Every finding on record at Applewood Center

Based on interview and record review, it was determined that the facility failed to ensure that trauma survivors have interventions identified to eliminate or mitigate triggers that may cause re-traumatization in 1 of 3 residents reviewed for PTSD (Post-Traumatic Stress Disorder) in a final sample of 17 residents (Resident identifier is #60). Findings include: 38218 Review on 5/14/25 of Resident #60's medical record revealed a Diagnosis List with a diagnosis of PTSD (Post-traumatic Stress Disorder) on admission on 10/2024. Further review of Resident #60's medical record revealed the following Social Service Assessments: Social Service Assessment, dated 10/15/24, .Mental Health 1. Does the patient/resident have a diagnosis of a major mental illness, 1. Yes. a1. Describe major mental illness, PTSD, anxiety .Trauma History, 1. Does the patient/resident report or does the medical record reflect any history of trauma and/or Post-Traumatic Stress Disorder, Yes .Military Related Trauma .2a. Ask: In the past month, have you had repeated, disturbing memories, thoughts or images of a stressful experience from the past? (Resident answered) Moderately. 2b. Ask In the past month, have you felt very upset when something reminded you of a stressful experience from the past? (Resident answered) Quite a bit ., Social Service Assessment, dated 4/5/25, .Trauma History .2a. Ask: In the past month, have you had repeated, disturbing memories, thoughts or images of a stressful experience from the past? (Resident answered) a little bit . 2b. Ask In the past month, have you felt very upset when something reminded you of a stressful experience from the past?(Resident answered) a little bit . Review on 5/14/25 of Resident #60's care plans revealed Focus, [Resident #60's name omitted] reports past experience of trauma as evidenced by: feeling upset when reminded of a stressful experience from the past, dx [diagnosis] of PTSD, Date initiated: 1/1/25 .Goal, [Resident #60's name omitted] will report feeling safe in the Center .[Resident #60's name omitted] will identify stressors and report to staff .Interventions, Encourage Resident/Patient to identify personal trauma and triggers and take steps to eliminate/minimize . Interview on 5/14/15 at approximately 1:00 p.m. with Staff A (Clinical Lead) revealed that there was no documentation to determine what the facility could do to mitigate/or determine if Resident #60's had any triggers. Review on 5/14/25 of the facility policy titled, OPS416 Person-Centered Care Plan, Revision Date 10/24/22, revealed: .Purpose .To eliminate or mitigate triggers that may cause re-traumatization of the patient . Review on 5/15/25 of the facility policy titled, SS100 Social Services Assessment, Revision Date 3/15/24, revealed .Purpose To determine the patient's social, functional, emotional, and cognitive status and history of trauma and or/ post-traumatic stress disorder (PTSD). To develop an individualized Social Services plan of care.

Based on interview and record review, it was determined that the facility failed to provide Physical Therapy (PT) services according to the physician's order frequency for 1 of 1 resident reviewed for Rehab (Rehabilitation) in a final sample of 17 residents. (Resident identifier is #57.) Findings include: Interview on 5/13/25 at approximately 11:00 a.m. with Resident #57 revealed that he/she had concerns of not receiving his/her therapy as ordered. Review on 5/14/25 of Resident #57's medical record revealed the following physician orders, rehab notes, and visits: Order #1 PT order on 4/3/25 for PT 5 x(times) weekly x 30 days to include:Therex (Therapeutic exercise), Gait training, therapeutic activities, neuro re-education (neurological re-education), group therapy, wheelchair management and training, end dated 4/15/25. Resident #57's rehab notes and visits revealed the following: Week #1: 4/3-4/9: Resident received a PT evaluation on 4/3/25, refused a visit on 4/4/25 and completed visits on 4/7/25,4/8/25, and 4/9/25. Frequency of 1 evaluation and 3 revisits Frequency not met. Week #2: 4/10/25-4/14/25 Resident received PT visits on 4/10. Resident refused visit on 4/11/25. Frequency not met. Order #2: PT order on 4/15/25 for PT 4-5 x weekly x 30 days to include:Therex, Gait training, therapeutic activities, neuro re-education (neurological re-education), group therapy, wheelchair management and training, end dated 5/1/25. Resident #57's rehab notes and visits revealed the following: Week #2: 4/22-4/28/25: Resident received therapy visits on 4/22/25, 4/23/25 and 4/28/25. The visit on 4/24 states rescheduled frequency not met. Order #3: PT order 5/1/25 for PT 4-5 x weekly for 30 days to include: Therex (Therapeutic exercise), Gait training, therapeutic activities, neuro re-education (neurological re-education), group therapy, wheelchair management and training. Resident #57's rehab notes and visits revealed the following: Week #1, 5/1/25-5/7/25: Resident #57 received therapy on 5/1/25 and 5/2/25. Frequency not met. Week #2, 5/8/25 -5/14/25 Resident #57 received therapy on 5/8/25 and 5/14/25. Frequency not met. Interview on 5/15/25 at approximately 9:00 a.m. with Staff F (Nurse Practitioner) confirmed that Staff F was not notified of Resident #57 not meeting required therapy visits and would expect to be notified. Interview on 5/15/25 at approximately 9:30 a.m. with Staff G (Director of Rehab) revealed that the expectation would be to see a resident in the same therapy week for a refusal or rescheduled visit. Staff G confirmed the above findings and confirmed that Staff F was not notified of Resident #57 not meeting physician ordered frequencies for PT services.

Based on interview and record review, it was determined that the facility failed to document a rationale in the resident's medical record for no change in the medication for 1 of 1 resident reviewed for Psych/Opioid Medication Side Effects in a final sample of 17 residents. (Resident identifier is #118.) Findings include: Review on 5/13/25 of Resident #118's May 2025 Medication Administration Record (MAR) revealed the following physician's order: Quetiapine Fumarate (antipsychotic) Oral Tablet 25 mg (milligrams), Give 1 tablet by mouth one time a day for refractory insomnia, Start Date 4/3/24. Review on 5/14/25 of Resident #118's Consultation Report from the pharmacist dated, 5/3/24 revealed the following recommendation: .Please consider reducing Quetiapine to 12.5 mg or discontinuing and changing to alternative therapy . Physician response, dated 5/9/24, revealed that the physician accepted the recommendation and change to Trazodone. Follow up response, dated 5/13/24, on the Consultation Report , per request Seroquel [Quetiapine] reinstated with no documented rationale. Interview on 5/14/25 at approximately 11:45 a.m. with Staff A (Clinical Lead) confirmed that there was no GDR attempted with Resident #118's Quetiapine Fumarate and that Resident #118 had no documented behaviors. Review on 5/14/25 of the facility policy titled, 8.4 Medication Management, Dated 1/25 revealed: . Gradual Dose Reductions, . Dose reductions should occur in the modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence. Compliance with the requirement to perform a GDR may be met if, for example, within the first year in which a resident is admitted on psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, a facility attempts a GDR in two separate quarters (with at least one month in between attempts), unless clinically contraindicated.

Based on interview and record review, it was determined that the facility failed to implement a care plan for essential hypertension for 1 resident in a final sample of 17 residents. (Resident identifier is #13.) Findings include: Review on 5/13/25 of Resident #13's current care plan revealed a focus for essential hypertension with the following interventions: Monitor blood pressure and pulse as indicated. Review on 5/13/25 of Resident #13's medical record revealed a physician's order dated 4/30/25 and rewritten on 5/3/25 that read (with no changes to the order): Orthostatic BP (blood pressure) Directions for orthostatic BP: Enter BPs in the W&V (Weights and Vitals) tab directly. Take BP when lying, take BP while standing. Evaluate both recording [sic] for potential orthostatic hypotension indicated systolic drop by 20 units or diastolic drop by 10 units. Document occurrence and action taken in Progress Note. Frequency of two times daily. Review on 5/15/25 of Resident #13's W&V and April and May 2025 Medication Administration Record (MAR) revealed the following documented orthostatic blood pressure obtained twice daily was on 5/2/25. The following orthostatic blood pressure was documented once daily on 4/30/25, 5/1/25, and 5/3/25. Resident #13's lying and standing blood pressures were not both documented between 5/4/25 to 5/14/25. Interview on 5/15/25 at approximately 9:15 AM with Staff E (Director of Nursing) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure residents' records were complete and accurate for 1 out of 5 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident Identifier #58). Findings include: Review on 5/5/24 of Resident #58's May 2024 Medication Administration Record (MAR) revealed the following physician's orders: 1. Hypoglycemia Protocol, observe signs/symptoms of hypoglycemia as needed if blood glucose is less than 70 milligrams (mg) / per deciliter (dl) or ordered low parameter follow Hypoglycemia protocol, start date: 4/23/24. 2. Check Fasting Blood Sugar (FBS) twice a day (BID), start date: 4/23/24 Further review of the MAR reavaled the following FBS results that would require an intervention: 5/1/24 at 6:00 a.m. Resident #58's FBS was 51 5/3/24 at 6:00 a.m. Resident #58's FBS was 38 Further review of Resident #58's medical record revealed that there was no documentation of the hypoglycemia protocol being followed on the above dates when Resident #58's FBS was below 70. Interview on 5/6/24 at approximately 12:20 p.m. with Staff B (Director of Nursing) confirmed that there was no documentation in Resident #58's medical record that the above FBS were addressed by the nurse. Further interview revealed that the hypogylcemic protocol was followed but it was not document in Resident #58's medical record. Review on 5/6/24 of the facility's policy titled: Hypoglycemia revision date 3/1/22 revealed: .2. Initiate the Hypoglycemia Protocol for patients experiencing a hypoglycemia episode .Patient Arousable, Conscious, Able to Swallow? Yes. Administer fast-acting oral carbohydrate (e.g. [example] 4 oz. [ounces] juice or tube of Insta-glucose gel) . repeat blood glucose in 15 minutes .

