**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and Nurse Practitioner, staff and resident interviews, the facility failed to provide a safe transfer using a mechanical lift for Resident #43. On 3/9/24 Nurse Aide (NA) #1 and NA #2 were transferring Resident #43 with the mechanical lift when a strap that was frayed on the left side of the lift pad broke, and Resident #43 fell approximately 3 feet to the tile floor hitting her head and landing on her right side. Resident #43 was assessed by Nurse #3 and was observed to have a huge hematoma (collection of blood underneath the skin) to the back right side of her head and reported her whole right side hurt. Resident #43 was transported to the Emergency Department (ED) for further evaluation. Computed tomography (CT) scans and x-rays obtained in the ED were negative for fracture or injury. While in the ED Resident #43 experienced acute respiratory insufficiency related to rib pain and/or narcotic administration. Resident #43 returned to the facility on [DATE]. Resident #43 was not receiving an anticoagulant (blood thinner). Most recently on 1/15/25 Resident #43 was transferred with the mechanical lift for a shower and suffered a panic attack because she was scared of the mechanical lift. There was a high likelihood of a serious adverse outcome or injury when one of the straps on the lift pad broke when Resident #43 was being transferred with the mechanical lift. Additionally, the facility failed to secure the mechanical lift brake when transferring Resident #76. This deficient practice occurred for 2 of 6 residents (Resident #43 and Resident #76) reviewed for accidents. Immediate jeopardy began on 3/09/24 when Resident #43 was transferred using a mechanical lift and fell to the floor when the strap on the lift pad broke. Immediate jeopardy was removed on 3/10/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 is being cited a scope and severity of D. The findings included: 1. A review of the manufacturer's instruction manual for the mechanical lift provided by the facility read in part: The operator shall inspect the mechanical lift before each use checking all bolts for tightness, checking the sling hardware, making sure all lift parts are in place and checking the lift sling for any wear. Resident #43 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, chronic kidney disease and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #43 was cognitively intact and dependent on staff for transfers. The care plan dated 2/06/24 revealed Resident #43 had a problem area related to activities of daily living self-care performance deficit and the intervention was to use a mechanical lift and two-person assistance for transfers. A review of the facility incident report dated 3/09/24 at 3:34 PM written by Nurse #3 revealed Resident #43 was being transferred with the mechanical lift when one of the left side straps on the lift pad snapped in half and Resident #43 flipped out of the lift pad and landed on the floor. Resident #43 was observed lying on the floor at the base of the mechanical lift, had a blank stare and was only responding to painful stimuli for approximately 1 minute. Resident #43 reported hitting her head and was complaining of pain to her whole right side. Resident #43 was assessed for injury and noted to have a huge hematoma to the back right side of her head. Nurse #1 called Emergency Medical Services (EMS), notified the Nurse Practitioner (NP) and Resident Representative (RR), and Resident #43 was transferred to the ED for further evaluation. A review of NA #1's statement dated 3/11/24 indicated on 3/09/24 NA #2 assisted her with transferring Resident #43 to a shower chair. The 4 straps on the lift sling were secured to the hooks on the mechanical lift. During the transfer one of the sling straps broke and Resident #43 fell to the floor hitting her head and landing on her right side. Several attempts were made to call NA #1 were unsuccessful. A review of NA #2's statement dated 3/11/24 revealed on 3/09/24 she was assisting NA #1 to transfer Resident #43 to a shower chair using the mechanical lift. When they began lifting Resident #43 one of the straps on the sling broke and she slipped out of the sling, fell to the floor and hit her head. An interview with NA #2 on 1/29/25 at 8:21 AM revealed on 3/09/24 she assisted NA #1 with transferring Resident #43 to a shower chair using the mechanical lift sometime after lunch. She stated NA #1 placed the lift sling under Resident #43 and hooked the sling straps to the mechanical lift before she entered the room, so she was unsure if NA #1 inspected the sling to ensure it was in good condition. NA #2 indicated they were supposed to check the lift slings before every use to make sure the sling was in good condition and the straps were not frayed or torn. NA #2 revealed when they were lifting Resident #43 from the bed one of the straps on the lift sling snapped and Resident #43 slid out of the sling and fell approximately 3 feet to the floor hitting her head. She indicated they immediately called out for help, Nurse #3 responded and assessed Resident #43 for injury. NA #2 stated she did not recall which strap on the lift sling broke nor did she look at the sling following the incident. A review of the Nurse Practitioner note dated 3/09/24 indicated Resident #43 fell to the floor from approximately 3 feet hitting her head and landing on her right side. Nurse #3 reported Resident #43 had a blank stare for one minute and was complaining of head pain and pain to her right side. EMS was called and Resident #43 was sent to the ED for further evaluation. A review of the hospital records revealed Resident #43 was evaluated in the ED on 3/09/24 due to falling from a mechanical lift and was complaining of pain to her head, right leg and hip. Computed tomography (CT) scans of the head, chest and spine were obtained as well as x-rays of the pelvis, right leg and hip. The CT scan results showed no acute trauma, and the x-rays were negative for fractures. Resident #43 experienced acute respiratory insufficiency while in the ED, suspected to be related