Based on resident and staff interviews, review of Resident Council Minutes, and review of the facility policy titled, Patient/Resident Council, the facility failed to ensure a response was provided to the members of the resident council when concerns were identified related to transportation accommodations for outings. During the resident council meeting four residents (R) (R30, R36, R54, and R78) had complaints of transportation not being provided for outings and had not received a response. Findings include: Review of documentation provided by the facility titled Patient/Resident Council Minutes/Report Form, from 8/29/2022 to 4/22/2024, included Old Business/Resolutions [store name] trip is on hold due to [transportation company name] does not have van available at this time. Vans is in shop & [sic] also have wrecked vans. Ongoing trip to [store name] pending a van for transportation. During a Resident Council Meeting held on 5/21/2024 at 10:30 am, R30, the Resident Council President stated that residents wanted to take trips, they want a van for transportation, and the Activities Director keeps telling them They're working on it. R30 reported this had been going on for over a year. R36, R54, and R78 confirmed the group had been requesting to go on outings to [store name] and to go out to eat. Additionally, they were told that if they did a van rental, it would cost 20 dollars per person, but have not been given the opportunity to go, and no response had been provided. During an interview on 5/22/2024 at 2:20 pm, the Director of Nursing (DON) stated that the facility did not have their own transportation vehicle, but the facility had a contract with a transportation company to provide transportation for medical appointments, but no transportation was available for outings. The DON was aware that the Resident Council members wanted to go on outings but was unaware if a response had been provided to the residents. During an interview on 5/22/2024 at 4:13 pm, the Social Services Director (SSD) confirmed the Resident Council concern regarding outings had been raised during morning meetings. The facility had discussed borrowing a van from another sister facility, but a response had not been provided that she was aware of. During an interview on 5/22/2024 at 4:35 pm, the Activities Director (AD) confirmed that the Resident Council group members had been asking for transportation for outings to [store name] for quite some time. Additionally, prior to COVID-19 the facility contracted with [transportation company name] for transportation for outings, then once COVID-19 happened, the outings stopped. AD stated that she had spoken with a supervisor at [transportation company name] who told her that there were new rules and no drivers. The facility had also reached out to other sister facilities to borrow a van but were told the vans were already booked and unavailable. Her practice had been to notify the Administrator of the transportation requests, the Administrator signs off on all Resident Council meeting minutes, but no resolution/response had been made. During an interview on 5/23/2024 at 8:21 am, the Administrator stated that she was aware that one resident wanted to go to [store name], but the facility did not provide transportation for outings. In the past, the facility had contacted [transportation company name] and was unable to get an agreement for the transportation company to take the residents on outings. The Administrator confirmed that this information was not conveyed to the residents. During an interview on 5/23/2024 at 2:00 pm, the Ombudsman stated that she had been to several Resident Council meetings and was aware that the residents had voiced requests for transportation for outings. She had advocated on behalf of the residents to the [Coalition group name], but no resolution had been provided to the residents that she was aware of. A review of the facility policy titled Patient/Resident Council, revised 10/20/2017, stated A Patient/Resident Council will be developed and supported by the administration. 2. Issues raised/discussed, and recommendations made by the Patient/Resident Council will be communicated to the healthcare center administration, considered in center planning, and responded to promptly. 3. The Recreation Services Director or Social Services Director will assist in the coordination of the council meetings as requested by the group President and provide assistance as needed in documentation of minutes and serving as liaison with the healthcare center administration in responding to issues that result from group meetings .10. Issues, concerns, ideas, or complaints of the Council will be transferred to the Patient/Resident Council/Family Council Department Response Form by the staff liaison person and given to the Administrator for distribution and response by the appropriate department. The response/action will be documented on this form, returned to the Administrator for review and signature and returned to the Council staff liaison for communication back to the Council Presiding Officer and presentation at the next council meeting. The department response form will be attached to the minutes of the meeting in which the issues was brought up .