Based on observation, interview, and record review, it was determined the facility failed to properly label a vial of multidose injectable medication when opened for 1 out of 2 medication refrigerators observed and failed to keep medications locked and secured in 2 out of 36 resident rooms observed (Resident Identifiers #46 and #48). Findings include: Observation on 5/5/24 at approximately 8:15 a.m. of the medication room vaccination refrigerator revealed an open vial of Tuberculin Purified Protein Derivative that was unlabeled with no open date or open expiration date. Interview on 5/5/24 at approximately 8:15 a.m. with Staff A (Licensed Practical Nurse (LPN)) confirmed the above findings. Review on 5/5/24 of manufacturer's instruction for Tuberculin Purified Protein Derivative revealed: Vials in use more than 30 days should be discarded. 38218 Resident #46 Observation on 5/5/24 at approximately 9:30 a.m. in Resident #46's room revealed a bottle of One A Day Multivitamins on his/her side table. Interview on 5/5/24 at approximately 9:30 a.m. with Staff A confirmed the above finding and that the medication should not have been unlocked. Resident #48 Observation on 5/6/24 at approximately 7:30 a.m. in Resident #48's room revealed a box of Loratidine, Allergy Relief 10 milligrams (mg) pills in a bin. Interview on 5/6/24 at approximately 7:30 a.m. with Staff C (LPN) confirmed the above finding and that the medication should not have been unlocked. Review on 5/5/24 of the facility's policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals revision date of 8/7/23 revealed: page 2 .5.3 If a multidose vial of an injectable medication has been opened or accessed .the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . Further review of this policy revealed: page 3 .13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room .

Based on observation, interview, record review, policy review, and manufacturer's instructions review it was determined that the facility failed to follow professional standards when administering insulin for 2 out of 30 medications observed (Resident Identifier #54). Findings include: Observation on 5/6/24 at approximately 7:45 a.m. of Staff C (Licensed Practical Nurse) preparing Resident #54's insulin revealed that both the Novolog insulin pen and the Semglee insulin pen were not primed prior to administration. Interview on 5/6/24 at approximately 7:45 a.m. with Staff C confirmed the above findings. Further interview revealed that Staff C was unaware of the need to prime insulin pens prior to administration and it was not his/her practice. Review on 5/6/24 of the manufacturer's instructions for Novolog insulin flexpen, dated 3/2023 revealed: .Check the insulin flow, Step 5 - Small amounts of air may collect in the cartridge during normal use. You must do an airshot before each injection to avoid injecting air and to make sure you receive the prescribed dose of your medicine . Review on 5/6/24 of the manufacturer's instruction for Semglee insulin pen, dated 7/2021 revealed: .Step 3. Perform a safety test, Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly, removing air bubbles. A. Select a dose of 2 units by turning the white dose knob, B. Take off the outer needle cap .Take off the inner needle cap and discard it .C. Hold the pen with the needle pointing upwards. D. Tap the cartridge so that any air bubbles rise up towards the needle. E. Press the purple injection button all the way in. Check if insulin comes out of the needle tip . Review on 5/6/24 of the facility's policy titled 6.0 General Dose Preparation and Medication Administration revision dated 4/30/24 revealed: 5.8 Follow manufacturer medication administration guidelines .

Based on observation, interview, and record review it was determined that the facility failed to identify resident's personal preferences with flexible dining times needed to ensure that resident's receive 3 meals a day for 1 out of 4 residents reviewed for nutrition in a final sample of 18 residents (Resident identifier is #32), Findings include: Observation on 4/3/23 at approximately 9:30 a.m. revealed Resident #32 laying in his/her bed with eyes closed. Further observation revealed Resident #32's breakfast table on the bedside table untouched. Observation on 4/3/23 at approximately 10:30 a.m. revealed Resident #32 laying in his/her bed with eyes closed. Further observation revealed Resident #32's breakfast table on the bedside table untouched. Observation on 4/3/23 at approximately 11:15 a.m. revealed Resident #32 laying in his/her bed with eyes closed. Further observation revealed Resident #32's breakfast table on the bedside table untouched. Observation on 4/5/23 at approximately 9:00 a.m. revealed Resident #32 laying in his/her bed with eyes closed. Interview on 4/5/23 at approximately 9:00 a.m. with Staff A Licensed Nursing Assistant (LNA) revealed that Resident #32 had not had breakfast and Staff A stated that he/she did not know why Resident #32 had not had breakfast. Observation on 4/5/23 at approximately 9:05 a.m. of the food truck in the hall revealed dirty trays in the cart. Resident #32's tray was in the cart untouched with his/her meal ticket ripped in half. Interview on 4/5/23 at approximately 9:05 a.m. with Staff B (Administrator in Training) revealed that sometimes Resident #32 prefers to sleep in and staff doesn't want to disturb him/her. Review on 4/5/23 of Resident #32's medical record revealed that he/she was admitted to the facility on [DATE]. Review on 4/5/23 of Resident #32's intakes for March 2023 and April 2023 revealed the following: 3/27/23 0% breakfast 3/28/23 0% breakfast 3/30/23 0% breakfast 4/1/23 0% breakfast 4/5/23 0% breakfast Interview on 4/5/23 at approximately 11:00 a.m. with Staff C (Dietary Aide) and Staff D (Dietary Aide) revealed that they were unaware of any special meal times for Resident #32. Interview on 4/5/23 at approximately 11:05 a.m. with Staff E (Lead Cook) revealed that there is currently only 1 resident with special times for meals and it is not Resident #32. Further interview with Staff E revealed that sometimes staff will bring back trays to the kitchen to warm up if the resident chooses to eat at a different time, and he/she is unaware of that happening with Resident #32. Interview on 4/5/23 at approximately 11:10 a.m. with Staff F (LNA) revealed that he/she came in at approximately 10:00 a.m. and was assigned to Resident #32. Staff F revealed that he/she was unaware that Resident #32 did not have breakfast. Interview on 4/5/23 at approximately 12:10 p.m. with Staff G (Registered Nurse) revealed that he/she would expect report of a resident not eating breakfast would be reported to staff coming on the floor. Review on 4/5/23 of Resident #32's care plans revealed the following: [Pronoun omitted] requires assistance for ADL [activities of daily living] care in . eating, ., date initiated 2/21/23. [Pronoun omitted] exhibits, or has potential to exhibit physical behaviors related to: cognitive loss/Dementia, date initiated 2/28/23. [Pronoun omitted] is at nutritional risk: related to weight loss, date initiated 3/1/23.

