice of transfer and bed hold policy was provided to residents or their representatives when residents were transferred to the hospital. This was true for 2 of 2 residents (#7 and #33) reviewed for hospital transfers. This deficient practice created the potential for psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility. Findings include:The facility's Discharge Process and Bed Holds policy, reviewed 12/1/25, documented:- under Notice before transfer, Before a facility transfers or discharges a resident, the facility must - (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. - under Notice of bed-hold policy and return, Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies: (i) the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including stage IV pressure ulcers, diabetes, and spinal cord injury.Resident #7's medical record documented he was transferred from the facility and admitted to the hospital on [DATE] and again on 3/14/26. Resident #7's medical record had not documented he was provided with a Notice of Transfer or Bed Hold Policy prior to being transferred to the hospital on 1/6/26 or 3/14/26.Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including cancer, hypertension, and spinal stenosis in the lumbar region (the narrowing of the spinal canal causing pain, numbness, and leg weakness).Resident #33's medical record documented she was transferred from the facility and admitted to the hospital on [DATE]. Resident #33's medical record had not documented she was provided with a Notice of Transfer or Bed Hold Policy prior to being transferred to the hospital on [DATE].On 3/18/26 at 1:40 PM, the DON stated they do not have the Notice of Transfer or Bed Hold documentation for Resident #7 or Resident #33.

Based on record review, policy review, and staff interview, it was determined the facility failed to maintain a person-centered comprehensive care plan for residents. This was true for 1 of 19 residents (Resident #24) whose record were reviewed for comprehensive care plans. This created the potential for harm when staff were not informed of person-centered care and treatment interventions. Findings include: The facility's Area of Focus: Care Planning - Baseline, Comprehensive, and Routine Updates policy, review date 12/4/25, documented.develop and implement a comprehensive person-centered care plan for each resident.Selecting interventions / planning care - identify and implement interventions and treatments to address the individual's physical, functional, and psychosocial needs, concerns, problems, and risks.the comprehensive care plan must be updated with each MDS assessment and periodically.Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including Hypertensive heart and chronic kidney disease and diabetes. On 3/17/26 at 11:06 AM, Resident #24's care plan documented last care plan review completed 12/21/25, Endocrine: Diabetes Mellitus, Interventions including High Risk Medications: Insulin per MD order, date initiated: 12/15/25. On 3/17/26 at 11:08 AM, Resident #24's medical record had not included a physician's order for insulin. On 3/17/26 at 2:58 PM, the DON stated Resident #24 had not had an order for insulin during her stay at the facility and the insulin intervention should not have been documented on Resident #24's care plan and had been.

Based on record review, policy review, and staff interview it was determined the facility failed to follow physician orders of delivering specific medications when residents do not have bowel movement within 72 hours for 1 of 22 residents (Resident #13) whose records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include:The facility's Bowel Protocol policy, reviewed date 9/15/25, documented Procedure 2. The facility in coordination with the resident's attending practitioner will implement standing orders to address a lack of bowel movement.Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including Hypertensive heart and chronic kidney disease and respiratory failure.Resident #13's medication administration record documented the following medication orders; Senna Tablet 8.6 mg - give 3 tablets by mouth as needed for constipation - no BM in 72 hours. Order date 1/22/26.Bisacodyl EC Tablet Delayed Release 5 mg - give 3 tablet by mouth as needed for constipation - No BM in 96 hours. Order date 1/22/26.Bisacodyl Suppository 10 mg - insert 1 suppository rectally as needed for constipation - if no BM by 10:00 following day after oral Bisacodyl. If no BM after 2 hours of suppository, give Fleet enema. Order date 1/22/26.Fleet Enema 7-19 Gm/118 ml (Sodium Phosphates) - insert 1 dose rectally as needed for constipation - if no result 2 hours after suppository, if no BM within 2 hours of enema, call MD for further instructions. Order date 1/22/26.On 3/18/26 at 2:01 PM, Resident #13's medical record documented she had a BM on 2/21/26 at 03:56 and not again until 2/26/26 at 22:39, over 120 hours later with no bowel management medications documented as being administered between 2/24/26 and 2/26/26.On 3/18/26 at 2:07 PM, Resident #13's medical record had no documentation in nursing progress notes that her physician had been contacted 2/25/26 through 2/26/26, regarding no BM for over 96 hours.On 3/18/26 at 2:20 PM, the Executive Director stated nursing staff for Resident #13 should have contacted the physician after 96 hours without a BM and had not.

Based on the State Operations Manual - Appendix PP, review of the State Agency's Long-Term Care Reporting Portal, record review, the facility's I&A reports, policy review, and staff interview, the facility failed to ensure residents were free from accident hazards for 2 of 3 residents (#4 and #65) whose a) fall was not documented timely, and b) whose rooms were observed for environmental safety. This failure increased the potential for avoidable accidents to go unnoticed. Findings include:The State Operations Manual, Appendix PP revised 7/23/25, documented extension cords should not be used to take the place of adequate wiring in a facility.extension cords should be connected to only one device to prevent overloading of the circuit. The facility's Incident and Reportable Event Management policy, reviewed 12/3/25, documented the following:-The facility must ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents.- The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:Identifying hazard(s) and risk(s)Evaluating and analyzing hazard(s) and risk(s)Implementing interventions to reduce hazard(s) and risk(s)Monitoring for effectiveness and modifying interventions when necessaryResident #65 was admitted to the facility on [DATE], with multiple diagnoses including, respiratory failure and diabetes.On 3/17/26 at 1:37 PM, observed an extension cord in Resident #65's room with the bed electrical cord, wheelchair electrical cord, and cellphone electrical cord plugged into it.On 3/17/26 at 1:40 PM, Resident #65 stated she had bought the extension cord at Walmart and she used it to plug in the bed, wheelchair, and her cellphone.On 3/17/26 at 1:50 PM, the Maintenance Director stated Resident #65 should not have had medical devices plugged into an extension cord in her room. On 3/17/26 at 2:03 PM, the Executive Director stated he was unaware Resident #65 had an extension cord in her room, and the medical devices should not have been plugged into it. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including Hemiplegia and Hemiparesis affecting the left dominant side following a cerebral infarction (stroke). On 11/24/25 at 12:15 PM, the Certified Occupational Therapy Assistant documented that Resident #4 was seated in wheelchair upon arrival and was agreeable to therapy however expressed left shoulder pain due to a fall earlier in the day. On 11/25/25 at 5:29 PM, the Physical Therapist documented that Resident #4 reported his left shoulder was hurting after an incident falling out of his wheelchair yesterday. On 11/28/25 at 2:09 PM, the Certified Occupational Therapy Assistant documented Resident #4 stated his left shoulder was in pain due to a fall a week ago and was not able to use ULE (upper left extremity). Nurse was notified that Resident #4 would like to meet with the doctor about left shoulder pain. Responded well to interventions however was limited due to left shoulder pain. On 12/1/25, a physician visit progress note documented Resident #4 stated that he has been having some increased left shoulder pain since he had a fall that he heard a small pop with. Physician documented we will start with an x-ray 2 view to further evaluate. On 12/1/25, a physician's verbal order documented an x-ray to left shoulder one time only for pain following trauma for 1 day. The physician verbal order was confirmed by RN #4. Resident #4's x-ray report dated 12/1/25, documented the following: Osteoporosis Mild to moderate shoulder osteoarthritis is visualized The distal clavicular irregularity is visualized, likely an acute fracture On 12/11/25, a physician's progress note documented the x-ray to the left shoulder on 12/1/25 was inconclusive and he will order a CT scan. On 12/31/25, a physician order documented a DEXA scan (an x-ray to measure bone mineral density and assess fracture risk) for Resident #4 to screen for Osteoporosis. From 1/12/26 – 1/15/26, the facility investigated the fall that Resident #4 had on 11/24/25 with the following results: On 1/13/26, a statement provided by the facility transportation driver documented that on 11/24/25 at 8:30 AM, Resident #4 fell out of his wheelchair and landed on the grass. On 1/13/26 a statement provided by LPN #3 documented the following events that happened on 11/24/25: - Resident #4 had a fall out of his wheelchair in front of the facility. - LPN #3 assessed Resident #4 for pain and ability to move extremities. - LPN #3 and the transportation driver assisted resident back into his wheelchair with a gait belt. - Resident #4 refused further assessment and wanted to go to scheduled appointment. On 1/13/26, the facility investigation documented LPN #3 directed LPN #1 to enter Resident #4's fall into the Risk Management system. On 1/13/26, the facility investigation documented LPN #1 acknowledged she was asked to enter Resident #4's fall on 11/24/25 into the Risk Management system but forgot. On 1/14/26, Resident #4's DEXA scan documented a diagnosis of Osteoporosis. On 3/18/26 at 1:48 PM, the ED stated he did not start the investigation until 1/13/26 because he did not know about Resident #4's fall on 11/24/25. During his investigation is when he found out LPN #3 had directed LPN #1 to document Resident #4's fall in the Risk Management system but LPN #1 forgot. The ED stated LPN #3 should have documented the fall but did not.

Based on observation, facility policy, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 1 of 4 residents (Resident #39) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. Findings include:The facility's Oxygen Administration policy dated 3/3/26, documented oxygen orders should include the specific liter flow required by the resident.Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including stroke and chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot adequately transfer oxygen into the blood). Resident #39's physician's oxygen ordered dated 11/12/23, documented oxygen 1 liter/NC continuously.Resident #39's care plan dated 7/21/22, documented provide supplemental oxygen, settings per MD order. Resident #39's MAR documented oxygen was administered at 1 lpm on 3/16/26, day and night shift and 3/17/26, day shift. On 3/16/26 at 1:29 PM, observed Resident #39 lying in her bed with her oxygen cannula in her nose and the oxygen concentrator was set at 2 lpm. Resident #39 stated she is on 2 lpm of oxygen.On 3/17/26 at 9:04 AM, observed Resident #39's oxygen concentrator was set at 2.5 lpm. On 3/17/26 at 9:08 AM, RN #1 stated Resident #39's oxygen should be set at 1 lpm and had not been. On 3/18/26 at 9:28 AM, the DON stated Resident #39's oxygen concentrator liter flow setting should be checked often or at least every shift by nursing staff and had not been.

Based on policy review, record review, observation, and staff interview, it was determined the facility failed to ensure that prior to the placement of bed rails, alternatives to bed rails were attempted and how the alternatives failed to meet the resident's assessed needs. This was true for 1 of 4 residents (Resident #72) reviewed for bed rails. This failure created the potential for harm due to the risk for injury, entrapment and/or death. Findings include:The facility's Bed Rails - Safe and Effective Use of Bed Rails policy, reviewed date 9/3/25, documented.Procedure 1. Residents will be assessed upon admission, readmission, or upon initiation utilizing the Evaluation for Use of Bed Rails Assessment. 3. If a bed rail will be utilized, the risks and benefits of bed rail(s) usage will be reviewed with the resident and/or resident representative, and consent will be obtained prior to installation of the bed rails or as soon as practically possible. Resident #72 was admitted to the facility on [DATE], with multiple diagnoses including hypothyroidism (a condition when the thyroid gland does not make enough thyroid hormone) and dementia.On 3/16/26, 3/17/26, and 3/18/26, observed Resident #72 with bilateral upper side rails on her bed and in the up position.On 3/18/26 at 10:20 AM, Resident #72's medical record did not have documentation of the evaluation of the alternatives attempted or documentation of the purpose of the intended use of the side rails or documented discussion of risks and benefits with a signed consent for use of bed rails.On 3/19/26 at 2:02 PM, the DON stated Resident #72 had not been assessed for the use of bed rails. The DON confirmed Resident #72's medical record had not contained documentation of the evaluation of alternatives attempted or the intended purpose of the use of side rails, a physician order for bed rails, or a consent for use of bed rails and should have.

Based on observation, State Operation Manual, Appendix PP, and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:The State Operation Manual, Appendix PP revised on 8/8/24, documented S483.35(g) Nurse Staffing Information. S483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.On 3/17/26 at 12:31 PM, observed the daily staffing sheet for 1/20/26 was missing CNA number of staff present and hours worked.On 3/17/26 at 12:45 PM, observed the daily staffing sheet for 2/15/25 was missing RN hours worked for day, evening, and night shift.On 3/18/26 at 9:30 AM, the Executive Director stated the CNA and RN worked hours and staff present data should have been documented on the daily staffing sheets for 1/20/26 and 2/15/25 and had not been.

