Every finding on record at Morning Breeze Retirement Community and Healthcare

Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for a hypertensive medication for 1 of 18 residents reviewed for Quality of Care. (Resident 7)Findings include:The clinical record for Resident 7 was reviewed on 07/30/2025 at 10:29 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 06/17/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, metabolic encephalopathy, anemia, heart failure, hypertension, orthostatic hypotension, diabetes, non-Alzheimer's dementia, anxiety, and depression.An open-ended physician's order, with a start date of 04/15/25, indicated for the staff to administer the resident's Metoprolol 25 milligrams, once a day. The medication was to be held if the resident's systolic (top number) blood pressure was less than 110 or the heart rate was less than 60.The clinical record, including the April, May, June, and July 2025 Electronic Medication Administration Record (EMAR), lacked documentation that the resident's blood pressures or heart rates were obtained and documented prior to the administration of the medication.During an interview, on 07/31/25 at 1:29 P.M., Licensed Practical Nurse 3 indicated if a resident had hold parameters for a medication, then she would obtain the vitals before administering the medication. If the vitals were outside the parameters, then she would hold the medication and document in the residents' record why the medication was not given. The resident's vitals should have been documented in the EMAR.The current facility policy titled, Administering Medications with a revision date of April 2019, was provided by the Director of Nursing on 07/31/25 at 3:03 P.M. The policy indicated, .Medications are administered in a safe and timely manner, and as prescribed.The following information is checked/verified for each resident prior to administering medications:.Vital signs, if necessary.3.1-37(a)

Based on record review and interview, the facility failed to follow physician's orders for weight monitoring for 2 of 5 residents reviewed for nutrition. (Residents 38 and 49)Findings include:1.The clinical record for Resident 38 was reviewed on 07/30/2025 at 1:53 P.M. An admission Minimum Data Set (MDS) assessment, dated 06/14/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, cellulitis, thyroid disorder, arthritis, and malnutrition.The resident had a diagnosis of heart failure, dated 06/15/25 and congestive heart failure, dated 06/25/25.A physician's order, dated 06/30/25 through 07/30/25, indicated the resident was to be weighed daily for congestive heart failure.A current open-ended physician's order, with a start date of 06/25/25, indicated the resident was to receive Torsemide (a diuretic/water pill) 20 milligrams, every twenty-four hours as needed for congestive heart failure for a three-pound (lbs.) weight gain in one day or a five-pound weight gain over one week.The clinical record lacked documented weights on the following days: 07/05/25, 07/07/25, and 07/09/25. The clinical record lacked documentation to indicate the resident refused to be weighed on the above dates. The resident's weight on 07/12/25 was 229.2 lbs. and; on 07/13/25, the resident's weight was 240.2. The resident had an 11 lb. weight gain in 24 hours.The clinical record lacked documentation that the resident had received the as needed Torsemide medication or that the physician was notified of the resident's weight gain.During an interview, on 07/31/25 at 1:40 P.M., the Director of Nursing (DON) indicated, if there was a blank in the EMAR for a weight, that meant the staff left it blank for the next shift to obtain the weight. The resident had refused to be weighed a lot. For the resident having the weight gain within 24 hours, she should have been given the as needed medication, and a progress note should have been documented.The current facility policy, titled Administering Medications with a revision date of April 2014, was provided by the DON on 07/31/25 at 3:03 P.M. The policy indicated, .Medications are administered in a safe and timely manner, and as prescribed.2.The clinical record for Resident 49 was reviewed on 07/31/2025 at 10:44 A.M. A Quarterly MDS assessment, dated 07/25/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, unspecified dementia, anemia, hypertension, neurogenic bladder, non-Alzheimer's dementia, and depression.An open-ended physician's order, with a start date of 05/15/25, indicated the resident was to be weighed every Monday for congestive heart failure.The clinical record lacked the resident's documented weights for the following dates: 05/26/25, 06/09/25, 06/16/25, 06/23/25, 6/30/25, 07/07/25, 07/14/25, 07/21/25, and 07/28/25.During an interview, on 07/31/25 at 1:29 P.M., Licensed Practical Nurse (LPN) 3 indicated residents that were ordered to have daily, or weekly weights completed the weights would be documented in the residents' Electronic Medication Administration Record (EMAR).The current facility policy titled, Weight Assessment and Intervention, with a revision date of March 2022, was provided by the DON on 08/01/25 at 10:56 A.M. The policy indicated, .weights are monitored for undesirable or unintended weight loss or gain.Weights are recorded in each unit's weight record chart and in the individual's medical record.3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to provide parenteral/IV (Intravenous) site maintenance related to dressing changes for 1 of 2 residents reviewed for vascular access sites. (Resident 34) Findings include:Resident 34 was observed in her room on 07/29/25 at 11:17 A.M. The resident indicated she was receiving antibiotics for an infection through a Peripherally Inserted Central Catheter (PICC) line that was placed in her right arm. The PICC dressing was observed. The dressing was intact and there were no signs of infection. The dressing was dated 07/22/25. The resident was observed in her room on 07/30/25 at 10:50 A.M. The PICC dressing was intact, but looked worn, and was wrinkled at the bottom. The dressing was dated 07/22/25. The resident indicated she received antibiotics through the PICC twice a day and the dressing had not been recently changed. The resident's record was reviewed on 07/30/25 at 10:53 A.M. A Quarterly Minimum Data Set assessment, dated 05/26/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, infection following a procedure, wound infection, coronary artery disease, and congestive heart failure. The resident's current physician's orders included, but were not limited to, an open-ended order, with a start date of 07/28/25, to change the resident's PICC line dressing every Monday in the afternoon. The resident's Electronic Treatment Administration Record (ETAR) for July 2025 was reviewed. The ETAR indicated the PICC dressing was to be changed on 07/28/25 (a Monday) but the ETAR was left blank for that day.During an interview, on 07/30/25 at 10:55 AM, Licensed Practical Nurse (LPN) 2 indicated a PICC dressing was to be changed every five to seven days. The LPN went into the resident's room and observed that the dressing was dated 07/22/25 and indicated the dressing should have been changed prior then. The current facility policy, titled Central Venous Catheter Care and Dressing Changes, with a revision date of October 2024, was provided by the Director of Nursing on 08/01/25 at 2:16 P.M. The policy indicated, .Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing or sterile gauze) for all central vascular access devices.Change the dressing.at least every 7 days. 3.1-47(a)(2)

Based on record review, interview, and observation, the facility failed to prevent a significant medication error related to diuretic medications for 1 of 6 residents reviewed for unnecessary medications. (Resident 1)Findings include:The clinical record for Resident 1 was reviewed on 07/31/2025 at 10:08 AM. A Quarterly Minimum Data Set (MDS) assessment, dated 06/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, diabetes, seizure disorder, anxiety, depression, and respiratory failure.A Progress Note, dated 07/21/25 at 11:32 P.M., indicated the resident was seen by the cardiologist earlier that day and had new orders for Torsemide 40 mg every morning and if the resident's weight was greater than 219 pounds then the staff were to administer an as needed Torsemide 40 mg in the evening. The resident had the following physician's orders:-An open-ended physician's order, with a start date of 07/22/25, for Torsemide (a diuretic medication) 40 milligrams (mg) at 5:00 A.M., for congestive heart failure.-An order, dated 07/23/25 through 07/27/25, for a daily weight at 6:00 A.M., if the resident's weight was greater than 219 pounds, the staff were to administer an extra (as needed) dose of Torsemide. The order did not specify an amount to be given. -An open-ended physician's order, with a start date of 07/27/25, indicated the resident was to be weighed daily at 6:00 A.M., if the resident weighed greater than 219 pounds, the staff were to administer an extra dose of Torsemide in the afternoon. The order did not specify an amount to be given. -An open-ended physician's order, with a start date of 07/23/25, indicated the staff were to administer Torsemide 40 mg, at 5:00 P.M., if the resident's morning weight was greater than 219 pounds.