Based on observations, staff interviews, and review of the facility policy titled Controlled Substances for Healthcare Centers, the facility failed to ensure that controlled medications (drugs that can cause physical and mental dependence and have restrictions on how they can be filled and refilled) were stored separately from other medications and were stored under a double-lock system in two of two medication storage room refrigerators. Findings include: Observation on 5/21/2024 at 9:18 am of the East Wing medication room, which was located behind the nurses' station, with Licensed Practical Nurse (LPN) 1 revealed the locked refrigerator in the medication storage room contained the following medications: 1. One Novolog insulin aspart flexpen for Resident (R)13. 2. One Levemir insulin flexpen for R22. 3. One Levemir insulin flexpen for R37. 4. One Novolog insulin flexpen and two Lantus Solostar insulin pen for R41. 5. Three Novolog insulin aspart flexpens for R31. 6. Four Novolog insulin aspart flexpens and one injection of Aranesp (a drug used to treat anemia) for R61. 7. Two injections of Risperdal (drug used to treat schizophrenia) Const for R8. 8. One bottle of Lorazepam Intensol Oral Concentrate (Schedule IV controlled medication) for R71. 9. One bottle of Lorazepam Intensol Oral Concentrate for R77. The controlled medications were not stored separately from any other medications and were not stored using a double-lock system. Observation on 5/21/2024 at 9:28 am of the [NAME] Wing medication room, which was located behind the nurse's station, with LPN2 revealed the locked refrigerator in the medication storage room contained the following medications: 1. One Novolog insulin aspart flexpen for R12. 2. One Fiasp insulin flextouch pen and one box of Lokelma (a drug used to treat high potassium levels) containing 14 packets for R25. 3. One box of Dupixent (a drug used to treat eczema) containing two pens for R42. 4. One box of Veltassa (a drug used to treat high potassium levels) containing 12 packets for R58. 5. One bottle of lorazepam (a drug used to treat anxiety) oral concentrate (Schedule IV controlled medication), for R1. The controlled medications were not stored separately from any other medications and were not stored using a double-lock system. During an interview on 5/21/2024 at 9:44 am, the Director of Health Services (DHS) acknowledged she was not aware that the controlled medications had to be stored separately from all other medications. The DHS stated the Pharmacy Consultant audited their medication rooms monthly and found no errors. During an interview on 5/21/2024 at 10:38 am, the Pharmacy Consultant confirmed the controlled medication policy stated controlled medications, Schedule II through V medications, were stored from other medications, but he had not seen them. The Pharmacy Consultant acknowledged he audited the medication rooms monthly but ensured the controlled medications were stored separately had not been completed because the task was not listed on the audit tool. A review of the facility's policy titled Controlled Substances for Healthcare Centers, revised 4/28/2021, revealed, . Storage: Controlled substances in Schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose and separate from all other medications .

Based on observations, staff interviews, and review of the facility policy titled Labeling, Dating, and Storage, the facility failed to ensure food items were securely closed, labeled, and dated after opening. This had the potential to affect 75 of 83 residents who consumed food from the kitchen. Findings include: 1. During observation and initial kitchen walk-through with the Dietary Manager (DM) on 5/20/2024 beginning at 9:35 am, the following was observed and confirmed by the DM: a. In the dry storage room, there was a one-pound bag of macaroni spiral pasta, open to air, undated and unlabeled. b. In the dry storage room, there was an opened bag of cookies (removed from the original container) that was undated and unlabeled. c. In the walk-in cooler, there were 15 cups of juice in cups that were undated and unlabeled. 2. During a second kitchen walkthrough on 5/21/2024 at 8:48 am with the DM, the following was observed and confirmed by the DM: a. In the walk-in cooler, there was a one-gallon container of ranch dressing that was open, undated, and unlabeled. b. In the walk-in cooler, there was one pound of butter that was open, undated, and unlabeled. During an interview on 5/21/2024 at 10:55 am, the DM stated she expected all foods to be stored properly, including being dated and labeled as required. During an interview on 5/23/2024 at 3:30 pm, the Administrator stated she expected the staff to follow policy, label with appropriate dates, and store food items properly. A review of the facility's undated policy titled Labeling, Dating, and Storage indicated. Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared on site, a 'use by' date will also be indicated. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc .

Based on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure it developed and maintained a program to provide systematic analysis and systemic action aimed at performance improvement. This failure had the potential to affect all 83 residents who currently live in the facility. Findings include: Review of the facility policy titled, [Company Name] Skilled Nursing and Rehabilitation Center Quality Assurance and Performance Improvement (QAPI), dated 02/26/2016, revealed, Policy Statement: The purpose of Quality Assurance and Performance Improvement (QAPI) Program at [Company Name] is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners and other stakeholders so that we may fully realize our vision, mission and commitment to caring pledge. Scope: This policy applies to [Company Name] Skilled Nursing and Rehabilitation Centers (SNRC) and partners as part of the overall QAPI Plan .Procedure: All [Company Name] partners and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the QAPI Program. Each Center must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. It is the expectation of the [Company Name] SNRC QAPI Program that each location will follow the established QAPI process in order to guide and direct the operations of that location . [Company Name] SNRC Standardized QAPI Tools Include: A standard Meeting Minutes template was designed based on the agenda, which will be maintained on the Regional SharePoint site to allow communication with the Regional team . The Quality Management System which is the software program utilized to document Performance Improvement Projects (PIP's) and an overview of the root cause analysis completed. Performance Improvement Projects (PIPs): As part of its QAPI Program, each [Company Name] SNRC develops, implements, and evaluates performance improvement projects. The facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the center must reflect the scope and complexity of the facility's services and available resources. a Performance Improvement projects must include at least annually a project that focuses on high risk, high volume or problem-prone areas for improvement identified through the data collection and analysis based on: Feedback an input from stakeholders; Data/metrics reported monthly from all departments; Adverse event monitoring and investigation/analysis . Documentation of the [Company Name] QAPI Program includes: All performance improvement projects being conducted; The reasons for conducting these projects; Measurable progress achieved during performance improvement projects; Evidence that demonstrates the operation of the center's QAPI Program . An attempt was made to review the meeting minutes and Performance Improvement Projects (PIP) for the previous four quarters. There was no documentation available for review. There was no documentation indicating the facility had been working to identify areas of concern for improvement or to determine the underlying causes of any problems. There was no documentation of current PIPs, or any PIPs having been completed and reviewed by the facility. During the QAPI interview on 05/23/2024 at 5:15 pm, the Administrator stated, There are no sign-in sheets and no meeting minutes to review. We don't have formal minutes of the meetings. We don't have any records of who was there or what we talked about. There are no PIPs in progress or records of any that have been completed.

Based on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings. This failure had the potential to affect all 83 residents who currently live in the facility. Findings include: Review of the facility policy titled, Skilled Nursing and Rehabilitation Center Quality Assurance and Performance Improvement (QAPI), dated 02/26/2016, revealed, Policy Statement: The purpose of Quality Assurance and Performance Improvement (QAPI) Program at [Company Name] is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners and other stakeholders so that we may fully realize our vision, mission and commitment to caring pledge. Scope: This policy applies to [Company Name] Skilled Nursing and Rehabilitation Centers (SNRC) and partners as part of the overall [Company Name] QAPI Plan .Procedure: All [Company Name] partners and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the [Company Name] QAPI Program. Each Center must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. It is the expectation of the [Company Name] SNRC QAPI Program that each location will follow the established QAPI process in order to guide and direct the operations of that location .Communication: The Center Quality Assurance and Assessment (QAA) committee is required to use the established QAPI Meeting Minutes for documenting and communicating QAPI efforts required to the regional committee level. The corporate and regional committees should communicate their efforts to the level below them to ensure all committees are working cohesively. [Company Name] SNRC Standardized QAPI Tools Include: A standard Meeting Minutes template was designed based on the agenda, which will be maintained