Based on record review, staff interview, and policy review it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include: The facility's Inventory Control of Controlled Substances policy, revision date 08/01/24, documented.1. Procedure 1.1 Facility should ensure the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift.and document the results on a Controlled Substance Count Verification/Shift Change Sheet. 2. Facility should ensure facility staff count all Schedule III-IV controlled substances in accordance with facility policy and applicable law. On 3/18/26 at 8:17 AM, observed during the Hall 2 medication cart audit, the Narcotic Card Item Count sheets, dated 1/1/26 to 1/15/26, 2/1/26 to 2/15/26, and 3/1/26 to 3/15/26, with 1 licensed nurse signature not documented on 1/1/26, 2/3/26, 2/10/26, 2/11/26, and 3/10/26. On 3/18/26 at 8:19 AM, LPN #1 stated two nurses should have signed the Narcotic Card Item Count sheet and had not. On 3/18/26 at 8:50 AM, observed during the Hall 4 medication cart audit, the Narcotic Card Item Count sheet, dated 3/11/26 to 3/21/26, with 1 licensed nurse signature not documented on 3/12/26. On 3/18/26 at 8:55 AM, LPN #2 stated two nurses should have signed the Narcotic Card Item Count sheet when they accepted the medication cart or released the medication cart. On 3/18/26 at 10:16 AM, the DON stated two nurses should have signed the Narcotic Card Item Count sheet when they accepted the medication cart or released the medication cart and had not.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were assessed appropriately for adequate indications for the use of opioid pain medications. This was true for 1 of 4 residents (Resident #74) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse consequences or increased risk of death. Findings include:The facility's Pain Management policy dated 12/2/25, documented the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Assess pain every shift and record on eMAR. Always indicate which pain scale was used and document the type of pain the resident is experiencing. Resident #74's physician order for medication for mild pain documented Acetaminophen Tablet 325 MG, give 2 tablets by mouth every 8 hours as needed for mild acute pain for 30 Days, not to exceed 3000 mg/day.Resident #74 received acetaminophen on March 8th at 0837 for a pain level of 4 but no documented administration of acetaminophen from March 9th, 2026, through March 16, 2026.Resident #74's physician order for medication for moderate to severe pain documented Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for moderate to severe acute pain related to OTHER ACUTE OSTEOMYELITIS, LEFT ANKLE AND FOOT (M86.172) for 30 Days -Order Date 03/12/2026 1550 On 3/17/26 at 12:39 PM, Resident #74's medical record documented Percocet was given on the following dates and times related to pain level. - March 13, 2026, 0707 pain level 3 - March 15, 2026, 0621 pain level 3 - March 16, 2026, 0625 pain level 3 On 3/17/26 at 12:58 PM, the DON stated the physicians have moved from the pain intensity number scale because some residents might report a pain level of 3 when it really is a 6 or 7.

Based on observations, staff interviews, policy review, and manufacturer manual it was determined the facility failed to ensure biologicals were labeled when opened, and medications were properly stored in a locked compartment. This was true for the facility. These deficient practices created the potential for use of expired biologicals, and undetected access to medications by unauthorized personnel. Findings include: The facility's Storage and Expiration Dating of Medications and Biologicals policy, revision date [DATE], documented Procedure 11. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates. The Assure Prism Blood Glucose Monitoring System Quality Assurance / Quality Control (QA/QC) Reference Manual documented, .when you first open a control solution bottle, record the discard date (date opened plus 3 months) in the space provided on the label. The facility's General Dose Preparation and Medication Administration policy, revision date [DATE], documented Procedure 7. Facility should ensure that medication carts are always locked when out of sight or unattended. 1. The following was observed for biologicals.On [DATE] at 1:25 PM, one set of Assure Prism glucose test solutions (CSYF24BN and CSYM26AM) were not dated when opened or had an expiration date written on the label. On [DATE] at 1:28 PM, RN #2 stated she did not know how long the test solutions had been opened and used. On [DATE] at 11:41 AM, review of the Blood Glucose testing logs from 10/25 to 3/26, blood glucose test solutions (CSYF24BN and CSYM26AM) were documented on the log as being opened and used for testing during 11/25, 12/25, 1/26, 2/26, and 3/26. On [DATE] at 11:53 AM, the IP stated the blood glucose test solutions should be dated when opened and were only to be used for 3 months. 2. The following was observed for unlocked medication cart. On [DATE] at 1:21 PM, observed Hall 2 medication cart had been left unlocked and unattended by the medication nurse. On [DATE] at 1:24 PM, observed RN #3 pushing a Hoyer lift down Hall 2 towards the medication room. On [DATE] at 1:25 PM, RN #3 stated the medication cart should have been locked when left unattended. On [DATE] at 1:37 PM, the DON stated the medication cart should have been locked when not attended by the nurse and had not been.

Based on observation, policy review, and staff interviews, it was determined the facility failed to ensure infection control and prevention practices were maintained for residents' Durable Medical Equipment (DME). This was true for 1 of 1 resident (Resident #71) reviewed during environmental observations. This failure had the potential to impact residents by placing them at risk for cross contamination and infection. Findings include:The facility's Infection Prevention and Control Program (IPCP) and Plan revised 6/2/25, documented under Implementing Strategies to Achieve the Goals.4. Methods to reduce the risks associated with procedures, medical equipment, and medical devices, including the following:a. Appropriate storage, cleaning, disinfection, and/or disposal of supplies and equipmentResident #71 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation, heart failure, and hypertension.On 3/16/26 at approximately 8:45 AM, observed Resident #71 operating her power wheelchair towards her room in the 200 Hall.On 3/16/26 at 9:24 AM, observed the following in the shower room on the 200 Hall:- Out Of Order sign on the outside of the door- A thick dirty black ring around inside toilet bowl- A dirty, brown substance on the floor and walls- Used paper towels on the back of the toilet and on the sink- Resident #71's power wheelchair with an open box of cereal in the bag attached to the back of the wheelchair and a Hoyer lift sling in the seat- A resident lounge shower chairOn 3/16/26 at 2:30 PM, observed a Hoyer lift stored in the shower room that was Out of Order on the 200 Hall.On 3/19/26 at 9:50 AM, observed a bariatric shower chair stored in the shower room that was Out of Order on the 200 Hall.On 3/19/26 at 10:30 AM, the Infection Preventionist stated staff should not be storing resident equipment in the Out of Order shower room on Hall 200.