-An open-ended physician's order, with a start date of 07/24/25, indicated the staff were to administer Torsemide 40 mg, at 2:00 P.M., if the resident's morning weight was greater than 219 pounds.The Electronic Medication Administration Record for July 2025 indicated the resident had received the medication, Torsemide daily at 6:00 A.M., 2:00 P.M., and 5:00 P.M., from 07/22/25 through 07/30/25.During an interview, on 07/31/25 at 1:29 P.M., Licensed Practical Nurse (LPN) 3 indicated if she received new orders from the physician they would input the orders into the clinical record for the resident to be administered the medications.During an interview, on 07/31/2025 at 1:42 P.M., the Director of Nursing (DON) indicated the resident was to receive a routine dose of the Torsemide in the morning. If their weight was greater than 219 pounds, the staff were to administer an extra dose 40 mg dose of the medication in the afternoon. It was a new order for the resident. She didn't believe the resident was getting an extra dose of the medication at both 2:00 P.M. and 5:00 P.M.The medication cart containing Resident 1's medications was observed with the DON on 07/31/25 at 1:53 P.M. The medication cart lacked any separate supply of the extra doses of the Torsemide medication. The DON indicated all of the extra, not routine, doses of the Torsemide medication would have been in their own plastic bag, separated from the daily routine medications.During an interview, on 07/31/25 at 1:55 P.M., the Pharmacy representative indicated the resident had 24 capsules of Torsemide, 40 mg, dispensed on 07/22/25.During an observation with the DON, on 07/31/25 at 1:58 P.M., the medication cart lacked any extra as needed Torsemide capsules.During an interview, on 07/31/2025 at 2:00 P.M., the DON indicated there was medication errors. A nurse had clarified the as needed medication order and a second order was added at 2:00 P.M. The 5:00 P.M. order should have been discontinued. During an interview, on 07/31/25 at 3:03 P.M., the DON indicated the resident had no ill effects or outcomes from the medication error. She had spoken with the physician. The resident had recent laboratory results, on 07/28/25, that were better than the prior results, so she wasn't going to order new labs to be drawn. The current facility policy, titled Adverse Consequences and Medication Errors, with a revision date of February 2023, was provided by the DON on 07/31/25 at 3:03 P.M. The policy indicated, .The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions [ADRs] and side effects.A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principals of the professional[s] providing services.3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a resident's medication administration record accurately reflected the administration of narcotic pain medication for 1 of 3 residents reviewed for medication administration. (Resident C). Findings include: The clinical record for Resident C was reviewed on 10/17/24 at 9:35 A.M. An Admission Minimum Data Set (MDS) assessment, dated 09/24/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, anemia, hypertension, diabetes, and seizure disorder. A Physician's order, with a start date of 09/20/24, indicated staff were to administer 15 mg (milligrams) of Morphine Sulfate by mouth every three hours as needed for severe pain for 14 days. The September Controlled Drug Receipt/Record/Disposition Form, for the resident's Morphine Sulfate 15 mg medication, indicated the resident's medication was signed out as given on the following dates and times: 09/21/24 at 3:30 A.M., 09/21/24 at 11:45 A.M., 09/21/24 at 9:01 P.M., 09/22/24 at 5:10 A.M., 09/23/24 at 1:45 A.M., 09/23/24 at 5:26 A.M., 09/23/24 at 1:30 P.M., 09/24/24 at 4:30 (no other specification noted), 09/24/24 at 9:00 A.M., and 09/25/24 at 11:00 A.M. The September 2024 Electronic Medication Administration Record (EMAR) lacked documentation that the medication was administered on the following dates and times: 09/21/24 at 11:45 A.M. and 09/24/24 at 4:30 (no other specification noted). During an interview on 10/17/24 at 3:30 P.M., RN 2 indicated that when staff were administering a resident's narcotic, they were to write it in the narcotic book with the current date and time, then documented it in the electronic system. Anytime anything was signed out on the narcotic sheet, it was also documented in the electronic system. A current facility policy, titled Documentation of Medication Administration, with a revision date of April 2007, was provided by the Director of Nursing (DON) on 10/17/24 at 3:00 P.M. The policy indicated, .A nurse .shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given . This citation relates to Complaint IN00444788. 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview, observation, and record review, the facility failed to provide safe water temperatures for 5 of 9 resident rooms observed. (Rooms 45, 47, 42, 43, and 1) Findings include: During an interview and observation on 08/13/24 at 12:53 P.M., Resident 11 indicated the water in his bathroom was hot. The water in the resident's bathroom sink was felt and found to be hot. The water stream was to hot to keep a hand under the water flow without discomfort. The water temperature was tested with a probe and was found to be 121.5 degrees Fahrenheit. On 08/13/24 the following water temperatures were checked using a probe thermometer: - At 12:56 P.M., Resident room [ROOM NUMBER] the water temperature was 124.1 degrees Fahrenheit, - At 1:00 P.M., Resident room [ROOM NUMBER] the water temperature was 122.6 degrees Fahrenheit, - At 1:02 P.M., Resident room [ROOM NUMBER] the water temperature was 122.2 degrees Fahrenheit, - At 1:04 P.M., Resident room [ROOM NUMBER] the water temperature was 121.6 degrees Fahrenheit. During an interview on 08/13/24 at 1:16 P.M., the Maintenance Director indicated he would check the facility water temperature using a laser gun. He would point the gun's [NAME] towards the the bottom of the sink where the water was pooled. The following water temperatures were observed on 08/13/24, with the Maintenance Director using the laser gun: - At 1:16 P.M., Resident room [ROOM NUMBER] the water temperature was 120.0 degrees Fahrenheit, - At 1:18 P.M., Resident room [ROOM NUMBER] the water temperature was 116.0 degrees Fahrenheit, and - At 1:24 P.M., Resident room [ROOM NUMBER] the water temperature was 116.0 degrees Fahrenheit. During an observation and interview on 08/13/24, of hot water temperatures with the Administrator using a probe thermometer, that was provided by the Dietary Manager, the following was observed: - At 1:33 P.M., Resident room [ROOM NUMBER] the water temperature was 121.0 degrees Fahrenheit, - At 1:35 P.M., Resident room [ROOM NUMBER] the water temperature was 121.2 degrees Fahrenheit, - At 1:36 P.M., Resident room [ROOM NUMBER] the water temperature was 120.7 degrees Fahrenheit, - At 1:39 P.M., Resident room [ROOM NUMBER] the water temperature was 121.5 degrees Fahrenheit, and - At 1:41 P.M., Resident room [ROOM NUMBER] the water temperature was 121.4 degrees Fahrenheit. During an interview on 08/13/24 at 1:33 P.M., the Dietary Manger indicated the thermometer was calibrated to read hot water temperatures. During an interview on 08/13/24 at 1:45 P.M., the Administrator indicated the hot water temperatures should be 120 or below per the facility policy. During an interview on 08/13/24 at 1:48 P.M., the Maintenance Director indicated he would test the hot water temperatures at each nurses station. He would only test resident rooms if there was a problem. The purpose to keep the temperatures below 120 was so that resident's didn't get burnt. During an observation on 08/13/24 at 1:54 P.M., the mixing valve thermometer was at 120 degrees Fahrenheit. During an interview on 08/13/24 at 2:02 P.M., the Maintenance Director indicated the mixing valve was turned down a notch. During an interview on 08/14/24 at 9:15 A.M., the Administrator indicated they had flushed the water lines and a company came in and replaced a part. The facility hot water monitoring logs from 06/24/24 through 08/09/24 indicated the only documented temperatures were at the two nurses stations, Nurse Station 1 and Nurse Station 2 . There were no resident rooms documented. The current facility policy, titled Water Temperatures were provided by the Administrator on 08/13/24 at 1:45 P.M. The policy indicated, .of no more than 120 [degrees] Fahrenheit, or the maximum allowable temperature per state regulations .Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures Tap water in the facility shall be kept within temperature range to prevent scalding of residents .Maintenance staff or designee shall conduct periodic tap water checks and record the water temperatures in a safety log .If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor .If the water temp [temperature] is found to be out of acceptable range nursing staff will be notified, maintenance notified and a maintenance request completed and the Administrator notified . 3.1-19(r)(1) 3.1-19(r)(2)

Based on observation and interview, the facility failed to appropriately store medications related to an expired medication vial for 1 of 2 medication rooms reviewed. (Long Hall medication room refrigerator) Findings include: The Medication Room for the Long Hall was observed with LPN 1 on [DATE] at 3:32 P.M. The refrigerator contained an open vial of TB (Tuberculin) serum with an open date written on the side of the bottle of [DATE]. The vial was over half full. During an interview on [DATE] at 3:57 P.M., the DON (Director of Nursing) indicated the TB serum should have been discarded after 30 days from the open date. She could not identify how many residents could have received this medication after its expiration due to limited documentation in their system. The TB serum package insert was provided by the DON on [DATE] at 4:00 P.M. The directions for storage indicated, .vials in use more than 30 days should be discarded . The current facility policy, titled Storage of Medications, and dated 2020, was provided by the DON on [DATE] at 4:15 P.M. The policy indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner . ,and .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . 3XXX,d+[DATE](o)

Based on record review and interview, the facility failed to notify the residents' physician for medications not administered for 2 of 15 residents reviewed for notification of change. (Residents 23 and 32) Findings include: 1. The clinical record for Resident 23 was reviewed on 06/28/23 at 9:29 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/05/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, Alzheimer's disease, anemia, hypertension, and diabetes. An open-ended physician's order, with a start date of 04/27/23, indicated the resident was to receive Humalog (an insulin medication) 20 units in the morning. The May and June EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had not received the medication on the following dates: - 05/05/23, due to the resident eating less than 50% of meal, - 05/06/23, due to the resident eating less than 50% of meal, - 05/07/23, due to out of range vital, - 05/12/23, due to out of range vital, - 05/15/23, due to the resident eating less than 50% of meal, - 05/17/23, due to out of range vital, - 05/18/23, refused, - 05/19/23, refused, - 05/21/23, due to out of range vital, - 05/22/23, due to out of range vital, - 05/28/23, unknown, - 06/02/23, due to the resident eating less than 50% of meal, - 06/12/23, due to no insulin required, - 06/15/23, due to out or range vital, - 06/16/23, due to out of range vital, and - 06/22/23, due to no insulin required. An open-ended physician order, with a start date of 04/27/23, indicated the resident was to receive Humalog 10 units in the afternoon. The May and June EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had not received the medication on the following dates: - 05/04/23, due to resident not eating well, - 05/05/23, due to out of range vital, - 05/08/23, due to out of range vital, - 05/09/23, due to low blood sugar of 83, - 05/11/23, due to the resident had a poor appetite, - 05/14/23, due to the resident refused, - 05/21/23, due to the resident was out of the facility, - 05/29/23, due to the resident refused - 06/01/23, due to the resident refused, - 06/06/23, due to resident refused meal, - 06/12/23, due to no insulin required, - 06/15/23, due to out of range vital, - 06/16/23, due to out of range vital, and - 06/22/23, due to no insulin required. The clinical record lacked documentation that the physician had been notified of the Humalog not being administered. During an interview on 06/29/23 at 9:54 A.M., LPN (Licensed Practical Nurse) 3 indicated if a resident had hold parameters (instructions for not administering a medication), then the nurse could hold a medication. If the medication did not have hold parameters, they could hold a medication as a nursing precaution, but the physician would have to be notified the medication was held and staff would have to document in a progress note that the physician was notified. 