Based on record review, interview, and policy review it was determined that the facility failed to re-assess a resident who goes outside independently to smoke for safety risks for 1 out of 1 resident reviewed for smoking (Resident identifier is #1). Findings include: Review on 4/5/23 of Resident #1's Smoking Evaluation, Effective Date 12/29/22 revealed: . B. Cognitive . 2. Does the resident have poor memory? Yes . C. Behavior 1. Does the resident have a history of fire setting or arson? No 2. Does the resident have a history of unsafe smoking habits? Yes . E. Evaluation 1. Smoking Decision, Independent smoking is allowed. . Review on 4/5/23 of Resident #1's Progress Notes dated 1/10/23, getting down the small hill in the driveway by letting go of the wheels on [pronoun omitted] wheelchair and letting the hill take [pronoun omitted] down. Further review of the note revealed that Resident #1 was going to the smoking area independently. Education was provided to Resident #1 by the staff due to the potential dangers to his/her self. Review on 4/5/23 of Resident #1's Progress Notes dated 1/20/23, revealed that the Dietary Director brought Resident #1 inside of the building from the smoking area as [pronoun omitted] could not make it into the facility Further review of the note revealed that Resident #1 had become short of breath and needed assistance to return from the smoking area. Review on 4/5/23 of Resident #1's Progress Notes dated 2/24/23, revealed an entry from Staff J (Social Service) that Resident #1 had expressed the desire to kill [pronoun omitted] when going out to smoke and had a plan to kill [pronoun omitted]. Resident #1's plan was to wheel into traffic while outside smoking at the smoking station. Review on 4/5/23 of Resident #1's Progress Notes dated 2/24/23, revealed an entry from Staff I (Registered Nurse) stating that Resident #1 had stated that [pronoun omitted] was feeling suicidal due to thoughts that are over powering [pronoun omitted] mind. They are saying for [pronoun omitted] to wheel [pronoun omitted] wheelchair into traffic while [pronoun omitted] is out at the smoking station. Review on 4/5/23 of Resident #1's Progress Notes dated 3/30/23, revealed that while outside smoking Resident #1 called for help as [pronoun omitted] was having difficulty breathing and needed help getting back into the facility from the smoking area. Interview on 4/5/23 at approximately 1:40 p.m. with Staff G (Registered Nurse) confirmed the latest assessment for Resident #1's smoking evaluation was completed on 12/29/22 and there have been no other evaluations done for Resident #1's safety for going outside independently. Review on 4/5/23 at 2:00 p.m. of the Facility policy titled Smoking Dated: 06/01/96 revised on 10/24/22 .2.3.1 Patients will be re-evaluated quarterly and with a change in condition.

Based on interview, record review, and policy review it was determined that the facility failed to notify the physician of a residents refusal for treatment for 1 resident out of 2 residents reviewed for notification in a final sample of 18 (Resident Identifier is resident #13). Findings Include: Review on 4/05/23 of Resident #13's medical record revealed Resident #13 had a diagnosis of Obstructive Sleep Apnea. Further review of Resident #13's Medication Administration Record March 2023 and April 2023 revealed the following physician's order: CPAP [Continuous Positive Air Pressure]: 15 Back-up Rate: N/A [Not Applicable] Oxygen Liter Flow (for bleed in): N/A Apply at HS [bed time] and remove in AM [morning].Dated 5/5/22. Further review revealed that in March 2023, Resident #13 refused to use the CPAP all but 6 times on 3/2/23, 3/11/23, 3/16/23, 3/23/23, 3/25/23, and 3/30/23. In the month of April 2023 Resident #13 had refused the use the CPAP from 4/1/23 to 4/4/23. Interview on 4/5/23 at 11:35 a.m. with Staff G (Registered Nurse) and Staff H (Director of Nursing) confirmed that Resident #13 had been refusing the application of the CPAP machine and that the physician had not been notified. Review on 4/5/23 at 1:00 p.m. of the facility policy titled, Treatment: Refusal of ., Revision date 03/01/22 .Process .3. Notify physician of the refusal of treatment

Based on record review and interview, it was determined that the facility failed to monitor parameters for medication administration for 1 of 7 residents reviewed for medication administration and failed to obtain physician's orders to appropriately provide [CONDITION(S)] (Continuous Positive Airway Pressure) treatments to 1 of 1 resident reviewed for respiratory care in a final survey sample of 19 residents. (Resident identifiers are #8 and #9.) Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #8 Review on 5/3/22 of Resident #8's April 2022 and May 2022 Medication Administration Records (MAR) revealed the following physician's order: [MEDICATION(S)] Tablet Give 12.5 mg (milligrams) by mouth two times a day. Hold for heart rate less than 50, Start Date 11/26/21. Further review of the April 2022 and May 2022 MAR's indicated that the medication was administered twice daily for the entire month of April 2022 and May 1st thru May 4th, 2022. There were no documented heart rates on the MAR's. Review on 5/4/22 of Resident #8's Weights and Vitals summary for April 2022 and May 2022 revealed the following dates did not have any heart rates documented for medication administration times of 8 a.m. and 8 p.m. : 8 a.m.-4/8, 4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/23, 4/24, 4/25, 4/26, 4/27, 4/29, 4/30, 5/1, 5/2, 5/3 8 p.m.-4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, 4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30, 5/1, 5/2, 5/3 Interview on 5/5/22 at approximately 8:00 a.m. with Staff D (Director of Nursing) confirmed that the above dates did not have documented heart rates prior to administration of the medication. Resident #9 Observation on 5/3/22 at 10:48 a.m. of Resident #9's room revealed there was a [CONDITION(S)] machine next to the bed. Review on 5/5/22 of Resident #9's electronic record revealed that Resident #9 discharged to the hospital on 4/22/22 and readmitted to the facility on [DATE]. Review on 5/5/22 of Resident #9's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/5/22 of Resident #9's April 2022 TAR (Treatment Administration Record) revealed the following orders were discontinued on 4/26/22: [CONDITION(S)] Pressure: 15. Apply at bedtime and remove in a.m. Full face mask Humidification (if appropriate) Heated. Fill humidifier with sterile or distilled water. On at bedtime, off in the a.m., nurse to assist as needed. Care was last signed off as being done on 4/22/22. Review on 5/5/22 of Resident #9's care plan revealed there was a care plan initiated on 2/12/22 that Resident #9 exhibits or is at risk for respiratory complication related to sleep apnea - [CONDITION(S)]. This included to utilize the [CONDITION(S)] at 15 flow rate. This care plan was canceled on 4/28/22. Review on 5/5/22 of Resident #9's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . 9. Obstructive sleep apnea. Treated with [CONDITION(S)] . Review on 5/5/22 of Resident #9's May 2022 TAR revealed there was no physician's order for the [CONDITION(S)] machine. Interview on 5/5/22 at 10:03 a.m. with Staff A (Licensed Practical Nurse) confirmed that Resident #9 used the [CONDITION(S)] at night. Staff A checked Resident #9's May TAR and orders, and confirmed that there were no orders for the [CONDITION(S)]. Staff A stated that Resident #9 had recently returned from the hospital and confirmed that there should have been orders for the [CONDITION(S)] machine. Staff A confirmed that the facility typically would get physician's orders for care and use of the [CONDITION(S)] machine. Interview on 5/5/22 at 10:05 a.m. with Staff B, (Licensed Practical Nurse) revealed that he/she had assisted Resident #9's with cleaning his/her [CONDITION(S)] machine on 5/4/22. Staff B confirmed that there were no orders for the [CONDITION(S)] machine for Resident #9. Interview on 5/5/22 at 11:00 a.m. with Staff D (Director of Nursing) confirmed that Resident #9 did not have physician's order for the [CONDITION(S)] machine. Review on 5/5/22 of the facility's policy titled Bi-level Positive Airway Pressure ([CONDITION(S)])/Continuous Positive Airway Pressure ([CONDITION(S)]), revised on 4/1/22, revealed, .Policy. Bi-level Positive Airway Pressure ([CONDITION(S)]) and/or Continuous Positive Airway Pressure ([CONDITION(S)]) is set up and monitored by a licensed nurse or Respiratory Therapist (RT) with a physician's/advanced practice provider's (APP) order . Practice Standards . 2. Orders for [CONDITION(S)] must include pressure and hours of use .