Based on policy review, record review, and staff interview, it was determined the facility failed to honor residents Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders. This was true for 1 of 1 resident (Resident #5) whose record was reviewed for code status. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented. Findings include:Resident #5 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic kidney disease and diabetes.A facility investigation documented on [DATE], Resident #5 was found unresponsive by CNA staff and nursing staff were notified. Nursing staff performed an assessment and determined Resident #5 was a DNR. LPN #1 then entered Resident #5's room with a POST document in hand and stated she was a full code and CPR was started. This POST document was later found to be for a different resident and not Resident #5. Nursing staff called 911 for an ambulance. When the ambulance crew arrived, facility staff had correctly identified Resident #5 was a DNR and CPR was stopped, and time of death was called at 3:30 PM.Resident #5's physician order dated [DATE] for code status was DNR. Resident #5's POST documented do not resuscitate and can use aggressive interventions to include positioning, oxygen therapy etc.Resident #5's care plan documented code status as DNR.On [DATE] at 2:05 PM, the Admissions nurse and RN #1 stated Resident #5 had been a DNR and CPR should not have been started on her.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 1 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 9/2/25 at 12:19 PM, during Hall 2 medication cart review, observed the narcotic accountability record, dated 9/1/25 to 9/2/25, with 1 licensed nurse signature not documented. On 9/2/25 at 12:32 PM, RN #1 stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart. On 9/2/25 at 12:40 PM, the Admissions Nurse stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on policy review, record review, and staff interview, it was determined the facility failed to honor residents' Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, and to ensure residents and their representatives received assistance to exercise their right to formulate an advanced directive. This was true for 1 of 18 residents (#24) whose records were reviewed for advanced directives. This deficient practice caused actual harm with the potential for more than minimal harm or adverse outcomes if residents' wishes were not followed or documented. Findings include: The facility's Cardiopulmonary Resuscitation (CPR) policy, dated [DATE], documented the facility should ensure resident preferences and physician orders related to CPR and other advance directive issues are communicated so that staff know immediately what action to take or not take when an emergency arises. 1. Resident #24 was admitted to the facility on [DATE], and readmitted [DATE], with multiple diagnoses including C2 level cervical spinal cord lesion (damage to the spinal cord at the level of the second cervical vertebra) and chronic kidney disease. Resident #24 nursing note dated [DATE] at 12:05 (late entry), documented nursing staff were assessing Resident #24 for possible choking issue when she was found in her room with agonal respirations. The DON and MD assisted Resident #24 to the floor to continue assessment and initially found but quickly lost her pulse and she was not breathing. On [DATE] at 8:45 AM, the facility called a code blue (a medical emergency code that indicates a patient needs immediate medical attention or resuscitation) for Resident #24. Facility staff connected Resident #24 up to an automated external defibrillator (AED) which indicated no shockable rhythm. Facility staff then continued CPR on Resident #24 for 13 minutes until EMS arrived. EMS took over CPR and intubated Resident #24. At no time did any facility staff member check Resident #24 medical record to confirm her code status. Resident #24's medical record contained a Physician Orders for Scope of Treatment (POST) in her medical record documenting she was a DNR and DNI. Resident #24's care plan, dated [DATE], documented she requested DNR status. On [DATE] at 8:53 AM, the surveyor reviewed Resident #24's medical record, confirmed she was a DNR, and notified the Executive Director Resident #24 was a DNR. A hospital emergency department report, dated [DATE], documented EMS staff were not notified by facility staff of Resident #24's code status until after she was intubated and loaded into the ambulance in route to the hospital. A hospital emergency department report, dated [DATE], documented when family arrived at the hospital, they confirmed Resident #24 was a DNR/DNI and should have been allowed to pass naturally. A statement submitted by the Medical Director (MD), dated [DATE], documented he was not aware Resident #24's code status was a DNR/DNI until after she was transferred to the hospital. On [DATE] at 9:30 AM, the DON stated she was not aware Resident #24's code status was a DNR/DNI until after the resident's care was turned over to EMS. Resident #24 expired at the hospital on [DATE] at 12:06 PM.

Based on observation, food code review, and staff interview, it was determined the facility failed to ensure food was stored in a safe and sanitary manner. These deficiencies had the potential to affect all residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA (Food Drug Administration) 2022 Food Code, Section ,d+[DATE].17 documented 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. During the initial kitchen inspection conducted on [DATE] at 7:00 AM, the following was observed: Walk-in refrigerator: - 8 individual yogurts with expired dates of [DATE] - A sandwich wrapped in cellophane labeled GC and dated [DATE] - An open bag of salad unlabeled On [DATE] at 7:20 AM, the Dietary Aide #1 stated the expired yogurts should have been thrown out and she did not know who the sandwich was for or why the salad did not have dates on it. During a second inspection on [DATE] at 11:15 AM, the following was observed: Walk-in freezer: - An opened package of chicken breast with ice crystals, undated, and a binder clip attached to the top of the bag - A previously opened package of chicken tenders, undated and a binder clip attached to the top of the bag On [DATE] at 11:25 AM, the Food Service Director stated the chicken breast and chicken tenders should have been dated and not sealed with a binder clip. On [DATE] at 11:40 AM, observed with the Food Service Director, RD, and [NAME] #1 , multiple ants on the food preparation table, underneath a dish towel and inside a logbook. On [DATE] at 11:41 AM, the Food Service Director stated the pest control contractor had done his inspection and treatment a couple of weeks ago. On [DATE] at 1:05 PM, the Maintenance Director stated the pest control contractor comes to the facility monthly and on an as needed basis. On [DATE] at 3:05 PM, the Food Service Director with the Registered Dietician present, stated there should not have been expired foods or an open, undated bag of salad in the walk-in refrigerator.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 8 of 18 Residents (#4, #6, #12, #29, #40, #54, #58, and #65) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/2024, documents section K0520 Nutritional Approaches, was to be checked if a resident receives nutrition from a feeding tube. The RAI, revised 10/1/2024, documents section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determines a resident has a serious mental illness and/or mental retardation, or related condition. 