2. The clinical record for Resident 32 was reviewed on 06/27/23 at 2:33 P.M. A Quarterly MDS assessment, dated 04/09/23, indicated the resident was moderate cognitively impaired. The diagnoses included, but were not limited to, dementia, cancer, hypertension, diabetes, anxiety, and depression. An open-ended physician's order, with a start of 12/15/22, indicated the resident was to receive Lantus (an insulin medication) 72 units at bedtime (7:00 P.M.). The June 2023 EMAR/ETAR indicated the resident had not received the Lantus on the following dates: - 06/01/23, due to blood sugar of 107, - 06/07/23, due to blood sugar of 178, - 06/08/23, due to blood sugar of 219, - 06/12/23, due to blood sugar of 115, - 06/15/23, due to blood sugar of 182, - 06/17/23, due to unknown, - 06/21/23, due to blood sugar of 167, - 06/22/23, due to blood sugar of 170, and - 06/25/23, due to no insulin required. The clinical record lacked documentation the physician had been notified of the resident's Lantus not being administered. During an interview on 06/29/23 at 10:10 A.M., a facility Nurse Practitioner indicated once a resident received Lantus it should last about 12 hours. A resident's Lantus shouldn't be held since it was a long-acting insulin. If the staff were holding the resident's Lantus, then the physician should have been notified. During an interview on 06/29/23 at 10:16 A.M., the DON (Director of Nursing) indicated if a resident's Lantus didn't have hold parameters the medications should not have been held. If it was held due to nursing judgement the physician should be notified and staff should document the notification in the clinical record. The current, undated, facility policy titled, Change in a Resident's Condition or Status was provided by the DON on 06/30/23 at 2:03 P.M. The policy indicated, .The nurse will notify the resident's attending physician or physician on call when there has been a(an): .need to alter the resident's medical treatment .The nurse will record in the resident;s medical record information relative to changes in the resident;s medical/mental condition or status . 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to ensure the resident's wound treatments were administered appropriately and accurately assess for 1 of 2 residents reviewed for pressure ulcers. (Resident 6) Findings include: During an interview on 06/28/23 at 10:46 A.M., the FWN (Facility Wound Nurse) indicated Resident 6 had a wound on her right heel and a wound on her coccyx. The heel wound was identified in March. The coccyx wound was identified more recently. The resident was receiving hospice services, so she worked with hospice to manage and treat the resident's wounds. There was a lack of communication related to documentation between the facility and hospice regarding the resident's wounds. Resident 6's wounds were observed with the FWN on 06/29/23 at 9:35 A.M. The FWN removed the resident's sock on her right foot. An undated dressing was observed on the resident's heel. The skin around the wound was dry and flaky. The wound measured 4 cm (centimeters) x 4 cm. The wound was reddish purple, with a quarter sized area in the center that was blackish purple in color. The skin appeared to be hard. There was no drainage or odor. The FWN indicated the dressing was last changed by a hospice nurse. The FWN administered the treatment to the heel and then prepared to treat the wound on the resident's coccyx. The resident rolled over and the FWN adjusted the resident's clothing to expose the wound. The dressing on the resident's coccyx was undated as well. There was reddish brown drainage visible through the transparent portion of the dressing. The coccyx wound measured 4.3 cm x 4.8 cm, with a depth of 0.4 cm. The wound bed was dark red in color. There was no odor or signs of infection. The FWN indicated the wound was a Stage 3 (Full-thickness skin loss in which subcutaneous fat may be visible in the ulcer) pressure ulcer and the dressing was changed daily and as needed. Both dressings should have been dated and initialed. The resident's clinical record was reviewed on 06/28/23 at 2:22 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/28/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, cancer, hypertension, renal disease, non-Alzheimer's dementia, and malnutrition. The resident was on hospice. The resident was at risk for pressure ulcers but had no pressure injuries at the time of the assessment. The FWN provided the resident's wound assessments on 06/28/23 at 11:15 A.M. The documentation included Skin Observation Tool assessments from the resident's EHR (Electronic Health Record), the FWN's handwritten notes, and a document from the hospice provider that listed measurements of the resident's wounds. The documentation included, but were not limited to, the following: - A Skin Observation Tool, dated 05/23/23, indicated sites observed as the right heel and coccyx. No new areas noted was documented in the notes section of the assessment. - A Skin Observation Tool, dated 05/30/23, indicated sites observed as the right heel and coccyx. There was no further documentation on the assessment. - A handwritten note, dated 05/31/23, that listed the resident's name and a measurement of the wound on the resident's right heel. The wound measured 1.1 cm x 1.1 cm. - A Skin/Wound Progress Note, dated 06/01/2023, indicated the resident had a new area on their coccyx that measured 3 cm x 3 cm x 0.1 cm. A necrotic area was observed. A new MD order was obtained to cleanse the wound and apply Santyl (an ointment that removes dead skin from wounds). - A Skin Observation Tool, dated 06/07/23, indicated sites observed as the right heel and coccyx. There was no further documentation on the assessment. - A handwritten note, dated 06/09/23, that listed the resident's name and indicated the wound on the right heel measured 1.0 cm x 1.2 cm. The wound on the coccyx measured 5.4 cm x 6.5 cm x 2.6 cm. During an interview on 06/30/23 at 11:44 A.M., the FWN indicated she would normally document wound measurements, the wound bed description, a description of the skin around a wound, signs of infection, and any drainage from the wound as part of the weekly wound assessment in the resident's EHR. The current wound documentation lacked information about the wounds. She thought the coccyx wound would have been classified as an Unstageable (obscured full-thickness skin and tissue loss, full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [moist dead tissue] or eschar [dry dead tissue]) wound when it was discovered. She would think it should have been discovered before it was unstageable. During an interview on 07/03/23 at 9:47 A.M., the resident's family member indicated she talked to the facility about dating the dressings on the resident's wounds because there was no date on the dressings when she was in the facility yesterday visiting with the resident. If the dressings weren't dated, staff wouldn't know when the dressings were last changed and if they still needed to be changed. The current facility policy, titled Skin and Wound Care Management Program, with an effective date of 04/12/23, was provided by the DON (Director of Nursing) on 06/30/23 at 2:35 P.M. The policy indicated, .the facility provides care and services consistent with professional standards of practice .weekly wound rounds are completed for residents with wounds. Rounds include wound assessment and measurements of wounds documented .as appropriate . The current facility policy, titled Dressings, Dry/Clean, with a revised date of September 2013, was provided by the DON on 07/03/23 at 9:21 A.M. The policy indicated, .label tape or dressing with date, time and initials .the following information should be recorded in the resident's medical record .or designated wound form .wound appearance, including wound bed, edges, presence of drainage .type of dressing used, and wound care given .all assessment data .wound bed color, size, drainage, etc . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to follow a physician's order related to fluid restriction for 1 of 1 resident reviewed for dialysis. (Resident 43) Findings include: During an observation on 06/30/23 at 10:25 A.M., Resident 43 was out of her room. A large plastic cup was sitting on the overbed table and was full of clear fluid. The cup was undated. During an observation on 06/30/23 at 1:23 P.M., Resident 43 was sitting in her recliner holding a glass of clear liquids and taking drinks. There was a large plastic cup full of clear liquids, that was undated on the overbed table. The clinical record for the resident was reviewed on 06/28/23 at 1:31 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/23/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, hypertension, renal insufficiency, diabetes, anxiety, and dependence on renal dialysis. The resident received dialysis while a resident at the facility. An open-ended physician's order, dated 06/15/23, indicated the resident was on a fluid restriction of 1200 ml (milliliters) per day, 240 ml per meal and 160 ml per shift for medication pass. The June 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) lacked a documented amount of fluids in ml during each shift. The June records for Amount Eaten and Fluids consumed during meals lacked documentation of fluid intakes on the following dates and meal times: - 06/21/23 at breakfast or lunch, - 06/22/23 at breakfast or dinner, - 06/23/23 at breakfast and dinner, - 06/24/23 at dinner, - 06/25/23 at dinner, and - 06/29/23 at dinner. During an interview on 06/29/23 at 9:50 A.M., LPN (Licensed Practical Nurse) 3 indicated the resident was alert and oriented and went to dialysis three time a week. The resident would consume breakfast before she left for dialysis and would then eat lunch when she returned. She was able to take snacks with her. During an interview on 06/30/23 at 10:15 A.M., LPN 4 indicated if a resident was on a fluid restriction, she would check the order to see how much they could consume in a day. She would continue to check the resident throughout the day to see if they had consumed extra fluids. The total amount of fluids consumed throughout the day would be documented in the EMAR. During an interview on 06/30/23 at 1:24 P.M., CNA (Certified Nurse Aide) 5 indicated to determine if a resident was on a fluid restriction, she would be informed during report at the beginning of her shift or look on the resident's profile. She was aware the resident was on a fluid restriction. The kitchen would bring out the fluids on the meal tray and the nurse would give fluids with medication pass. She wouldn't pass ice water to the resident. If the resident refused to abide by the fluid restriction and wanted more to drink, she would alert the nurse. The current facility policy titled, Encouraging and Restricting Fluids with a revised date of October 2021, was provided by the DON (Director of Nursing) on 06/30/23 at 2:03 P.M. The policy indicated, .The purpose is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids .Record fluid intake .Documentation .The amount (in mLs) of fluids consumed by the resident during the shift .If the resident refused the treatment, the reason(s) why and the intervention taken . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to follow manufacturer's guidelines related to insulin pen usage for 1 of 6 residents observed for medication administration (Resident 49) and failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 33) Findings include: 1. During an observation on 08/11/22 at 8:05 A.M., LPN (Licensed Practical Nurse) 2 prepared to administer medications to Resident 49. The LPN opened a new, unused [MEDICATION(S)] (a long acting insulin) insulin pen and attached a needle to the pen. She held the pen sideways and indicated she was priming the pen, to expel any air bubbles. She continued to hold the pen sideways and dialed up 20 units of insulin. She entered the resident's room and administered the medication. LPN 2 did not cleanse the pen prior to attaching the needle and did not hold the pen upright when she primed the pen. During an observation on 08/11/22 at 8:25 A.M., LPN 2 gathered Resident 49's [MEDICATION(S)] (a short acting insulin) insulin pen from the medication cart. LPN 2 attached a needle to the pen, held the pen sideways and primed the pen. She continued to hold the pen sideways and dialed up 30 units of insulin. LPN 2 did not cleanse the pen prior to attaching the needle and did not hold the pen upright when she primed the pen. During an interview on 08/11/22 at 8:28 A.M., LPN 2 indicated she would normally cleanse the top of an insulin pen with alcohol prior to attaching a needle. She did not hold the pens upright when she primed them. The LPN then detached the needle from Resident 49's [MEDICATION(S)] pen, cleansed the top of the insulin pen with an alcohol swab, and attached a new needle. The LPN held the pen upright, primed the pen with 2 units of insulin, and dialed up 30 units of insulin to administer to the resident. The current, undated [MEDICATION(S)] package insert was provided by the DON (Director of Nursing) on 08/11/22 at 2:55 P.M. The insert indicated, .ATTACH THE NEEDLE .wipe the pen tip (rubber seal) with an alcohol swab .PERFORM A SAFETY TEST .Dial a test dose of 2 units .Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose .Press the injection button all the way in and check to see that insulin comes out of the needle .Always perform the safety test before each injection . The current [MEDICATION(S)] package insert, with a revised date of 03/2021, was provided by the DON on 08/12/22 at 11:45 A.M. The insert indicated, .Pull off the pen cap .wipe the rubber stopper with an alcohol swab .To avoid injecting air and to ensure proper dosing .Turn the dose selector to select 2 units. Hold your insulin .Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the bottom all the way in .A drop of insulin should appear at the needle tip . The current facility policy, titled Insulin Administration, with a revised date of September 2014, was provided by the Administrator on 08/11/22 at 2:50 P.M. The policy indicated, .Disinfect the top of the vial with an alcohol wipe . 2. During an observation and interview on 08/08/22 at 2:05 P.M., Resident 33 was sitting in a chair in her room. Her left ankle was visible and swollen. She indicated she had worn those tight socks once and she was not going to wear them again. During an observation and interview on 08/10/22 at 1:45 P.M., the resident was sitting in a chair in her room. Both of her ankles were swollen and her short socks were making indentations on her ankles. She indicated she was taking a medication for the swelling in her legs, but they continued to swell. The resident was not wearing long compression stockings. During an observation on 08/11/22 at 10:50 A.M., the resident was sitting in her room in a recliner with her feet elevated. She was not wearing compression stockings. Both of her legs were visibly swollen. She was wearing shoes and socks and her socks were making indentations on her ankles. During an interview on 08/11/22 at 2:25 P.M., CNA (Certified Nurse Aide) 3 and CNA 4, indicated if a resident had refused to wear their compression stockings they would report to the nurse and the nurse would go and try to assist the resident with putting them on. The CNAs educated the residents on the need for the compression stockings. During an interview on 08/11/22 02:31 PM., LPN 2, indicated if a resident had refused to wear their compression stockings the CNAs would report it to the nurse. The nurse would re-approach and educate the resident. If the resident continued to refuse, they would notify the physician and see if they wanted to order something else or discontinue the order. If the physician was notified it would be documented in the progress notes. Sometimes the resident would allow putting the compression stockings on then took them off. The physician should have been notified of the resident's refusals. The clinical record was reviewed on 08/11/22 at 2:47 P.M A Quarterly MDS (Minimum Data Set) assessment, dated 08/01/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The order indicated the resident was to wear compression stockings during the day and to remove them at bedtime. Staff were to assist the resident with putting them on in the morning. The progress notes for July and August 2022, were provided by LPN 2 on 08/11/22 at 3:03 P.M. The progress notes lacked documentation the physician had been notified of the resident's refusals to wear the compression stockings. The current Requesting, Refusing and/or Discontinuing Care or Treatment policy, with a revised date of February 2021, was provided by the ADON (Assistant Director of Nursing) on 08/11/22 at 3:24 P.M. The policy indicated, .Documentation pertaining to a resident's .refusal of treatment includes at least the following: .The date and time the practitioner was notified as well as the practitioner's response .The healthcare practitioner must be notified of refusal of treatment . 3.1-37(a) 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to ensure residents' safety related to unauthorized medications at the bedside for 2 of 24 residents observed (Residents 49 and 54) and failed to implement appropriate interventions for a resident with an altered mental status prior to a fall for 1 of 4 residents reviewed for falls. (Resident 6) Findings include: 1. During an observation and interview on 08/08/22 at 10:46 A.M., Resident 49 was sitting in her room in her wheelchair. A full cup of medications were on the resident's over the bed table. The resident indicated the staff trusted her. She had been down to the therapy gym for therapy, then gone to the exercise activity so the staff had left them in her room for her. When she left for therapy and the group exercise activity her medications were not in her room. When she returned to her room the medications had been left on her table. There were 13 whole pills and one half of a pill visible in the medication cup. During an interview on 08/12/22 at 9:39 A.M., the DON (Director of Nursing) indicated if a resident was permitted to self-administer medications they would have a lock box and a self-administration of medication evaluation completed. They would also be care planned to self-administer medications. The August 2022, EMAR (Electronic Medication Administration Record) was provided by the DON on 08/12/22 at 11:45 A.M. The record indicated the resident had not received narcotics during the morning medication administration. The record lacked an order for the resident to self-administer medications. The resident's prescribed medications ordered by the physician, for 6:00 A.M. on 08/08/22, included, but were not limited to: - a cranberry capsule 400 mg (milligrams), - [MEDICATION(S)] monitrate 30 mg for [CONDITION(S)], - [MEDICATION(S)] 10 mg for cough, - potassium chloride 20 MEQ (Milliequivalents) for [CONDITION(S)], - [MEDICATION(S)] 20 mg, two tablets for [CONDITION(S)], - [MEDICATION(S)] 20 mg for depression, - [MEDICATION(S)] 7.5 mg for anxiety, - [MEDICATION(S)] 300 mg for urinary tract infection, - [MEDICATION(S)] 2.5 mg for [CONDITION(S)], and - [MEDICATION(S)] 300 mg for polyarthritis. The complete care plan record was provided by the DON on 08/12/22 at 11:45 A.M. The record lacked a care plan and an intervention to permit the resident to self-administer her medications. The clinical record was reviewed on 08/09/22 at 1:08 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/21/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, [CONDITION(S)] ([CONDITION(S)]), heart failure, and [CONDITION(S)]. The resident required extensive assistance of two or more staff members for bed mobility, transfers, personal hygiene, dressing, toilet use, and locomotion on and off the unit. 2. Resident 54 was observed in her room on 08/09/22 at 9:44 A.M. The resident was sitting in her wheelchair at her overbed table. She was holding a cup of unidentified medications. The resident was actively taking the medications unsupervised and drinking milk to wash them down. The resident indicated the cup of medications had been left in her room for a little while that morning. Sometimes the nurses stood over her while she took her medicine and sometimes they did not. She could take her medications by herself. The resident's clinical record was reviewed on 08/11/22 at 1:56 P.M. An Admission MDS assessment, dated 