to rib pain and/or narcotic administration. Resident #43 was admitted to the hospital on [DATE] for observation and discharged back to the facility on 3/13/24 with no new orders. An interview conducted with Resident #43 on 1/29/25 at 4:30 PM revealed she did not recall the date, but during a transfer with the mechanical lift from her bed to the shower chair a strap on the lift sling broke and she fell to the floor. She indicated she fell left out of the sling, flipped as she fell to the floor landing on her right side and hitting her head. Resident #43 indicated her head and whole right side hurt and the nurse responded and called EMS. She revealed she was transferred to the ED for further evaluation but did not have any injuries or fractures. Resident #43 stated she had to use the mechanical lift to be transferred to a shower chair and only received a few showers since the incident because she was scared to use the mechanical lift. She stated staff were giving her bed baths, but she really enjoyed taking a shower once or twice a week. Resident #43 indicated the few times she received a shower and was transferred with the mechanical lift she had a panic attack. An interview conducted with Nurse #3 on 1/29/25 at 9:54 AM indicated she was assigned to Resident #43 on 3/09/24. She revealed she heard NA #1 and NA #2 yelling for help and responded to Resident #43's room and observed her lying on the floor. She stated NA #1 and NA #2 reported they were using the mechanical lift to transfer Resident #43 when one of the straps on the lift sling snapped and Resident #43 fell to the floor and hit her head. Nurse #3 revealed she assessed Resident #43 but did not recall if she had any visible injuries. She stated because Resident #43 hit her head she immediately called EMS, notified the NP and Resident #43 was transferred to the ED for further evaluation. Nurse #3 revealed she did not recall which of the 4 straps on the lift sling broke, but she observed the sling after the incident and the broken strap was frayed which caused it to rip in half. An interview conducted with the NP on 1/30/25 at 12:47 PM revealed she was notified by Nurse #3 that Resident #43 had a fall to the floor from approximately 3 feet and hit her head. The NP stated Resident #43 was transferred to the ED for further evaluation. She indicated CT scans and x-rays obtained in the ED were negative for acute injury or fractures. The NP revealed she was not immediately aware that Resident #43 fell during a transfer with the mechanical lift, however that would not have changed the course of treatment. She revealed when a resident falls and hits their head they were at risk for suffering injuries including a concussion or brain bleeding and standard protocol was to transfer them to the ED for further evaluation. The NP stated she could not comment on the safety measures that staff should take when using a mechanical lift to transfer a resident. An attempt was made to call the Former Director of Nursing, but the phone number was no longer in service. An interview with the Former Director of Maintenance on 1/31/25 at 3:45 PM revealed he inspected all the mechanical lifts and lift slings once a month to ensure they were in good repair. He stated the nursing staff were responsible for inspecting the lift slings before every use. He stated he was aware of the incident on 3/09/24 involving Resident #43 falling from the mechanical lift due to a strap on the lift sling breaking. The Director of Maintenance indicated he did not recall observing any lift slings during his monthly inspections prior to the incident on 3/09/24 that were damaged or had frayed or torn straps. An interview was conducted with the Former Administrator on 1/29/25 at 12:58 PM. He stated on 3/09/24 he was notified that NA #1 and NA #2 were using a mechanical lift to transfer Resident #43 when one of the straps on the lift sling broke and Resident #43 fell to the floor. He revealed he initiated an investigation that day and determined the lift sling that NA #1 used to transfer Resident #43 was damaged and she did not inspect it prior to use. The Former Administrator indicated when staff were using the mechanical lift to transfer a resident, they should inspect the lift sling prior to every use for damage and ensure it was in good repair. The Administrator was notified of immediate jeopardy on 1/29/25 at 6:00 PM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered or are likely to suffer a serious adverse outcome as a result of the noncompliance: On 03/09/2024, Resident #43 experienced a fall during a transfer using a mechanical lift. The loop on the sling that connects to the mechanical lift tore resulting in the resident falling to the floor. The Licensed Nurse immediately assessed the resident, found unresponsive to vocal stimulation for about one minute, but responded to painful stimuli. The Licensed Nurse also observed a hematoma on the right side of the back of her head and the resident reported pain to her full right side but denied pain to her neck or back. The Nurse Practitioner was notified of the incident. Resident #43 was subsequently transferred to the hospital via EMS for further evaluation. The hospital evaluation resulted in no fractures reported from the performed imaging and the CT scan of chest, abdomen, pelvis, and spine did not show acute trauma. The resident returned to the facility on [DATE] with no new orders. On 03/09/2024 the Nurse Aide initially removed the damaged sling from Resident #43's room after the incident occurred and was inspected by the Maintenance Director and Nurse Aide. The sling was immediately thrown in the trash after it was inspected. Residents at risk of experiencing similar adverse outcomes would include those who rely on mechanical lifts for transfers. A facility-wide audit of all mechanical lift slings was conducted on 03/09/2024 by the facility Maintenance Director with the assistance of a nurse aide. The audit's purpose was to identify residents at risk. The lift slings were thoroughly inspected for rips, tears, and frays. No other lift slings were found to have been defective. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be completed: On 3/9/24 one on one competency assessments were completed for the two nurse aides involved in the incident by Licensed Charge Nurse with emphasis on safety procedures including how to inspect lift slings for rips, tears, and frays, and to immediately remove any slings that are defective. The two nurse aides demonstrated correct usage of the mechanical lift. On 3/9/24 in-person education was provided to all nurse aides and licensed nurses on duty by the Maintenance Director on proper lift usage and safety procedures including how to inspect lift slings for rips, tears, and frays before each use, as well as to immediately remove any slings from use if they are defective and take them to their immediate supervisor. The in-person training was continued after 3/9/24 for all direct care staff, including agency staff, for the rest of the month for those not on duty the day of the incident. All agency staff were in-serviced during facility orientation. The Director of Nursing was responsible for tracking the staff that required education and for providing the education. Staff were not allowed to work until education was completed. New hires, including agency staff, are required to complete education during orientation. Alleged date of immediate jeopardy removal: 03/10/24 The facility's credible allegation of immediate jeopardy removal was validated on 1/31/25. Observations conducted of the facility's lift slings revealed they were in good repair and there were no slings observed to have frayed straps or other damage. An observation conducted of a resident being transferred with a mechanical lift revealed the NA inspected the lift sling prior to use, it was observed to be in good condition and was used per the manufacturer's instructions. An interview conducted with NA #2 indicated she received education on how to inspect mechanical lifts and lift slings prior to every use for damage, removing damaged equipment immediately from service and then reporting equipment concerns to administration. NA #2 revealed she also received education on performing a safe resident transfer using the mechanical lift and then completed a return demonstration. Interviews conducted with nurses and nurse aides revealed they received education on how to properly inspect mechanical lifts and lift slings prior to every use, immediately removing equipment from service that was damaged, and reporting equipment concerns to administration. An interview conducted with the Former Director of Maintenance indicated he completed safety inspections of all the mechanical lifts and lift slings, and no concerns were identified. Additionally, it should be noted that the facility was unable to locate the initial audit completed on 03/09/24 of all of the facility's mechanical lifts nor was the facility able to locate the audit completed on 03/09/24 of all the lift slings that were inspected for rips, tears, and frays. The facility was also unable to provide any ongoing monitoring that had occurred since the 03/09/24 incident. The facility's immediate jeopardy removal date of 03/10/24 was validated on 1/31/25. 2. A review of the mechanical lift manufacturer's instructions provided by the facility read in part: Operating instructions: Preparation before lifting - widen the base and engage the caster (wheel) brake. Resident #76 was admitted to the facility 8/15/24 with diagnoses including: Right tibia fracture, muscle weakness and cognitive communication deficit. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #76 was severely cognitively impaired and required substantial to maximal assistance with transfers. The care plan dated 11/26/24 revealed Resident #76 had a problem area related to activities of daily living self-care performance deficit. The intervention was to provide substantial to maximal assistance with transfers but did not include the use of a mechanical lift. An observation was conducted on 1/29/25 at 11:50 AM of Nurse Aide (NA) #2 and NA #3 using the mechanical lift to transfer Resident #76 from her bed to the wheelchair. Nurse Aide (NA) #2 positioned the base of the mechanical lift under the bed while NA #3 locked the brake on the bed. NA #2 did not secure the wheel brake on the base of the mechanical lift. NA #2 was operating the mechanical lift and when she was raising Resident #76 from the bed the base of the lift moved and shifted to the right. After Resident #76 was raised from the bed NA #2 moved the mechanical lift from the bed to the wheelchair while NA #3 guided Resident #76 in the lift sling positioning her over the wheelchair. NA #3 made sure the wheelchair brakes were locked and NA #2 lowered Resident #76 into the wheelchair. NA #2 did not secure the wheel brake on the mechanical lift before lowering Resident #76. An interview was conducted with NA #3 on 1/29/25 at 3:30 PM. She stated she was assisting NA #2 to transfer Resident #76 with the mechanical lift. NA #3 indicated she was not operating the mechanical lift during the transfer, and it was the responsibility of the person operating the lift to ensure the wheel brake was secured prior to lifting the resident. NA #3 revealed she did not notice that the brake on the mechanical lift was not secured prior to Resident #76 being lifted from the bed and she was unsure as to why NA #2 did not secure the brake. A phone interview with NA #2 on 1/30/25 at 1:18 PM revealed when using the mechanical lift to transfer a resident, the wheel brake on the mechanical lift should be secured prior to lifting or lowering the resident. NA #2 stated when she was using the mechanical lift to transfer Resident #76 on 1/29/25 she did not recall that the wheel brake on the mechanical lift was not secured when she was lifting and lowering Resident #76 and she thought she had secured the brake. A phone interview was conducted with the Director of Nursing (DON) on 1/30/25 at 8:40 AM. She stated when staff were transferring a resident with the mechanical lift they should operate the lift per the manufacturer's guidelines. The DON further stated if the manufacturer's guidelines indicated the wheel brake on the mechanical lift should be secured prior to lifting or lowering the resident then staff should secure the wheel brake accordingly. A phone interview was conducted with the Administrator on 1/31/25 at 9:30 AM. He stated nursing staff should operate the mechanical lifts per the manufacturer's guidelines including securing the wheel brake on the mechanical lift prior to lifting or lowering a resident to ensure the resident was transferred safely.