1. Resident #4 was admitted to the facility on [DATE], with a diagnosis of Cerebral Palsy (permanent, nonprogressive motor dysfunction due to abnormalities in developing the brain). Resident #4's physician order dated 12/31/18, documents she received her nutrition through a feeding tube. Resident #4's MDS assessment dated [DATE], documented she did not receive nutrition through a feeding tube. On 1/7/25 at 3:41 PM, the MDS Coordinator stated resident #4's MDS assessment dated [DATE], was not coded correctly and should have been marked that she does receives her nutrition through a feeding tube. 2. Resident #6 was admitted to the facility on [DATE], with a diagnosis of schizophrenia (mental disorder involving chronic or recurrent psychosis). Resident #6's PASRR Level II dated 5/31/16, and PASRR Level II dated 1/7/25, documented she had a diagnosis of schizophrenia (a diagnosis catagorized as a major mental illness). Resident #6's MDS assessment section A1500, dated 10/14/24, did not document she had a major mental illness. On 1/7/25 at 3:41 PM, the MDS Coordinator stated Resident #6's MDS assessment, dated 11/12/24, was not coded correctly and they would do a modification. 3. Resident #12 was initially admitted to the facility on the 10/14/24, with multiple diagnoses including bipolar disorder (a major mental mood disorder) and PTSD (post-traumatic stress disorder). Resident #12's PASRR I dated 10/11/24, documented under section 2.5 A if resident has an MMI (major mental illness) a PASRR II needs to be done. Resident #12 had bipolar checked for her MMI. Resident #12's care plan dated 10/15/24, documented she had an active diagnosis of bipolar depression. Resident #12's Admission MDS assessment, dated 10/15/24, documented in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? On 1/8/25 at 3:22 PM, the DON stated Resident #12's MDS assessment should have had Yes checked for a MMI. 4. Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (characterized by damage to the lungs that narrows the airways and makes breathing more difficult), schizoaffective disorder (a chronic mental illness that combines symptoms of schizophrenia and a mood disorder, such as bipolar disorder or depression), and major depressive disorder with severe psychotic symptoms (a serious mental illness that involves depression and psychosis). Resident #29's MDS assessment dated [DATE], documented under A1500 No for PASRR II however there was a PASRR II found in her medical paper chart dated 10/25/24. On 1/9/25 at 11:10 AM, the DON stated Resident #29's MDS assessment under A1500 PASRR II should have been documented as Yes. 5. Resident #40 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including hemiplegia and hemiparesis (both conditions that cause weakness or paralysis on one side of the body), dementia with psychotic disturbance/agitation, and depression. Resident #40's MDS assessment, dated 8/13/24, documented resident did not have a catheter in place. Resident #40's MDS assessment, dated 11/12/24, documented resident had a catheter in place. On 1/7/25 at 1:39 PM, Resident #40 confirmed she did not have a catheter in place. On 1/7/25 at 3:42 PM, the MDS coordinator confirmed Resident #40 did not have a catheter in place and the MDS assessment was coded in error. 6. Resident #54 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and opioid abuse. On 1/8/25, Resident #54's MDS assessment dated [DATE], documented under A1500 No for PASRR II however there was a PASRR II found in her medical paper chart dated 12/27/24. On 1/9/25 at 11:12 AM, the DON stated Resident #54's MDS assessment under A1500 PASRR II should have been documented as Yes. 7. Resident #58 was admitted to the facility on [DATE], with a diagnosis of bipolar disease (a severe mental illness causing mania or depression). Resident #58's PASRR Level II, dated 7/31/24, documented he had a diagnosis of bipolar disease. Resident #58's MDS assessment section A1500, dated 8/5/24, did not document he had a serious mental illness. On 1/7/25 at 3:41 PM, the MDS Coordinator stated Resident #58's MDS assessment, dated 8/5/24, was not coded correctly. 8. Resident #65 was admitted to the facility on [DATE], with multiple diagnoses including dysphagia (difficulty swallowing) and emphysema (chronic lung condition). Resident #65's physician's order, dated 12/13/24, documented his Dobhoff (small flexible nasogastric tube used to deliver nutrition to the stomach) was for enteral feedings only. No medications. Resident #65's Admission/Medicare - 5 Day/MDS assessment, dated 12/17/2024, documented, YES under section K0520 for Nutritional Approaches: A. Parenteral/IV feeding. Under B. NO was documented for Feeding tube (e.g., nasogastric, or abdominal tube (PEG). On 1/9/25 at 3:05 PM, the MDS coordinator stated Resident #65's MDS assessment should have been marked as B for his Dobhoff. 49552 51121

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 4 of 18 residents (#12, #23, #59, and #65) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Care Planning-Baseline, Comprehensive, and Routine Updates policy, revision date 11/25/24, documented the facility would monitor the individual's progress and adjusts interventions to their care plan as needed. 1. Resident #12 was initially admitted to the facility on the 10/14/24, and readmitted to the facility on [DATE], with multiple diagnoses including bipolar disorder (a major mental mood disorder) and post-traumatic stress disorder (a major mental illness). Resident #12's care plan, dated 11/22/24, documented she had clostridium difficile (a bacterial inflammation of the colon). During an interview with the DON on 1/9/25, at 4:42 PM, the DON stated Resident #12 had not had clostridium difficile for a while and her care plan should have been updated. 2. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including heart failure and kidney disease. On 1/6/25, at 7:43 AM, a bottle of Biofreeze (a pain relief gel) was observed on Resident #23's bedside table. Resident #23's medical record documented a physician's order, dated 1/7/25, for Biofreeze Roll-On External Gel 4% Menthol (topical analgesic) to be applied to affective area topically every 6 hours as needed for pain, and may be kept at bedside. Resident #23's care plan dated 12/11/24, did not document self-administration of Biofreeze. On 1/8/25, at 9:45 AM, LPN #1 stated residents can self-administer medications if they have had a self-administration assessment completed, an order to self-administer the medication, and it is care planned. LPN #1 stated Resident #23 should have had her Biofreeze care planned. 3. Resident #59 was admitted to the facility on [DATE], with multiple diagnoses including stroke and benign prostatic hyperplasia (prostate gland enlargement). On 1/6/25 at 4:41 PM, Resident #59's record review documented a physician's order for Calmoseptine Ointment 0.44-20.625 % (Menthol-Zinc Oxide). Apply to affected area topically two times a day for excoriation. On 1/8/25 at 3:52 PM, a record review of Resident #59's care plan did not document excoriation or treatment for excoriation. On 1/10/25 at 12:05 PM, LPN #1 stated Resident #59 should have had wounds and treatment orders on his care plan. 4. Resident #65 was admitted to the facility on [DATE], with multiple diagnoses including dysphagia (difficulty swallowing) and emphysema (chronic lung condition). A physician's order, dated 1/6/25, documented Resident #65's Dobhoff (nasogastric tube) was discontinued. On 1/9/25, Resident #65's care plan documented he had a Dobhoff for enteral feedings. On 1/9/25 at 4:10 PM, the DON stated Resident #65's Dobhoff was discontinued and should have been removed from his care plan.