07/02/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, [CONDITION(S)], heart failure, diabetes, and end stage renal disease. The resident's current medication orders were as followed: [MEDICATION(S)] patch 0.3 mg, [MEDICATION(S)] 25 mg BID, [MEDICATION(S)] Tab 800 mg 3 tab by mouth before meals, [MEDICATION(S)] 4 mg, insulin [MEDICATION(S)] [MEDICATION(S)] 5/325, [MEDICATION(S)] 2.5 mg, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 100 mg give 200 mg, [MEDICATION(S)] 25 mg, [MEDICATION(S)] 50 mg, [MEDICATION(S)] 1 mg daily for chf x 90 days, [MEDICATION(S)] inject 1.5 mg every evening on Fridays, [MEDICATION(S)] 18 units before meals, and renal-vite 0.8 mg. The August 2022, EMAR was provided by the DON on 08/12/22 at 11:45 A.M. The record indicated the resident had not received narcotics during the morning medication administration. The record lacked an order for the resident to self-administer medications. The complete care plan record was provided by the DON on 08/12/22 at 11:45 A.M. The record lacked a care plan and an intervention to permit the resident to self-administer her medications. During an interview on 08/11/22 10:53 A.M. the Administrator indicated there were no residents that self administered their medications. During an interview on 08/12/22 09:48 A.M., QMA (Qualified Medication Aide) 5 indicated there were no residents in the facility that self administered medications. Nursing staff were never to leave a resident's medications at bedside. The current facility policy, titled Self-Administration of Medications, with a revision date of February 2021, was provided by the Administrator on 08/12/22 at 11:28 A.M. The policy indicated, .Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan. The decision .is reassessed periodically . The current facility policy, titled Administering Oral Medications, with a revision date of October 2010, was provided by the Administrator on 08/12/22 at 1128 A.M. The policy indicated, .Remain with the resident until all medications have been taken . 3. The clinical record for Resident 6 was reviewed on 08/09/22 at 2:44 P.M. An Annual MDS assessment, dated 05/26/22, indicated, the resident was cognitively intact. The diagnoses, included but were not limited to, stroke, hypertension, diabetes, anxiety, and depression. The resident had a fall with injury since the last assessment. A Progress Note, dated 05/22/22 at 5:30 P.M., indicated the resident had returned from being out of the facility with family. The resident and family had stated the resident had consumed alcohol and upon the assessment the resident was inebriated (intoxicated). A Progress Note, dated 05/22/22 at 7:45 P.M., indicated the resident was attempting to transfer himself from a chair to the bed. The resident had lost his balance and fell to the floor. He suffered a 2 centimeter by 0.1 centimeter laceration to the forehead with steri-strips applied and neurological assessments were initiated. The family and physician were notified. A Progress Note, dated 05/22/22 at 9:00 P.M., indicated the resident had a fall while ambulating himself to the bathroom. The resident had no injuries from the fall. Neurological assessments were reinitiated and all appropriate notifications were made. A Progress Note, dated 05/23/22 at 9:40 A.M., indicated the IDT (Interdisciplinary Team) had reviewed the falls and indicated the root cause was determined to be lack of safety awareness and impaired balance. A new intervention was implemented for education on using the call light during periods of time when the cognition was altered. The clinical record lacked a care plan for alcohol use or any documentation that the resident was placed on any increased monitoring after his return to the facility intoxicated. During an interview on 08/11/22 at 9:32 P.M., LPN (Licensed Practical Nurse) 8 indicated Resident 6 had weakness on one side of the body due to a stroke. During an interview on 08/11/22 at 11:01 A.M., the DON indicated the resident had a couple of falls on a weekend shift. She was the nurse on duty when the resident had gone of the facility with family and consumed some alcohol while out. He had decreased safety awareness and imbalance upon returning to the facility. After returning he had two falls. Assessments were completed on each fall and the family was educated to not allow the resident to consume alcohol while out on visits. The resident had obtained a laceration to his head on one of the falls that did not require him to be sent to the hospital. Increased safety checks were not documented in the clinical record. The IDT had reviewed the falls and education was provided to use the call light when cognition was altered. She would determine the intervention was appropriate by verbal and demonstration reinforcement. The current facility policy titled, Falls and Fall Risk, Managing, with a revised date of March 2018, was provided by the DON on 08/11/22 at 12:02 P.M. The policy indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Fall Risk Factors: .2. Resident conditions that may contribute to the risk of falls include: .c.[CONDITION(S)] and other cognitive impairment . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines to prevent UTIs (Urinary Tract Infections) for residents with indwelling urinary catheters for 1 of 1 resident reviewed for catheter care with a [CONDITION(S)]. (Resident 49) Findings include: During an observation and interview on 08/08/22 at 10:39 A.M., Resident 49 was sitting in her wheelchair in her room. Her indwelling urinary catheter tubing was on the floor under her foot. She was wearing tennis shoes. She indicated she had the urinary catheter because her urine was not draining well enough and she'd had a lot UTIs. She'd had the catheter for about a year. The drainage bag was emptied two to three times a day. She could not remember how often the staff cleaned around the insertion site. During an observation on 08/09/22 at 12:52 P.M., the resident was sitting in her wheelchair at the door to the therapy gym. Part of her indwelling urinary catheter bag was resting against the floor along with approximately three inches of her catheter tubing. During an observation on 08/09/22 at 2:45 P.M., the resident was in the main dining room in a group activity. Her urinary catheter bag was hanging on the back of her wheelchair at the middle of her back above her bladder. During an observation and interview with LPN (Licensed Practical Nurse) 2 on 08/12/22 at 9:00 A.M., the resident was in her room in her wheelchair with one to two inches of her urinary catheter tubing touching the floor. LPN 2 indicated the tubing should not be touching the floor and went into the resident's room to adjust the catheter tubing. The clinical record was reviewed on 08/09/22 at 1:08 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/21/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two or more staff members for bed mobility, transfers, personal hygiene, dressing, toilet use, and locomotion on and off the unit. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The order indicated the resident received [MEDICATION(S)] (an antibiotic) 300 milligrams, two times a day for a [CONDITION(S)] until 08/09/22. The current Catheter Care, Urinary policy, with a revised date of September 2014, was provided by the DON on 08/12/22 at 10:10 A.M. The policy indicated, .purpose .to prevent catheter-associated urinary tract infections .The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-41(a)(2)

Based on record review and interview, the facility failed to develop a resident-center care plan related to dementia for 1 of 2 residents reviewed for dementia care. (Resident 28) Findings include: The clinical record for Resident 28 was reviewed on 08/09/22 at 3:06 P.M. An Annual MDS (Minimum Data Set) assessment, dated 06/20/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Complete Care Plan, was provided by the ADON (Assistant Director of Nursing) on 08/11/22 at 10:00 A.M. and lacked a care plan related to dementia. During an interview on 08/11/22 at 9:34 A.M., LPN (Licensed Practical Nurse) 8 indicated the resident would wander the building and yell out for her kids. The resident loved to drink coke. The staff all knew the resident liked to drink coke. If it was a new staff member, they would just let them know. During an observation on 08/11/22 at 1:01 p.m., the resident was sitting in her wheelchair in the common area outside the nurses station. She was observing other residents and staff while staff were attempting to engage the resident in an activity. During an interview on 08/12/22 at 1:07 P.M., TNA (Temporary Nurse Aide) 9 indicated if she needed to see resident interventions, she would look at the care plan in the clinical record. This resident should have a care plan for dementia care but she had never looked at it before. She knew to help calm the resident would be distractions, talking with the resident, and getting her drinks. She was unable to locate a dementia care plan for the resident. During an interview on 08/12/22 at 1:14 P.M., the ADON indicated all staff were made aware of resident centered interventions for dementia by report and looking at the care plan. This resident's non-pharmalogical interventions included one on one, food, drinks, and expressing selves. The resident was lacking a care plan for dementia and should have had one in place. The current facility policy titled, Dementia-Clinical Protocol with a revised date of November 2018, was provided by the ADON on 08/12/22 at 1:26 P.M. The policy indicated, .Treatment/Management .1. For the individual with confirmed dementia, the IDT [Interdisciplinary Team] will identify a resident-centered care plan to maximize remaining function and quality of life . 3.1-37(a)