Based on observation, record reviews and staff interviews, the facility failed to ensure Medication Aide (Agency MA #1) and other nursing staff were trained and competent in cleaning and disinfecting glucometers (blood glucose machine) according to manufacturer recommendations using an Environmental Protection Agency (EPA) approved disinfectant cloth, between resident usage. Agency MA #1 was observed not cleaning and disinfecting a shared glucometer between use with three residents (Resident #28, Resident #30, and Resident #57). Interviews with Nurse #2, Nurse #6 and Nurse #10 revealed each nurse was unable to describe glucometer disinfection procedures. This deficient practice involved four of four nursing staff. The immediate jeopardy began on Sunday, 8/20/23 when a Medication Aide (Agency MA #1) demonstrated she was not competently disinfecting a shared glucometer between resident use per manufacturer's recommendations. The immediate jeopardy was removed on 8/23/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. The findings included: Cross refer to tag F 880. Based on observations, record reviews, staff, Nurse Practitioner #1, Medical Director, and Local Health Department Nurse interviews, the facility failed to clean and disinfect a glucometer used for more than one resident (blood glucose meter) according to manufacturer's recommendations using an Environmental Protection Agency (EPA) - approved disinfectant cloth, between resident usage. The risk of spreading bloodborne infections is very serious if the products and procedures are not followed. The facility confirmed there were residents who had bloodborne pathogens. This occurred for 3 of 3 sampled residents who were required to have their blood sugars checked (Resident #28, Resident #30, and Resident #57) and 1 of 1 staff observed performing blood glucose monitoring (MA#1). This practice affected 3 of 4 residents on the assigned unit and could potentially affect 17 residents in the facility who required glucose monitoring. A review of Agency MA #1's employee training records from the nursing home and staffing agency revealed there was no medication aide training to include cleaning and disinfecting of a glucometer. An interview with Medication Aide (MA #1) with the DON present on 8/20/23 at 1:30 PM revealed she acknowledged was previously shown glucometers should be cleaned and disinfected between resident use, however, she stated she rushed to obtain blood glucose monitoring before the residents received their lunch trays and did not take the time to clean and disinfect the shared glucometer. MA #1 was also unable to verbalize the correct procedure to use with the EPA approved disinfecting wipes. An interview with Nurse #10 who was working the East Wing Cart #2 at 4:50 PM revealed she was responsible for obtaining blood glucose monitoring and aware the glucometers should be cleaned between residents but was unable to verbalize the correct procedure for cleaning and disinfecting the glucometers using the EPA approved disinfecting wipe. An interview with Nurse #2 who was working the [NAME] Wing Cart #1 at 4:53 PM revealed he was responsible for obtaining blood glucose monitoring and aware the glucometers should be cleaned between residents but was unable to verbalize the correct procedure for cleaning and disinfecting the glucometers using the EPA approved disinfecting wipe. A telephone interview with Nurse #6 on 8/21/23 at 8:55 AM revealed she had last worked in the facility as an agency nurse on Thursday 8/17/23. Nurse #6 had been responsible for blood glucose monitoring and was aware the glucometers were required to be cleaned and disinfected between each resident use but was unable to recall the correct procedure for performing this task or the correct kill time for the EPA wipes used in the facility. An interview with the Director of Nursing (DON) on 8/20/23 at 1:30 PM revealed DON verified she was responsible for all staff training because the facility did not have a staff development coordinator. She also explained MA #1 had no education/training on how to clean and disinfect the glucometers by the facility or the staffing agency which she was hired as a nurse aide. MA #1 had received Nurse Aide competencies in the facility, but no medication aide training to include glucometer cleaning and disinfecting. The DON stated the facility did not currently have a system in place to verify credentials and competencies of agency staff and relied on the staffing agency to verify these. A telephone interview with the Medical Director on 8/29/23 at 9:49 AM revealed he would expect all staff to perform care in a manner to prevent potential cross contamination of bloodborne illnesses. An interview with the Administrator on 8/24/23 at 1:09 PM revealed he was new to the facility and left all training of nursing personnel to the DON, but he would have expected the glucometer to be cleaned and disinfected before and after use to decrease the spread of any potential illness. Facility administration (Administrator and Director of Nursing) was notified of immediate jeopardy on 8/22/23 at 12:09 PM. The facility provided the following plan for IJ removal. Noncompliance Allegation: Based on observation, record reviews, and staff interviews, the facility failed to ensure Medication Aide #1 and other nursing staff were trained on how to thoroughly clean and disinfect a glucometer (blood glucose machine) according to manufacturer guidelines using an EPA- approved disinfectant cloth, between resident usage. This occurred for 3 of 3 residents who were required to have their blood sugars checked (Resident #28, Resident #30, and Resident #57). Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Observation, record review, resident, and staff interviews completed by the surveyor on 8/20/23 identified the facility failed to ensure training was provided to nursing staff for glucometer cleaning according to manufacturer guidelines using an EPA-approved disinfectant cloth between each resident usage. This occurred for 3 residents who were required to have their blood glucose levels checked (Resident #28, Resident #30, and Resident #57). Clinical staff failed to use the appropriate procedure to clean and disinfect a shared glucometer. On 8/20/23 and 8/21/23 the Director of Nursing and Unit Managers conducted interviews to evaluate understanding of the facility's glucometer disinfectant procedure prior to providing education with 25 Licensed Nurses- 11 of 25 are facility employees and 14 of 25 are agency nurses It was determined there was a knowledge deficit related to the facility process for disinfecting glucometers and Licensed Nurses were unable to recall previous training. No documentation of previous glucometer disinfection training during the last 3 months was identified by the Director of Nursing after reviewing completed training logs. Re-education of the facility process for disinfecting glucometers was initiated immediately by the Director of Nursing and Unit Managers. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Director of Nursing and Administrator educated the Unit Managers regarding the Glucometer Disinfection policy and procedures for using fingerstick blood glucose checks, managing glucometers and cleaning requirements. This was completed on 8/21/23. Current Licensed Nurses have received training from the Director of Nursing and Unit Managers: o The purpose for following the cleaning checklist process, for glucometers due to the likelihood of cross-contamination and the spread of bloodborne pathogens among residents. o The importance of cleaning and disinfecting the glucometer per manufacturer's guidelines, using the training/education checklist for Cleaning Glucometers that includes the process of cleaning and includes observation and return demonstration. o This includes cleaning and disinfecting the individually issued glucometers that are stored at the residents' bedside. o On 8/22/23 return demonstration of process was observed by the Director of Nursing and Unit Managers to validate understanding. The Director of Nursing and Unit Managers completed this education for current Licensed Nurses, including those working for agencies, on 8/21/23. This education was provided verbally with written documents for reference and a return demonstration completed by the Director of Nursing and Unit Managers. The orientation for new hires and agency staff will be updated to include the procedure for cleaning glucometers after use. The Director of Nursing approves all new Nursing Department hires and will maintain a log of all Licensed Nurses to ensure no staff are allowed to work without receiving this training. The facility alleges the removal of Immediate Jeopardy on 8/23/23. On 8/24/23, the facility's immediate jeopardy removal plan effective 8/23/23 was validated by the following: Staff interviews revealed all nurses were able to verbalize they had received training on the proper cleaning procedure to clean and disinfect the glucometer before and after each use using an EPA approved disinfectant wipe and allow it to dry the appropriate amount of time based on the wipe used. Inservice training records of return demonstrations and of the updated policy were reviewed.

Based on observations, record reviews, staff, Nurse Practitioner #1, Medical Director, and Local Health Department Nurse interviews, the facility failed to clean and disinfect a glucometer used for more than one resident (blood glucose meter) according to manufacturer's recommendations using an Environmental Protection Agency (EPA) - approved disinfectant cloth, between resident usage. The risk of spreading bloodborne infections is very serious if the products and procedures are not followed. The facility confirmed there were residents who had bloodborne pathogens. This occurred for 3 of 3 sampled residents who were required to have their blood sugars checked (Resident #28, Resident #30, and Resident #57) and 1 of 1 staff observed performing blood glucose monitoring (MA#1). This practice affected 3 of 4 residents on the assigned unit and could potentially affect 17 residents in the facility who required glucose monitoring. The immediate jeopardy began on Sunday, 8/20/23 when a Medication Aide (MA #1) hired through an agency was observed to perform blood glucose checks on residents using a shared glucometer without disinfecting per manufacturer's guidelines. The immediate jeopardy was removed on 8/22/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. The findings included: The facility policy titled, Glucometer Disinfection (a blood glucose meter) dated 11/1/20 indicated 1) facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 2)If the manufacturers are unable to provide information specifying how glucometers should be cleaned and disinfected then the meter should not be used for multiple patients. 3)The glucometer should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against Human Immunodeficiency Virus (HIV), Hepatitis C, and Hepatitis B virus. 