1. Based on observation, interview, and medical record review, it was determined that the facility failed meeting professional standards for following physician's orders for 2 residents out of a final sample of 35 residents. (Resident identifiers are #12 and #39.) Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #39 Observation on 3/30/21 at approximately 10:30 a.m. of Resident # 39's forearm revealed an undated dressing. Review on 3/31/21 of Resident # 39's physician's orders and TAR (Treatment Administration Record) revealed that there was no physician's order for a dressing to Resident #39's forearm. Interview on 3/31/21 at approximately 1:15 p.m. with Staff A (Registered Nurse) confirmed that there was no physicians order for a dressing to Resident # 39's forearm. Staff A stated there were a couple of scratches and I talked to the nurse who put the dressing on and they said he/she scratched himself/herself during a shower. Review on 3/31/21 of Resident # 39's March MAR (Medication Administration Record) revealed the following physicians orders: [MEDICATION(S)] Solution 100 UNIT/ML (milliliter) Inject 10 unit subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY (E11.42) hold for glucose <80, Start Date 2/8/21. Fingerstick glucoses BID two times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY (E11.42), Start date 2/15/21. Interview on 3/31/21 at approximately 12:45 p.m. with Staff B (Licensed Practical Nurse) confirmed the above physcian orders. Staff B confirmed that the order for insulin with glucose 3 times a day on 2/8/21 did not match the order for glucose two times a day on 2/15/21 and it would be clarified and corrected. Resident # 12 Review on 3/31/21 at approximately 12:09 p.m. of Resident # 12's progress notes revealed that Resident #12 had an indwelling catheter with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 3/31/21 of Resident # 12's physician's orders revealed that there was no order for an indwelling catheter. Interview on 3/31/21 at approximately 12:58 p.m. with Staff C (Licensed Practical Nurse) confirmed that Resident #12 was sent to the hospital on 1/31/20 and was readmitted to the facility on [DATE] with a catheter. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Based on observation, interview, and review of facility policy, it was determined that the facility failed to ensure meet professional standards for cleaning resident equipment for 1 resident of 1 resident reviewed for respiratory care in a final sample of 35 residents. (Resident identifier is #13.) Findings include: Resident #13 CDC (Center for Disease Control) website titles: Guidelines for Preventing Health Care--Associated Pneumonia,2003, retrieved from www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm, revealed .5. Small-volume medication nebulizers: in-line and hand-held nebulizers a. Between treatments on the same patient clean, disinfect, rinse with sterile water (if rinsing is needed),and dry . Observation on 3/30/21 at approximately 10:56 a.m. revealed Resident #13's nebulizer mask laying across the head of bed directly on sheet. Further observation of the nebulizer mask revealed debris on the inside of mask. Interview on 3/30/21 at approximately 10:56 a.m. with Resident #13 revealed the resident used his/her nebulizer mask 4 times a day. Observation on 3/30/21 at approximately 1:00 p.m. revealed Resident #13's nebulizer mask laying on the top of side table. Further observation of the nebulizer mask revealed debris on the inside of mask. Observation on 3/31/21 at approximately 11:00 a.m. revealed Resident #13's nebulizer mask laying on the top of side table, further observation of the nebulizer mask revealed debris on the inside of mask. Observation on 4/1/21 at approximately 8:20 a.m. of Resident #13's nebulizer face mask revealed mask to be laying on the side table with a dark colored cloth face mask touching nebulizer mask. Further observation revealed debris on the inside of the nebulizer mask. Observation on 4/1/21 at approximately 8:30 a.m. revealed Staff D (Registered Nurse) to hand Resident #13 their nebulizer mask to begin a treatment. Interview on 4/1/21 at approximately 8:30 a.m. with Staff D revealed nebulizer masks would be cleaned if soiled. Staff D also said that nebulizer masks are changed out weekly and are kept on side table when not in use. Observation on 4/1/21 at approximately 8:30 a.m. of Resident #13's nebulizer mask revealed debris on the inside of the mask. Interview on 4/1/21 at approximately 8:30 a.m. with Staff D confirmed the above findings. Interview on 4/1/21 at approximately 8:40 a.m. with Staff E (Licensed Practical Nurse) revealed when asked about process for cleaning and storage of nebulizer masks revealed the nebulizer masks are cleaned when they become soiled and are changed once a week. When not in use they are stored at the bedside. Interview on 4/1/21 at approximately 11:00 a.m. with Staff G (Infection Preventionist) revealed that nebulizer masks are to be cleaned before and after use and if soiled. The nebulizer tubing, handheld attachment and masks are changed out weekly and if needed. When not in use the nebulizer mask is to be stored in a black bag that is changed out on the first of each month. and kept at the bedside. Review on 4/1/21 of facility policy titled Nebulizer: Small Volume effective date 1/1/04 revealed .20. Rinse SVN [small volume nebulizer], mouthpiece, and T piece with sterile water and dry. 20.1 Place in treatment bag labeled with patient name and date .

Based on interview, facility policy and review of the manufacturer's instructions for the facility it was determined the facility failed to clean the glucometer and that the facility failed to date the test strips according to the manufacturer's instructions. Findings include: Review of the facility EVEN CARE G2 Blood Glucose Test Strips manufacturer's instruction revealed the following: WARNING AND PRECAUTIONS . Do not use test strips after their expiration date. Please check the expiration date on the test strip bottle. STORAGE AND HANDLING . Use within 6 months after first opening . Review of the facility Glucose Meter with an effective date of 06/01/96 and a revision date of 06/01/15 revealed the following .2. Disinfect meter before patient use. Observation of the medication pass on 11/1/16 at 4:10 p.m. with Staff B (Registered Nurse), revealed that Staff B obtained a blood glucose from Resident #7. Staff B removed the glucometer from the medication cart and removed one test strip from the test strip container and place the test strip on top of the glucose meter. After the blood glucose was obtained Staff B placed the glucose meter back into the medication cart without cleaning it. Observation and review Staff B (RN) verbally confirmed the above listed findings for not cleaning the glucose meter. Observation of the medication pass on 11/2/16 at 8:15 a.m. with Staff C (Licensed Practical Nurse) revealed 2 opened bottles of glucose test strips that were not dated with a date for the time of opening. During this observation and review Staff C (LPN) confirmed the above listed findings for the glucose test strips.

Based on the review of the resident trust fund account and interview it was determined that the facility failed to notify residents when the amount in the resident's account reached $200 less than the SSI resource limit for the State of NH ($2500) as specified in section 1611(a)(3)(B) of the Act for 1 of 5 sampled residents. (Resident identifier is #16.) Findings include: Resident #16. Review on 11/3/16 of the Individual Statement for Resident #16 revealed that from 08/03/16-09/07/16 the balance continually exceeded $200 less than the SSI resource limit for the State of NH, in fact exceeding the $2500 limit the entire time. On 09/07/16 the balance was still within the $200.00 less than $2500.00. There was no documented evidence that the resident or their representative had been notified. Interview on 11/13/16 at the time of the review with Staff A (Business Office Manager), confirmed the above finding.

Based on a facility investigation report and resident record review the facility failed to ensure that 1 Resident in an expanded sample of 16 received adequate supervision (Resident identifier is #16). Findings include: Resident #16 Resident #16 was identified as an elopement risk on their comprehensive care plan of 4/29/11 due to confusion. The care plan goal for elopement stated that Resident #16 "will not wander from secure location unattended." On 4/30/11 at approximately 4p.m. according to a facility investigation report dated 5/4/11, Resident #16 was accompanied outdoors by Staff E (LPN). Staff E left Resident #16 unattended sitting in the outdoor patio area. Staff E, according to the facility investigation, conducted checks on Resident #16 every 5-10 minutes. Resident #16 at 5:43 p.m. was noted by the facility investigation to have proceeded to wander to the end the the facility driveway adjacent to Warwick Road before being assisted back into the facility by four staff members. The facility failed to ensure that Resident #16 received adequate supervision while outdoors on 4/30/11.

Based upon a review of a facility investigation and resident's record review the facility failed to implement the comprehensive care plan for 1 in an expanded sample of 16 residents (Resident identifier is #16). Findings include: Resident #16 Resident #16 was identified as an elopement risk on their comprehensive care plan of 4/29/11 due to confusion. The care plan goal for elopement stated that Resident #16 "will not wander from secure location unattended." On 4/30/11 at approximately 4p.m. according to a facility investigation report dated 5/4/11, Resident #16 was accompanied outdoors by Staff E (LPN). Staff E left Resident #16 unattended sitting in the outdoor patio area. Staff E, according to the facility investigation, conducted checks on Resident #16 every 5-10 minutes. Resident #16 at 5:43 p.m. was noted by the facility investigation to have proceeded to wander to the end the the facility driveway adjacent to Warwick Road before being assisted back into the facility by four staff members. The facility failed to ensure that the comprehensive care plan of Resident #16 was followed in regard to their identified elopement risk.