Based on record review and interview, the facility failed to monitor residents blood pressure and heart rate before administering medications for 2 of 5 residents reviewed for unnecessary medications. (Residents 28 and 45) Findings include: 1. The clinical record for Resident 28 was reviewed on 08/09/22 at 3:06 P.M. An Annual MDS (Minimum Data Set) assessment, dated 06/20/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The July and August 2022 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) was reviewed and indicated the resident had received the hypertension medication the following day when the blood pressure was less than 120 or the heart rate was less than 80: - 07/01/22 with a heart rate of 65, - 07/04/22 with a heart rate of 59, - 07/05/22 with a heart rate of 79, - 07/06/22 with a heart rate of 63, - 07/07/22 with a heart rate of 58, - 07/09/22 with a heart rate of 68, - 07/10/22 with a heart rate of 61, - 07/11/22 with a heart rate of 72, - 07/12/22 with a heart rate of 77, - 07/15/22 with a heart rate of 68, - 07/18/22 with a heart rate of 70, - 07/20/22 with a heart rate of 68, - 07/24/22 with a heart rate of 74, - 07/25/22 with a heart rate of 76, - 07/26/22 with a heart rate of 70, - 07/27/22 with a heart rate of 68, - 07/28/22 with a heart rate of 64, - 07/29/22 with a heart rate of 76, - 07/30/22 with a heart rate of 67, - 08/03/22 with a heart rate of 78, - 08/08/22 with heart rate of 68, and - 08/10/22 with a heart rate of 55 and a blood pressure of 103/76. The July and August 2022 clinical record lacked indication the medication had been held. During an interview on 08/11/22 at 9:22 A.M., LPN (Licensed Practical Nurse) 8 indicated residents' medications would be signed on the EMAR. If a medication had hold parameters and was out of the parameters, she would hold the medication and document it on the EMAR why it wasn't given. If she had to hold the medication continuously then she would document in the clinical record and notify the physician. During an interview on 08/11/22 at 10:39 A.M., the ADON (Assistant Director of Nursing) indicated if a resident's medication had hold parameters and the medication was out of the parameters the nurse should have not administered the medication and document in the EMAR that the medication was held. If there was a check on the EMAR then it meant the mediation was administered. 2. The clinical record for Resident 48 was reviewed on 08/09/22 at 3:15 P.M. A Quarterly MDS assessment, dated 07/30/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The July and August 2022 EMAR/ETAR indicated the resident had received the [MEDICATION(S)] the following days when the systolic blood pressure was less than 100 or was not obtained: - 07/14/22 at 6:00 P.M. with no blood pressure noted, - 07/19/22 at 6:00 P.M. with no blood pressure noted, - 07/20/22 at 6:00 A.M. with a blood pressure of 72/42 and 6:00 P.M. with no blood pressure noted, - 07/22/22 at 6:00 A.M. with a blood pressure of 83/53 and 6:00 P.M. with no blood pressure noted, - 07/23/22 through 07/30/22 at 6:00 P.M. with no blood pressure noted, - 08/01/22 through 08/05/22 at 6:00 P.M., with no blood pressure noted, - 08/07/22 through 08/10/22 at 6:00 P.M. with no blood pressure noted, - 08/08/22 at 6:00 A.M. with a blood pressure of 98/43, and - 08/09/22 at 6:00 A.M. with a blood pressure of 88/43. The clinical record lacked indication that the medication had been held. A Care Plan, initiated on 07/12/22, indicated the resident had hypertension. Interventions included, but were not limited to, give antihypertensive medications as ordered. During an interview on 08/12/22 at 1:14 P.M., the ADON indicated Resident 28 and 45 suffered no ill effects from receiving the medications outside of the parameters. The current facility policy, titled Administering Medications', with a revised date of April 2019 was provided by the ADON on 08/11/22 at 10:00 A.M. The policy indicated, .Medications are administered in a safe and timely manner, and as prescribed . 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to store medication appropriately related to unlabeled insulin pens for 1 of 3 medication carts observed (Team 1 Medication Cart). Findings include: 1. During an observation on 08/11/22 at 8:05 A.M. LPN (Licensed Practical Nurse) 2 prepared to administer medications to Resident 49. The LPN opened the Team 1 Medication Cart and gathered a used [MEDICATION(S)] insulin pen with 200 of 300 units remaining, labeled with the resident's name. The pen lacked an opened on date. 2. During an observation of the Team 1 Medication Cart with QMA (Qualified Medication Aide) 5 on 08/12/22 at 09:30 A.M. the following items were improperly labeled: - Resident 48's used [MEDICATION(S)] insulin pen with 195 of 300 units remaining. The pharmacy label indicated the pen was received from the pharmacy on 07/12/22. The pen was not labeled with an opened on date, and - Resident 54's used [MEDICATION(S)] insulin pen with 100 of 300 units remaining. The pharmacy label indicated the pen was received from the pharmacy on 07/28/22. The pen was not labeled with an opened on date. During an interview on 08/12/22 at 09:35 A.M., QMA 5 indicated she was unsure how long the insulin pens were good for after they were opened. The pens should be labeled with an opened on date. The current facility policy titled Storage of Medications, with a revised date of November 2020 was provided by the Director of Nursing on 08/12/22 at 11:45 A.M. The policy indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 3.1-25(k)(6)

Based on interview and record review, the facility failed to document resident information related to discharge for 1 of 15 residents reviewed for identifiable information. (Resident 26) Findings include: During an interview on 08/11/22 at 9:17 A.M., LPN (Licensed Practical Nurse) 8 indicated Resident 26 had complaints of chest pain one evening and she had received orders to send her to the emergency room . When she would receive the orders to send someone to the hospital she would complete her assessment on paper, prepare the appropriate paperwork, call report to the hospital, notify the family and emergency transport. She would send all the paperwork with the resident and did not keep any copies and would document in a progress note the situation with the resident and where they went. The clinical record for Resident 26 was reviewed on 08/09/22 at 2:06 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/18/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The census report for Resident 26 indicated she was discharged to the hospital on 08/06/22. The clinical record lacked documentation or an assessment indicating the resident had been sent to the hospital on 08/06/22 until a late entry note was entered on 08/11/22 at 1:42 P.M. after the concern was brought to the attention of DON during the survey process. During an interview on 08/12/22 at 9:46 A.M., the DON (Director of Nursing) indicated the resident's clinical record should have had a progress note prior to the late entry note indicating she was sent to the hospital. The management team usually discuss in morning meeting and those notes would be reviewed at that time. The current facility policy titled, Charting and Documentation, was revised July 2017 was provided by the DON on 08/11/22 at 2:49 P.M. The policy indicated, .All services provided to the resident, progress toward the care plan goal, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to follow care plan interventions to prevent falls for 1 of 3 residents reviewed for accident hazards. (Resident D) Findings include: The clinical record for Resident D was reviewed on 5/31/22 at 11:57 a.m. The diagnoses included, but were not limited to, dementia, muscle wasting and atrophy of both shoulders and both thighs, abnormal gait and mobility, [CONDITION(S)], and dorsalgia (back pain). The Quarterly MDS (Minimum Data Set) assessment, dated 4/7/22, indicated the resident had adequate hearing and vision with corrective lenses, had clear speech, was understood, and understands others. He required the assistance of one staff member for mobility and ADLs (Activities of Daily Living), and two staff members assistance for transfers. He was frequently incontinent of bladder and bowel. He had two or more falls since admission. A Progress Note, dated 1/6/22 at 1:33 p.m., indicated the resident called for help. Upon staff entering the room the resident was lying on his left side. The resident stated he was reaching for an item on the floor and slid out of the chair. The resident was not wearing slippers. An IDT (Interdisciplinary Team) review, dated 1/7/22 at 9:15 a.m., indicated the root cause analysis was completed and determined the resident was not wearing proper footwear. The intervention implemented was for staff to encourage the resident to wear non-skid footwear at all times, when out of bed. A Progress Note, dated 3/31/22 at 3:46 a.m., indicated the resident was found sitting on the floor in front of his chair. The resident stated he was getting up and his feet slipped. An IDT review, dated 3/31/22 at 9:40 a.m., indicated the root cause analysis was completed and determined to be the resident's imbalance. The intervention implemented was to apply non-skid strips to the floor in front of the resident's chair. A Progress Note, dated 5/15/22 at 9:25 a.m., indicated the resident was found on the floor per staff. An IDT review, dated 5/16/22 at 9:46 a.m., indicated the root cause analysis was completed and determined to be related to the resident's impaired balance. The intervention implemented was for non-skid strips to be placed along the side of the resident's bed. A Care Plan, with the revision date of 5/16/22, indicated the following: - On 7/15/21. the resident had an actual fall related to poor balance, unsteady gait, and improper footwear. - On 1/7/22, the resident had a fall related to improper footwear and poor balance. The intervention, dated 1/7/22, was for staff to encourage the resident to wear non-skid footwear at all times when out of bed. - On 3/31/22, the resident had a fall related to impaired balance. The intervention, dated 3/31/22, was non-skid strips to floor in front of chair. The intervention, dated 4/23/21, was for a psych evaluation related to a change in behaviors, possibly contributing to falls. The intervention, dated 4/20/21, was for staff to remind and assist resident to wear non-skid footwear at all times when out of bed. - On 5/15/22, the resident had an unwitnessed fall related to imbalance. The intervention, dated 5/16/22 , was non-skid strips to be placed alongside bed. During an observation on 5/31/22 at 12:18 p.m., the resident was sitting in his recliner with the tray table in front of the chair. He was eating his lunch. His feet were bare and there were no non-skid strips observed in front of the chair or beside the bed. During an observation on 5/31/22 at 2:45 p.m., the resident was lying on the bed in his room. There were no non-skid strips in front of the bed or the chair, and the resident was barefooted. During an interview on 5/31/22 at 3:10 p.m., Licensed Practical Nurse (LPN) 2 indicated the resident was alert and oriented but with confusion, and she was not sure what his fall care plan interventions were. During an interview on 5/31/22 at 3:15 p.m., CNA 3 indicated the resident was independent and only needed supervision, she was not sure what his care plan interventions were for falls and would have to ask the nurse. During an interview on 5/31/22 3:18 p.m., CNA 4 indicated the resident was independent, liked Bingo, sometimes used walker sometimes wheelchair depending on how he was feeling that day. She did not know what his fall care plan interventions were and would have to ask the nurse. During an interview 5/31/22 3:39 p.m., CNA 5 indicated the resident was independent and she was not sure what his fall care plan interventions were. The current facility policy Goals and Objective, Care Plans and with a revision date of April 2009, was provided by the DON. The policy indicated, .1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem .4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . 3.1-45(a)