Based on a complaint from the general public received by the BFS on 2/24/12, record review, and staff interview, it was determined the facility did not ensure a resident received the necessary interventions to prevent the development of pressure/friction injuries. This failed practice resulted in harm to 1 of 4 residents (#2) reviewed for pressure ulcer prevention and/or intervention. Resident #2 was admitted to the facility with a recent history of a pressure to her sacral region. On 11/11/11 she developed two Stage II pressure/friction injuries to her heels. On 1/17/12 she was observed by staff to have a Stage III pressure ulcer at the same previous sacral location. Findings include: The complainant stated an identified resident developed wounds while in the facility. a) Resident #2 was admitted to the facility on [DATE] following hospitalization for right [MEDICAL CONDITION] with repair. While in the hospital she was also being treated for [REDACTED]." Additional [DIAGNOSES REDACTED]. Resident #2's admission MDS, with the assessment reference date of 6/29/11, identified she sometimes made herself understood and usually understood others. Her BIMS score was "5", indicating severe impairment in cognitive abilities. She exhibited physical behaviors which did not interfere with her care and she did not reject cares. She required two + persons physical assist for bed mobility, transfers, and toilet use. She required one person physical assist for eating and personal hygiene. The MDS section M - Skin Conditions, identified she was at risk for developing pressure ulcers, and currently had no pressure ulcers. Section M also identified the facility provided pressure reducing devices for her chair and bed, and she was on a turning/repositioning program. Resident #2's Braden Scale for Predicting Pressure Sore Risk form identified she scored "13", indicating she was at moderate risk for the development of pressure ulcers. On 10/5/11, she scored "12", indicating she was at high risk. Her last Braden scale assessment, dated 2/13/12, also scored as "12." The resident's Initial Data Collection Tool/Nursing Service form, dated 6/22/11 and signed by the admitting LN, documented the resident had dry heels bilaterally, and a dressing to her sacral region which was dry and intact. The form also contained a section, Additional Nursing Comments, which contained two entries. The first entry documented, "...hard to understand at times, will require total assistance to re-position..." The second entry, undated, was written by the WCC LN and documented, "2nd skin (check) noted multiple bruising to body. removed drsg (wound dressing) from sacrum (with) intact skin below. Place [MEDICATION NAME] (with no) drsg." NOTE: [MEDICATION NAME] is a multi-purpose moisture barrier ointment. The resident's admission Nurse's Notes, dated 6/22/11 at 5:00 pm, documented in part: "...Resident unable to reposition self will require assistance turning every two hours...skin check revieiled (sic) drsg over coccyx, D/I (dry/intact changed) today by hospital. Hospital reports a stage II pressure sore..." Mult podus boots on to protect heels..." A Nurse's Note, dated 6/23/11 no time recorded, documented in part: "Res(ident) admitted (with) drsg & notes pertaining to sacral wound. 2nd skin check performed & [MEDICATION NAME] removed, intact skin under drsg (with) noted scaly dry skin. In maturation phase. Place [MEDICATION NAME] ointment for protection (no) drsg required. Will monitor." The entry was signed by the WCC LN. Resident #2's record contained a four page report from the hospital faxed to the facility on [DATE]. The typed report documented in part: "Order: wound care for sacral wound...shearing/friction injury on the right buttox (sic) sacral area...partial thick(ness) open raw dermis...Dressing: oval HCLD ([MEDICATION NAME] wound dressing.)" NOTE: Page 1 of the report contained a handwritten note which documented," Upon inspection on admit (no) open area remains." The note was signed, but not dated, by the facility's WCC LN. Resident #2's admission Interim Care Plan, dated 6/22/11, identified: "Resident Need: Has break in skin integrity Relating to: Pressure Ulcer... Interventions: Heel mult. boots (Multi podus boots.) Elevate heels off bed surface and "float" heels - no pressure on heels Reposition q (every) 2 hours in bed; Reposition q 1 hours in chair...Assess podus boots, shoes, straps, heel protectors...for pressure..." NOTE: There was a handwritten entry, dated 6/23/11, which documented, "wound to sacrum resolved." Resident #2's revised Care Plan, dated 7/1/11, included: "Problem Onset, 7/01/2011, Potential for alteration in skin r/t impaired mobility and incont of b/b (incontinent of bowel/bladder)...She is resistive to cares at times... Approaches: *Stat II LAL/AP (low air-loss/alternating pressure) mattress (with) bolsters *Ext(ensive) assist of two for positioning *Encourage her to reposition every two hours *Cushion in w/c... *Podus boots on while in bed." NOTE: The intervention, "Elevate heels off bed surface and "float" heels - no pressure on heels" was not included on the revised care plan. A second revised Care Plan, dated 9/28/11, included the same "Problem Onset" as on 7/1/11. The Approaches included: "*Ext(ensive) assist of two for positioning *Encourage her to reposition every two hours." NOTE: The specialty LAL/AP mattress was discontinued on 10/19/11 and replaced with a "concave mattress with bolsters." The Podus boots were discontinued on 11/11/11 and replaced with "Foam heel lift boots to BLE at all times." The following Nurse's Notes on Resident #2 revealed her behavioral status for the three week time period before she was observed to have blisters on both heels on 11/11/11 at 8:00 pm: 10/19/11, 6:30 pm: "Res(ident) pleasant & talkative today. Easily upset x 2 (times two with) ADLs but calms quickly..." 10/22, 10:00 pm: "Pleasant and cooperative (with) cares..." 10/23, 2:30 pm: "Resident very agitated and anxious this shift..." 10/24, 3:30 pm: "Resident had some periods of (increased) agitation and anxiety but mostly calm today..." The Nurse's Notes also documented she was "calm" and/or "cooperative" on 10/25, 10/26, 10/27, 10/29, 11/2, and 11/5. The Nurse's Notes documented she was "agitated" and/or "combative" on 10/27, 10/28, 10/29, and 11/4. The Nurse's Notes continued: 11/6, 3:05 pm: "Resident has been very quiet today...She was lethargic and difficult to wake in a.m..." 11/7, at 4:15 am: "Resident remains lethargic, slept all noc (night) arouses slightly (with) cares...Repositioned hourly..." 11/8, 5:00 am: "...opens eyes when repositioned...very sleepy..." 11/9, 5:00 am: "Res slept, lethargic difficult to awaken during rounds..." 11/10, 5:00 am: "Crying @ HS (at hour of sleep after) put to bed & also during noc anytime she was given care or moved - combative (with) attempts to give fluids/HS snak (sic). Returns to sleep most of noc." 11/11, 4:00 am: "...(No) crying or combative behavior. Resident has slept most of noc." 11/11, 5:34 pm: "Res continues to cry (with) daily cares and transfers, staff works gently (with) her and tries to explain what they are doing. Res will at times start a loud talk with no one in the room, (-) (Negative or no) call for help or expression of needing anything..." 