Based on record review and interview it was determined that the facility failed to follow the professional standard of practice for documentation for 1 resident and for following a physician's orders [REDACTED]. (Resident identifiers are #7, and #14.) Findings include: Standards: Review of "Fundamentals of Nursing," Patricia A. Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, revealed the following: On page 336- Physicians' Orders states, "The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary..." On pages 699-714 "...The prescriber often gives specific instructions about when to administer a medication." This reference also relates on page 713 that "....a registered nurse compares the list of medications on the MAR indicated [REDACTED]." Receiving Medication Orders page 713 relates, "A medication order is required for a nurse to administer any medication. Before any other interventions, ensure that the medication order contains all of the elements in Box 35-13. If the medication order is incomplete, inform the prescriber and ensure completeness before carrying out any medication order." Resident #14. Review of the medical record for Resident #14 on 6/23/11 revealed that the resident has [DIAGNOSES REDACTED]. Review of the MAR's for March 2011 and April 2011, revealed the order, "[MEDICATION NAME] (Carvedilol) 6.25 mg 1 tab by mouth tid (three times a day)- hold SBP (systolic blood pressure) < (Less than) 90 or hr (heart rate) < 60-Pulmonary Congestion and Hypostasis." Review of the MAR for June 2011 revealed the order was changed to, "[MEDICATION NAME] (Carvedilol) 12.5 mg 1 tab by mouth bid (twice a day)- hold SBP <100 or hr < 60-Pulmonary Congestion and Hypostasis." Review of the above MAR's revealed that there was no documented evidence that the parameters of HR and systolic BP were taken or recorded at the time of medication administration for 3/1/11 and 4/1/11, the a.m. doses for 3/9/11, 3/22/11, and 6/11/11, and the p.m. doses for 3/20/11, and 4/2/11. The parameter sections of the MAR's were blank. Findings were reviewed with Staff A (Unit Manager) on 6/23/11 in the afternoon. Staff A confirmed the above findings and noted that the parameters should have been written on the MAR. Resident #7. Resident #7 was admitted on [DATE] from the hospital with a Patient Care Referral Form and under "physician's orders [REDACTED]. 1) [MEDICATION NAME] 50 mg po(by mouth) q a.m.(once daily in the a.m.) at 9 a.m. 2) [MEDICATION NAME] 100 mg po(by mouth) q 5 p.m.(once daily ) at 5p.m. On review of the MAR (Medication Administration Record) for the month of May 2011 revealed that on 5/21/11 and 5/22/11 the medication [MEDICATION NAME] was administered only one time daily as a single dose of 150 mg. Staff A (Unit Manger) was interviewed on 6/23/11 at 11 a.m. and confirmed that the medication nurse for those two days failed to follow physicians order by administering [MEDICATION NAME] 150 mg on 5/21/11 at 3 p.m. and on 5/22/11 at 2 p.m. instead of administering [MEDICATION NAME] 50 mg at 9 a.m. and [MEDICATION NAME] 100 mg at 5 p.m. as the physician order [REDACTED].

Based on record review, interview and review of facility's policies and procedures the facility failed to implement its written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #2.) Findings include: Review of facility policy number CL-676-0020 effective date 1/08 Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Section 1:7 Reporting/Response reveals "...The center ensures that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property is reported immediately to the administrator of the center and to other officials, in accordance with state law through established procedures (including to the state survey and certification agency)". Review of Resident # 2's medical record on 6/22/11 revealed nurses notes dated 5/22/11 at 2350 "...(Staff C) (LNA) told me that Resident was not changed and saturated with urine and feces stating neglect was evident with resident. I witnessed laundry, towels, + other disposals in a ... bag showing saturated weighted bag that was very heavy...". Review of LNA flow sheets for April, May and June 2011 revealed incontinence care provided two or three times on each shift consistently throughout the three month period. Interview of Staff D (Administrator) on 6/22/11 at 1 p.m. revealed Staff D had not been made aware of the alleged neglect until 6/21/11 when infromed by surveyor. Staff D contacted all staff involved and interviewed them. Staff D determined through interview and written statements that care had been provided to Resident #2

Based on record review and interview the facility failed to ensure that all alleged violations involving neglect were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures for 1 resident in a standard survey sample of 15 residents. (Resident identifier is #2.) Findings include: Review of Resident # 2's medical record on 6/22/11 revealed nurses notes dated 5/22/11 at 2350 "...(Staff C) (LNA) told me that Resident was not changed and saturated with urine and feces stating neglect was evident with resident. I witnessed laundry, towels, + other disposals in a ... bag showing saturated weighted bag that was very heavy...". Review of LNA flow sheets for April, May and June 2011 revealed incontinence care provided two or three times on each shift consistently throughout the three month period. Interview with Staff D (Administrator) on 6/22/11 at 1 p.m. revealed Staff D had not been made aware of the alleged neglect until 6/21/11 when informed by surveyor. Staff D contacted all staff involved and interviewed them. Staff D determined through interview and written statements that care had been provided to Resident #2.

Based on review of the documentation provided during the Resident Account review and interview, the facility failed to notify residents that receive Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for the State of NH ($2500) as specified in section 1611(a)(3)(B) of the Act for 2 of 5 sampled Medicaid residents. (Resident identifiers are #18 and #19.) Findings include: Resident Trust Account was reviewed on 6/23/11. Review of the selected Resident Account Individual Statements dated 7/1/10-6/21/11 revealed that 2 of 5 selected Resident Account reviews had amounts totaling over $2500, in their resident trust fund for greater than 30 days. Further review of the provided documentation revealed that no attempt to notify residents or representatives (when the accounts reached $200 less than the SSI resource limit) had been documented until after $2500 had been surpassed for greater than 30 days. Resident #18. Review of the Individual Statement for Resident #18 revealed that from 7/30/10-10/29/10 the balance continually exceeded $200 less than the SSI resource limit for the State of NH, in fact exceeding the $2500 limit. Balances ranged from $2784.36 on 7/30/10 to $4279.43 on 10/29/10, with a high of $5299.92 on 9/3/10. Review of the documentation of an e-mail dated 9/14/10 of the facility's notification to medicaid was reviewed with Staff B (BOM) on 6/23/11 following the Account review. Staff B stated that this was the only correspondence. There was no documented evidence that the resident or their representative had been notified at all. Resident #19. Review of the Individual Statement for Resident #19 revealed that from 3/3/11-4/26/11 and from 5/3/11-6/14/11 the balances continually exceeded the $200 less than the SSI resource limit for the State of NH. Balances ranged from $3141.70 on 3/3/11 to $2360.82 on 4/26/11, and from $3161.64 on 5/3/11 to $2372.73 on 6/14/11. There was no documented evidence that the resident or representative had been notified. Interview with Staff B on 6/23/11 at 12 noon revealed that notification to residents or representatives should have been completed, when the accounts reached $200 less than the SSI resource limit of $2500. Staff B also confirmed that no further documentation existed for above findings.