Based on interview and record review, the facility failed to prevent significant medication administration errors for 2 of 3 residents reviewed for medication administration. (Residents B and C) Findings include: 1. During an interview on 01/13/22 at 9:57 A.M., RN 2 indicated she came in to work the evening of 01/01/22. She received report on the residents from LPN (Licensed Practical Nurse) 3. LPN 3 indicated she had already administered evening medications to 3 residents that weren't scheduled to receive their medications until later that evening. RN 2 finished receiving report on the residents and began passing the evening medications. The medications LPN 3 indicated she had already given were not checked off as administered in the residents' EMARs (Electronic Medication Administration Records). RN 2 called LPN 3 with questions about the lack of documentation. LPN 3 indicated she forgot to tell RN 2 that she had also administered Resident B's evening medications early that day. RN 2 told LPN 3 that she had just administered Resident B's evening medications, resulting in the resident receiving the medications twice. The DON (Director of Nursing), MD, and the resident's family were notified of the medication error. The resident was monitored in the facility but was sent to the hospital later that evening for observation because her blood pressure was low. The resident returned to the facility the following day. During an interview on 01/13/22 at 10:00 A.M., RN 2 indicated Resident B's evening medications were not checked off on the EMAR on 01/01/22. She did not know they had already been administered. Residents' medications were in packets with multiple tablets and capsules in each packet based on the medication administration times. When RN 2 retrieved the packet and administered the evening medications to Resident B, she did not verify the date on the packet. The packet was dated for the next day's evening medication pass. The clinical record for Resident B was reviewed on 01/13/21 at 10:38 A.M. An Admission MDS (Minimum Data Set) assessment, dated 12/16/21, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance with all ADLs (Activities of Daily Living). The resident's January 2022 EMAR was reviewed. The resident received the evening doses of the following medications twice on 01/01/22: - [MEDICATION(S)] tablet 40 mg (milligrams). Give 40 mg by mouth at bedtime for [CONDITION(S)], administration time 7:00 P.M., - [MEDICATION(S)] (a medication for nerve pain) tablet 600 mg. Give 600 mg by mouth at bedtime for [CONDITION(S)], administration time 7:00 P.M., - [MEDICATION(S)] FlexTouch Insulin Pen. Inject 22 units subcutaneously at bedtime for diabetes, administration time 7:00 P.M., - [MEDICATION(S)] (an antianxiety medication) tablet 5 mg. Give 5 mg by mouth two times a day for anxiety, administration times 6:00 A.M. and 6:00 P.M., - Tylenol Tablet 325 mg. Give 650 mg by mouth two times a day for pain, administration times 6:00 A.M. and 6:00 P.M., and - [MEDICATION(S)] (an antibiotic) tablet 500 mg. Give 500 mg by mouth three times a day for [CONDITION(S)] for 10 days, administration times 6:00 A.M., AFTERNOON, and 7:00 P.M. During an interview on 01/13/22 at 3:08 P.M., LPN 3 indicated she was working on Resident B's unit on 01/01/22. Resident B was anxious that day. She gave her a PRN (as needed) [MEDICATION(S)] (an anxiety medication) around 3:30 P.M. It calmed the resident some, but not much. The resident had medications that were due at 6:00 P.M. and 7:00 P.M. When it was time to administer the 6:00 P.M. medications, she went ahead and administered the 7:00 P.M. medications too, including the insulin. She did not sign the medications out when she administered them. She forgot to click the box on the EMAR that indicated the medications were administered. During an interview on 01/13/2022 at 11:28 A.M., LPN 4 indicated the EMAR colors in the computer indicated the status of a medication. If the medication was yellow, it was okay to administer. If it was red the medication was overdue, and if it was green, there was nothing to administer at that time. The medication packets were labeled with the resident's name, room number, date, time for administration, and the names of the medications in the packet. 2. The clinical record for Resident C was reviewed on 01/13/22 at 11:35 A.M. An Annual MDS, dated [DATE], indicated the resident was moderately cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMAR for January 2022, was provided by the MDS Coordinator on 01/13/22 at 3:00 P.M. The record lacked documentation the following medications, scheduled for 6:00 A.M., were given on January 4, 11, and 12, 2022: - Aspirin 81 mg, take 1 tablet by mouth in the morning, - [MEDICATION(S)] 100 mg, take 2 capsules by mouth in the morning, - [MEDICATION(S)] (an antidepressant medication) 5 mg, take 1 tablet by mouth one time a day for depression. - [MEDICATION(S)] 1 mg, take 1 tablet by mouth in the morning for bone loss. - [MEDICATION(S)] (a blood pressure medication) 10 mg on 01/04/22, take one time a day for hypertension. - [MEDICATION(S)] 20 mg on 01/11/22 and 01/12/22, take by mouth one time a day for hypertension. - Multivitamin plus minerals, take 1 tablet by mouth in the morning. - Potassium Chloride 10 Meq (milliequivalent), take 1 tablet by mouth in the morning. - Vitamin B-6 50 mg, take 1 tablet by mouth in the morning. - [MEDICATION(S)] (a [CONDITION(S)] medication) 1 mg, take 1 tablet by mouth in the morning for seizures. - Calcium [MEDICATION(S)] - vitamin D 600-400 mg, take 1 tablet by mouth two times per day. - [MEDICATION(S)] (an antianxiety medication) 0.5 mg, take 1 tablet by mouth two times per day for anxiety. - [MEDICATION(S)] (an anticonvulsant medication) 500 mg, take 1 tablet by mouth two times a day for behaviors. - [MEDICATION(S)] (a [CONDITION(S)] medication) 100 mg, take 1 tablet by mouth two times a day for seizures. and, - [MEDICATION(S)] 300 mg, take 1 capsule three times a day for nerve pain. The progress notes for January 2022, were provided by the MDS Coordinator on 01/13/22 at 3:00 P.M. The notes lacked documentation of any reason the resident should not have received her medications. The facility census did not indicate the resident was out of the building during the medication pass time. During an interview on 01/13/22 at 2:44 P.M., the DON indicated the EMAR should have shown documentation the medications were given or a reason as to why they were not given. The current facility policy, titled Administering Medications, with a revision date of April 2019, was provided by the DON on 01/13/22 at 1:31 P.M. The policy indicated, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This Federal deficiency relates to Complaint IN 235. 3.1-37(a) 3.1-48(a)(1) 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to develop Care Plans in a timely manner for residents who were at risk for falls and at risk for pressure ulcers for 6 of 18 residents reviewed for Care Plans. (Residents 35, 18, 17, 2, 37, and 48) Findings include: 1. During an observation and interview on 06/21/21 at 11:27 A.M., Resident 35 indicated she had fallen in the facility and she had a sore on her right heel. Her right foot was wrapped with a compression wrap all the way to her knee. A SKIN OBSERVATION TOOL record, dated 04/30/21, was provided by the DON (Director of Nursing) on 06/23/21 at 1:22 P.M. The record indicated the resident had an injury to her right heel. The clinical record was reviewed on 06/25/21 at 2:13 P.M. A comprehensive Admission MDS (Minimum Data Set) assessment, dated 04/14/21, indicated the resident was moderately cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment section V, CAAS (Care Area Assessment Summary) indicated the resident should have had Care Plans for falls and pressure ulcer/injury. During an interview on 06/24/21 at 10:04 A.M., MDS Coordinator 2 indicated after they completed an MDS assessment then updated the Care Plans based on the assessment findings. After the MDS assessment was completed, they had 14 days to complete the Care Plan based on the assessment. The Admission MDS assessment date, 04/14/21, was the last day of the look back review period. The Care Plans should have been completed within 21 days from the date the resident was admitted to the facility. The resident's complete Care Plan was provided by MDS Coordinator 2 on 06/23/21 at 1:42 P.M., and lacked an at risk for skin impairment and an at risk for falls Care Plan initiated in the designated time frame. During an interview on 06/25/21 at 3:19 P.M., the DON indicated what a resident CAAS for on the MDS assessment they should have had a Care Plan. 2. The clinical record for Resident 18 was reviewed on 06/23/21 at 1:51 P.M. An Annual MDS assessment, dated 08/02/20, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at risk for the development of pressure ulcers and had pressure reducing devices in the bed and chair. The assessment section V (Care Area Assessment Summary) indicated the resident should have a Care Plan for pressure ulcer/injury. The resident's complete Care Plan was provided by the DON on 06/23/21 at 3:52 P.M., and lacked an at risk for skin impairment Care Plan.e 3. The clinical record for Resident 17 was reviewed on 06/24/21 at 3:59 P.M. A Significant Change MDS assessment, dated 06/19/20, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at risk for the development of pressure ulcers and had pressure reducing devices in the bed and chair. The assessment section V (Care Area Assessment Summary) indicated the resident should have had a care plan for pressure ulcer/injury. The resident's complete Care Plan was provided by the DON on 06/23/21 at 4:23 P.M., and lacked an at risk for skin impairment Care Plan. 4. The clinical record for Resident 2 was reviewed on 06/23/21 at 1:37 P.M. A Quarterly MDS assessment, dated 03/18/21, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was always incontinent of bowel and had a [CONDITION(S)]. The resident's complete Care Plan was provided by the DON on 06/24/21 at 2:27 P.M. and lacked a Care Plan for the resident's [CONDITION(S)]. During an interview on 06/24/21 at 4:14 P.M., the DON indicated the resident should have had a Care Plan for the [CONDITION(S)]. 