11/11, Friday at 8:00 pm: "Notified wound nurse and MD of res, having bilateral heels (with) a blister on ea (each) heel. Areas not red blisters intact (with) clear appearance of fluid..." The WCC LN documented her wound evaluation/care entries on nurse's notes which were separate from the daily nurse's notes and contained the following documentation: 11/14, Monday, no time recorded: "Notified by LN of bilateral heel blisters to heels. Upon inspection of site res has L(eft) lateral & R(ight) medial heel blister, both shallow & fluid filled, clear. Assessed initial interventions for appropriateness. MP (Multi Podus) boots (changed) to foam heel lift boots, tx (treatment) orders also appropriate @ this time...Wound shows (no signs/symptoms) of infection. Staff report blisters not present prior to placing her in bed & she had podus boots on. She became agitated & kicked boots off causing blistering R/T (related to) friction..." NOTE: The three nursing entries for 11/11/11 contained no documented evidence Resident #2 was "agitated" that day. The nurses's notes for 11/6 through 11/9 did, however, document the resident had increased lethargy and was difficult to wake on two occasions. Resident #2's record also contained an Interdisciplinary Care Plan form, dated 11/11/11, which documented in part: "Res. presents with bilateral heel blisters. Upon assess blisters are on L lateral & R medical heel. Res has had recent increased agitation (with) crying, (increased) aggression toward others...Blisters are clear fluid filled, shallow & (no or not) infected. Friction related." NOTE: The form was signed/dated by the WCC LN on 11/11/11, however, according to her nurse's notes, she did not evaluate Resident #2 until 11/14/11. In addition, there was no documented evidence in the resident's record that she was exhibiting increased agitation, except in the 11/10/11, 5:00 am entry which documented, "Crying @ HS (at hour of sleep after) put to bed & also during noc anytime she was given care or moved - combative (with) attempts to give fluids/HS snak (sic). Returns to sleep most of noc." The resident's TARS included: *6/2011: Mult.Podus boots on at all times while res. in bed." NOTE: The Time of Day column had "FYI" (For Your Information) listed. There were no LN initials in any date column from 6/22 through 6/30/11. *7/2011: "Protection boots on at all times while in bed. FYI." NOTE: There were no LN initials in any date column from 7/1 through 7/31/11. *8/2011 through 10/2011: "Multi Podus boots at all times. FYI. " NOTE: There were no LN initials in any date column from 8/1 through 10/31/11. *11/2011: "Multi Podus boots at all times." NOTE: The "FYI" was lined through and next to it was written, "6A-6P" and "6P-6A". There were LN initials documented in each of the 12 hour shift boxes for 11/1 through 11/11/11, when the treatment plan was changed to the following: "Foam heel boots on at all times, 11-11-11." On 3/14/12 at 3:15 pm, during an interview with the DON the survey team requested all documentation regarding Resident #2 as it related to her pressure/friction injuries and all documentation of cares/treatments performed in the facility's attempts to prevent the pressure/friction injuries, including documentation in the facility's computerized documentation system, RITA. On 3/15/12 at 11:20 am, the Administrator provided printed forms from the RITA computerized system for Daily Care, for the months of June 2011 through March 13, 2012. The daily cares to be performed and documented regarding Resident #2 were identified as, "Repositioned Every Hour" and "Repositioned Every 2 Hours." The form did not include any direction to staff regarding applying the heel protectors or floating heels. The form contained vertical columns designated for each of the three shifts (D/E/N) and for each day of the month. The following dates and/or shift columns contained no documentation that the resident was repositioned either every one or two hours: July 2011: 3 (D); 5 & 7 (E); /9 (E,N); 10 (E); 13 & 15 (N); 28 (D). August: 1 & 2 (D,N); 8 (N); 10 (E); 12 (D); 14 & 15 (N); 17 (D); 18 (D,N); 19 (D,E); 20 (D,N); 22 & 25 (D); 28, 29, & 30 (N); 31 (D, N). September: 3 (D,N); 5 & 6, (D); 10 (D,N); 11 (D); 17, 18, & 19 (D); 20 & 22 (D,N); 23 (D); 28 (D/N); 30 (N.) October: 1 & 2 (D,E,N); 3 (D); 4 (N); 6 & 7 (D); 10, 11, & 12, (D); 16 (D); 19, 20, 21 (D); 22 (D,N); 23 (N); 24 (D); 26, 27, 29, 30 & 31 (D). November: 2 (E); 3 (D); 4 (N); 5 (D); 7 (D,E) 10, 12, 13, 14 & 16 (D); 17 (E); 19 (D); 20 (N); 21 (D); 24 (N); 25 (D); 26 (N); 28 (D,E); 30 (E). NOTE: The RITA documentation from 12/2011 through 1/31/12 is included in part "b" below. Resident #2's Non-Pressure Skin Condition Record documented in part: "11/11/11 Friction blisters L heel lateral 3 x 3.4 cm; R heel medial 2.8 x 3.2 cm." There were weekly assessments of the bilateral heels through 1/23/12 when the wounds were "resolved." The facility could provide no further documentation in Resident #2's permanent record to ensure Resident #2 was consistently repositioned when in bed with heels floated and that staff applied the heel protectors in attempts to prevent the bilateral heel injuries. b) Resident #2's Nurse's Notes also documented in part: *11/17/11, 5:00 am: "...No episodes of crying. Sleeps all noc did holler once (with) repositioning..." *11/18/11, 1:30 or 2:30 am: "...Scabbing to right buttocks. Ointment applied regularly..." NOTE: This is the first documentation identifying a wound to this site since her admission to the facility on [DATE]. The next documentation regarding the scab to the resident's right buttock was on 11/25/11, "...scabbing to R buttock. Ointment applied regularly..." On 12/23, 12/31/11 and 1/6/12, the documentation identified, "No new skin issues noted..." There were no nurse's notes provided for the dates after 1/9/12, at 4:00 pm until the entry on 1/15/12 at 12:00 pm. There was no further documentation regarding the condition of the resident's right buttock. The only documentation in the nurse's notes that Resident #2 was repositioned while in bed was on 11/17/11. From 1/4 through 1/16/12, there were only three nursing entries that documented the resident was agitated: 1/7/12 at 2:30 pm, "She has been crying and agitated all shift..." 