4) Glucometers should be cleaned and disinfected after each use and according to manufacturers' instructions regardless of whether they are intended for single resident use or multiple resident use. The blood glucose meter manufacturer's instructions for cleaning and disinfecting page 47-48 of the booklet indicated healthcare workers should wear gloves when cleansing the meter. Option 1) Wash hands after gloves are doffed. Contact with blood products presents a potential infection risk. We suggest cleaning and disinfecting between each use. Many wipes function as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; one wipe to clean and a second wipe to disinfect. The wipes container which was in the bottom drawer of the medication cart located on the East Wing read in part to disinfect nonfood contact surfaces to thoroughly wet surface, allow treated surface to remain wet for 3 minutes and let air dry. These wipes were an EPA-registered germicidal wipe and approved for bloodborne pathogen use. An observation was made on 8/20/23 at 11:28 AM and revealed a Medication Aide (MA#1) carried a glucometer from the medication cart to the dining room located just adjacent to the nurses' station on the East Unit where Resident #28 was sitting in his wheelchair. MA #1 performed a task with her back to the door, then exited the dining room holding a used blood glucose test strip, the glucometer, and a used lancet in her right hand. When she arrived near the medication cart, she discarded the used lancet in the sharps box and then removed the used test strip from the glucometer and discarded it and her gloves in the trash can located on the medication cart. MA #1 then documented the blood glucose reading for Resident #28 on a piece of paper located on the medication cart before leaving the medication cart. MA #1 was not observed to clean the glucometer after usage. MA #1 left the medication cart to speak to another staff member and then returned at 11:33 AM. A continuous observation on 8/20/23 from 11:33 AM to 11:45 AM revealed MA #1 retrieved a bottle of glucose test strips and a lancet from the top drawer of the medication cart then, pick up the glucometer which had been used on Resident #28 and walked down the hallway to locate Resident #30 outside the facility at the main lobby entrance along with other residents and visitors. MA #1 then applied gloves and performed a fingerstick using the lancet and obtained blood from Resident #30 on the blood glucose test strip. Once she got a reading on the monitor, MA #1 left Resident #30 outside and entered the building (both hands remained gloved) carrying the glucometer with the test strip and soiled lancet in her right hand. MA #1 then removed her right glove and the test strip from the meter and the lancet in her left hand. MA #1 was observed to carry the glucometer to the medication cart in her ungloved hand where she laid the glucometer again on a white towel located on the top of the medication cart and discard the used lancet and test strip in the sharps box and soiled gloves in the trash can. MA #1 was not observed to perform hand hygiene or disinfect the glucometer before she reached into the top drawer of the medication cart and retrieved a clean blood glucose test strip from a bottle and a clean lancet. MA #1 closed the top drawer, picked up the glucometer from the white towel on the cart and rapidly walked down the hall towards Resident #57's room. MA #1 retrieved a pair of gloves from the hallway outside Resident #57's room and entered the room. She approached Resident #57 who was lying in her bed, and she placed the test strip in the glucometer before sitting it on Resident #57's bedside table to apply her gloves. The surveyor attempted to stop MA #1 from performing any further contamination and asked MA #1 to stop and exit the room. MA #1 demanded the surveyor to come there instead and again turned to Resident #57 and lifted her right-hand pricked Resident #57's finger. The surveyor again told MA #1 to stop before she picked up the glucometer and the MA #1 grabbed the glucometer, test strip and lancet and briskly walked past the surveyor who was standing in the doorway without acknowledging the surveyors questions, hurried toward the medication cart, and placed the glucometer on the cart on the same white towel. The surveyor asked MA #1 about cleaning and disinfecting the glucometer between resident use. Without answering MA #1, grabbed a container of disinfecting wipes from the bottom drawer of the cart and wiped the glucometer for approximately 3-5 seconds and walked off from the surveyor without answering any further questions. Following the observation and attempt of interview, the Director of Nursing (DON) was made aware of the observation and request for interview. An interview with Medication Aide (MA #1) with the DON present on 8/20/23 at 1:30 PM revealed she acknowledged she performed blood glucose monitoring on multiple residents at both 7:30 AM and at 11:00 AM using the multi-use glucometer located in the top drawer of the medication cart. MA #1 verified she did not clean and disinfect the glucometer between each resident using an EPA approved disinfecting wipe. She stated during the lunch time observations, she wanted to make sure she obtained the blood glucose level before each resident received their lunch and did not take the time to clean the monitor or perform hand hygiene between each resident. She stated she had always used a multi-use glucometer on all residents in the facility when obtaining fingerstick blood glucose monitoring and had never used individually assigned glucometers in this facility. An interview with the Director of Nursing (DON) on 8/20/23 at 1:30 PM revealed she had no knowledge MA #1 had performed fingerstick glucose checks on multiple residents without disinfecting the device between use until the surveyor notified her. The DON indicated the glucometer device should have been disinfected between usage and MA #1 should not perform blood glucose checks without proper cleaning and disinfecting using approved EPA wipes. The facility was unable to determine if any residents who resided in the facility had a bloodborne pathogen illness during the survey. An observation of the East Wing Cart #1 (the medication cart where Resident #28, Resident #30, and Resident #57 resided) and interview with Nurse #5 on 8/20/23 at 4:45 PM revealed a multi-use glucometer in the top drawer of the medication cart along with a partially used bottle of glucose test strips. Nurse #5 stated the procedure had changed on 8/20/23 and all residents at that time, now had their own glucometers stored in their room and the multi-use glucometer observed should not have been on the medication cart and available for potential usage. Using a gloved hand, the glucometer and test strips were