on the Regional SharePoint site to allow communication with the Regional team. This template also includes a sign in sheet that should be printed and utilized in each center's monthly meeting. An attempt was made to review the sign-in sheets for the previous four quarters. There were no sign-in sheets available for review. There was no documentation indicating who attended any of the meetings or to confirm that the meeting occurred. During the QAPI interview on 05/23/2024 at 5:15 pm, the Administrator stated, The QAPI committee meets at least quarterly but, normally we meet monthly. The Medical Director, Director of Health Services (DHS), myself, the Infection Preventionist (IP), and department heads normally attend the meetings. There are no sign-in sheets and no meeting minutes to review. We don't have formal minutes of the meetings. We don't have any records of who was there or what we talked about.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement, the facility failed to ensure a thorough investigation was completed for an injury of unknown origin for one of 26 sampled residents (R) (R#14). Findings include: A review of the policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement with a review date of 1/8/19 indicated that it is the mission of Pruitthealth and its affiliated providers actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. The organization recognizes that every patient has the right be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. A review of the clinical record for R#14 revealed resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, Altered Mental Status and Chronic Obstructive Pulmonary Disease (COPD). A review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed R#14 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. Section G revealed R#14 required extensive assistance of two persons for bed mobility and dressing/personal hygiene required total dependence of two persons. A review of Progress Note dated 8/28/22 at 10:29 a.m., written by Licensed Practical Nurse (LPN) BB, revealed R#14 reads, during morning care this morning resident noted to have a few skin tears on his right hand on the top and on his right wrist, left hand on top as well. (Physician) notified. Cleansed the areas, dried applied antibacterial ointment, and covered with clean dry dressings. A review of Progress Note dated 8/29/22 at 2:36 a.m. noted (R#14) resident resting in bed. Skin warm and dry to touch. No signs of infection or new areas noted to hand and wrist. Dressing intact clean and dry. Will continue to monitor. Review of progress note dated 8/30/22 at 12:24 a.m. reads - Resident resting in bed. Skin warm and dry to touch. (Respirations) even and non-labored. Dressing remains to both hands with no drainage noted. No new skin tears noted. Will continue to monitor. During an interview and observation on 8/30/22 at 9:32 a.m. with R#14, he was observed to have multiple purple bruises and a band aid to both hands. R#14 stated that he did not know what happened to his hands. During an observation on 8/30/22 at 2:36 p.m., R#14 had a white bandage on the right and left hand. R#14 stated, They put these bandages on my hands while you were gone. During an observation on 8/31/22 at 9:02 a.m. R#14 was lying in bed conversing on his cell phone. Skin tears and bruises observed to both hands. There are two white soiled dressings observed on the bedside table. A review of the electronic mediation record (eMAR) revealed that there was not an order for treatment to the skin tears on R#14's bilateral hand as of 8/31/22 at 10:34 a.m. During an interview with R#14 on 8/31/22 at 11:02 a.m., R#14 stated that the day before yesterday a big girl and little one came in to change him up and the big one grabbed his hand and caused the bruises and skin tears to both his arms. During an interview on 8/31/22 at 11:06 a.m. with Certified Nursing Assistant, (CNA) AA she stated that she works part time and worked at the facility, Monday (8/29/22), Tuesday (8/30/22) and today this week. She further stated that when she reported to work on 8/29/22, R#14 told her that a girl jumped on him. CNA AA stated that she reported that to the nurse on duty at that time and was told, that the nurses are aware of the situation. CNA AA further stated that R#14 does not and has not ever refused care or been combative with her while giving care. During an interview with LPN BB on 8/31/22 at 11:12 a.m. She stated that two CNAs came to the medication cart and told her that R#14 had open areas to his hands that that the areas were new, and they had not seen the areas before. LPN BB stated that after observing R#14's hands, she determined the areas were fresh and notified the doctor and R#14's wife. LPN BB stated she might not have written an order. LPN BB further stated that R#14 told her that the injuries occurred on the night shift during care that a girl had her hand on his arm, and it opened up. LPN BB stated that R#14 is not all the way there and he makes things up. LPN BB stated that at the beginning of the shift, R#14 was