Based on record review and interview the facility failed to ensure that it implements policies and procedures to prohibit the neglect of residents requiring wound and pressure ulcer care management that resulted in a toe amputation, for 2 residents. (Resident idnetifiers are: #1 and #2.) Findings include: On 12/13/2010, review on of the facility ' s " Skin Care & Pressure Ulcer Management Program " policy and procedure, dated January 2008, reveals " Section 1: Assessment: Identifying Residents at Risk of Skin Breakdowns " " When a Resident Arrives, the licensed nurse reviews the preadmission screen and completes a head-to-toe assessment, documenting findings on the Nursing Assessment. This process provides the team with an accurate description of the resident ' s actual skin condition. If the resident has a pressure or other wounds at the time of admission, treatment begins promptly in accordance with physician orders. The licensed nurse continues the evaluation process to determine the risk of additional skin breakdown, evaluates rehabilitation and nutritional needs, and prepares a plan of care of the existing condition and prevention of additional skin breakdown. " " Using Standardized Tools to Evaluate Risk of Skin Breakdown. After examining a resident ' s current skin condition, the next step is to evaluate the resident ' s likelihood for future skin breakdown. Evaluating risk is an important step, because once it is determined who may be at risk of developing pressure ulcers, the team may attempt to prevent them. The licensed nurse completes the Norton Plus Pressure Ulcer Scale. " - "SECTION 2 PLANNING, IMPLEMENTATION, AND EVALUATION : CARE PLANNING APIE ... - Putting the Plan Into Action ... - Once the Care Plan is written, it is important to be vigilant. Licensed nurses, nursing assistants, and the entire interdisciplinary team must ensure that all planned interventions and treatments are carried out as written in the Care Plan ... - Weekly Evaluation - A licensed nurse performs head-to-toe skin check of the resident and documents the findings on the Treatment Administration Record (TAR). The licensed nurse documents using the following notations: 'Y' = skin intact 'N' = not intact - If a licensed nurse documents "N," the licensed nurse writes a note in the narrative section of the TAR describing the area. If skin integrity is comprised, the process moves into the wound management phase, the physician/responsible party is notified, and the care plan is updated with appropriate interventions. Section 3: The " War on Wounds, Program " Under the section " Wound Management, ... " A Systematic Approach, for Pressure Ulcer Treatment, the nursing team manages pressure ulcer treatment as defined by the physician order. " " Weekly Wound Rounds, the team makes rounds weekly to evaluate wound treatment and other care interventions. The licensed nurse evaluates the pressure ulcer and documents pressure ulcer healing using the pressure ulcer documentations form. " " Using the Pressure Ulcer/Vascular Ulcer Log, This surveillance system ensures that residents with pressure ulcers are evaluated, treated and documented on a routine basis. The licensed nurse updates their pressure/vascular ulcer log as areas heal or when a new pressure ulcers are identified. " - SECTION 4: EVALUATION: EVALUATING OUTCOMES - Clinical Weekly Report - On a weekly basis, the director of nursing service (DNS) gathers information from the center daily report that may also be addressed in the C.A.R.E. process, including: pressure ulcers, acquired pressure ulcers, worsening pressure ulcers, unplanned weight loss, falls, restraints, antipsychotic drugs, hypnotics, new infections, precautions, and other clinical concerns. The purpose of this report is to identify and document actions planned or taken to effect positive clinical outcomes." Resident #1 Review of the podiatry note dated 9/28/10 " The ulceration right 5th toe has healed. There is no [DIAGNOSES REDACTED]. There is no pain with palpation. " The resident ' s shoe is to be stretched. The resident may return to diabetic shoes. The resident will use a foam tube over the toe. The resident will discontinue wound care. Nursing will check the toe daily. The resident will follow up with an appointment in 2 months. The resident may resume using the custom stockings, but if there is any recurrence of the problem, the resident is to stop using the stocking, right leg, until further notice. Review of the Podiatry order sheet sent to the facility dated 9/28/10, reveals the following orders, D/C (Discharge) Wound Care R (right) 5th toe. Begin foam sleeve over toe daily (R (right) 5th toe). Return to compression stocking R (right) leg. Return to shoes. F/U (follow up) in 2 months. Review of Resident #1's October 10 TAR (Treatment Administration Record) reveals the order " Apply foam sleeve to right 5th toe daily " there are no nursing initials to indicate that the physician's order [REDACTED]. The following dates had nursing initials circled which indicated that the treatment was not completed on October 3,5,6,and 16, 2010. The October 2010 TAR also reveals the physician's order [REDACTED]. were put on October 8, AM, 10 AM and PM, 18 PM, 27, 28,29 in AM. The weekly Skin Assessment section on the October 2010 TAR indicated that on October 1, 8, 15, 22 and 29th the resident had a head to toe skin assessment performed by a nurse. On each of the above skin assessment dates, there was a Y (Yes) written and the nurse ' s initials which indicates the resident ' s skin is intact Review of Resident #1's November 2010, TAR reveals the order to apply the foam sleeve to right 5th toe daily. On November 14 and 23 there TAR was blank which indicates that the treatment was not done. The order for Compression stockings on in the AM and off in the PM was also not signed off on November 4 in PM and the 23 in the AM. The November 2010, TAR also indicates that a skin assessment was performed on November 3, 10,17 and 24. All 4 skin assessments has a Y indicating that resident #1 ' s skin is intact and has no breakdown. Review of Resident #1's podiatry note dated 12/2/10 indicates Resident #1 returns to the office with family member for follow up of ulceration right fifth toe. "Resident states that the toe hurts. The right fifth toe appears swollen. There is ulceration to the plantar fifth toe sulcus at the metatarsal phalangeal joint that extends to the bone. The bone is visible. The tendon is dry. There is significant malodor and drainage. There is tube foam dressing over the toe, which is deeply adhered plantarly to the bone and tendon. The joint is involved. The foot is moderately swollen compared to the other foot. Radiographs do show osteopenic bone right foot with air pocket and what appears to be erosive change at the metatarsal head. " Probable osteo[DIAGNOSES REDACTED] with abscess right foot. X-rays ordered today, right foot. Discussion with resident and family member, partial fifth ray amputation. physician progress notes [REDACTED]. During an interview with Resident #1 on 12/13/10 at 3:30 p.m. Resident #1 confirmed having undergone an amputation of the 5th toe of right foot. When questioned if facility licensed staff visualized or administered any treatment to the right foot 5th toe on a daily basis prior to amputation, Resident #1 responded " not always " . An interview on 12/13/10 with Staff A, Administrator, revealed that Resident #1 did have an unplanned amputation of the right 5th toe on 12/2/2010. Staff A indicated that the facility initiated an investigation and that several nursing staff members were interviewed and it was confirmed that the foam dressing to Resident #1 ' s right 5th toe was signed off on the TAR for October and November, 2010 but the foam dressing was never removed by a nurse or the toe assessed by a licensed nurse. Staff A, indicated that the interviews with the nurses indicated it was their belief that the foam dressing was to be self applied by the resident and that the self application was part of Resident #1 ' s discharge plan preparation. Staff A, confirmed that the documentation requirement for weekly skin assessments required by the facility's policy and procedure and the podiatrists order to monitor Resident #1 ' s right 5th toe was not followed. Resident #2. Record review on 12/13/10 revealed no documented evidence that the physician was notified of a change in skin condition for Resident #2 from 7/30/10 through 9/21/10 for a total of 52 days. Review of the facility "Pressure Ulcer Documentation Form" for Resident #2 dated "9/21" revealed a Stage 2 pressure ulcer on the right 5 th metatarsal. Record review on 12/13/10 of the"Treatment Administration Record" (TAR) for Resident #2 dated " 8/1/2010 - 8/31/2010" showed no documented evidence that a "WEEKLY SKIN ASSESSMENT" was done on 8/10/10 or 8/31/10. Review of the TAR dated " 8/1/2010 - 8/31/2010" for Resident #2 revealed an "N", indicating skin not intact, for the weekly skin assessment on 8/17/10 with no other documentation found supporting this "N", 8/24/10 revealed an "Y", indicating skin intact and 8/31 was blank with no documentation. Record review on 12/13/10 of the TAR for Resident #2 dated "9/1/2010 - 9/30/2010" showed in the area for the "WEEKLY SKIN ASSESSMENT" documentation on 9/6 a "Y", 9/14 a "Y", 9/21 a "Y", indicating skin intact, and on 9/28/10 an "N", indicating skin not intact with no other supporting documentation for the "N". During interview with Staff A (Administrator) and Staff B (Director of Nursing) on 12/13/10 at approximately 1:15 p.m. after both Staff A & B reviewed the above listed findings for Resident #2, Staff A and Staff B confirmed that there was no documented evidence to show that the physician had been notified of a Stage 2 pressure ulcer on the right 5 th metatarsal for Resident #2 , no documented evidence in the narrative section of the TAR describing the compromised skin integrity to support the "N" documented on the 8/17/10 and 9/28/10, no documentation completed on 8/10 and 8/31 for Resident #2's "WEEKLY SKIN ASSESSMENT" sheets that showed multiple "Y"s indicating skin intact skin for Resident #2. Staff A and Staff B indicated there is no documented evidence of the identification, assessment, monitoring and evaluation of the right 5 th metatarsal pressure ulcer prior to 9/21/10 that required Resident #2 to undergo surgical intervention with amputation of the right 5 th metatarsal on 9/29/10 due to the pressure ulcer. Based on review of the facility documentation with educational review it was determined on 12/13/10 that the facility's immediate jeopardy was removed effective 12/6/10. The facility reviewed the Skin policy and procedure and re-educated all nurses and licensed nursing assistants on the Skin policy and procedure. The facility also educated all nurses on 12/2/10 through 12/6/10 on Changes in condition, Reading TAR orders, Wound documentation and Diabetic foot inspection. The facility educated the licensed nursing assistants on 12/6/10 on Skin inspection during care and special attention to feet and reporting to the nurse. The facility did a full skin assessment on all the residents including a foot assessment. No other residents were found to have any areas of skin/foot breakdown. The facility implemented a monitoring tool to include Weekly skin assessment completion and documentation and included daily foot/toe inspections on all residents. .