removed from the cart and taken to the DON who was in her office. An observation of the East Wing Cart #2 at 4:50 PM revealed no multi-use glucometers on the cart and an interview with Nurse #10 revealed she was aware each resident was now assigned their own glucometers which was kept in their rooms but was unable to verbalize the correct procedure for cleaning and disinfecting the glucometers using the EPA approved disinfecting wipe. An observation of the [NAME] Wing Cart #1 at 4:53 PM revealed no multi-use glucometers on the cart and an interview with Nurse #2 revealed he was aware each resident was now assigned their own glucometers which were kept in their rooms but was unable to verbalize the correct procedure for cleaning and disinfecting the glucometers using the EPA approved disinfecting wipe. A telephone interview with Nurse #6 on 8/21/23 at 8:55 AM revealed she had last worked in the facility as an agency nurse on Thursday 8/17/23. Nurse #6 stated she had been assigned to work on each unit and had always used a multi-use glucometer from the top drawer of each medication cart when she worked at this facility. Nurse #6 was aware the glucometer required to be cleaned and disinfected between each resident use but was unable to recall the correct procedure for performing this task or the correct kill time for the EPA wipes used in the facility. A telephone interview with the Local Health Department Nurse on 08/22/23 at 12:15 PM revealed she was notified about Medication Aide #1 obtaining blood glucose checks on Resident #28, Resident #30, and Resident #57 while not cleaning and disinfecting the shared glucometer meter on 8/20/23. The Local Health Department Nurse indicated she had advised the facility to obtain a Hepatitis Panel (lab to test for Hepatitis B, Hepatitis C) and a Human Immunodeficiency Virus (HIV) lab, review the three resident's immunization records, notify the medical provider, residents, and Resident Representatives (RP) of the occurrence and monitor for any adverse effects. A review of labs presented by the facility for Resident #28 and Resident #30 revealed the facility drew labs to assess immunity instead of the Hepatitis Panel originally requested by the local health department. When the facility was notified, the facility presented a letter from the local health department dated 8/29/23 that indicated since MA #1 used a clean lancet and a clean test strip, the local health department no longer considered it to be a potential transmission and labs no longer needed to be drawn to determine each resident's health status for Hepatitis B, Hepatitis C or HIV. A telephone interview with the facility Nurse Practitioner (Nurse Practitioner #1) on 8/28/23 at 3:53 PM revealed she became aware of the potential for transmission of a bloodborne illness involving Resident #28, Resident#30, and Resident #57 which occurred on 8/20/23 when she arrived the at facility in the afternoon on Monday, 8/21/23 by the DON. The NP #1 indicated the DON notified her MA #1 had not thoroughly cleaned and disinfected the blood glucose monitoring device between residents when blood sugar levels were obtained on 8/20/23. The NP did not understand why the labs had been ordered because she said she would not have drawn labs without one of the residents having a known bloodborne communicable disease diagnosis listed in the medical record. A telephone interview with the Medical Director on 8/29/23 at 9:49 AM revealed he had not been made aware of the occurrence where a single glucometer was used on multiple residents without disinfecting. He stated he would expect all staff to perform care in a manner to prevent potential cross contamination of bloodborne illnesses. An interview with the Administrator on 8/24/23 at 1:09 PM revealed he learned about the occurrence on 8/20/23 when MA #1 performed fingerstick glucose checks using a single glucometer without cleaning and disinfecting it between residents which placed the residents at risk for a bloodborne illness. The Administrator indicated he would have expected the glucometer to be cleaned and disinfected before and after use to decrease the spread of any potential illness. Facility administration (Administrator and Director of Nursing) was notified of immediate jeopardy on 8/20/23 at 5:02 PM. The facility provided the following plan for IJ removal. Noncompliance Allegation: The facility has been found noncompliant in ensuring that the glucometer was cleaned according to manufacturer guidelines using an EPA approved disinfectant cloth between each resident usage. This has resulted in potential exposure to bloodborne pathogens for the residents who were required to have their blood glucose levels checked. The noncompliance was identified through observation, record review, resident, and staff interviews, and is specifically attributed to a Certified Medication Aide failing to follow the proper procedure for cleaning and disinfecting a shared glucometer. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Observation, record review, resident, and staff interviews completed by the surveyor on 8/20/23 identified the facility failed to ensure a glucometer was cleaned, according to manufacturer guidelines using an EPA approved disinfectant cloth, between each resident usage. This occurred for 3 residents who were required to have their blood glucose levels checked (Resident #28, Resident #30, and Resident #57). Clinical staff failed to use the appropriate procedure to clean and disinfect a shared glucometer. Every resident that receives a fingerstick blood glucose level is at risk. On 8/20/23 the Director of Nursing and Unit Managers completed an audit of all current residents and identified those with physician's orders requiring blood glucose levels. On 8/21/23, the Director of Nursing and Unit Managers ensured that each resident requiring fingerstick blood glucose levels was assigned an individual use glucometer stored at their bedside. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Administrator and Director of Nursing changed the facility's policy and procedure to include a new process to assign completion of blood glucose levels to only Licensed Nurses as well as issuing individual glucometers to each resident requiring blood glucose levels. On 8/20/23 the Director of Clinical Services educated the Director of Nursing and the Administrator regarding the new process for obtaining blood glucose levels by only assigning Licensed Nurses and the revisions to the Glucometer Disinfection policy and procedures including cleaning and disinfecting of each device and the management of glucometers by issuing individual glucometers to each resident requiring blood glucose levels. The Director of Nursing and Administrator educated the Unit Managers regarding the revisions to the Glucometer Disinfection policy and procedures including cleansing and disinfecting of each device and the management of glucometers by issuing individual glucometers to each resident requiring blood glucose levels. The Unit Managers were also educated regarding the change in process to allow only Licensed Nurses to complete blood glucose levels. This was completed on 8/21/23. On 8/21/23, responsible parties (RP) for residents and those residents that receive fingerstick blood glucose levels have been notified by the Director of Nursing or Unit Manager of the potential exposure of bloodborne pathogens due to not properly disinfecting a shared glucometer. They were informed that we will now be using individual glucometers for each resident. RPs and Residents were informed that the local Health Department had been notified and we will be following any recommendations that they provide regarding the potential exposure to blood borne pathogens. Current Licensed Nurses have received training by the Director of Nursing and Unit Managers on the following: o Only Licensed Nurses will perform blood glucose levels beginning 8/21/23. In the event a Medication Aide is assigned to administer medications to a resident requiring a blood glucose level, the Medication Aide will notify the Licensed Nurse for completion of the blood glucose level. o The purpose for following a cleaning checklist process, for disinfecting glucometers due to the likelihood of cross-contamination and the spread of bloodborne pathogens among residents o The importance of cleaning and disinfecting the glucometer per manufacturer's guidelines, using the training/education checklist for Cleaning Glucometers that includes the process of cleaning and includes observation and return demonstration. o This includes cleaning and disinfecting the individually issued glucometers that are stored at the residents' bedside. o The glucometer cleaning process is as follows: Upon entering the resident's room with 2 EPA approved disinfectant wipes, wash hands and don clean gloves. Obtain the resident's individual glucometer from the bedside table. Insert a test strip into glucometer, complete fingerstick using a lancet, and collect a small amount of blood on the sample test strip. Wait for the results of the sample to appear. Remove the test strip and dispose of the lancet and test strip in the sharps container on the med cart. Use one EPA approved disinfectant wipe to wipe the glucometer of any visible materials covering all surfaces. Remove soiled gloves and don clean gloves. Use the second wipe to allow the glucometer to remain moist for 3 minutes and allow to air dry, return to storage case and place case in the bedside drawer. Remove gloves, wash hands well. Record Blood Sugar result in the electronic record. On 8/21/23 Licensed Nurses were notified by the Director of Nursing and Unit Managers that extra glucometers are available in the Nurses Medication Room to ensure new admissions or residents with new orders for blood glucose levels have their own glucometer assigned. This education was completed for current Licensed Nurses including those working for agencies on 8/21/23 by the Director of Nursing and Unit Managers. This education was provided verbally with written documents for reference and a return demonstration completed by the Director of Nursing and Unit Managers. The Director of Nursing will maintain a log of all Licensed Nurses to ensure no staff are allowed to work without receiving this training. On 8/21/23, the Administrator and Director of Nursing notified the county Health Department Nurse and the Physician of the concerns identified regarding a Medication Aide failing to use the appropriate procedure to disinfect a shared glucometer for 3 residents and requested guidance for follow-up for possible exposure to bloodborne pathogens. Recommendations were completed by the Director of Nursing and Unit Managers. On 8/21/23, the Director of Nursing and Unit Managers ensured that each resident requiring fingerstick blood glucose levels was assigned an individual use glucometer stored at their bedside. This was completed on 8/21/23. Current Medication Aides have received training from the Director of Nursing and Unit Managers that only Licensed Nurses will perform blood glucose levels beginning 8/21/23. Medication Aides will no longer be assigned to perform blood glucose levels. In the event a Medication Aide is administering medications on an assignment with residents requiring blood glucose levels the Medication Aide will notify the Licensed Nurse for completion. The facility alleges removal of Immediate Jeopardy 8/22/23. On 8/24/23, the facility's immediate jeopardy removal plan effective 8/22/23 was validated by the following: Staff interviews revealed all nurses were able to verbalize they had received training that medication aides were no longer allowed to perform fingerstick glucose monitoring, each resident who required blood glucose monitoring had been assigned an individual glucometer which would be kept in the residents' room and the proper cleaning procedure to clean and disinfect the glucometer before and after each use using an EPA approved disinfectant wipe and allow it to dry the appropriate amount of time based on the wipe used. Inservice training records of return demonstrations and of the updated policy were reviewed and observation of glucometers in each individual resident's room were made.