asleep under blankets, and she did not see his arms. LPN BB verified that she did not transcribe a treatment order to the eMAR after speaking with the physician on 8/28/22. During an interview on 8/31/22 at 11:21 a.m. with Registered Nurse (RN) CC, she stated that there was not an order written for the Skin tears on R#14's hands and that LPN BB put the order in today (8/31/22). RN CC stated that due to R#14's low BIMs score, this incident should have been investigated. During an interview with Administrator on 8/31/22 at 11:37 a.m., she stated that she is not aware of anything going on with R#14 hands. She further stated that the staff communicates with her through a phone call or text messages. The Administrator stated that LPN BB may have reach out to the DHS (Director of Health Services) but confirmed that she did not know anything related to R#14 injuries. The Administrator stated that R#14 injuries should have been reported to the state and an investigation should have been conducted; including getting statements from the nurses and the staff that were working at the time of the injuries. During an interview with DHS on 9/1/22 at 9:55 a.m., she stated that she was out on medical leave this week and returned today. She confirmed that she did not have any knowledge of R#14 injuries until today (9/1/22) when the Administrator informed her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of the facility policy titled Stop Orders-Healthcare Centers revealed the facility failed to ensure that a psychotropic medications/antianxiety medication was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) (R#64) reviewed for unnecessary medications. Fundings include: A review of the facility policy titled Stop Orders-Healthcare Centers reviewed 6/22/22 revealed: Policy Statement: It is the policy of the healthcare center to automatically stop medications after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy given. Procedure: 1.The following classes of medications are stopped automatically after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given. PRN antipsychotic medications-14 days 3.When entering medications covered by the Stop Order Policy on the Medication Administration Record (MAR), the automatic stop date is recorded in the appropriate area on the MAR. A review of R#64's diagnoses revealed (partial list) diabetes mellitus, metabolic encephalopathy, major depressive disorder, dementia with behavioral disturbance, and anxiety disorder. Review of R#64's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of three (3) indicating very poor cognitive deficit; Section G-Functional Status: resident required supervision with bed mobility, personal hygiene, toileting, independent with transfers, walking, locomotion dressing, bathing and eating; Section N-Medications: resident received antipsychotic. A review of R#64 Care Plans revealed (partial): At risk for injury related to side effects from antipsychotic medication usage. Behavioral symptoms resident has been noted to wander, refuse care, and be physically and verbally abusive to staff. A review of R#64's Physician orders revealed an order for lorazepam tablet 0.5 milligrams (MG) 1 tablet by mouth (PO) every (Q) six hours PRN for anxiety ordered on 8/29/22 with no stop date indicated. During observations on 8/30/22 through 9/1/22 of R#64 revealed no behaviors or concerns. An interview held on 9/01/22 at 8:51 a.m. with the Director of Nursing (DON) revealed she would expect the lorazepam order to have a stop date. She verified the order did not have a stop date. An interview held on 9/1/22 at 11:14 a.m. with the Administrator revealed residents should have a stop date on antipsychotic medications that are ordered as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy titled Care Plans, and staff interview, the facility failed to develop a comprehensive care plan to address antipsychotic and antidepressant medication for one resident (R) (#58) of five residents reviewed for unnecessary medications. Findings include: Review of the clinical record revealed R#58 was readmitted to the facility on [DATE] and has a diagnosis of dementia with behavioral disturbances. Review of the August 2019 Physician Orders revealed an order dated 6/27/19 for escitalopram (antidepressant medication) 5 milligrams (mg) daily and an order dated 6/26/19 for aripiprazole (antipsychotic medication) 10 mg daily. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#58 received antipsychotic and antidepressant medication for seven days of the look back period. The care plan for R#58 last revised on 9/12/19 did not address the residents use of psychotropic medications. During an interview on 9/19/19 at 10:45 a.m., the Registered Nurse (RN) Case Mix Director confirmed that a care plan to address the use of an antipsychotic and antidepressant medication had not been developed for R#58. RN stated that a care plan for an antipsychotic and antidepressant with interventions to monitor possible side effects should be developed for any resident who receives these medications. She stated that this was an oversight on her part. Observations on 9/17/19 at 1:30 p.m., 9/18/19 at 8:50 a.m., and 9/19/19 at 8:51 a.m. revealed R#58 in her room, sitting on the bed and exhibiting no behaviors. A review of the facility policy titled Care Plans reviewed 10/28/18 documented under Care Plan Review and Update: 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to provide evidence that deep tissue injury (DTI) to the heels, that were present on readmission from the hospital on 8/30/19, were assessed or treated for five days after discovery for one of five residents (R)(#2) reviewed for pressure ulcers. Findings include: Review of R#2's electronic health record (EHR) revealed that he had diagnoses including lung cancer, hemiplegia following CVA (stroke), hypertension, diabetes mellitus, heart failure, peripheral vascular disease, vascular dementia, and chronic peripheral venous insufficiency. Review of R#2's Annual Minimum Data Set (MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 10 (a BIMS score of 8 to 12 indicates moderate cognitive impairment), was independent for bed mobility and transfers, was a pressure ulcer risk, and had no unhealed pressure ulcers. Further review of the MDS listing revealed that R#2 had a Discharge MDS on 8/26/19, and an Entry MDS from an acute hospital on 8/30/19. Review of R#2's Cognitive Loss/Dementia care plan revealed that he was usually able to communicate needs and understand others but did have problems communicating words and usually spoke in one word phrases or non-verbal communication. Review of R#2's Pressure Injuries care plan with a problem start date of 6/6/18 revealed that it was updated on 9/17/19 to include that he had actual pressure areas to the bilateral heels s/p (status post) hospital return and remained at risk for further skin breakdown d/t (due to) incontinence and impaired mobility. Review of R#2's Braden Scale score dated 9/6/19 revealed that he was moderate risk for pressure ulcer development. Review of a Nurse's Note dated 8/30/19 at 3:30 p.m. revealed that R#2 was readmitted to the facility from the hospital, and had diagnoses of pneumonia, bronchitis, CHF (congestive heart failure), and right lung cancer with metastases. Skin assessment done per writer. Review of R#2's admission Observation assessment dated [DATE] at 3:30 p.m. revealed: Redness to sacrum area. Resident's right lateral heel and left heel has discoloration. (deep tissue injury). Review of a 24-Hour Report Form dated 8/30/19 revealed that R#2 was readmitted from the hospital and had discoloration to bilateral heels. Review of a Nurse Practitioner's (NP) Post Hospitalization Progress Note dated 9/3/19 at 9:21 a.m. revealed that R#2 was admitted to the hospital from [DATE] to 8/30/19 for acute hypoxic respiratory failure, pulmonary edema, interstitial pneumonia, and bronchitis, and was found to have right lung cancer with mets (metastasis). Patient remains unable to get out of bed/stand/ambulate due to deconditioning and weakness. Right sided weakness post old CVA-but functional, moving bilateral upper extremities. BLE (bilateral lower extremities) without edema. Further review of this progress note revealed no mention of the pressure ulcers to R#2's heels. Review of nursing Progress Notes from the date of readmission to the facility on 8/30/19 through 9/5/19 revealed that there was no mention of a DTI to his heels, that the physician and/or responsible party (RP) were notified of the wounds, and no mention that his heels were being floated on pillows to relieve pressure, nor any mention that heel protectors had been applied. The first notation in the nursing Progress Notes seen that R#2's heels were floated on pillows was dated 9/6/19 at 2:38 a.m. Review of a SBAR (Situation-Background-Appearance-Review and Notify) Communication Form dated 9/5/19 at 5:41 p.m. revealed that R#2's bilateral heels had purple discoloration, which started on 8/30/19, and had gotten worse since it started. The description of the wounds was a purple blister-like areas to bilateral heels. Further review of the SBAR revealed that R#2's NP was notified on 9/5/19 at 2:00 p.m., and the family was notified that day at 5:41 p.m. Review of the Nursing Notes section on the form revealed that R#2 already had on pressure relief boots, the BLE were floated, and orders were received for wound care. Review of a Physician's Order dated 9/5/19 revealed a treatment order to clean R#2's bilateral heels with NS (normal saline), pat dry, apply betadine solution, cover with an ABD (abdominal) pad, wrap with Kerlix every Tuesday, Thursday, and Saturday until healed. Review of another Physician's Order dated 9/5/19 revealed to turn and reposition R#2 every shift, and to float heels on pillows as tolerated. Review of R#2's Treatments Administration History revealed that the treatment to the heels was not documented as done until Saturday 9/7/19. Review of a NP's Progress Note dated 9/12/19 at 2:25 p.m. revealed that R#2 was having bilateral heel pain, was not able to get out of bed without assistance, and the bilateral heels