1/8/12, no time recorded, "She continues to be upset and agitated...", 1/15/12, 12:00 pm, "...Continues (with) crying and agitation..." The nurse's notes from 1/15 at 11:10 pm through 1/17/12 at 4:00 am, documented the resident was "Pleasant and cooperative with cares." *1/17/12, 9:00 am: "Stage III pressure wound noted on res coccyx..." The wound care nurse's notes, dated 1/16/12, not written by the WCC LN, documented in part: "...Also assessed coccyx because staff informed me of wound. Stage III pressure sore noted...Wound measure 2 x 4.2 cm, minimal drainage noted..." NOTE: This date was one day earlier than the date on the routine nurse's note documentation. The wound care nurse's notes further documented: *1/19/12, 11:00 am: "Reassed (sic) wound to L buttock, sero sang (serosanguineous) drainage noted - Moderate amount (with) some odor. MD assessed wound and stated it was from friction because of where it was located. Area is dark purple/black on center of wound. Wound is indurated & red around wound bed. Measured at 2.3 x 3 (cm) at this time." The treating physician note, dated 1/19/2012, documented in part: "...Extremities: buttocks with a open area on her right side just off of center. This involves the epidermis and some induration. Tis (sic) appears to more (sic) a shearing type wound as it is not on a bony prominence..." The wound care nurse's notes continued: *1/23/12, no time recorded: "Assessed wound to L buttock/coccyx area..." *3/12 and 3/14/2012, no times recorded, and written by the WCC LN: "...wound assess(ment) to coccyx..." NOTE: The Pressure Ulcer Status Record, also dated 1/16/12, identified the wound as located on the resident's "coccyx." Based on the documentation it was unclear if the wound was on the resident's right or left buttock or her coccyx. The TARS for 11/2011 through 1/2012 contained the following skin care directions for LNs: 11/2011: "[MEDICATION NAME] to affected areas as needed for excoriation. PRN." NOTE: There were no LN initials in any shift/date box for this time period. It is uncertain what "ointment" was applied to the scabbed area on the right buttock as described in the nurse's notes on 11/18 and 11/ 25/11. The TAR also documented that the specialty LAL/AP mattress was discontinued on 10/19/11 and replaced with a "concave mattress with bolsters on 10/19/11." On 1/16/12 the specialty air mattress was again applied to the resident's bed. The following dates and/or shift columns on the RITA forms contained no documentation that the resident was repositioned either every one or two hours: December 2011: 2 (E); 3 (D); 6 (N); 7 (E); 8 & 10 (D); 11 (N); 12 (E); 13 &14 (D); 15 (N); 16 (D); 18 (N); 19 & 20 (D); 23 (D,E); 24, 26, & 28 (D); 29 (N); 30 (D,N); 31 (D). January 2012: 2, 3, & 5 (D); 6 & 8 (E); 9 & 10 (D,E,N)); 11 (N); 13 thru 18 (D); 19 (D,E); 20 (D,N); 22, 28, 30, & 31 (D). On 3/14/12 at 3:15 pm, the DON was informed of the concern regarding Resident #2's pressure/friction ulcers to her bilateral heels and her buttock and/or coccyx area. The DON was asked to provide a timeline of events that may have lead to the resident's skin breakdown. The DON agreed to this request. On 3/15/12 at 9:15 am, the DON and WCC LN were interviewed. The DON presented the timeline and provided a letter, dated 3/14/12, signed by the treating physician, DON and WCC LN. The letter documented in part: "...Call placed by wound care nurse to wound clinic on 6-23-11 which reported stage II to right buttocks/sacral (friction wound.)...Due to having a previous wound the resident is at a higher risk for developing a wound in the same location because after a wound is resolved the tinsel (sic) strength is only 70%...On 6/23/2011 stat 2 low air loss mattress applied on bed... Also placed on 2-hours turn sheet for pressure reduction. Wound to sacrum/buttocks continues to be closed at this time. [MEDICATION NAME] applied....On 10-19-11 air mattress discontinued due to risk vs benefits regarding resident safety. Resident placed on concave mattress to clearly identify for resident mattress edges...On 10-29-2011...Resident continued and continues with behaviors including but not limited to...aggressive behaviors with staff, resistant to cares, excessive movements at times...1/19/2011 (sic)...MD did not stage wound due to not pressure related. Resident with known behaviors of sliding/frequent movements while in wheelchair/bed at times of increased behaviors..." NOTE: The Federal guidance under F 314, DEFINITIONS, states,"...Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers...." and, "Pressure Points and Tissue Tolerance, ...Friction and shearing are also important factors in tissue ischemia, necrosis and pressure ulcer formation..." During the same interview with the DON and WCC LN, the LN stated she would provide her documentation of Resident #2's turning schedule. She was asked if these documents were a permanent part of the resident's record. She stated she only kept the turning schedule and documentation for six months and were not part of the permanent record. The WCC LN was asked how the coccyx/buttock wound looked currently. She indicated that the wound had more slough in the base and some granulation tissue. She was asked if she acknowledged that the wound was at least a Stage III. She stated, "Yes." She was asked how the wound suddenly appeared as a Stage III on 1/17/12 (Monday) without anyone at least first noticing any redness to the site. She stated, "I can't answer that. I wasn't here when it developed." The DON stated, "We have evidence and documentation of weekly skin checks." The DON was asked if the skin checks on Resident #2 were performed on Fridays, as per the TAR. She stated, "Yes." She was informed that this was performed on 1/13/12, (Friday), at least 72 hours prior to the Stage III wound being observed. The DON stated Resident #2 had "increased agitation while in her chair, especially, with increased movements, wiggling." The DON and WCC LN were informed that according to the documentation in the nurse's notes, for at least five days prior to the observed bilateral heel blisters the resident was observed to be "lethargic" and "very sleepy." There was no documentation that she had increased agitation and increased movements. In addition, during the twelve days prior to the observed Stage III pressure ulcer, there were only three nursing entries that the resident had increased agitation, otherwise she was "pleasant and cooperative with cares." On 3/15/12 at 11:20 am, the Administrator and WCC LN provided four large binders containing pressure ulcer prevention audits for all residents in the facility as requested during the 3/14/12 interview with the DON and WCC LN. The LN was again asked if any of these documents were part of the residents' records. She stated, "After six months I purge the notes from binders. I was told by a surveyor that I didn't have to keep the sheets." The Administrator stated, "RITA is a permanent part of the record." She acknowledged that the RITA system did not contain documentation that staff applied the Multi-Podus boots on the resident. Although the audits were not included as part of Resident #2's record, the surveyor reviewed them and found the following dates with no audits performed for each 24 hour period: July 2011: 6, 17, 26, & 27 August: 29 & 30 (September and October not reviewed) November: 2, 3, & 4. NOTE: These dates documented the resident was "OOF", however, there were nurse's notes for each of the dates and no indication the resident was out of the facility. On 3/15/12 at 3:20 pm, the surveyor went to the DON's office. The DON, one RN consultant and one DON from a sister facility were present. The DON was informed of the missing audit dates and that, according to the audits, the resident was not in the facility on 11/2, 3, and 4. The DON stated, "Yes, she was out." The DON was informed that according to the nurse's notes the resident was in the facility. On 3/15/12 at 3:40 pm, the Administrator informed the survey team that the missing audit dates could not be located. She also stated there was no documentation that staff applied the Multi-Podus boots on Resident #2 from the time of her admission to the facility.