Based on record review and interview the facility failed to ensure that it provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for a diabetic resident with a non-pressure related wound resulting in the amputation of a toe. (Resident identifier is #1.) Findings include: Review on 12/13/10, of Resident #1 ' s medical record reveals, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's physician ' s progress notes reveals the following: 7/16/10 Resident has [MEDICAL CONDITION]. Has diabetic [MEDICAL CONDITION]. Sees podiatrist ... regularly. There is 2+ readily [MEDICAL CONDITION] present at both shins. Plantar pain, left foot. Perhaps marked [MEDICAL CONDITION] is playing a roll. Podiatrist (Md name omitted) is being consulted. Compression stockings to be tried once Ace wraps and [MEDICATION NAME] have brought the [MEDICAL CONDITION] under some degree of control. 8/3/10 Resident is getting regular podiatry follow-up. Has diabetic [MEDICAL CONDITION], but also has had Achilles tendonitis and corns. Review of Resident #1's podiatry note dated 9/14/10, indicates the following The resident returned to the podiatrist office and was " complaining of a very painful right fifth toe. The resident reported to the podiatrist that the resident could not stand anything to touch the toe. The resident had been wearing the compression stockings and had been wearing slippers and not regular shoes. Chronic leg [MEDICAL CONDITION] and diabetic [MEDICAL CONDITION]. Has on going problems with corns of the toes. The right fifth toe has [DIAGNOSES REDACTED] (corn/callous), which is removed to reveal an underlying ulceration over the right fifth toe proximal interphalangeal joint. The wound was gently and minimally debrided. Iodosorb and a dry dressing were applied on the toe and the nursing facility will start Iodosorb and a dry dressing daily. Review of the podiatry note dated 9/28/10 " The ulceration right 5th toe has healed. There is no [DIAGNOSES REDACTED]. There is no pain with palpation." The resident's shoe is to be stretched. The resident may return to diabetic shoes. The resident will use a foam tube over the toe. The resident will discontinue wound care. Nursing will check the toe daily. The resident will follow up with an appointment in 2 months. The resident may resume using the custom stockings, but if there is any recurrence of the problem, the resident is to stop using the stocking, right leg, until further notice. Review of the Podiatry order sheet sent to the facility dated 9/28/10, reveals the following orders, D/C (Discharge) Wound Care R (right) 5th toe. Begin foam sleeve over toe daily (R (right) 5th toe). Return to compression stocking R (right) leg. Return to shoes. F/U (follow up) in 2 months. Review of Resident #1's October 10 TAR (Treatment Administration Record) reveals the order " Apply foam sleeve to right 5th toe daily " there are no nursing initials to indicate that the physician's order [REDACTED]. The following dates had nursing initials circled which indicated that the treatment was not completed on October 3,5,6,and 16, 2010. The October 2010 TAR also reveals the physician's order [REDACTED]. were put on October 8, AM, 10 AM and PM, 18 PM, 27, 28,29 in AM. The weekly Skin Assessment section on the October 2010 TAR indicated that on October 1, 8, 15, 22 and 29th the resident had a head to toe skin assessment performed by a nurse. On each of the above skin assessment dates, there was a Y (Yes) written and the nurse ' s initials which indicates the resident ' s skin is intact Review of Resident #1's November 2010, TAR reveals the order to apply the foam sleeve to right 5th toe daily. On November 14 and 23 there TAR was blank which indicates that the treatment was not done. The order for Compression stockings on in the AM and off in the PM was also not signed off on November 4 in PM and the 23 in the AM. The November 2010, TAR also indicates that a skin assessment was performed on November 3, 10,17 and 24. All 4 skin assessments has a Y indicating that resident #1 ' s skin is intact and has no breakdown. Review of Resident #1's podiatry note dated 12/2/10 indicates Resident #1 returns to the office with family member for follow up of ulceration right fifth toe. "Resident states that the toe hurts. The right fifth toe appears swollen. There is ulceration to the plantar fifth toe sulcus at the metatarsal phalangeal joint that extends to the bone. The bone is visible. The tendon is dry. There is significant malodor and drainage. There is tube foam dressing over the toe, which is deeply adhered plantarly to the bone and tendon. The joint is involved. The foot is moderately swollen compared to the other foot. Radiographs do show osteopenic bone right foot with air pocket and what appears to be erosive change at the metatarsal head. " Probable osteo[DIAGNOSES REDACTED] with abscess right foot. X-rays ordered today, right foot. Discussion with resident and family member, partial fifth ray amputation. physician progress notes [REDACTED]. During an interview with Resident #1 on 12/13/10 at 3:30 p.m. Resident #1 confirmed having undergone an amputation of the 5th toe of right foot. When questioned if facility licensed staff visualized or administered any treatment to the right foot 5th toe on a daily basis prior to amputation, Resident #1 responded " not always " . An interview on 12/13/10 with Staff A, Administrator, revealed that Resident #1 did have an unplanned amputation of the right 5th toe on 12/2/10. Staff A indicated that the facility initiated an investigation and that several nursing staff members were interviewed and it was confirmed that the foam dressing to Resident #1 ' s right 5th toe was signed off on the TAR for October and November, 2010 but the foam dressing was never removed by a nurse or the toe assessed by a licensed nurse. Staff A, indicated that the interviews with the nurses indicated it was their belief that the foam dressing was to be self applied by the resident and that the self application was part of Resident #1 ' s discharge plan preparation. Staff A, confirmed that the documentation requirement for weekly skin assessments required by the facility's policy and procedure and the podiatrists order to monitor Resident #1 ' s right 5th toe was not followed. Based on review of the facility documentation with educational review it was determined on 12/13/10 that the facility's immediate jeopardy was removed effective 12/6/10 as evidenced by the facility's immediate implementation of an investigation of the occurrence on 12/2/10. The facility reviewed Resident #1's medical record and interviewed staff involved. The facility reviewed the Skin policy and procedure and re-educated all nurses and licensed nursing assistants on the Skin policy and procedure. The facility also educated all nurses on 12/2/10 through 12/6/10 on Changes in condition, Reading TAR orders, Wound documentation and Diabetic foot inspection. The facility educated the licensed nursing assistants on 12/6/10 on Skin inspection during care and special attention to feet and reporting to the nurse. The facility did a full skin assessment on all the residents including a foot assessment. No other residents were found to have any areas of skin/foot breakdown. The facility implemented a monitoring tool to include Weekly skin assessment completion and documentation and included daily foot/toe inspections on all residents.