were purplish in color. Review of the Plan section revealed to reduce the risk for further skin breakdown, continue care for heels, offload both heels when patient in bed, and would add acetaminophen three times a day to decrease bilateral heel pain. During interview on 9/17/19 at 10:16 a.m., R#2 indicated by nodding that he had been in the hospital recently and pointed to his feet. Observation at this time revealed that he had bilateral heel protectors on, and dressings to both feet could be seen. When asked if he had sores on his heels, R#2 said yes. During interview with the Licensed Practical Nurse (LPN) Skin Integrity Coordinator (SIC) on 9/17/19 at 3:21 p.m., she stated that she did not know why the physician was not contacted and treatment begun to R#2's heels after he was readmitted from the hospital with the DTIs on 8/30/19. She verified that the first mention that the NP was notified of the wounds was on the 9/5/19 SBAR, and that treatment to the heels were not documented on the treatment record as done until 9/7/19. The SIC stated during continued interview that she did wound assessments and measurements as soon as she was made aware of a new wound and then every Monday thereafter, thought she was notified of R#2's wounds on 9/5/19, but did not remember where the measurements of the wounds were. Review of a computerized Weekly Wound Note dated 9/9/19 revealed that the DTI to the right lateral heel measured 3 by 1.7 cm (centimeters), and the DTI to the left lateral heel measured 2.3 by 5 cm. Observation of wound care performed by the SIC and assisted by Certified Nursing Assistant (CNA) AA on 9/18/19 at 1:51 p.m. revealed that the skin to R#2's right lateral heel was dark purple, and measured by the SIC at 2.6 by 3.0 cm. Further observation revealed the left lateral heel was measured as 3.7 by 5.0 cm, with a dark purple discoloration. During interview with the SIC after the wound care observation, she verified that she could not find any other documentation other than what was in the 8/30/19 admission Observation note of the resident having a DTI until 9/5/19. During interview with LPN BB on 9/19/19 at 1:41 p.m., she verified that she readmitted R#2 back from the hospital in August and did his admission Observation. She further stated that R#2 had discoloration to both of his heels, but that she did not notify the physician or begin any treatment, other than she floated his heels. LPN BB stated during continued interview that the Treatment Nurse usually came in the day after an admission and did skin assessments on all new admissions and readmissions. She stated that she noted on the 24-Hour Report that R#2 had returned from the hospital, and that he had discoloration to his heels. During interview with the Director of Health Services (DHS) on 9/19/19 at 1:48 p.m., she stated that all Department Heads looked at the 24-Hour Report, and they discussed items on the form in the morning meetings. She stated during continued interview that if a resident had a new wound, the physician and RP should be notified right away, and treatment begun by the charge nurse until the treatment nurse could assess the resident. The DHS stated that R#2 returned from the hospital 8/30/19, which was a Friday, but the Treatment Nurse should check the 24-Hour Report on the following Monday for any new wounds. She further stated that the charge nurses could notify the Treatment Nurse of any skin issues either by notation on the 24-Hour Report, verbally, or by putting a note in the SIC's box, but notification did not have to be done on both the 24-hour report and SIC box. The DHS stated during continued interview that wounds should be assessed during treatments, and documentation including measurements, description, changes in the wound, and interventions made at least weekly. She stated that the Treatment Nurse should do the initial skin assessment and/or readmission skin assessment within 24 hours (or on Monday for a late Friday or weekend admission). On 9/19/19 at 1:55 p.m., the DHS provided Documentation of Wound Observation and Assessment Forms dated 9/5/19 with the of the assessment of R#2's heels which revealed: DTI to left lateral heel, unstageable, 2.2 by 5 cm in size, with intact dry skin and pain. The right lateral heel assessment noted the wound to be an unstageable DTI, measuring 2.8 by 1.7 cm, with intact dry skin and no pain. Review of the narrative description of the wounds on the Documentation of Wound Observation and Assessment Form revealed that the SIC was notified on 9/5/19 of areas to R#2's bilateral heels that were present upon hospital readmission. Further review of the form revealed that she removed a dressing from the bilateral heels, and to the right lateral heel she noted a SDTI (suspected DTI), with deep discoloration to the skin. She noted that the left heel also had a SDTI, and that the area was discolored with approximately 0.1 cm of redness to the surrounding area. Review of the facility's Wound Assessment policy dated 11/11/16 revealed: A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing.