5. The clinical record for Resident 37 was reviewed on 06/23/21 at 10:59 A.M. An Annual MDS assessment, dated 07/11/20, indicated the resident was moderately cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was at risk for pressure ulcers and utilized a pressure reducing device for her chair and her bed. The assessment section V (Care Area Assessment Summary) indicated the resident should have a care plan for pressure ulcer/injury. The complete Care Plan was provided by MDS Coordinator 2 on 06/24/21 at 10:52 A.M., and lacked an at risk for skin impairment Care Plan. During an interview on 06/25/21 at 3:15 P.M., the DON indicated if section V of an MDS assessment indicated a Care Plan was required, a Care Plan should have been put into place. 6. The clinical record for Resident 48 was reviewed on 06/23/21 at 1:14 P.M. An Annual MDS assessment, dated 07/15/2020, indicated the resident was moderately cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required staff supervision for all ADLs (Activities of Daily Living), and used a walker and a wheelchair. The resident had no falls since admission to the facility. The assessment Section V (Care Area Assessment Summary) indicated the resident should have had a care plan for risk for falls. The resident's complete Care Plan was provided by MDS Coordinator 2 on 06/24/21 at 10:05 A.M. and lacked a Care Plan for the resident's risk for falls. During an interview on 06/24/21 at 10:05 A.M., MDS Coordinator 2 indicated the resident should have had a risk for falls Care Plan. The current facility policy, titled Care Plans, Comprehensive Person-Centered, with a revision date of December 2016, was provided by the DON on 06/24/21 at 4:24 P.M. The policy indicated, .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 3.1-31(a) 3.1-31(b)(1) 3.1-31(c)(1) 3.1-31(e)

Based on interview and record review, the facility failed to ensure a resident's pain was controlled related to providing scheduled pain medication for 1 of 30 residents reviewed for pain. (Resident #16) Findings include: During an interview on 07/18/2016 at 10:47 A.M., RN #1 indicated Resident #16's pain patch had been scheduled to be changed on 07/17/2016, but the old patch, dated 07/14/2016, was still in place. The RN further indicated the resident did not have any more medication patches in the medication cart. During an interview on 07/18/2016 at 11:31 A.M., RN #1 indicated she would need to call the doctor to get an order so she could get Resident #16 medication from the EDK (Emergency Drug Kit). During an interview on 07/19/2016 at 10:20 A.M. the DON (Director of Nursing) indicated the nurse that was supposed to replace Resident #16's medication patch on 07/17/2016 attempted to call the pharmacy that day (07/17/2016), but could not reach them. The nurse got busy and forgot to call the pharmacy back later. The DON was not sure why the old medication patch had not been removed. The DON also indicated RN #1 checked for placement of the medication patch on 07/18/2016, but did not check the date as she should have. During an interview on 07/19/2016 at 10:31 A.M., the family member of Resident #16 indicated the resident's pain patch was missed on Sunday and the resident had been in a lot of pain. The family member further indicated when Resident #16's pain patches were changed, as scheduled, the resident's pain was well controlled. During an interview on 07/19/2016 at 11:13 A.M., Resident #16 indicated he had been in some pain yesterday (07/18/2016). The resident further indicated his pain was usually controlled by the pain patches, but it was not yesterday until they applied the new pain patches. During an interview on 07/19/2016 at 11:35 A.M., RN #1 indicated Resident #16's family member brought the outdated patch to her attention. The RN further indicated she had checked the placement of the patch, but had missed the dates. Resident #16's clinical record was reviewed on 07/19/2016 at 11:55 A.M. The Admission MDS (Minimum Data Set) assessment, dated 06/30/2016, indicated the resident had a BIMS (Brief Interview for Mental Status) of 15 and was cognitively alert and oriented. The resident's [DIAGNOSES REDACTED]. The assessment indicated the resident did receive scheduled pain medication. Resident #16's physician orders [REDACTED]. An Event report for Resident #16 indicated on 07/17/2016 the resident's [MEDICATION NAME] was not changed due to the medication not being available. A new order was received on 07/18/2016 to put two 50mcg patches on from the EDK. The current facility policy, titled [MEDICATION NAME] Drug Delivery Systems and dated 01/01/05, was provided by the DON (Director of Nursing) on 07/19/2016 at 10:51 A.M. and was reviewed at that time. The policy indicated, .if patch remains in place, remove . 3.1-37(a)

Based on observation, interview and record review, the facility failed to put individualized interventions in place to prevent a pressure ulcer for a dependent resident who was at risk for pressure ulcers, and failed to promptly provide treatment when the area first developed, resulting in a painful unstageable pressure ulcer (eschar (necrotic) tissue present preventing adequate staging of pressure ulcer) on the right heel for 1 of 1 resident reviewed for pressure ulcers of 1 who met the criteria for pressure ulcers (Resident #15). Finding include: 1.) Review of the record of Resident #15 on 4-25-13 at 9:10 a.m. indicated the resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment for Resident #15 dated 3-17-13, indicated the resident's BIMS (Brief Interview for Mental Status) was a 15, with a range of 13-15, indicating the resident was cognitively intact, bed mobility- extensive assistance of two people, transfer- total dependence of two people, toilet use- total dependence of two people, walk in room- activity did not occur, and the resident was assessed as at risk of developing a pressure ulcer. The care plan for Resident #15 dated 12-21-12, indicated the resident was at risk for impaired skin integrity related to impaired mobility and incontinence. The resident interventions included, but were not limited to, encourage nutrition, encourage fluid intake, pressure reducing mattress and chair cushion. The Braden scale assessment for skin impairment for Resident #15 dated 12-21-12, indicated the resident scored a 16, indicating the resident was at risk for pressure ulcers. The nursing note for Resident #15 dated 2-8-13 at 9:10 p.m. indicated the resident's right heel was soft with a water filled blister. The physician was aware. The care plan for Resident #15 dated 2-8-13 indicated the resident was at risk for impaired skin integrity related to a cardiac history, diabetes and [MEDICAL CONDITION]. The interventions included, but were not limited to, avoid dry soaps, encourage elevation of extremities when seated, encourage position changes at least every two hours, and on 3-19-13 heel protector waffle boots were added as an intervention. The physician order [REDACTED]. Monitor the area and notify the physician of any changes. The physician order [REDACTED]. The vascular versus pressure ulcer flow sheet for Resident #15 dated 2-13-13 indicated the resident had an 8 centimeter (cm) by 6 cm wound on the right heel. The word "vascular" was written with a question mark. The local wound center assessment of the right heel dated 3-14-13 indicated the resident had a 2.8 cm by 4.5 cm by 0.1 cm wound covered with 67-100% black eschar. The impression was "nonhealing ulcer, right heel, presumed secondary to pressure potentially complicated by arterial insufficiency." The eschar covering the wound was debrided. The ultrasound report for Resident #15 dated 4-1-13 indicated the resident had mild to moderate arterial insufficiency/ischemia to the right leg. The local wound center assessment for Resident #15 dated 4-2-13 indicated the resident had a stage 3 pressure ulcer on her right heel measuring 2.2 cm by 4.0 cm by 0.2 cm. The wound was red with yellow [MEDICATION NAME]/slough. The local wound center assessment for Resident #15 dated 4-16-13 indicated the resident had a right heel wound measuring 2.2 cm by 3.4 cm by 0.1 cm. The wound was red with yellow [MEDICATION NAME]/slough. Interview with Resident #15 on 4-25-13 at 10:00 a.m. indicated on 4-24-13 on night shift she requested the staff to put her pressure relieving boot on because the heel wound was hurting her. Resident #15 indicated the staff do not always put the pressure relieving boot on when she goes to bed. Resident #15 indicated she thought the reason the staff did not always put her pressure relieving boot on when she goes to bed was because there were "different workers" and they don't know she is supposed to wear it. The resident was observed to have pillows under her legs and a pressure reducing boot on her right foot; the resident did not have a pressure relieving boot on her left foot. During interview with the Director Of Nursing (DON) on 4-26-13 at 12:40 p.m., when queried what was done to prevent the pressure ulcer on Resident #15's heel, the DON indicated it was standard for every resident that was in bed to have their heels floated, weekly skin assessments, CNA's monitor skin closely and it was standard to reposition residents in bed as needed. The DON indicated the facility did not hear back from the physician on 2-8-13 about Resident #15's right heel. The Physician responded on 2-11-13 and that was when the first treatment was ordered for the resident's right heel. When queried what does the facility do when a physician does not respond, the DON indicated they monitored the right heel and ensured there was no pressure on the area. The DON indicated if the facility needed something right away, the Medical Director would get involved. During observation on 4-26-13 at 2:00 p.m., Resident #15 was receiving a dressing change to right heel pressure ulcer. The old dressing had brown and red drainage on it. The pressure ulcer was red/pink with yellow slough. The wound measured 1.9 cm by 3.1 cm. The left heel appeared to be soft but no open area was observed. Interview with Resident #15 on 4-29-13 at 11:10 a.m. indicated staff only assist her to turn in bed if she requests them to. The resident indicated she required assistance to reposition in bed; she could hold onto the siderails on her bed but needed staff's help to turn. The resident indicated she only wears the pressure relieving boot on her right foot. The resident indicated she does not have a wound on her left heel, but the wound care center told her she could get one on it. The "skin care and wound management program," provided by the DON on 4-30-13, indicated the interdisciplinary team develops an individualized care plan to prevent or treat skin breakdown. 3.1-40(a)(1) 3.1-40(a)(2)