Based on record review, interview and review of the facility policy and procedure it was determined that the facility failed to ensure that a resident who has a pressure sores receives necessary treatment and services to promote healing and prevent infection that required the amputation of a toe for 1 resident. (Resident identifier is #2.) Findings include: Review of the facility policy and procedure on 12/13/10 titled "SKIN CARE & PRESSURE ULCER MANAGEMENT PROGRAM" dated "January 2008" revealed the following: - "SECTION 2 PLANNING, IMPLEMENTATION, AND EVALUATION: CARE PLANNING APIE... - Putting the Plan Into Action... - Once the Care Plan is written, it is important to be vigilant. Licensed nurses, nursing assistants, and the entire interdisciplinary team must ensure that all planned interventions and treatments are carried out as written in the Care Plan... - Weekly Evaluation - A licensed nurse performs head-to-toe skin check of the resident and documents the findings on the Treatment Administration Record (TAR). The licensed nurse documents using the following notations: 'Y' = skin intact 'N' = not intact - If a licensed nurse documents "N," the licensed nurse writes a note in the narrative section of the TAR describing the area. If skin integrity is comprised, the process moves into the wound management phase, the physician/responsible party is notified, and the care plan is updated with appropriate interventions. - SECTION 4: EVALUATION: EVALUATING OUTCOMES - Clinical Weekly Report - On a weekly basis, the director of nursing service (DNS) gathers information from the center daily report that may also be addressed in the C.A.R.E. process, including: pressure ulcers, acquired pressure ulcers, worsening pressure ulcers, unplanned weight loss, falls, restraints, antipsychotic drugs, hypnotics, new infections, precautions, and other clinical concerns. The purpose of this report is to identify and document actions planned or taken to effect positive clinical outcomes." Resident #2. Record review on 12/13/10 of the physician progress notes [REDACTED]. - "SUBJECTIVE: This patient is being seen for routine recertification. Has a couple of complaints.... Also reports pain at the right little toe." Review of the "Interdisciplinary Progress Notes" for Resident #2 dated 9/21/10 revealed the following: - " IDT Note ... (Medical Director) in. Resident seen for recert (recertification) with order to keep feet elevated off the bed & inform ... (Medical Director) if R (right) little toe ulcer does not improve. Review of physician orders dated 9/21/10 indicates, Inform ... (physician) if right little toe ulcer does not improve. Review of Resident #2's podiatry visit dated 9/22/10 revealed the following: - "Podiatry Note S: This [AGE] year-old returns to the office today complaining of the right 5th toe significant pain ... states was told the toe was black. O: The patient is alert and oriented x3. In no apparent distress. The right 5th toe has ulceration overlying the proximal interphalangeal joint that does frankly invade the joint. There is mild periwound [DIAGNOSES REDACTED]. No active drainage. The toe is mildly swollen with no increased warmth. A: ULCERATION RIGHT 5TH TOE THAT IS INVOLVING THE PROXIMAL INTERPHALANGEAL JOINT. I CANNOT RULE OUT OSTEO[DIAGNOSES REDACTED]. P: X-rays are ordered today of the right foot ... and reviewed with the patient. Wound culture of the proximal interphalangeal joint is obtained for aerobic and anaerobic organisms, ... The ulceration has been recurrent and at this point, due to the trauma that this toe routinely takes due to her positioning and due to the involvement of the joint. I feel that amputation of the right 5th toe is indicated." This podiatry note also revealed that the podiatrist had discussed the test results and surgical plan with Resident #2's physician and that the "Patient will follow up with me next Wednesday (9/29/10) morning for surgical intervention and will call in the interim with any questions, problems or concerns." Review on 12/13/10 of the physician orders for Resident #2 revealed the following order: - 9/22/10 Cleanse right little toe ulcer with normal saline apply wet to moist dressing change daily and as needed." Review of the "Interdisciplinary Progress Notes" for Resident #2 continued as follows: - "9/23/10 ... Cleanse R little toe ulcer with NS (normal saline) apply wet to moist dsg (dressing) ... change daily & PRN (as needed). - 9/23/10 7:30 p Resident agreed to dressing change ... Wet to dry applied. Resident tolerated with no extra pain. Dressing on R foot. Continue to monitor swelling with gauge bandage. - 9/24/10 IDT Note: Ulcer assessed as 0.4 x 0.4 x 0.2/cm with scant exudate on dressing. Upon assessment, ulcer may be determined as vascular 2 (secondary) position of ulcer on foot as well as character of ulcer. Culture results obtained today were positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus), contact precautions have been initiated. Resident scheduled for amputation of that toe on 9/29/10... - 9/24/10 @ 11:30 p.m. ... R 5th toe wound [MEDICAL CONDITION] ... toe removal scheduled and transportation scheduled as well - resident aware and agrees." There is no documented entry on 9/25/10 in this section of notes regarding the care and services provided for the right little toe on Resident #2. The "Interdisciplinary Progress Notes" for Resident #2 dated "9/26/10" revealed "... DSG (dressing) changed on R foot little toe, no drainage..." No documented evidence could be found describing Resident #2's right 5th toe in the "Interdisciplinary Progress Notes" from 9/27/10 through 9/29/10 for a total of three days prior to the amputation of the right 5th toe on 9/29/10. Review of Resident #2's "Pressure Ulcer Documentation Form" dated " 9/21" reveals a Stage 2 pressure area on the right 5th metatarsal with no further documentation identifying the "Wound Measurements, presence of undermining, odor, exudate, wound bed tissue type, condition of surrounding wound or evidence of wound related pain." Further documentation indicates "bandaged from MD visit will observe during DRG (dressing) ... (change) per request of resident." Record review on 12/13/10 of the "Treatment Administration Record" (TAR) for Resident #2 dated " 8/1/10 - 8/31/10" showed no documented evidence that a "WEEKLY SKIN ASSESSMENT" was done on 8/10/10 or 8/31/10. Documentation on the 8/1/10 - 8/31/10 treatment sheet for Resident #2 also showed an "N" for the weekly skin assessment on 8/17/10 with no other documentation found supporting this "N" indicating skin not intact for Resident #2. Review of Resident #2's TAR dated "9/1/10 - 9/30/10" reveals in the area for the 'WEEKLY SKIN ASSESSMENT" documentation on 9/6, 9/14 and 9/21 a "Y" indicating skin intact and documentation dated for 9/28/10 reveals an "N" indicating skin not intact with no other supporting documentation for the "N". During interview with Staff A (Administrator) and Staff B (Director of Nursing) on 12/13/10 at approximately 1:15 p.m. after both Staff A & B reviewed the above listed findings for Resident #2, Staff A and Staff B confirmed that there was no documented evidence to show the identification, assessment, monitoring and evaluation of a right 5th metatarsal pressure ulcer prior to 9/21/10. Staff A & Staff B further confirmed that Resident #2 required surgical intervention with the amputation of the right 5th metatarsal on 9/29/10 due to the pressure ulcer. Based on review of the facility documentation with educational review it was determined on 12/13/10 that the facility's immediate jeopardy was removed effective 12/6/10. The facility reviewed the Skin policy and procedure and re-educated all nurses and licensed nursing assistants on the Skin policy and procedure. The facility also educated all nurses on 12/2/10 through 12/6/10 on Changes in condition, Reading TAR orders, Wound documentation and Diabetic foot inspection. The facility educated the licensed nursing assistants on 12/6/10 on Skin inspection during care and special attention to feet and reporting to the nurse. The facility did a full skin assessment on all the residents including a foot assessment. No other residents were found to have any areas of skin/foot breakdown. The facility implemented a monitoring tool to include Weekly skin assessment completion and documentation and included daily foot/toe inspections on all residents.

Based on the investigation survey conducted 12/1310 it was determined that the facility was not administered in a manner that enables it to provide the highest practicable physical and psychosocial well-being of each resident. Findings include: As a result of the investigation survey it was determined that the facility has immediate jeopardy with substandard quality of care being identified in the area of resident behavior and facility practices 42 CFR 483.13(c) and in the areas of quality of care 42 CFR 483.25 and 42 CFR 483.25(c) Cross refer to F224, F309 and F314.

Based on record review and interview it was determined that the facility failed to ensure the implementation of the care plan for 2 of 2 residents. (Resident identifiers are #1 and #2.) Findings include: Review of Resident #1's Skin Integrity care plan with an initial date of 9/24/10 reveals under the "Interventions" column, Administer treatment as ordered. Change Dressing as per order, Observe skin tear for signs/symptoms of infection (redness, warmth, [MEDICAL CONDITION], pain/tenderness, drainage). Notify MD if present. Preventative measures as ordered. Antibiotics per MD order. Review of the weekly Skin Assessment section on the October 2010 TAR indicated that on October 1, 8, 15, 22 and 29th the resident had a head to toe skin assessment performed by a nurse. On each of the above skin assessment dates, there was a Y (Yes) written and the nurse ' s initials. Review of the November 2010, TAR revealed that a skin assessment was performed on November 3, 10,17 and 24. All 4 skin assessments has a Y indicating that resident #1 ' s skin is intact and has no breakdown. Review of Resident #1's 12/2/10 podiatry note reveals the following: " Subjective, resident returns to the office with family member for follow up of ulceration right fifth toe. Resident states that the toe hurts. " Objective: The right fifth toe appears swollen. There is ulceration to the plantar fifth toe sulcus at the metatarsal phalangeal joint that extends to the bone. The bone is visible. The tendon is dry. There is significant malodor and drainage. There is tube foam dressing over the toe, which is deeply adhered plantarly to the bone and tendon. The joint is involved. The foot is moderately swollen compared to the other foot. Radiographs do show osteopenic bone right foot with air pocket and what appears to be erosive change at the metatarsal head." "Assessment: Probable osteo[DIAGNOSES REDACTED] with abscess right foot. Plan: X-rays ordered today, right foot. Discussion with resident and family partial fifth ray amputation. During interview on 12/13/10 with Staff A, Administrator, revealed that Resident #1 did have an unplanned amputation of the right 5th toe on 12/2/10. Staff A indicated that the facility initiated an investigation and that several nursing staff members were interviewed and it was confirmed that the foam dressing to Resident #1 ' s right 5th toe was signed off on the TAR for October and November, 2010 but the foam dressing was never removed by a nurse or the toe assessed by a licensed nurse. Staff A, confirmed that the documentation requirement for weekly skin assessments by the facility's policy and procedure and the podiatrists order to monitor Resident #1 ' s right 5th toe was not followed. Resident #2 Record review on 12/13/10 of the comprehensive care plan for Resident #2 dated "8/17/10" revealed in the section titled "Lower extremity [MEDICAL CONDITION]" the intervention to "Monitor skin with AM/HS care, Ace wraps per MD order". In the section titled "Resident has impaired skin integrity r/t (related to) pressure ulcer secondary to immobility, incontinence" dated "8/17/10" showed the intervention "Weekly skin assessments." Review of the "WEEKLY SKIN ASSESSMENT" TAR for Resident #2 dated "8/1/10 - 8/31/10" revealed no documented evidence that weekly skin assessment was done on 8/10 and 8/31 and no documentation that the "ace warp to R (right) foot and distal leg start at toes observe them to be sure they do not become more swollen" was done on 8/31/10. Review of the "WEEKLY SKIN ASSESSMENT" TAR for Resident #2 dated "9/1/10 - 9/30/10" revealed no documented evidence that the "ace wrap to R foot and distal leg start at toes observe them to be sure they do not become more swollen" was done on 9/16, 9/19, 9/21 and 9/23. During interview with Staff A (Administrator) and Staff B (Director of Nursing) on 12/13/10 at approximately 1:15 p.m. after both Staff A & B reviewed the above listed findings, Staff A and Staff B confirmed that there was no documented evidence of the findings listed above to show that the care plan interventions for Resident #2 were implemented.