Based on observation, record review, and staff interview, the facility failed to disinfect the glucometer per facility policy for four residents (R) observed (R#100, R#18, R#34, R#8) on two of five halls. Findings include: 1. On 9/18/19 at 11:30 a.m., Licensed Practical Nurse (LPN) CC was observed to obtain a hand-held basket containing a glucometer and other supplies, and it was taken to R#100's room. LPN CC was observed to clean the glucometer with an alcohol prep pad only and placed it on a paper towel on top of the resident's bed. After the FSBS was performed, the nurse cleaned the glucometer with a Healthcare Bleach Germicidal Wipe only (the machine was not cleaned with alcohol first). Following this observation, LPN CC stated that she had not used the glucometer on any other residents that day prior to performing the FSBS on R#100 and verified that she did not clean the glucometer with a disinfectant wipe prior to doing his FSBS. LPN CC stated during further interview that she assumed that the nurse on the previous shift had cleaned the glucometer properly with a bleach wipe. 2. On 9/18/19 at 11:47 a.m., LPN CC was observed performing a FSBS measurement for R#18 (this was done immediately following the observation on R#100). After the FSBS was done, the nurse was observed to clean the glucometer with a Germicidal Bleach Wipe only (no alcohol was used first). LPN CC was then observed to continue to another resident's room to do their blood sugar. On 9/18/19 at 1:36 p.m., LPN CC was observed to re-check R#18's blood sugar, as the result obtained earlier at 11:47 a.m. was lower than normal for him. LPN CC was observed to clean the glucometer first with a bleach wipe and allowed to air dry for 25 seconds, before wiping the machine with an alcohol wipe. Without changing her gloves used to clean the machine, LPN CC performed the FSBS on R#18, and then gave him an injection of insulin from a Novolog FlexPen (labeled with R#18's name) that she had in the basket containing the FSBS supplies. Continued observation revealed that LPN CC then cleaned the glucometer with a disinfectant wipe with the same pair of gloves on, before placing the machine in a clean plastic cup inside the supply basket. Interview with LPN CC at this time revealed that each hall had their own glucometer and FSBS supplies. During interview with the Infection Control Nurse on 9/19/19 at 10:42 a.m., she stated that none of the residents that got FSBSs had a bloodborne illness. 3. On 9/19/19 at 11:29 a.m., Registered Nurse (RN) DD was observed to take the basket with the FSBS supplies to R#34's room. After cleaning the glucometer with an alcohol prep pad, RN DD was observed to place the glucometer directly on top of the resident's overbed table, with no clean barrier underneath. The nurse then cleaned the glucometer with a bleach wipe and again placed it directly on top of the overbed table. After performing R#34's FSBS, RN DD put the glucometer directly on top of the overbed table, cleaned it with an alcohol wipe, and then placed it in the zippered glucometer pouch before going to the next resident's room. 4. Immediately after doing R#34's FSBS, RN DD took the glucometer supplies to R#8's room at 11:39 a.m. After removing the glucometer from the zippered pouch, RN DD cleaned it with an alcohol wipe, and then placed it directly on top of the resident's overbed table, with no clean barrier underneath. The nurse then cleaned the glucometer with a bleach wipe and again placed it on top of the overbed table. After obtaining R#34's FSBS, RN DD placed the glucometer directly on top of the overbed table, removed her gloves, and wrapped the uncleaned glucometer in a clean glove, put it in the zippered pouch, and exited the resident's room. During interview with RN DD immediately following this observation at 11:47 a.m., she stated that she did not clean the glucometer after doing R#8's FSBS, because she had run out of gloves, and that was why she wrapped the machine in the last clean glove. She verified that she put the glucometer directly on an unclean surface for both R#34 and R#8, and that she should have put a clean paper towel underneath the machine. During interview with the Director of Health Services (DHS) on 9/19/19 at 1:55 p.m., she stated that she would expect for staff to clean the glucometer before and after each use with alcohol and bleach. She further stated that the glucometer should be placed on a clean barrier, and that gloves should be changed after cleaning the glucometer and after performing the FSBS. Review of the facility's Diabetes Monitoring: Blood Glucose Equipment & Supplies policy issued September 2012 revealed: Accuchecks/glucometers or other blood sugar monitor devices will be cleaned and disinfected in the following manner before and after each patient/resident use. 1. Wash hands. 2. Put on clean gloves. 3. Clean the outside of the glucometer with isopropyl alcohol wipe . 4. Disinfect the meter with a bleach solution wipe . 5. Remove gloves & wash hands after cleaning glucometer. Review of Skills Competency Checklist Form: Blood Glucose Equipment & Supplies revealed competency checkoffs were done with the nurses on 7/11/19 and 9/11/19 to 9/14/19, with a checkoff form seen for RN DD dated 9/14/19. Further review of the checkoff forms revealed that one was not provided for LPN CC. Review of the steps on the checkoff form revealed that it included to clean the glucometer before and after each patient/resident use, and to clean the outside of glucometer with isopropyl alcohol wipe, then disinfect the meter with a bleach solution wipe, remove gloves and wash hands after cleaning glucometer.